To provide first aid you need:

* Correctly assess the nature and severity of the injury.

* Knowing the nature of the injury, take the correct steps to provide first aid.

The bullet, penetrating the body, causes damage to the latter. These injuries have certain differences from other injuries to the body that should be taken into account when providing first aid.

First, the wounds are usually deep and the injuring object is often left inside the body.

Secondly, the wound is often contaminated with tissue fragments, projectiles and bone fragments.

These features of a gunshot wound should be taken into account when providing first aid to the victim.

The severity of the injury should be assessed by:

* the location and type of entrance, the behavior of the victim and other signs.

Wounds to the extremities

The first thing you should pay attention to when providing first aid for injured limbs is the presence of bleeding. If the arteries of the thigh or shoulder are destroyed, death from blood loss can occur within a second. So, if you are wounded in the arm (and the artery is damaged), death from blood loss can occur within 90 seconds, and loss of consciousness within 15 seconds. By the color of the blood we determine whether it is venous or arterial bleeding. Deoxygenated blood dark, and the arterial one is scarlet and comes out of the wound intensely (a fountain of blood from the wound). Bleeding is stopped by applying a pressure bandage, tourniquet, or wound packing. When a tourniquet is applied, venous bleeding stops below the wound, and arterial bleeding stops above the wound. It is not recommended to apply a tourniquet for more than two hours. This time should be enough to deliver the victim to medical institution. For venous bleeding, it is advisable to apply a pressure bandage rather than a tourniquet. A pressure bandage is applied to the wound. Wound tamponade for injuries of the extremities is rarely performed. To pack a wound, you can use a long, narrow object to tightly pack the wound with a sterile bandage. The higher the artery is affected, the faster blood loss occurs. The arteries of the limbs project to inner side hips and shoulders (those areas where the skin is more difficult to tan).

As a result of excessive blood loss, hemorrhagic shock develops. The pain can be so severe that it causes painful shock.

ANTI-SHOCK MEASURES FOR BLOOD LOSS:

1. Immediate stop of bleeding.

2. Giving the victim a body position in which the limbs are slightly elevated.

3. Immediate replenishment of blood deficiency with blood-substituting solutions.

4. Antishock drugs, painkillers.

5. Providing warmth.

6. Call an ambulance.

The second thing to do is possible fractures bones. In case of fractures, the limb must be immobilized. It is better not to try to move the limb at all, because... broken bones have sharp edges that can damage blood vessels, ligaments and muscles. The wound should be covered with a sterile bandage. Self-transportation of the victim is possible.

GUNSHOT WOUND OF THE HEAD

Does not always cause instant death. Approximately 15% of those injured survive. Wounds to the face are usually accompanied by an abundance of blood due to the large number of vessels located in the facial part of the skull. A head injury should be considered a concussion. The victim may lose consciousness due to the raush and show no signs of life, but the brain may not be damaged. If there is a gunshot wound to the head, the victim is laid horizontally and kept at rest. It is better not to touch the head wound (excluding facial wounds) (cover with a sterile napkin), and immediately call an ambulance. If breathing or heart stops, do artificial respiration and cardiac massage. Facial wounds with profuse bleeding: clamp the wound with a sterile swab. Self-transportation is not recommended or must be carried out with all precautions.

GUNSHOT WOUND OF THE SPINE

With spinal injuries, a short-term loss of consciousness may occur. The victim is immobilized (layed down). If there is bleeding, apply a bandage. For head and spine injuries, up to medical assistance limited to immobilizing the victim and stopping possible bleeding. In case of respiratory and cardiac arrest, indirect massage heart and artificial respiration. Self-transportation is not recommended.

GUNSHOT WOUND OF THE NECK

The injury may be complicated by damage to the larynx and spinal injuries, as well as carotid arteries. In the first case, the victim is immobilized, and in the second, the bleeding is immediately stopped. Death from blood loss when the carotid artery is injured can occur within 10-12 seconds. The artery is pinched with your fingers, and the wound is immediately tightly packed with a sterile bandage. Gentle transportation.

GUNSHOT WOUND IN THE CHEST AND ABDOMEN

All organs located in the human body are divided into three sections: the pleural cavity, the abdominal cavity and the pelvic organs. The organs located in the pleural cavity are separated from the organs located in the abdominal cavity by the diaphragm, and the abdominal organs are separated from the pelvic organs by the peritoneum. When internal organs are injured, blood does not always pour out, but accumulates in these cavities. Therefore, it is not always easy to judge whether large arteries and veins are affected by such injuries. Stopping bleeding is difficult. Injuries to the pleural cavity organs may be complicated internal bleeding, pneumothorax, hemothorax or pneumohemothorax.

Pneumothorax is the entry of air through the wound opening into the pleural cavity. Occurs with knife and gunshot wounds to the chest, as well as with open rib fractures. The volume of the chest is limited. When air gets there, it interferes with breathing and heart function because... occupies the volume used by these organs.

