Assisting with chest injuries. When the lungs are injured in the first place. Lung rupture, consequences, causes of damage. The mechanism of the development of the clinical picture and the factors that determine it. Closed lung injury Lung contusion: symptoms

Due to anatomical features organs of the breast, with penetrating wounds, the lungs are most often (in 70-80%) damaged. In the pathogenesis of vital disorders, in this case, pneumothorax comes to the fore with the exclusion of a large alveolar surface from the function of external respiration. Tension pneumothorax leads to displacement of the mediastinum with impaired blood flow through the large vessels of the chest.

Lung damage due to stabbing most often localized in the lower parts: on the left - on the anterolateral surface of the lower lobe (V, less often IV segments, as well as VII, VIII and IX segments), on the right - on the posterolateral surface of the middle and lower lobes (VII, VIII, IX segments, less often - IV, V and VI segments).
The wound canal in the lung with stab wounds can be blind, through and tangential (tangential).

The blind injuries depending on the depth, they are divided into superficial and deep. The criteria for such a division are very relative, in a 2005 publication we divided the stab wounds of the lungs into superficial (up to 5 mm deep), shallow (5 to 15 mm), and deep (more than 15 mm). However, this division was used in relation to the possibilities of thoracoscopic interventions for chest injuries, and therefore was of a private nature.

More significant is localization of stab wounds... Their location in the peripheral zone of the lung (regardless of whether they are blind or through) is not accompanied by profuse bleeding or the flow of air into the pleural cavity. Injury of the superficial layers of the lung tissue leads to moderate bleeding, which quickly stops on its own. In contrast, wounds in the root zone of the lungs are often accompanied by damage to the vasculature of the lungs and the bronchial tree, which makes them very dangerous.

For stab wounds of the lung a slit-like shape with smooth edges and moderate bleeding is characteristic. With a deep wound due to the obstructed outflow of blood from the wound channel, hemorrhagic impregnation occurs in the circumference. With penetrating gunshot wounds to the chest, the wounding projectile only in 10% passes through the pleural sinuses, bypassing the lung. In the remaining 90%, lung tissue is damaged to some extent.

Gunshot wounds of the lung subdivided into through, blind and tangent. Damage to the great vessels and large bronchi, according to the testimony of military field surgeons, does not occur often. However, we believe that wounded with such injuries die faster than they appear in the field of vision of surgeons.

Porous and elastic lung tissue, which provides insignificant resistance to the wounding projectile, is damaged only in the immediate vicinity of the wound channel. Bullet wounds in the lung parenchyma form a channel with a diameter of 5 to 20 mm, filled with blood and detritus. When the ribs are damaged, small fragments of them are often located in the wound channel, as well as infected (contaminated) foreign bodies - scraps of clothing, parts of the wad (with a shot wound), fragments of bullet shells.

In a circle wound channel after a few hours, fibrin falls out, which, together with blood clots, fills the wound canal, stopping air seepage and bleeding. The zone of traumatic necrosis around the wound drip does not exceed 2-5 mm, the zone of molecular concussion with a diameter of 2-3 cm is represented by thrombosis of small blood vessels and hemorrhages in the lung tissue. Focal hemorrhages, ruptures of the interalveolar septa lead to atelectasis.

In a significant number of observations, with a smooth course, hemorrhage into the lung tissue resolves within 7-14 days.

However, with high velocity bullet wounds there are extensive ruptures and crushing of the pulmonary parenchyma. In this case, fragments of damaged ribs, which have received large kinetic energy, inflict numerous additional injuries.

In the vast majority of observations for lung injuries hemopneumothorax appears immediately, the volume of hemothorax depends on the caliber and number of damaged blood vessels, and the volume of pneumothorax depends on the caliber and number of damaged airways.

Extensive destruction of the lung parenchyma observed with shrapnel wounds and mine-explosive injury. The fragments of shells and mines form wound channels of irregular shape with crushing of tissues, depending on the size of the fragment and the speed with which it penetrated the body.

Sometimes whole share or even most of the lungs are areas of broken tissue soaked in blood. Such traumatic hemorrhagic infiltration, with a favorable course of the post-traumatic period, is organized over time with an outcome in fibrosis. But much more often the process proceeds with necrosis, infection and the formation of lung abscesses.

One of the first publications of a successful outcome with abscess formation of lung tissue after a gunshot wound belongs to NI Pirogov. He cites the case of the Marquis de Ravaglia, who, 10 years after a gunshot wound to a lung with cough and pus, a wad of tow came out, which caused an abscess.

Of the 1218 patients admitted to Institute with lung wounds, 1064 (87.4%) had stab and cut wounds, 154 (12.6%) had gunshot wounds. Stab-cut wounds of the superficial layers of the parenchyma were present in the overwhelming majority of the wounded - (915 observations, which amounted to 75.1%). However, in 303 (24.9%), the depth of wounds was 2 cm or more, including in 61 (5%) it reached the root zone and the root of the lung. When analyzing this group of victims, it was revealed that left-sided wounds prevailed (171 victims, which amounted to 56.4%). Injuries to the right lung were noted in 116 (38.3%), bilateral injuries were in 16 (5.3%). In 103 patients of this group, wounds were of a gunshot nature, and in 56 (54.4%) they were blind, in 47 (45.6%) - through.

The length of the wound channels at 303 victims are presented in the table, while the number of wounds exceeds the number of observations due to multiple injuries of the lung. The table shows that the length of the wound channel in our observations ranged from 2 to 18 cm, including with wounds with cold weapons. In more than 50% of cases, the length of the wound channel was 4-8 cm.

From the table it follows that the victims with established lung injury most often, there were simultaneously damage to the vessels of the chest wall, diaphragm and heart.

Quite often there were rib damage, including wounds with melee weapons. Injuries to the thoracic vertebrae and spinal cord were encountered only with gunshot wounds.

From the abdominal organs at the same time with lung injury wounds of the liver and stomach were most often observed. Of the concomitant injuries, there were most often injuries to the upper and lower extremities.

Lung injuries on the OIS scale are distributed as follows (the volume of hemothorax is not taken into account here):

The presence of bilateral injuries increases the severity of grade I-II injury by one more degree.

When the lungs are injured, first of all, it is necessary to insert some kind of tube into the wound, which is open on both sides. This can be a catheter, pen, or some other suitable item that is close at hand. Only you should first disinfect it. This will help the excess air out.

Orthopedist-traumatologist: Azalia Solntseva ✓ Article reviewed by a doctor

Bullet wound

Such damage occurs due to a fracture of the ribs and a simultaneous injury to the chest area. The situation is dangerous because there is severe bleeding and pneumothorax of valvular or open type.

These symptoms are very dangerous for the life of the victim.

They can cause complications that require urgent surgery.

In case of a bullet wound of the lungs, when the victim has a closed injury to the chest, it is necessary to urgently apply a pressure bandage. This should be done during the maximum expiration. These actions are performed when the ribs, sternum are broken.

If the victim has a significant closed pneumothorax, then a puncture of the pleural cavity is performed. The procedure must be done when the mediastinum is displaced. Then air is aspirated from the cavity.

With subcutaneous emphysema, which is often a consequence of pneumothorax, there is no emergency.

In case of a bullet wound of the lungs, you should very quickly cover the wounded area with a sealing bandage. On top of it they put a large gauze napkin folded many times. After that, it should be glued with something.

When transporting the victim to a medical facility, he should be given a half-sitting position. If possible, Novocaine is injected locally for anesthesia even before he is taken to the doctor.

If the victim is in a state of shock, his breathing is impaired, then it will be very effective to perform a vagosympathetic blockade according to Vishnevsky on the side that was injured.

Video

Penetrating trauma

Penetrating symptoms - bleeding from a wound on the chest, characterized by the formation of bubbles - while air passes through the wound.

If the lungs are injured, the first thing to do is:

First, you should make sure that there is no foreign object in the wound.
Then you need to press your palm to the damaged area to restrict the flow of air.
In the case when the victim has a through wound, the exit and entry holes in the wound should be closed.

Then you should cover the damaged area with a material that allows air to pass through, and fix it with a bandage or plaster.
The patient should be given a half-sitting position.
Something cold must be applied to the wound site, but before that, attach a gasket.
If there is a foreign body with a knife wound of the lung, then it is necessary to fix it with a roller made from scrap materials. You can fix it with a cloth or plaster.
It is strictly forbidden to independently remove stuck foreign bodies from the wound. After the performed procedures, the patient should be taken to the doctor.

Video

Closed wounds

For a closed type of chest injury, a fracture of the chest bones is characteristic. A closed heart injury is also characteristic, while there is no open wound in the chest cavity.

This injury is accompanied by traumatic pneumothorax, hemothorax, or hemopneumothorax. With a closed chest injury, the victim develops traumatic subcutaneous emphysema and traumatic asphyxia.

A closed chest injury is a rib cage injury. In this case, organs in the chest are injured, but the skin remains intact.

These injuries are often the result of one or more blunt force injuries or hitting surfaces in a traffic accident. Often, the chest is injured when they fall from a height, during a beating, a sharp one-time or numerous short, or prolonged squeezing of a patient in a crowd of people or rubble.

Closed form

Promedol or analgin should be administered intramuscularly.
Inhalation anesthesia with nitrous oxide and oxygen.
Oxygen therapy for pain relief.
You can use a circular bandage from a plaster or an immobilizing bandage. They should be used only when the deformations of the rib frame are not visible.
When the condition worsens significantly, shortness of breath increases, and the mediastinum moves to the intact side, there is a need to puncture the pleural cavity. This will help to translate the tense type of pneumothorax into an open one.
Any drugs for the heart are effective. Anti-shock agents can be used.
After the assistance provided, the patient should be taken to a hospital.
It is necessary to transport the patient on the back or on a stretcher. In this case, the upper half of the body must be lifted. You can take the victim to the doctor in a half-sitting position.

What do we have to do

The wound of the lungs is open and closed.

The latter occurs when the chest is squeezed sharply.

It can also arise from a blow with a blunt object or a blast wave.

An open type of injury is accompanied by open pneumothorax, but it can be without it.

Injury of the lungs with a closed injury is determined by the degree of damage. If they are severely injured, bleeding appears and the lung ruptures. Hemothorax and pneumothorax sets in.

An open wound is characterized by a ruptured lung. It is characterized by damage to the chest.

Depending on the characteristics of the damage, different degrees of severity are distinguished. It is not easy to see a small, closed light wound to the chest.

When the lungs are damaged, the victim has hemoptysis, subcutaneous emphysema, pneumothorax, and hemothorax. It is impossible to see the accumulated blood in the pleural cavity, if it is not more than 200 ml there.

The techniques that can be used to help the victim are varied. Their choice is determined by the severity of the injury.

The main goal is to quickly stop bleeding and restore habitual breathing and cardiac activity. Simultaneously with the treatment of the lungs, the walls of the chest should also be treated.

Causes

Closed damage is the result of impact on a hard surface, compression, impact of a blast wave.

The most common circumstances in which people are injured are road traffic crashes, unsuccessful falls on the chest or back, blunt force blows to the chest, falling under a blockage as a result of collapses, etc.

Open injuries are usually associated with penetrating wounds with a knife, arrow, sharpening, military or hunting weapons, shell fragments.

In addition to traumatic injuries, physical damage, for example, ionizing radiation, is possible. Radiation damage to the lungs usually occurs in patients receiving radiation therapy for cancer of the esophagus, lungs, and breast. In this case, the areas of lung tissue damage topographically correspond to the applied irradiation fields.

The injury can be caused by a disorder that ruptures the weakened lung tissue by coughing or exertion. In some cases, foreign bodies of the bronchi act as a traumatic agent, which can cause perforation of the bronchial wall.

Another type of injury that deserves special mention is ventilator-induced lung injury that occurs in ventilated patients. These injuries are caused by oxygen toxicity, volumotrauma, barotrauma, teletrauma, biotrauma.

Diagnostics

External signs of injury: the presence of hematomas, wounds in the chest area, external bleeding, air suction through the wound channel, etc.

Physical findings differ depending on the type of injury, but the most common finding is the weakening of breathing on the side of the affected lung.

For a correct assessment of the nature of the damage, chest radiography in two projections is required.

X-ray examination reveals displacement of the mediastinum and collapse of the lung (with hemo- and pneumothorax), spotty focal shadows and atelectasis (with bruises of the lung), pneumathocele (with rupture of small bronchi), emphysema of the mediastinum (with rupture of large bronchi) and other characteristic signs of various injuries lungs.

If the patient's condition and technical capabilities allow, it is desirable to clarify the X-ray data using computed tomography.

Bronchoscopy is especially informative for the detection and localization of bronchial rupture, detection of the source of bleeding, foreign body, etc.

Upon receipt of data indicating the presence of air or blood in the pleural cavity (based on the results of fluoroscopy of the lungs, ultrasound of the pleural cavity), a therapeutic and diagnostic pleural puncture can be performed.

With concomitant injuries, additional studies are often required: plain radiography of the abdominal organs, ribs, sternum, fluoroscopy of the esophagus with barium suspension, etc.

In the case of an unspecified nature and volume of lung damage, they turn to diagnostic thoracoscopy, mediastinoscopy or thoracotomy. At the stage of diagnosis, a patient with lung injury should be examined by a thoracic surgeon and a traumatologist.

First aid for injured lungs

In a significant number of observations, with a smooth course, hemorrhage into the lung tissue resolves within 7-14 days.

From the table it follows that the victims with established lung injury most often, there were simultaneously damage to the vessels of the chest wall, diaphragm and heart.

Quite often there were rib damage, including wounds with melee weapons. Injuries to the thoracic vertebrae and spinal cord were encountered only with gunshot wounds.

Lung injuries on the OIS scale are distributed as follows (the volume of hemothorax is not taken into account here):

The presence of bilateral injuries increases the severity of grade I-II injury by one more degree.

Injuries to the pleura and lungs are divided into closed and open. Closed injuries are called injuries that occurred without violating the integrity of the skin, open - injuries accompanied by a violation of their integrity, that is, injuries.

OPEN INJURIES (WOUNDS) OF THE PLEURA AND LUNGS

Injuries to the pleura and lungs are a type of penetrating chest injury. In peacetime, these injuries are rare. In wartime, their number increases dramatically. Among the gunshot wounds of the chest, there are tangents, often accompanied by a fracture of the ribs, through and blind. These damages are very complex and peculiar and require special consideration.

The pleura is rarely injured in isolation. Isolated damage to the pleura is possible with tangential injuries or injuries to the spare pleural spaces (sinuses) during exhalation, while they are free of the lungs. Pleural injuries are almost always combined with lung injury.

Injuries of the pleura and lungs are characterized by some peculiar phenomena: accumulation of blood in the pleural cavity - hemothorax, entry into the pleural cavity of air - pneumothorax and air infiltration of peri-wound tissue - traumatic emphysema.

1. Hemothorax ( haemothorax) ... The source of bleeding into the pleural cavity is usually the pulmonary vessels, less often the vessels of the chest wall (intercostal, a. mammaria interna) and diaphragmatic and even more rarely large vessels of the mediastinum and heart.

The amount of blood flowing into the pleural cavity primarily depends on the caliber of the damaged vessel. Negative pressure in a difficult cavity, exerting a suction effect, maintains bleeding. The volume of hemothorax, in addition, increases due to concomitant aseptic exudation (hemopleuritis). Large hemothorax in the amount of 1,000-1,500 ml strongly compresses the lung and pushes the mediastinum with the non-organs imprisoned in the opposite direction. The latter leads to significant obstruction of blood circulation and breathing and sometimes ends in death (Fig. 78). As for the immediate fate of the blood that poured into the pleural cavity, then, according to the observations of B.E. Linberg and other Soviet surgeons conducted during the Great Patriotic War, the blood in the pleural cavity remains liquid for a long time.