Hemothorax is the entry of blood into the pleural cavity. Occurs with knife and gunshot wounds to the chest, as well as with open rib fractures. The volume of the chest is limited. When blood gets there, it interferes with breathing and heart function because... occupies the space used by these organizations. Pneumothorax is the entry of both blood and air into the pleural cavity.

To prevent air from entering the pleural cavity, it is necessary to apply an airtight bandage to the wound - a gauze pad coated with boron ointment or petroleum jelly, a piece of polyethylene, or, in extreme cases, tightly clamp the wound with the palm of your hand. The victim is placed in a semi-sitting position. Stopping bleeding is difficult. Transportation is gentle.

If there is a wound in the heart area, the worst is assumed. External signs, such as rapid (instant) deterioration in the victim’s condition, sallow complexion, and rapid loss of consciousness, help determine whether the heart is injured. It should be noted that death as a result of acute heart failure (when the heart is injured) does not always occur. Sometimes there is a gradual decline in the body’s activity as a result of the pericardium filling with blood and, as a result, difficulty in the functioning of the heart. Assistance in such cases should be provided by a specialist (pericardial drainage, suturing of a cardiac wound), who should be called immediately.

The pericardium is the cavity in which the heart is located. When the heart is injured, blood can enter this cavity and compress the heart, interfering with its normal functioning.

GUNSHOT WOUND OF THE ABDOMINAL CAVITY

For injuries to the abdominal organs, I place the victim in a semi-sitting position. Warning wound infection. In case of severe blood loss - antishock therapy.

Prevention of wound infection:

*disinfect the edges of the wound;

*apply a sterile napkin.

GUNSHOT WOUND OF THE PELVIC ORGANS

Injuries to the pelvic organs can be complicated by fractures of the pelvic bones, ruptures of arteries and veins, and nerve damage. Urgent Care for wounds in the pelvic area - anti-shock measures and prevention of wound infection. When wounded in the gluteal region, profuse bleeding may occur, which is stopped by tight tamponade of the bullet entry hole. For fractures of the pelvic bones and hip joint the victim is immobilized. Gentle transportation. Self-transportation is not advisable.

USEFUL TIPS

When providing first aid, dressing material is always needed. When it is not at hand, you have to use a handkerchief, parts of clothing; but if you find a place to store the gun, then maybe a sterile bag will fit in your pocket. A first aid kit is required in the car. At home, it is advisable to have a first aid kit no worse than a car one. The most necessary thing for blood loss is blood replacement solutions, sold in pharmacies without a prescription along with an intravenous injection machine.

Do not forget that some advice can be obtained over the phone when calling an ambulance. It is better if by the time you call an ambulance you have correctly determined the injury and condition of the victim. Remember that there are often cases when the victim could not be saved due to the fact that, based on the message from those who called the ambulance, the operator sent a doctor of a different profile to the scene of the incident.

In some cases, self-delivery of the victim to the hospital is preferable (faster). City hospitals are on duty on a rotating basis. The address of the duty hospital can be found by calling the ambulance phone. The dispatcher can warn the emergency room of the hospital where you intend to deliver the wounded person about the nature of the injury so that the medical staff can prepare to receive the victim.

HOW TO REMOVE A BULLET

According to statistics, per one inhabitant of the planet there is one and a half Kalashnikov assault rifles, considering that there are 30 rounds in the clip, this is quite enough to fill you with lead like a mincemeat, so if you faint at the sight of blood and, if you pinch your finger, blow on it in the old fashioned way , as in childhood, it’s better to immediately forget about military field surgery.

However, if you are not a timid person, then here we will tell you how to remove a bullet after a gunshot wound (as an option, remove a shell fragment) and about the rules that an improvised operating room must comply with if you really find yourself in the military field conditions, and the infirmary is no longer there, because it was just bombed.

Immediately after injury

Do not rush to immediately pull the foreign object out of the body; a large blood vessel may be hit and severe bleeding will occur after removing the object.

Apply a tourniquet to arterial bleeding (blood bright color and flows like a fountain) above the wound site (the bandage is located between the wound and the heart), and when a vein is wounded, a tight compressive bandage is applied lower along the vessel (the wound is located between the bandage and the heart).

Do not forget that you should not stop the blood supply to the wounded limb for more than 2 hours, after which allow at least 15 minutes for recovery normal operation blood flow, after which the tourniquet can be reapplied (in case of dangerous arterial bleeding).

Provide warmth to the wounded person and place his body in a position in which his arms and legs are above body level.

If a gunshot or shrapnel wound is located in the chest area, there is a possibility of pneumohemothorax, which occurs if blood and air enter the pleural cavity located in the chest. This can be avoided by bandaging the wound with an airtight bandage (an ordinary napkin covered with a layer of Vaseline will also work),

a piece of polyethylene or, if nothing is at hand, simply clamp it with your palm.

You need to have time to tightly clamp the wound on the artery with your fingers and quickly pack it with a sterile bandage. And remember, for the first time you have 10 seconds at most.

Operating room rules

Only a certified surgeon can carry out successful operations in military field conditions, and in extreme situations a person at least somewhat familiar with anatomy, so that when pulling out a bullet in passing, he would not immobilize a limb by accidentally cutting a tendon, or hit an important vessel. Everyone else needs to focus on sterilizing the instruments and ensuring the most comfortable conditions for the surgeon and the patient during the operation.

The most effective tools for conducting operations in the military field conditions - knife and tweezers.

Everything needs to be sterilized, including gauze bandages or a respirator from a surgeon, soak the metal in alcohol and keep it on fire, harden the steel, then put it back in alcohol until the operation itself. A sterile apron and thoroughly washed and soaked hands in alcohol, if you do not have sterile rubber gloves.

How to remove a bullet

Before removing the bullet, check to see if it has gone through. You need to remove the bullet (fragment) as soon as possible, otherwise it will begin to slowly poison the body due to metal oxidation products. The exception is such serious injuries when vital organs, the brain or spinal cord are affected, or there is a possibility that the wounded person may die from blood loss during surgery. This, again, is the case if help does not come soon and all the rules of the operating room in the conditions of military field surgery are followed.

If the wounded person is conscious, then it is necessary to give alcohol as an anesthesia and squeeze something between the teeth so that you do not harm yourself with your teeth and tongue. It is very difficult to pull out a bullet alone; blood will constantly pour into the wound, preventing you from properly seeing the situation. It would be best to take on your “team” an assistant who will suck out the interfering blood, for example with a pre-sterilized enema, not to mention the fact that the responsibility for carrying out such an operation can also be shared with him. Remember, it is the blood that fills the gunshot wound that will VERY hinder the removal of the bullet quickly.

The patient is breathing, the bullet was used as a souvenir, but a huge number of microbes have just been introduced into the wound. You can disinfect it with alcohol, or you can be more extreme - pour gunpowder into the wound and set it on fire. The method is also good because it stops bleeding, but most likely it will lead to suppuration, especially if the wound is deep.

CHAPTER 19 COMBAT INJURY OF THE NECK

CHAPTER 19 COMBAT INJURY OF THE NECK

Combat injuries to the neck include gunshot injuries(bullet, shrapnel wounds, MVR, blast injuries), non-gunshot injuries(open and closed mechanical injuries, non-gunshot wounds) and their various combinations.

For many centuries, the incidence of combat wounds to the neck remained unchanged and amounted to only 1-2%. These statistics were greatly influenced by the high rate of death of those wounded in the neck on the battlefield, which in the pathological profile reached 11-13%. Due to the improvement of personal protective equipment for military personnel (helmets and body armor) and their rapid aeromedical evacuation, the proportion of neck wounds in armed conflicts in recent years amounted to 3-4%.

For the first time in the world, the most complete experience in the treatment of combat wounds of the neck has been summarized N.I. Pirogov during the Crimean War (1853-1856). During the Second World War, domestic ENT specialists ( IN AND. Voyachek, K.L. Khilov, V.F. Undrits, G.G. Kulikovsky) a system and principles of staged treatment of those wounded in the neck were developed. However, due to a restrained attitude towards early surgical interventions, the mortality rate for neck wounds at the advanced stages of medical evacuation exceeded 54% and almost 80% of the wounded developed severe complications.

In local wars and armed conflicts of the second half of the 20th century. The treatment and diagnostic tactics for those wounded in the neck acquired an active character, aimed at quickly and completely eliminating all possible vascular and organ damage (the tactics of mandatory diagnostic revision of internal structures). When this tactic was used during the Vietnam War, the mortality rate for deep neck wounds dropped to 15%. At the present stage, in the treatment of combat wounds of the neck, early specialized care is of great importance, in the provision of which the mortality rate among those wounded in the neck does not exceed 2-6% ( Yu.K. Yanov, G.I. Burenkov, I.M. Samokhvalov, A.A. Zavrazhnov).

19.1. TERMINOLOGY AND CLASSIFICATION OF NECK INJURIES

According to the general principles of classification of combat surgical trauma, there are different isolated, multiple and combined injuries (wounds) of the neck. Isolated called a neck injury (wound) in which there is one damage. Multiple lesions within the cervical region are called multiple injury (wound). Simultaneous damage to the neck and other anatomical areas of the body (head, chest, abdomen, pelvis, thoracic and lumbar spine, limbs) is called combined injury (wound). In cases where a combined neck injury is caused by one RS (most often a combined injury of the head and neck, neck and chest), for a clear idea of ​​the course of the wound channel, it is advisable to highlight cervicocerebral(cervicofacial, cervicocranial) and cervicothoracic injuries.

Gunshot and non-gunshot wounds there are necks superficial, extending no deeper saphenous muscle(m. platis-ma), and deep, spreading deeper than it. Deep wounds, even in the absence of damage to the vessels and organs of the neck, can have a severe course and end in the development of severe IOs.