The blood poured into the pleural cavity, after 5 hours, loses its ability to clot. A test is based on this fact, which finds out whether the bleeding into the pleural cavity has stopped. If the liquid blood of hemothorax, obtained by a puncture more than 5 hours after the injury, does not clot, then the bleeding can be considered stopped. If the blood coagulates, then the bleeding continues.

In the future, the liquid part of the blood is absorbed, the convolutions are organized and the pleural cavity is obliterated, or the hemothorax becomes infected, and the most severe complication of hemothorax, pleural empyema, develops. Microbes enter the pleural cavity through an external wound or from the side of the lung from a damaged bronchus. Microbes are especially often carried in by foreign bodies. Therefore, infected hemothorax is a common companion of blind lung wounds. It is also possible hematogenous intake of infection from a purulent focus in the body.

The clinical picture of hemothorax. Symptoms of hemothorax are signs of internal bleeding, a dull sound when tapping, movement of the dullness of the heart due to displacement of the mediastinum, expansion of the lower part and smoothing of the intercostal spaces of the corresponding half of the chest, disappearance or weakening of respiratory noises when listening, absence of voice tremor. Non-abundant hemothorax in the amount of 150-200 ml, which fits in the spare pleural space, is not detected by tapping, but is recognized radiologically. With significant hemothorax, the patient has pallor with a bluish tinge, anemia, difficulty breathing, etc.

The accumulation of blood in the pleural cavity in connection with exudation initially increases for several days, and then, due to resorption, gradually decreases.

Recognition of hemothorax is completed with a test puncture and X-ray examination.

A rapid increase in the level of dullness during the first or second day after injury, especially accompanied by the patient's blanching and increased and weakening of the pulse, indicates a resumption of bleeding. Absorption of uninfected hemothorax lasts about three weeks or longer and is accompanied by a moderate increase in temperature.

With suppuration of hemothorax due to inflammatory exudation, the level of dullness increases, the temperature and leukocytosis rise, ROE accelerates and the general condition worsens. The diagnosis of suppuration is made on the basis of the test puncture data.

In doubtful cases, to distinguish aseptic hemothorax from an infected one, N.N.Petrov's test can be used. A certain amount of blood from the pleural cavity obtained by puncture is poured into a test tube, and diluted with a fivefold amount of distilled water. In uninfected blood, after 5 minutes, complete hemolysis occurs and the liquid becomes transparent. If there is pus in the blood, the fluid remains cloudy, with a flocculent sediment. In this regard, the determination of the quantitative ratio of leukocytes and erythrocytes contained in the extracted blood can also help. The normal ratio is 1: 600-1: 800. The ratio of 1: 100 and below speaks for suppuration.

2. Pneumothorax ( pneumothorax) is formed as a result of entering the pleural cavity, which has negative air pressure before opening. A wound opening that allows air to pass through can be located in the outer wall of the chest or in the bronchus. Consistent with this, a pneumothorax is distinguished, open to the outside and open to the inside. With a free pleural cavity, if enough air enters it, the lung collapses completely. In the same cases, when there are adhesions between the pleural sheets, the lung partially collapses. If the penetrating wound opening is within the adhesions, pneumothorax does not form.

There are three types of pneumothorax: closed, open and valve.

Closed pneumothorax is the accumulation of air in the pleural cavity, which does not have or, more precisely, has lost communication with the external space or bronchus, since the wound channel is closed. With an open pneumothorax, the communication of the pleural cavity with the outer space, due to the continuing gaping of the wound channel, remains. Valvular pneumothorax is called a pneumothorax that is open inward (in the bronchus) with such an arrangement and shape of the wound canal, in which air entering the pleural cavity during inhalation cannot come back when exhaled (Fig. 79). The wound channel in the chest wall is closed at the same time.

Closed pneumothorax does not cause any significant respiratory distress, since the collapse of one lung is sufficiently compensated by the increased activity of the other and shortness of breath is almost not felt. Within a few days, the air contained in the pleural cavity and the effusion caused by the entry of air are absorbed without residue.

A pneumothorax open to the outside with a large wound opening that exceeds the lumen of the main bronchus causes severe shortness of breath, cyanosis, and usually a decline in cardiac activity. Several factors play a role in the origin of dyspnea. The first is the loss of the respiratory function of the collapsed lung. However, this factor is not the main one. An example of a closed pneumothorax shows that the collapse of one lung is sufficiently compensated by the increased activity of the other. A more significant role is played by the second factor - displacement to the healthy side of the mediastinum, which causes bending and compression of the large blood vessels of the mediastinum and thus impedes blood circulation. An even greater influence is exerted by respiratory oscillations of the mediastinum, which protrudes in the direction of the pneumothorax - during inhalation, then in the opposite direction - during exhalation. Oscillatory movements of the mediastinum cause reflex irritation of the nerve nodes and plexuses of the mediastinum, which can cause shock.

The third factor is the pendulum movement of air containing an increased amount of carbon dioxide from one lung to another, preventing the flow of fresh air from the outside. The "spoiled" air exhaled from a non-collapsed lung partially enters the collapsed lung, and when inhaled, it enters the healthy lung.

The air that enters the pleural cavity with an open pneumothorax in large quantities and is continuously exchanged has an adverse effect on the pleura, subjecting it to cooling and irritating the nerve endings in the pleura and the nerve centers of the lung root, which can cause pleural shock.

With a wide wound channel, microbes inevitably penetrate into the pleural cavity together with the incoming air and the dust and blood sprays from the skin surface. With a narrow wound channel, the entry of air into the pleural cavity is accompanied by a whistling sound ("sucking pneumothorax").

A pneumothorax, open to the outside, with a small wound hole in the chest wall (with a diameter less than half of the main bronchus), in terms of the degree of respiratory dysfunction, approaches a closed pneumothorax and, moreover, the smaller the wound hole.

Pneumothorax open in the bronchus is often valvular. Valvular (tension) pneumothorax is a particularly severe type of pneumothorax. The progressive accumulation of air in the pleural cavity that occurs with valve pneumothorax is apparently caused not so much by the formation of a valve in the wound canal as by the fact that the narrow wound canal, due to the expansion of the lung, opens during inhalation and collapses during exhalation, and thus the return air exit becomes impossible (see fig. 79). The amount of air in the pleural cavity, penetrating with each inhalation, quickly reaches a maximum. Air strongly compresses the lung and displaces the mediastinum. In this case, the mediastinum and the large vessels located in it are bent and squeezed with special force. In addition, the suction activity of the chest cavity, which is of great importance for blood circulation, sharply weakens or stops. As a result, blood circulation and respiration are impaired and severe, rapidly progressing shortness of breath occurs, sometimes ending in the strangulation of the wounded.

Right-sided pneumothorax is more difficult to carry than left-sided. Experiments and clinical observations have shown that bilateral pneumothorax is not definitely fatal.

The clinical picture of pneumothorax. Symptoms of pneumothorax are: a feeling of tightness in the chest, shortness of breath of varying strength depending on the form of pneumothorax, pallor and cyanosis of the face in severe cases, especially in valvular form, high tympanic sound when tapping, displacement of heart dullness to the healthy side, absence of voice tremor, greater translucency sore side during X-ray examination.

In the vast majority of cases, hemothorax and pneumothorax are combined. With hemopneumothorax in the lower chest, tapping gives a dull sound, in the upper - tympanic. The concussion of the chest causes a splash (see below for treatment of pneumothorax).

3. Traumatic emphysema often accompanies injuries to the pleura and lungs. Usually air infiltrates the subcutaneous tissue, and then emphysema is called subcutaneous. Less often, air enters the mediastinal tissue, and then emphysema is called mediastinal.

Air enters the subcutaneous tissue of the chest wall almost exclusively from the affected lung, extremely rarely through the chest wound, and even then in small quantities. In the first case, with a free pleural cavity, the appearance of subcutaneous emphysema is preceded by pneumothorax and air enters the subcutaneous tissue through an opening in the parietal layer of the pleura.