Within the cervical region, soft tissue and internal structures may be damaged. TO internal structures of the neck include main and secondary vessels (carotid arteries and their branches, vertebral artery, internal and external jugular veins, subclavian vessels and their branches), hollow organs (larynx, trachea, pharynx, esophagus), parenchymal organs ( thyroid, salivary glands), cervical spine and spinal cord, peripheral nerves (vagus and phrenic nerves, sympathetic trunk, roots of the cervical and brachial plexuses), hyoid bone, thoracic lymphatic duct. For the morphological and nosological characteristics of injuries to the internal structures of the neck, private classifications are used (Chapters 15, 18, 19, 23).

Based on the nature of the wound channel, neck injuries are divided into blind, through (segmental, diametrical, transcervical- passing through the sagittal plane of the neck ) and tangents (tangential)(Fig. 19.1).

It is also necessary to take into account the localization of the wound channel relative to those proposed by N.I. Pirogov three neck zones(Fig. 19.2).

Rice. 19.1. Classification of neck wounds according to the nature of the wound channel:

1 - blind superficial; 2 - blind deep; 3 - tangent; 4 - through

segmental; 5 - through diametrical; 6 - through transcervical

Rice. 19.2. Neck areas

Zone I , often referred to as the superior opening of the chest, is located below the cricoid cartilage to the lower border of the neck. Zone II located in the middle part of the neck and extends from the cricoid cartilage to the line connecting the angles lower jaw. Zone III located above the angles of the lower jaw to upper limit neck. The need for such a division is due to the following provisions, which have a significant impact on the choice surgical tactics: firstly, a significant difference between the zonal localization of wounds and the frequency of damage to the internal structures of the neck; secondly, the fundamental difference in methods for diagnosing the extent of damage and operational access to the vessels and organs of the neck in these areas.

More than 1/4 of all neck wounds are accompanied by the development life-threatening consequences (continuing external and oropharyngeal bleeding, asphyxia, acute cerebral circulation, air embolism, ascending edema of the brainstem), which can lead to fatal outcome in the first minutes after injury.

All of the given sections of the classification of gunshot and non-gunshot wounds of the neck (Table 19.1) serve not only for the correct diagnosis, but are also decisive in the choice of rational treatment and diagnostic tactics (especially the sections that describe the nature of the wound, the location and nature of the wound canal).

Mechanical injuries necks occur due to a direct impact on the neck area (impact with a blunt object), during sharp hyperextension and rotation of the neck (exposure to a shock wave, a fall from a height, an explosion in armored vehicles) or strangulation (during hand-to-hand combat). Depending on the condition of the skin, mechanical injuries to the neck can be closed(with integrity skin) And open(with the formation of gaping wounds). Most often, mechanical neck injuries are accompanied by damage cervical region spine and spinal cord (75-85%). Closed injuries of the larynx and trachea are less common (10-15%), which in half of the cases are accompanied by the development of dislocation and stenotic asphyxia. Contusions of the main arteries of the neck may occur (3-5%), leading to their thrombosis with subsequent acute cerebrovascular accident, as well as traction injuries peripheral nerves(roots of the cervical and brachial plexuses) - 2-3%. IN isolated cases With closed neck injuries, ruptures of the pharynx and esophagus occur.

Table 19.1. Classification of gunshot and non-gunshot wounds of the neck

Examples of diagnoses of wounds and neck injuries:

1. Bullet tangential superficial wound of the soft tissues of the first zone of the neck on the left.

2. Shrapnel blind deep wound of soft tissues of zone II of the neck on the right.

3. Bullet through segmental wound of zones I and II of the neck on the left with damage to the common carotid artery and internal jugular vein. Continued external bleeding. Acute massive blood loss. Traumatic shock of the second degree.

4. Shrapnel multiple superficial and deep wounds of zones II and III of the neck with a penetrating wound of the hypopharynx. Continued oropharyngeal bleeding. Aspiration asphyxia. Acute blood loss. Traumatic shock of the first degree. ODN II-III degree.

5. Closed injury neck with damage to the larynx. Dislocation and stenotic asphyxia. ARF II degree.

19.2. CLINICAL AND GENERAL PRINCIPLES OF DIAGNOSIS OF NECK INJURIES

The clinical picture of wounds and mechanical trauma to the neck depends on the presence or absence of damage to internal structures.

Damage only soft tissues of the neck observed in 60-75% of cases of combat neck trauma. As a rule, they are represented by blind superficial and deep shrapnel wounds (Fig. 19.3 color and illustration), tangential and segmental bullet wounds, superficial wounds and bruises due to mechanical trauma. Soft tissue injuries are characterized by a satisfactory general condition of the wounded. Local changes are manifested by swelling, muscle tension and pain in the wound area or at the site of impact. In some cases, mild external bleeding is observed from neck wounds or a relaxed hematoma is formed along the wound canal. It should be remembered that with superficial gunshot wounds (usually tangential bullet wounds), due to the energy of the side impact, damage to the internal structures of the neck can occur, which at first do not have any clinical manifestations and are diagnosed already against the background of the development of severe complications ( acute disorder cerebral circulation with contusion and thrombosis of the common or internal carotid arteries, tetraparesis with contusion and ascending swelling of the cervical segments of the spinal cord, stenotic asphyxia with contusion and swelling of the subglottic space of the larynx).

Clinical picture damage to the internal structures of the neck determined by which vessels and organs are damaged, or a combination of these damages. Most often (in 70-80% of cases), internal structures are damaged when the second zone of the neck is injured, especially with a through diametrical (in 60-70% of cases) and through transcervical (in 90-95% of cases) course of the wound canal. In 1/3 of the wounded, damage to two or more internal structures of the neck occurs.

For damage great vessels of the neck characterized by intense external bleeding, a neck wound in the projection of the vascular bundle, a tense interstitial hematoma and general clinical signs of blood loss (hemorrhagic shock). Vascular injuries in cervicothoracic wounds in 15-18% of cases are accompanied by the formation of a mediastinal hematoma or total hemorrhage. When auscultating hematomas in the neck, vascular sounds can be heard, which indicate the formation of an arteriovenous anastomosis or false aneurysm. Quite specific signs of damage to the common and internal carotid arteries are contralateral hemiparesis, aphasia and Claude Bernard-Horner syndrome. When the subclavian arteries are injured, there is an absence or weakening of the pulse in the radial arteries.

Main physical symptoms of injury hollow organs (larynx, trachea, pharynx and esophagus) are dysphagia, dysphonia, dyspnea, release of air (saliva, drunk liquid) through a neck wound, widespread or limited subcutaneous emphysema of the neck area and asphyxia. Every second wounded person with such injuries also experiences oropharyngeal bleeding, hemoptysis or spitting of blood. In more late dates(on the 2-3rd day), penetrating injuries to the hollow organs of the neck are manifested by symptoms of severe wound infection (cellulitis of the neck and mediastinitis).

In case of injury cervical spine and spinal cord tetraplegia (Brown-Séquard syndrome) and leakage of cerebrospinal fluid from the wound are most often observed. Damage neck nerves can be suspected by the presence of partial motor and sensory disorders of the upper extremities ( brachial plexus), paresis of the facial muscles (facial nerve) and vocal cords(vagus or recurrent nerve).

Injuries thyroid gland characterized by intense external bleeding or the formation of a tense hematoma, salivary (submandibular and parotid) glands- bleeding

and accumulation of saliva in the wound. In case of damage, lymphorrhea from the wound or the formation of chylothorax (with cervicothoracic wounds) is observed, which appear on the 2-3rd day.

Clinical diagnosis of injuries to blood vessels and organs of the neck is not difficult when there are reliable signs damage to internal structures : ongoing external or oropharyngeal bleeding, increasing interstitial hematoma, vascular murmurs, release of air, saliva or cerebrospinal fluid from the wound, Brown-Séquard palsy. These signs occur in no more than 30% of the wounded and are absolute indication to perform emergency and urgent surgical interventions. The rest of the wounded, even with complete absence any clinical manifestations of injuries to internal structures, a complex of additional (radiological and endoscopic) research.

Among the radiological diagnostic methods, the simplest and most accessible is X-ray of the neck in frontal and lateral projections. Radiographs may reveal foreign bodies, emphysema of the perivisceral spaces, fractures of the vertebrae, hyoid bone, and laryngeal (especially calcified) cartilages. Used to diagnose injuries to the pharynx and esophagus oral contrast fluoroscopy (radiography), but heavy and extremely serious condition Most people wounded in the neck cannot use this method. Angiography through a catheter inserted into the aortic arch using the Seldinger method, is the “gold standard” in diagnosing damage to the four main arteries of the neck and their main branches. If appropriate equipment is available, angiography can perform endovascular control of bleeding from the vertebral artery and distal branches of the external carotid artery, which are difficult to access for open intervention. It has undeniable advantages in the study of neck vessels (speed, high resolution and information content, and most importantly - minimally invasiveness). spiral CT (SCT) with angiocontrast. The main symptoms of vascular injury on SC tomograms are extravasation of contrast, thrombosis of a separate section of the vessel or its compression by a paravasal hematoma, and the formation of an arteriovenous fistula (Fig. 19.4).

In case of injuries to the hollow organs of the neck, on SC tomograms one can see gas stratifying the periviscal tissues, swelling and thickening of their mucosa, deformation and narrowing of the air column.

Rice. 19.4. SCT with angiocontrast in a wounded person with marginal damage to the common carotid artery and internal jugular vein: 1 - displacement of the esophagus and larynx by interstitial hematoma; 2 - formation of a hematoma in the prevertebral space; 3 - arteriovenous fistula

More specific methods for diagnosing injuries to the hollow organs of the neck are endoscopic examinations. At direct pharyngolaryngoscopy(which can be performed with a laryngoscope or a simple spatula) an absolute sign of a penetrating wound to the pharynx or larynx is a visible wound to the mucous membrane, indirect signs- accumulation of blood in the hypopharynx or increasing supraglottic edema. Similar symptoms of damage to the hollow organs of the neck are detected during fibrolaryngotracheo- And fibropharyngoesophagoscopy.