When there are pleural adhesions in the area of injury, air enters the subcutaneous tissue directly from the lung, bypassing the pleural cavity. Usually, subcutaneous emphysema occupies a small area around the wound and quickly disappears, but sometimes, especially with valvular pneumothorax, subcutaneous emphysema reaches large sizes, captures a significant part of the trunk, spreads to the neck and face, while remaining superficial (Fig. 80). Increasing traumatic emphysema usually develops with valvular pneumothorax.

With the infiltration of deep tissue located along the bronchi and subpleurally, air penetrates into the tissue of the mediastinum and squeezes the organs contained in it, primarily the large veins, and causes a deep violation of breathing and blood circulation, sometimes ending in death. With emphysema of the mediastinum, air, spreading through the pretracheal tissue, appears at the base of the neck, in the jugular and supraclavicular fossa.

Traumatic emphysema is easily recognized by the characteristic crunch, crepitus, felt when pressing on the skin. A significant air content in the subcutaneous tissue can be detected by tapping, which gives a tympanic shade, as well as radiographically.

Anaerobic gas phlegmon is sometimes taken for subcutaneous emphysema. With gas phlegmon, in addition to crepitus, there is a bronze color of the skin and a very serious general condition. In addition, gas infection does not develop immediately after injury. Subcutaneous emphysema itself has almost no effect on the general condition of the patient, even if it spreads over a very long stretch. With mediastinal emphysema, there is moderate crepitus in the jugular and supraclavicular fossa, a tympanic sound on the sternum when tapped, and a patchy shadow enlightenment on an x-ray of the sternum.

When the lungs are injured, the air contained in the chest cavity and under pressure sometimes penetrates into the damaged veins of the lung, and from there into the vessels of the systemic circulation. When the patient is upright, air can enter the small cerebral arteries and cause an air embolism in the brain. Clinically, a cerebral embolism is manifested by a sudden loss of consciousness, which either passes or ends in death. Depending on the location of the emboli, one or the other focal cerebral symptoms may be observed.

Stab and cut wounds of the chest wall and lungs provide a smooth wound channel that heals quickly and easily if the bronchus or large blood vessel has not been damaged of a significant caliber. Gunshot wounds at known distances and wounds from small fragments of explosive shells also provide a narrow, easily healing wound channel.

Bullet wounds at close range, wounds from large bullets, explosive bullets or large fragments of explosive shells produce more extensive, more complex and therefore more difficult to heal wounds. The wound channel often contains foreign bodies (bullets, shell fragments, pieces of clothing, etc.).

The general clinical picture of injuries to the pleura and lungs consists of symptoms of a general and local nature.

Phenomena of a general nature include: cough, pallor of the mucous membranes and skin, coldness of the extremities, frequent and small pulse, shallow breathing, i.e., the phenomenon of shock and acute anemia. Since these symptoms are caused by shock, they are transient and usually disappear after 3-4 hours. Further continuation or strengthening of them speaks for internal bleeding. Unlike acute anemia, shock is characterized by an increased content of red blood cells in the blood.

Local phenomena, in addition to the wound, include hemothorax, pneumothorax, traumatic emphysema, and if the lung is damaged, hemoptysis. The symptomatology of hemothorax, pneumothorax and traumatic emphysema is described above. As for the wound itself, the location of the entrance and exit (if any) holes and the nature of the wound are of paramount importance. The location of the wound holes orients in relation to the area of damage.

With a small wound hole and a narrow wound channel, the gap in the chest wall collapses, the pleural cavity closes and a hemothorax of a greater or lesser size remains in it, as well as a closed, soon disappearing pneumothorax. Little or no shortness of breath. It is more significant only with profuse hemothorax. With a narrow, but gaping wound opening, air whistling is sucked into the pleural cavity and an open pneumothorax is formed, which causes significant shortness of breath.

With a wide wound channel in the chest wall, air mixed with foamy blood, when breathing, enters the pleural cavity with a noise, introducing an infection, then it is thrown out with a noise. Wide open pneumothorax is accompanied by severe shortness of breath.

The main symptom of a lung injury is hemoptysis, which may be the only clinical symptom of lung injury. The absence of hemoptysis does not prove the absence of lung injury. The same applies to pneumothorax. Hemoptysis usually lasts 4-10 days, and if there is a foreign body in the lung, it is often much longer. Respiratory movements of the chest on the side of the wound are limited, the abdominal muscles on the same side are reflexively tense due to damage or irritation of the intercostal nerves.

In case of blind wounds, an X-ray examination is mandatory to detect and determine the location of foreign bodies. It is forbidden to examine the wound with a probe or finger, since in this case it is easy to infect an uninfected wound, and to make a non-penetrating wound penetrating

Lung wounds are sometimes complicated by secondary bleeding, which can be fatal, as well as secondary pneumothorax, which is formed as a result of the secondary opening of the wound canal that was previously closed by surgery. A later, frequent and dangerous complication of penetrating chest wounds is infection in the form of pleural empyema, suppuration along the wound canal, pulmonary abscess, rarely lung gangrene, later bronchial fistulas.

The prediction for injuries to the pleura and lung is serious. The main causes of death are blood loss, asphyxia and infection.

Wounds with a narrow, easily collapsing wound channel, better at resisting infection, provide incomparably more reassuring predictions than wide-gaping wounds.

Treatment for injuries to the pleura and lungs pursues three main goals: stopping bleeding, restoring the normal respiratory mechanism and preventing infection.

Minor bleeding from an external wound is stopped by applying a light pressure bandage. With a small, "pinpoint" hole as a result of injury by a small-caliber rifle bullet or a small fragment of a projectile, a collodion or cleol sticker is sufficient. Bleeding from intercostal arteries or a. mammaria interna requires ligation of these vessels.

Moderate hemothorax (up to the mid-scapula level) does not require immediate intervention. With a very abundant and especially progressive accumulation of blood in the pleural cavity (above the level of the middle of the scapula), in order to weaken the life-threatening excessive intrapleural pressure, excess blood (200-500 ml) is slowly aspirated.

Only in the case of a very rapid increase in hemothorax, in order to stop life-threatening bleeding, do they resort to a wide opening of the pleural cavity to treat the wound of the lung and ligate the bleeding pulmonary vessels. The pleural cavity is opened under local anesthesia. Before the operation, a vago-sympathetic blockade is performed. This prevents life-threatening bronchopulmonary shock.

Vago-sympathetic blockade is performed according to Vishnevsky, by injecting 30-60 ml of 0.25-0.5% novocaine solution into the deep cervical tissue through a needle injected behind the sternocleidomastoid muscle in the middle of its extension.

It is not often possible to find a bleeding lung vessel. Then you have to be limited to the imposition of a light hemostatic suture on the wound. After that, the lung is brought to the wound and fixed with a suture to the chest wall.

With open hemopneumothorax, complete (early or delayed) wound treatment of the chest wall and lung is fundamentally indicated, however, such intervention is justified only if the operator is fully qualified and the entire range of measures taken for complex intrapleural operations is feasible.

The blood accumulated in the pleural cavity is removed as soon as possible, since the prolonged stay of a large amount of blood in the pleural cavity contributes to the development of infection and the formation of too powerful inflammatory layers that impede the expansion of the lung (B.E. Linberg, N.N. Elansky, etc.) ... Typically, suction begins 1-2 days after injury. Suction is carried out slowly until the pleural cavity is completely emptied. If necessary, pumping out is repeated after 2-3 days. After suction, penicillin is injected into the pleural cavity. If there is a large accumulation of blood bundles in the pleural cavity, which impede the excretion of blood, thoracotomy can be performed to remove the bundles. The wound is sewn up tightly. A small hemothorax does not require active intervention.

Suppurative hemothorax is treated as empyema.

Closed pneumothorax resolves by itself and therefore does not require treatment. When treating open pneumothorax, they try to translate it into an incomparably lighter - closed one. As an initial temporary measure, a hermetic bandage is applied to the opening in the chest wall. One of the best dressings of this kind is a tile-like bandage over which a regular gauze is applied.

To firmly close the hole, surgical intervention is required, which is performed urgently (see below).

In case of suffocating valve pneumothorax for first aid, a thick short needle (a needle for blood transfusion) is inserted into the pleural cavity and fixed with a bandage. Usually, either a short drain tube is used, on the free end of which a thin rubber glove with a cut end is put on, or a long drain tube, the end of which is immersed in a container with a disinfectant liquid below. If this is not enough, further air removal is carried out by continuous active suction using a system of two bottles (Fig. 81) or a water jet or electric pump.

Subcutaneous emphysema does not require special treatment. In cases of very large and widespread development of emphysema, in extreme cases, skin incisions are made. With mediastinal emphysema, a deep incision above the jugular notch and opening of the pretracheal tissue, which is a continuation of the mediastinal tissue, is sometimes necessary to free the mediastinum from air.

In general, for wounds of the pleura and lungs with a narrow collapsed wound channel and a closed pleural cavity, therefore, in most peacetime wounds (stab and knife), with narrow bullet wounds and wounds with small fragments of explosive shells in wartime, conservative treatment is indicated.

With wide wounds of the chest with an open pleural cavity, for example, with large-caliber or tangential bullet wounds, with injuries from large fragments of explosive shells, an early surgical intervention is indicated. The operation is performed under local anesthesia. The operation consists in active surgical debridement of the wound and in layer-by-layer closure of the opening in the chest wall. To do this, use a muscle flap on the leg, a flap of the periosteum of the rib, suture a lung (pneumopexy) or a diaphragm to the edges of the wound, mobilize the adjacent section of the chest, resect the rib. A lung wound is rarely treated, usually only with threatening bleeding. The skin is not sewn up in a military environment.

The operation converts an open pneumothorax into a closed one, which restores the normal breathing mechanism. This also prevents infection, since during the operation the wound is cleaned and fragments of bones and foreign bodies (scraps of tissue, fragments of shells) are removed. The location of the fragments is established by preliminary X-ray examination.

To reduce the effects of shock, as well as cough, which can cause secondary bleeding, morphine or pantopon is injected subcutaneously. In case of shock and acute anemia, the patient is injected subcutaneously or intravenously with saline, 5% glucose solution, or, better, blood transfused by the drip method. In cases of shock, a vago-sympathetic blockade is also performed. To weaken the pleural infection, a drainage tube is inserted into the pleural cavity through a small opening in the chest wall made below the wound canal, and a constant active suction of the accumulating effusion is established. Patients with penetrating chest wounds require complete rest and hospitalization. The most comfortable position for wounded of this kind is half-sitting.

The degree of disability after injuries of the pleura and lungs depends on the complications that have developed and the consequences remaining after them from the organs of the chest cavity (adhesions, displacement of the heart and large vessels of the mediastinum, the presence of fistulas and deformities of the chest and the functional disorders caused by them). Most patients with such changes are enrolled in the third group of disabled persons.

PREVENTION OF PNEUMOTORAX DURING OPERATIONS

Respiratory distress with operative pneumothorax can be sufficiently prevented. To do this, either a closed pneumothorax is preliminarily applied, or during the operation, air is gradually and fractionally introduced into the pleural cavity through a small opening in the pleura, or the lung is extracted into the wound and fixed with sutures to the edges of the chest wall wound (pneumopexy). The experience of transpleural operations has shown that these precautions are not absolutely necessary.

ICD-10

S27.3 Other lung injuries

General information

Causes

Classification

crush injury

Symptoms of Lung Damage

Closed lung injury

Open lung injuries

Radiation damage to the lungs

worried about a small dry cough or shortness of breath on exertion;
worried about a constant hacking cough, for the relief of which the use of antitussive drugs is required; shortness of breath occurs with light exertion;
worried about a debilitating cough that cannot be stopped by antitussive drugs, shortness of breath is expressed at rest, the patient needs periodic oxygen support and the use of glucocorticosteroids;
severe respiratory failure develops, requiring constant oxygen therapy or mechanical ventilation.

Diagnostics

Conducting bronchoscopy is especially informative for the detection and localization of bronchial rupture, detection of a source of bleeding, a foreign body, etc. When receiving data indicating the presence of air or blood in the pleural cavity (based on the results of lung fluoroscopy, ultrasound of the pleural cavity), a therapeutic and diagnostic pleural puncture. With associated injuries, additional research is often required: an overview

- lung injuries accompanied by anatomical or functional disorders. Lung lesions vary in etiology, severity, clinical manifestations, and consequences. Typical signs of lung injury are severe chest pain, subcutaneous emphysema, shortness of breath, hemoptysis, pulmonary or intrapleural bleeding. Lung damage is diagnosed by chest x-ray, tomography, bronchoscopy, pleural puncture, diagnostic thoracoscopy. The tactics of eliminating lung damage varies from conservative measures (blockade, physiotherapy, exercise therapy) to surgery (wound closure, lung resection, etc.).

Lung damage is a violation of the integrity or function of the lungs caused by mechanical or physical factors and accompanied by respiratory and circulatory disorders. The prevalence of lung injuries is extremely high, which is primarily due to the high frequency of thoracic injury in the structure of peacetime injuries. In this group of injuries, the level of mortality, long-term disability and disability is high. Lung injuries from chest injuries occur in 80% of cases and are 2 times more likely to be recognized at autopsies than during the life of the patient. The problem of diagnostics and treatment tactics for lung injuries remains complex and relevant for traumatology and thoracic surgery.

Lung injury classification

It is generally accepted to divide all lung injuries into closed (with no chest wall defect) and open (with a wound hole). The group of closed lung injuries includes:

lung bruises (limited and extensive)
lung ruptures (single, multiple; linear, patchwork, polygonal)
crush injury

Open injuries of the lungs are accompanied by a violation of the integrity of the parietal, visceral pleura and chest. By the type of wounding weapon, they are divided into stab-cut and firearms. Lung wounds can occur with closed, open or valvular pneumothorax, with hemothorax, with hemopneumothorax, with rupture of the trachea and bronchi, with or without mediastinal emphysema. Damage to the lungs can be accompanied by fractures of the ribs and other bones of the chest; be isolated or combined with injuries to the abdomen, head, limbs, pelvis.

To assess the severity of damage in the lung, it is customary to distinguish safe, threatened and dangerous zones. The concept of "safe zone" includes the periphery of the lungs with small vessels and bronchioles (the so-called "lung cloak"). The central zone of the lung with segmental bronchi and vessels located in it is considered "threatened". Dangerous for injury is the root zone and the root of the lung, including the bronchi of the first-second order and the great vessels - damage to this zone of the lung leads to the development of intense pneumothorax and profuse bleeding.

The post-traumatic period following lung injury is divided into acute (first day), subacute (second or third day), distant (fourth or fifth day) and late (starting from the sixth day, etc.). The greatest lethality is observed in the acute and subacute periods, while the distant and late periods are dangerous for the development of infectious complications.

Causes of Lung Damage

Closed injuries of the lungs can be the result of impact on a hard surface, compression of the chest, exposure to a blast wave. The most common circumstances in which people are injured are road traffic crashes, unsuccessful falls on the chest or back, blunt force strikes to the chest, falling under a blockage as a result of collapses, etc. Open injuries are usually associated with penetrating chest wounds knife, arrow, sharpening, military or hunting weapons, shell fragments.

In addition to traumatic injuries of the lungs, they may be affected by physical factors, for example, ionizing radiation. Radiation damage to the lungs usually occurs in patients receiving radiation therapy for cancer of the esophagus, lungs, and breast. In this case, the areas of lung tissue damage topographically correspond to the applied irradiation fields.

Lung damage can be caused by a disorder that ruptures weakened lung tissue by coughing or exertion. In some cases, foreign bodies of the bronchi act as a traumatic agent, which can cause perforation of the bronchial wall. Another type of injury that deserves special mention is ventilator-induced lung injury that occurs in ventilated patients. These injuries can be caused by oxygen toxicity, volumotrauma, barotrauma, teletrauma, biotrauma.