They are also used to study the condition of soft tissues, great vessels, and the spinal cord. nuclear MRI, Ultrasound scanning and Dopplerography. To diagnose the depth and direction of the wound channel of the neck, only in an operating room (due to the risk of resumption of bleeding) can a examination of the wound with a probe.

It should be noted that most of the above diagnostic methods can only be performed at the stage of providing agricultural products . This

This circumstance is one of the reasons for the use of diagnostic surgery in those wounded in the neck - audits of internal structures. Modern experience in providing surgical care in local wars and armed conflicts shows that a diagnostic revision is mandatory for all deep blind, through diametrical and transcervical wounds of zone II of the neck, even if the results of instrumental examination are negative. For wounded patients with wounds localized in zones I and/or III of the neck without clinical symptoms of damage to vascular and organ formations, it is advisable to undergo X-ray and endoscopic diagnosis, and operate on them only after identifying instrumental signs of damage to internal structures. The rationality of this approach in the treatment of combat wounds of the neck is due to for the following reasons: due to the relatively greater anatomical extent and low protection of the II zone of the neck, its injuries occur 2-2.5 times more often than injuries to other zones. At the same time, damage to the internal structures of the neck with wounds in zone II is observed 3-3.5 times more often than in zones I and III; typical quick access for revision and surgical intervention on vessels and organs of zone II of the neck, it is low-traumatic, rarely accompanied by significant technical difficulties and does not take much time. Diagnostic examination of the internal structures of the neck is performed in compliance with all the rules of surgical intervention: in an equipped operating room, under general anesthesia(endotracheal intubation anesthesia), with the participation of full-fledged surgical (at least two-medical) and anesthesiological teams. It is usually performed from an approach along the inner edge of the sternocleidomastoid muscle on the side of the wound location (Fig. 19.5). In this case, the wounded person is placed on his back with a bolster under his shoulder blades, and his head is turned in the direction opposite to the side of the surgical intervention.

If a contralateral injury is suspected during the operation, then a similar approach can be performed on the opposite side.

Despite a large number of negative results diagnostic revision of the internal structures of the neck (up to 57%), this surgical intervention allows in almost all cases to make a timely accurate diagnosis and avoid serious complications.

Rice. 19.5. Access for diagnostic inspection of internal structures in zone II of the neck

19.3 GENERAL PRINCIPLES OF TREATMENT OF NECK INJURIES

When providing assistance to those wounded in the neck, it is necessary to solve the following main tasks:

Eliminate life-threatening consequences of injury (trauma)

Necks; restore the anatomical integrity of damaged internal structures; prevent possible (infectious and non-infectious) complications and create optimal conditions for wound healing. Life-threatening consequences of the wound (asphyxia, ongoing external or oropharyngeal bleeding, etc.) are observed in every fourth person wounded in the neck. Their treatment is based on emergency manipulations and operations that are performed without

preoperative preparation, often without anesthesia and in parallel with resuscitation measures. Elimination of asphyxia and restoration of patency of the upper respiratory tract is performed by the most accessible methods: tracheal intubation, typical tracheostomy, atypical tracheostomy (conicotomy, insertion of an endotracheal tube through a gaping wound of the larynx or trachea). Stopping external bleeding is initially done by temporary methods (by inserting a finger into the wound, tightly tamponade the wound with a gauze pad or a Foley catheter), and then typical accesses to the damaged vessels are performed with final hemostasis carried out by ligating them or performing a reconstructive operation (vascular suture, vascular plasty).

To access the vessels of zone II of the neck (carotid arteries, branches of the external carotid and subclavian arteries, internal jugular vein), a wide incision is used along the medial edge of the sternocleidomastoid muscle on the side of the injury (Fig. 19.5). Access to the vessels of the first zone of the neck (brachiocephalic trunk, subclavian vessels, proximal part of the left common carotid artery) is provided by combined, rather traumatic incisions with sawing of the clavicle, sternotomy or thoracosternotomy. Access to vessels located close to the base of the skull (in zone III of the neck) is achieved by dividing the sternocleidomastoid muscle in front of its attachment to the mastoid process and/or dislocating the temporomandibular joint and shifting the mandible anteriorly.

In patients wounded in the neck without life-threatening consequences of injury, surgical intervention on internal structures is performed only after preoperative preparation (tracheal intubation and mechanical ventilation, replenishment of the blood volume, insertion of a probe into the stomach, etc.). As a rule, access is used along the inner edge of the sternocleidomastoid muscle on the side of the injury, which allows for inspection of all the main vessels and organs of the neck. In case of combined injuries (traumas), the fundamental principle is the hierarchy of surgical interventions in accordance with the dominant injury.

To restore the integrity of damaged internal structures of the neck, the following types of surgical interventions are used.