Symptoms of Lung Damage

Closed lung injury

Contusion, or contusion of the lung occurs with a strong blow or compression of the chest in the absence of damage to the visceral pleura. Depending on the strength of the mechanical effect, such injuries can occur with intrapulmonary hemorrhages of various volumes, rupture of the bronchi and crushing of the lung.

Minor bruises often go unrecognized; the stronger are accompanied by hemoptysis, pain when breathing, tachycardia, shortness of breath. On examination, hematomas of the soft tissues of the chest wall are often detected. In the case of extensive hemorrhagic infiltration of lung tissue or crushing of the lung, shock phenomena, respiratory distress syndrome occur. Complications of a bruised lung can be post-traumatic pneumonia, atelectasis, air cysts of the lung. Hematomas in the lung tissue usually resolve within a few weeks, but if they become infected, a lung abscess may form.

Lung rupture includes injuries accompanied by injury to the pulmonary parenchyma and visceral pleura. "Companions" of the rupture of the lung are pneumothorax, hemothorax, cough with bloody sputum, subcutaneous emphysema. A bronchial rupture that has occurred may be indicated by the patient's shock state, subcutaneous and mediastinal emphysema, hemoptysis, tension pneumothorax, severe respiratory failure.

Open lung injuries

The peculiarity of the clinic of open lung damage is caused by bleeding, pneumothorax (closed, open, valve) and subcutaneous emphysema. The consequence of blood loss is pallor of the skin, cold sweat, tachycardia, a drop in blood pressure. Signs of respiratory failure caused by a collapsed lung include difficulty breathing, cyanosis, and pleuropulmonary shock. With an open pneumothorax during breathing, air enters and leaves the pleural cavity with a characteristic “squelching” sound.

Traumatic emphysema develops as a result of air infiltration of the peri-wound subcutaneous tissue. It is recognized by the characteristic crunch that occurs when pressing on the skin, an increase in the volume of soft tissues of the face, neck, chest, and sometimes the entire body. Particularly dangerous is the penetration of air into the tissue of the mediastinum, which can cause compression mediastinal syndrome, deep disturbances of breathing and blood circulation.

In the late period, penetrating wounds of the lung are complicated by suppuration of the wound channel, bronchial fistulas, pleural empyema, pulmonary abscess, gangrene of the lung. The death of patients can occur from acute blood loss, asphyxia and infectious complications.

Ventilator-induced lung injury

Barotrauma in intubated patients occurs due to rupture of the tissues of the lungs or bronchi during high-pressure mechanical ventilation. This condition may be accompanied by the development of subcutaneous emphysema, pneumothorax, lung collapse, mediastinal emphysema, air embolism and a threat to the patient's life.

The mechanism of volumotrauma is based not on rupture, but on overstretching of the lung tissue, which entails an increase in the permeability of the alveolar-capillary membranes with the occurrence of noncardiogenic pulmonary edema. Atelectotrauma is the result of a violation of the evacuation of bronchial secretions, as well as secondary inflammatory processes. Due to a decrease in the elastic properties of the lungs, on exhalation, the alveoli collapse, and on inhalation, their disintegration. The consequences of such damage to the lungs can be alveolitis, necrotizing bronchiolitis and other pneumopathies.

Biotrauma is damage to the lungs caused by increased production of systemic inflammatory response factors. Biotrauma can occur with sepsis, disseminated intravascular coagulation, traumatic shock, prolonged compression syndrome and other severe conditions. The release of these substances damages not only the lungs, but becomes the cause of multiple organ failure.

Radiation damage to the lungs

Radiation damage to the lungs proceeds as pneumonia (pulmonitis) with the subsequent development of post-radiation pulmonary fibrosis and pneumosclerosis. Depending on the period of development, it can be early (up to 3 months after the start of radiation treatment) and late (after 3 months and later).

Radiation pneumonia is characterized by fever, weakness, expiratory dyspnea of varying severity, and cough. Complaints of chest pain associated with forced inhalation are typical. Radiation damage to the lungs should be differentiated from metastases to the lung, bacterial pneumonia, fungal pneumonia, tuberculosis.

Depending on the severity of respiratory disorders, there are 4 degrees of severity of radiation damage to the lungs:

1 - worried about a small dry cough or shortness of breath on exertion;

2 - worried about a constant hacking cough, for the relief of which the use of antitussive drugs is required; shortness of breath occurs with light exertion;

3 - worried about a debilitating cough that is not relieved by antitussive drugs, shortness of breath is expressed at rest, the patient needs periodic oxygen support and the use of glucocorticosteroids;

4 - severe respiratory failure develops, requiring constant oxygen therapy or mechanical ventilation.

Diagnosis of lung injury

External signs of injury may indicate probable damage to the lung: the presence of hematomas, wounds in the chest area, external bleeding, air suction through the wound canal, etc. Physical data vary depending on the type of injury, however, the weakening of breathing on the side of the affected lung is most often determined ...

For a correct assessment of the nature of the damage, a chest X-ray in two projections is required. X-ray examination reveals displacement of the mediastinum and collapse of the lung (with hemo- and pneumothorax), spotty focal shadows and atelectasis (with bruises of the lung), pneumathocele (with rupture of small bronchi), emphysema of the mediastinum (with rupture of large bronchi) and other characteristic signs of various injuries lungs. If the patient's condition and technical capabilities allow, it is desirable to clarify the X-ray data using computed tomography.

Conducting bronchoscopy is especially informative for the detection and localization of bronchial rupture, detection of a source of bleeding, a foreign body, etc. When receiving data indicating the presence of air or blood in the pleural cavity (based on the results of lung fluoroscopy, ultrasound of the pleural cavity), a therapeutic and diagnostic pleural puncture. With concomitant injuries, additional studies are often required: plain radiography of the abdominal organs, ribs, sternum, fluoroscopy of the esophagus with barium suspension, etc.

In the case of an unspecified nature and extent of lung damage, they resort to diagnostic thoracoscopy, mediastinoscopy or thoracotomy. At the stage of diagnosis, a patient with lung injury should be examined by a thoracic surgeon and a traumatologist.

Treatment and prognosis of lung injury

Tactical approaches to the treatment of lung injuries depend on the type and nature of the injury, concomitant injuries, and the severity of respiratory and hemodynamic disorders. In all cases, patients need to be hospitalized in a specialized department for a comprehensive examination and follow-up. In order to eliminate the phenomena of respiratory failure, the patient is shown the supply of humidified oxygen; with pronounced disorders of gas exchange, the transition to mechanical ventilation is carried out. If necessary, anti-shock therapy is performed, blood loss replenishment (transfusion of blood substitutes, blood transfusion).

In case of bruises of the lungs, conservative treatment is usually limited: adequate anesthesia is performed (analgesics, alcohol-novocaine blockades), bronchoscopic sanitation of the airways to remove sputum and blood, breathing exercises are recommended. In order to prevent suppurative complications, antibiotic therapy is prescribed. For the speedy resorption of ecchymosis and hematomas, physiotherapeutic methods of exposure are used.

In the case of lung injury, accompanied by the occurrence of hemopneumothorax, the first priority is to aspirate air / blood and expand the lung through therapeutic thoracocentesis or drainage of the pleural cavity. If the bronchi and large vessels are damaged, and the collapse of the lung persists, thoracotomy with revision of the chest cavity organs is indicated. The further scope of intervention depends on the nature of the damage to the lung. Superficial wounds located on the periphery of the lung can be sutured. If extensive destruction and crushing of the lung tissue is detected, resection is performed within healthy tissues (wedge resection, segmentectomy, lobectomy, pulmonectomy). In case of bronchial rupture, both reconstructive and resection interventions are possible.

The prognosis is determined by the nature of the damage to the lung tissue, the timeliness of emergency care and the adequacy of subsequent therapy. In uncomplicated cases, the outcome is most often favorable. The factors aggravating the prognosis are open lung injuries, concomitant trauma, massive blood loss, and infectious complications.

Often, injuries and various kinds of injuries to the thoracic region mean a fracture of the ribs, in addition, the most important organs of the human body (heart, lungs, main blood vessels) are injured. When providing first aid to the victim, do not forget to determine if there are breathing disorders that are extremely dangerous to human life. It is this consequence that is most typical for the type of injury under consideration.

Effects

There are several of the most dangerous consequences of chest injuries:

Pneumothorax (accumulation of a large amount of air in the pleural cavity).
Hemothorax (blood entering the pleural cavity).
Mediastinal emphysema (begins to press on large veins).
Traumatic suffocation.
Heart contusion.
Cardiac tamponade (accumulation of blood in the pericardium as a result of its damage by fragments of the ribs).

Types of injury

Types of damage:

thoracic injuries (injuries can be open and closed);
lung damage;
injuries characterized by increased complexity (this can be a rupture of the bronchi or diaphragm, dysfunction of the heart muscle).

These types of chest injuries can be inflicted with a knife or other weapon. Stab wounds often occur during fights and various domestic quarrels, stab wounds can also occur through negligence and during road accidents, emergencies and various natural and man-made disasters.

Injuries received by a person from firearms mainly occur during hostilities, demonstrations, pickets, as well as during fights, shootings and quarrels. These wounds can be inflicted on the human body by a bullet, automatic or machine-gun burst, shrapnel or shot. And also during the explosion of mines, grenades and the use of explosive cluster shells.

Depending on the weapon used, they are divided into through, blind and tangential wounds. The first wounds have two holes - into which the damaging object entered, and the second hole from where this object exited. The second type of wounds has only an entrance hole, there is no exit hole.

Characteristics of injuries

Chest wounds can be tangentially inflicted, then only soft tissues are damaged. With a penetrating wound, the bones of the chest can be broken, the area around the lungs is disturbed, and the lungs are damaged. As a result of an injury inflicted by a knife, the integrity of soft tissues is mainly destroyed and blood vessels are damaged, the bones remain intact. If the wound is received after the use of any of the types of weapons, not only soft tissues and blood vessels are destroyed, but bones are broken, and the broken bones under the force of a shot after them break and tear the internal organs and bones of the chest.

Stab wounds

Injuries caused by sharp stabbing and cutting objects are accompanied by the following damage to organs, soft tissues and blood vessels. In many cases, a penetrating injury damages the lungs, causing air to enter or bleeding.

Bleeding can be caused by ruptured internal intercostal and other arteries that are located in the chest. As a result of this bleeding, a person's respiratory function and heart function deteriorate. In the event that air has entered the lungs, but there is no bleeding, all necessary medical methods must be taken. After a few days, the air will be able to escape from the lungs.

Injury in the region of the heart

In addition to soft tissues, arteries and blood vessels, the wound can affect both the lining of the heart and the organ itself. very serious, as it can lead to a stop of this organ, as a result of which the person dies.

Basically, as a result of injury to an organ such as the heart, the atrium or ventricles are damaged, in rare cases, only the membrane of the organ is damaged. The wound is very dangerous due to bleeding in the form of a fountain, and blood also fills nearby organs.

Gunshot wounds

With a gunshot wound to the chest, the damage is more serious, as it entails rupture of tissues, tendons, bones, blood vessels and arteries. In addition to the charging substance itself, which gets into the wound, pieces of clothing and other foreign objects are also involved in it. With such an injury, in addition to the organs that are in the chest, the organs in the abdominal region of the human body may also be damaged.

The locality of the wound depends on the type of weapon used, the angle and distance from which the shot is fired. If fired from above, the bullet can enter the stomach through the respiratory tract. Depending on the power and caliber of bullets or projectiles in the body, the liver, kidneys and other internal organs can also be damaged.

Since breathing is impaired, a person does not feel well due to a lack of oxygen in the blood. In addition, there is pain, a violation of the heartbeat. Blood emerges from the wound, as if filled with oxygen, in the form of foam. This means that the lungs are damaged, and the wounded can also show blood in the saliva. Or bleeding from the mouth and from the wound at the same time. In case of heart injury, the person has an altered complexion, sweating increases on the body. People with this type of injury are in shock, often they are admitted to the hospital unconscious. When checking the pulse, the result is barely perceptible. In the case of a bullet wound, blood pressure is greatly reduced.

Visually, if the heart is damaged, an enlarged area can be seen on the chest in the region of the heart. If during a shot a bullet hits the liver, blood vessels or spleen, blood from these organs fills all the empty space and all organs inside the abdominal part of the body.

Symptoms

The chest, despite its rigid structure, is more likely to be traumatized than any other part of the bone skeleton. A careless fall, a sharp blow, illness or an emergency is quite capable of disrupting the integrity of the costal arch and sternum, leading to multiple problems with the respiratory and cardiovascular system.

In order to diagnose the onset of serious failures, you need to know the symptoms of damage to the walls of the sternum:

Pain syndrome that occurs every time you take a deep breath or exhale.
The cough is chest and very violent, with a wheezing sound.
Coughing up blood. If there is internal bleeding and inflammation of internal organs, the cough is quickly supplemented with sputum mixed with blood.
Deformation of the bone corset. If there was a fracture of the arches.
Development of pneumothorax - that is, excessive accumulation of air in the pleural cavity. Its signs are gurgling, whistling, hoarse tones when inhaling or exhaling. The main danger of this condition is the development of acute respiratory failure, asphyxia, atony.
An increase in body temperature up to 38-39 degrees.
Fever.
Lung edema. It is manifested by the appearance of white foam near the mouth in combination with impaired respiratory function, heart palpitations, a decrease or sharp rise in blood pressure, dizziness, weakness, nausea.

First aid

It turns out she is both on the spot and urgently at the nearest medical facility. First aid for a penetrating chest wound must be provided on the spot, if this is not done, medical assistance will already be useless. This is the case when the required amount of oxygen does not enter the body. It is urgent to apply a cotton or gauze swab to the wound site, smearing it with something greasy so that air does not enter the wound. Then you need to put a piece of polyethylene and a bandage on top.

For any type of injury, the patient urgently needs to be delivered to the nearest medical institution.

Saving life

First aid for a penetrating chest wound is to give the patient anesthetic, since such injuries are quite painful. You can apply metamizole sodium, ketorolac, tramadol in a dosage of 1-2 ml. And only medical workers in exceptional cases can give the victim a narcotic analgesic, for example, a 1% solution of promedol. You also need to find how to treat an open wound (hydrogen peroxide, iodine, brilliant green).

If the ribs are broken, the first thing to do is to apply an airtight fixation bandage. If there are wounds, they must be treated, followed by a cellophane applied to the damaged area, and only then a fixing bandage.

For a bruised heart, accompanied by chest pain, low blood pressure and a rapid heartbeat, medications are used to block the pain. As a rule, they are administered intravenously. Transportation of victims is possible only in a supine position with a slightly raised upper body on a stretcher. With cardiac tamponade, transportation is carried out in a semi-sitting position using a stretcher. All victims with chest injuries, without exception, need urgent medical attention. For this, the patient is taken to the nearest surgical department, where doctors stop bleeding, and also use pain relieving drugs and drugs to support heart function. Additionally, oxygen inhalation is used.

In case of cardiac tamponade, a puncture of the pericardium is necessary. From the needle with which the pericardium was pierced, blood begins to run continuously. It is not taken out until the patient is taken to the hospital, where doctors will completely stop the bleeding. Also, during development, the doctor pierces the pleural cavity with a needle, and then removes the air and blood that has accumulated there.

How to transport with chest injury?

The transportation of the victim should be carried out observing certain rules regarding the position in which he is. Thus, the escort must pay particular attention to the posture in which the injured person is transported. Assistance should be provided to bring him to a semi-sitting position with bent knees. Having brought the victim into this position, it is necessary to put a roller under him. Transportation must also be carried out in accordance with the following principles:

efficiency;
safety - it is required to ensure the patency of the victim's airways, ensure gas exchange, as well as the availability of access to the respiratory tract;
sparing attitude - it is not allowed to inflict pain on the victim from injury by not observing the conditions of transportation, as this can lead to a state of shock.