Great vessels of the neck restored with a lateral or circular vascular suture. For incomplete marginal defects of the vascular wall, an autovenous patch is used, for complete extensive defects, autovenous plasty is used. For the prevention of ischemic

brain damage that can occur during the period of restoration of the carotid arteries (especially with an open circle of Willis), intraoperative temporary prosthetics are used. Restoration of the common and internal carotid arteries is contraindicated in cases where there is no retrograde blood flow through them (a sign of thrombosis of the distal bed of the internal carotid artery).

Without any functional consequences, unilateral or bilateral ligation of the external carotid arteries and their branches, unilateral ligation of the vertebral artery and internal jugular vein are possible. Ligation of the common or internal carotid arteries is accompanied by 40-60% mortality, and half of the surviving wounded develop a persistent neurological deficit.

In the absence of acute massive blood loss, extensive traumatic necrosis and signs of wound infection, wound pharynx and esophagus must be sutured with a double-row suture. It is advisable to cover the suture line with adjacent soft tissues (muscles, fascia). Restorative interventions necessarily end with the installation of tubular (preferably double-lumen) drainages and the insertion of a probe into the stomach through the nose or pyriform sinus of the pharynx. The primary suture of hollow organs is contraindicated in the development of neck phlegmon and media astinitis. In such cases, the following is performed: VChO of neck wounds from wide incisions using large-volume anti-inflammatory blockades; the area of ​​the wound channel and the mediastinal tissue are drained with wide double-lumen tubes; gastrostomy or jejunostomy is performed to provide enteral nutrition; small wounds of hollow organs (up to 1 cm in length) are loosely packed with ointment turundas, and in cases of extensive wounds of the esophagus (wall defect, incomplete and complete intersection) - its proximal section is removed in the form of an end esophagostomy, and the distal section is sutured tightly.

Small wounds (up to 0.5 cm) larynx and trachea may not be sutured and treated by draining the damaged area. Extensive laryngotracheal wounds undergo economical primary surgical treatment with restoration of the anatomical structure of the damaged organ on T-shaped or linear stents. The issue of performing tracheostomy, laryngeal or tracheopexy is decided individually, depending on the extent of laryngotracheal damage, the condition of the surrounding tissues and the prospects for rapid restoration of spontaneous breathing. If there are no conditions for early reconstruction of the larynx, tracheostomy is performed

level of 3-4 tracheal rings, and the operation ends with the formation of a laryngofissura by suturing the edges of the skin and walls of the larynx with tamponade of its cavity according to Mikulicz.

Wounds thyroid gland sutured with hemostatic sutures. The crushed areas are resected or a hemistrumectomy is performed. For gunshot wounds submandibular salivary gland, in order to avoid the formation of salivary fistulas, it is better to completely remove it.

Damage thoracic lymphatic duct on the neck are usually treated by bandaging it in the wound. Complications during dressing, as a rule, are not observed.

The basis for the prevention of complications and the creation of optimal conditions for wound healing from combat wounds of the neck is surgery - PHO. In relation to neck injuries, PCO has a number of features arising from the pathomorphology of the injury and the anatomical structure of the cervical region. Firstly, it can be performed as an independent dissection operation - excision of non-viable tissue (with clinical and instrumental exclusion of all possible organ and vascular damage, i.e. when only soft tissues of the neck are injured). Secondly, include both surgical intervention on damaged vessels and organs of the neck , so diagnostic audit internal structures of the neck.

By doing PHO wounds s soft tissues of the neck, its stages are as follows:

Rational dissection of the wound canal openings for healing (formation of a thin skin scar);

Removal of superficially located and easily accessible foreign bodies;

Due to the presence of important anatomical formations (vessels, nerves) in a limited area - careful and economical excision of non-viable tissue;

Optimal drainage of the wound channel.

Good blood supply to the cervical region, the absence of signs of wound infection and the possibility of subsequent treatment within the walls of one medical institution make it possible to complete the postsurgical treatment of neck wounds by applying a primary suture to the skin. In such wounded patients, drainage of all formed pockets is performed using tubular, preferably double-lumen, drainages. Subsequently, fractional (at least 2 times a day) or constant (like inflow)

ebb drainage) washing the wound cavity with an antiseptic solution for 2-5 days. If, after PSO of neck wounds, extensive tissue defects are formed, then the vessels and organs gaping in them are (if possible) covered with intact muscles, gauze napkins soaked in water-soluble ointment are inserted into the resulting cavities and pockets, and the skin over the napkins is brought together with rare sutures. Subsequently, the following can be performed: repeated PSO, application of primary delayed or secondary (early and late) sutures, incl. and skin grafting.

Surgical tactics in relation to foreign bodies in the neck is based on the “quaternary scheme” of V.I. Voyachek (1946). All foreign bodies of the neck are divided into easily accessible and difficult to access, and according to the reaction they cause - into those that cause any disorders and those that do not cause them. Depending on the combination of topography and pathomorphology of foreign bodies, four approaches to their removal are possible.