The likelihood of saving the life of a wounded person directly depends on the success of the transportation performed, in particular, on the position occupied. Thus, adherence to the principles of transportation is one of the most important points in rendering to the chest area.

Treatment

Necessary primary care - find how to treat an open wound, applying a bandage with a thick layer of sterile cotton, sheathed with a bandage, the edges should be several centimeters larger than the diameter of the injury. It will also help to stop the flow of air into the tissues with a special plaster.

Before transporting the wounded, anesthetic drugs should be administered:

morphine;
pantopon, etc.

For bullet wounds, shattered parts or severe bruises should be surgically removed. This will help prevent sepsis and further tissue decay.

Treating bruises

In case of severe bruising of the chest, it is necessary to provide the patient with free access to oxygen, to introduce an anesthetic blockade. Regardless of the type of chest injury, an x-ray is required to fully understand the extent of the injury.

Only after that, further treatment is prescribed and a decision is made about whether surgery is necessary. With a mechanical concussion of the chest, the victim experiences a state of shock and problems with spontaneous breathing. In this case, it is required to organize the supply of air by artificial means.

Open wound treatment

In the event of open, lacerated injuries, the bleeding must be stopped, and in injuries of this nature, sutures must not be avoided. If the ribs are broken, the victim's body movements should be limited until an ambulance arrives, as the bone can touch the heart, blood vessels or lungs, which will lead to more serious consequences, such as hemorrhage. In the hospital, the ribs will be fixed in the correct position using a special corset. Radiography should not be neglected as it can reveal the presence of debris that must be surgically removed. Pain relievers such as Novocain are used throughout the healing process (4 to 7 weeks).

If the lungs are injured, the first step is to apply a tight bandage during exhalation. Do not let the victim pass out from blood loss, as this can even lead to death. Further, the wounded person needs artificial respiration, taking measures to treat soft tissues with antiseptic agents to prevent infection and suturing. Later, if the lungs are injured, regular dressings are first of all necessary to avoid the appearance of purulent wounds.

When the lungs are injured, it is necessary to insert some kind of tube into the wound, which is open from 2 sides. This can be a catheter, pen, or some other suitable item that is close at hand. Only you should first disinfect it. This will help the excess air out.

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Bullet wound

Such damage occurs due to a fracture of the ribs and a simultaneous injury to the chest area. The situation is dangerous because there is severe bleeding and pneumothorax of valvular or open type.

These symptoms are dangerous for the life of the victim.

They will cause complications that require urgent surgical intervention.

With subcutaneous emphysema, which is often a consequence of pneumothorax, there is no emergency.

In case of a bullet wound to the lungs, quickly cover the wounded area with a sealing bandage. On top of it they put a large gauze napkin folded many times. It should be sealed with something.

When transporting the victim to a medical facility, he should be given a half-sitting position. If possible, Novocaine is injected locally for anesthesia even before he is taken to the doctor.

If the victim is in a state of shock, his breathing is impaired, then it will be effective to perform a vagosympathetic blockade according to Vishnevsky on the side that was injured.

Penetrating trauma

Penetrating symptoms - bleeding from a wound on the chest, characterized by the formation of bubbles - air passes through the wound.

If the lungs are injured, first of all, it is necessary to perform:

First, you should make sure that there is no foreign object in the wound.
Then you need to press your palm to the damaged area to restrict the flow of air.
In the case when the victim has a through wound, the exit and entry holes in the wound should be closed.

Then you should cover the damaged area with a material that allows air to pass through, and fix it with a bandage or plaster.
The patient should be given a half-sitting position.
Something cold must be applied to the wound site, but before that, attach a gasket.
If there is a foreign body with a knife wound to the lung, then you need to fix it with a roller made from scrap materials. You can fix it with a cloth or plaster.
It is strictly forbidden to independently remove stuck foreign bodies from the wound. After the performed procedures, the patient should be taken to the doctor.

Video

Closed wounds

For a closed type of chest injury, a fracture of the chest bones is characteristic. A closed heart injury is characteristic, there is no open wound in the chest cavity.

This injury is accompanied by traumatic pneumothorax, hemothorax, or hemopneumothorax. With a closed chest injury, the victim develops traumatic subcutaneous emphysema and traumatic asphyxia.

A closed chest injury represents a rib cage injury. The organs in the chest are injured, but the skin remains intact.

Injuries are often the result of one or more blunt force hits or hitting surfaces in a traffic accident. Often, the chest is injured when they fall from a height, during a beating, a sharp one-time or numerous short, or long squeezing of the patient in a crowd of people or rubble.

Closed form

Promedol or analgin should be administered intramuscularly.
Inhalation anesthesia with nitrous oxide and oxygen.
Oxygen therapy for pain relief.
You can use a circular bandage from a plaster or an immobilizing bandage. They must be used when deformations of the rib frame are not visible.
When the condition worsens significantly, shortness of breath increases, and the mediastinum moves to the intact side, there is a need to puncture the pleural cavity. This will help to translate the tense type of pneumothorax into an open one.
Any drugs for the heart are effective. Anti-shock agents can be used.
After the assistance provided, the patient should be taken to a hospital.
It is necessary to transport the patient on the back or on a stretcher. The upper half of the torso should be raised and the victim can be brought to the doctor in a half-sitting position.

What do we have to do

The wound of the lungs is open and closed.

The latter occurs when the chest is squeezed sharply.

It can also arise from a blow with a blunt object or a blast wave.

An open type of injury is accompanied by open pneumothorax, but it can be without it.

Injury of the lungs with a closed injury is determined by the degree of damage. If they are severely injured, bleeding appears and the lung ruptures. Hemothorax and pneumothorax sets in.

An open wound is characterized by a ruptured lung. It is characterized by damage to the chest.

Depending on the characteristics of the damage, different degrees of severity are distinguished. It is not easy to see a small, closed light wound to the chest.

The techniques that can be used to help the victim are varied. Their choice is determined by the severity of the injury.

The main goal is to quickly stop bleeding and restore habitual breathing and cardiac activity. Simultaneously with the treatment of the lungs, the walls of the chest should also be treated.

Causes

Closed damage is a consequence of impact on a hard surface, compression, impact of a blast wave.

The most common circumstances in which people get these injuries are road traffic crashes, unsuccessful falls on the chest or back, blunt force strikes to the chest, or falling under a blockage as a result of collapses.

Open injuries are usually associated with penetrating wounds with a knife, arrow, sharpening, military or hunting weapons, shell fragments.

In addition to traumatic injuries, physical damage, for example, ionizing radiation, is possible. Radiation damage to the lungs usually occurs in patients receiving radiation therapy for cancer of the esophagus, lungs, and breast. Areas of lesion of the lung tissue topographically correspond to the applied irradiation fields.

The damage will be caused by diseases that break the weakened lung tissue by coughing or physical exertion. Sometimes the traumatic agent is foreign bodies of the bronchi, which can cause perforation of the bronchial wall.

Another type of injury that should be mentioned is ventilator-induced lung injury that occurs in patients on IVL. These injuries are caused by oxygen toxicity, volumotrauma, barotrauma, teletrauma, biotrauma.

Diagnostics

External signs of injury: the presence of hematomas, wounds in the chest area, external bleeding, air suction through the wound channel.

Physical data differ depending on the type of injury, more often the weakening of breathing on the side of the affected lung is determined.

For a correct assessment of the nature of the damage, chest radiography in 2 projections is required.

If the patient's condition and technical capabilities allow, it is desirable to clarify the X-ray data using computed tomography.

Conducting bronchoscopy is especially informative for the detection and localization of bronchial rupture, detection of a source of bleeding, a foreign body.

With concomitant injuries, additional studies are often required: plain radiography of the abdominal organs, ribs, sternum, fluoroscopy of the esophagus with barium suspension, etc.

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