1. Easily accessible and causing disorders - removal is mandatory during the primary surgical intervention.

2. Easily accessible and not causing disturbances - removal is indicated in favorable conditions or with the persistent desire of the wounded.

3. Difficult to reach and accompanied by disorders of the corresponding functions - removal is indicated, but with extreme caution, by a qualified specialist and in a specialized hospital.

4. Difficult to reach and not causing problems - surgery is either contraindicated or is performed when there is a threat of severe complications.

19.4. ASSISTANCE AT THE STAGES OF MEDICAL EVACUATION

First aid. Asphyxia is eliminated by cleaning the mouth and pharynx with a napkin, introducing an air duct (breathing tube TD-10) and placing the wounded in a fixed position “on the side” on the side of the wound. External bleeding is initially stopped by digital pressure on the vessel in the wound. Then a pressure bandage is applied with counter support across the arm (Fig. 19.6 color illustration). When wounded

The cervical spine is immobilized with a collar bandage with a large amount of cotton wool around the neck. An aseptic bandage is applied to the wounds. For the purpose of pain relief, an analgesic (Promedol 2% -1.0) is injected intramuscularly from a syringe tube.

First aid. Elimination of asphyxia is carried out using the same methods as when providing first aid. In cases of development of obstructive and valvular asphyxia, the paramedic performs a conicotomy or a tracheostomy cannula is inserted into their lumen through a gaping wound of the larynx or trachea. If necessary, mechanical ventilation is performed using a manual breathing apparatus and oxygen is inhaled. If external bleeding continues, a tight tamponade of the wound is performed, a pressure bandage is applied with counter support through the arm or a ladder splint (Fig. 19.7 color illustration). Injured patients with signs of severe blood loss are given intravenous administration of plasma-substituting solutions (400 ml of 0.9% sodium chloride solution or other crystalloid solutions).

First aid. In armed conflict First medical aid is considered as pre-evacuation preparation for aeromedical evacuation of seriously wounded people in the neck directly to the 1st echelon MVG for the provision of early specialized surgical care. In a large scale war After first medical aid is provided, all the wounded are evacuated to the medical hospital (omedo).

In emergency first aid measures wounded with life-threatening consequences of a neck injury (asphyxia, ongoing external or oropharyngeal bleeding) are needed. In a dressing room, they urgently perform: in case of breathing problems - tracheal intubation (in case of stenotic asphyxia), atypical (Fig. 19.8 color illustration) or typical tracheostomy (in cases of development of obstructive or valvular asphyxia), sanitation of the tracheobronchial tree and giving a fixed position “on the side” on the side of the wound (with aspiration asphyxia); in case of external bleeding from the vessels of the neck, apply a pressure bandage with counter support through the arm or a ladder splint, or tight tamponade of the wound according to Beer (with suturing of the skin over the tampon). In case of oropharyngeal bleeding, after tracheostomy or tracheal intubation, a tight tamponade of the oropharyngeal cavity is performed;

For all deep neck wounds - transport immobilization of the neck with a Chance collar or Bashmanov splint (see Chapter 15) in order to prevent resumption of bleeding and/or aggravation of severity possible damage cervical spine; in cases of traumatic shock - infusion of plasma-substituting solutions, use of glucocorticoid hormones and analgesics; in case of combined injuries with damage to other areas of the body - elimination of open or tension pneumothorax, stopping external bleeding of another location and transport immobilization for fractures of the pelvic bones or limbs. Wounded with signs of damage to the internal structures of the neck, but without life-threatening consequences of injury need priority evacuation to provide specialized surgical care for emergency indications. First aid measures for such wounded people are carried out in a triage tent and consist of correcting loose bandages, immobilizing the neck, administering analgesics, antibiotics and tetanus toxoid. With the development of shock and blood loss, without delaying the evacuation of the wounded, intravenous administration of plasma-substituting solutions is established.

The rest were wounded in the neck first medical aid is provided in order in the triage room with evacuation in the 2nd-3rd stage (stray bandages are corrected, analgesics, antibiotics and tetanus toxoid are administered).

Qualified health care. In armed conflict with established aeromedical evacuation, the wounded from medical companies are sent directly to the 1st echelon MVG. When delivering those wounded in the neck to the Omedb (Omedo SpN), they perform pre-evacuation preparation in the scope of first medical aid. Qualified surgical care appears only according to vital indications and in volume the first stage of programmed multi-stage treatment tactics- “damage control” (see Chapter 10). Asphyxia is eliminated by tracheal intubation, performing a typical (Fig. 19.9 color illustration) or atypical tracheostomy. A temporary or permanent stop of bleeding is carried out by applying a vascular suture, ligating a vessel or tight tamponade of the damaged area, or temporary prosthetics of the carotid arteries (Fig. 19.10 color illustration). Further infection of the soft tissues of the neck with the contents of hollow organs

Nature of the gunshot wound depends not only on the type of wounding projectile, but also on the anatomical and physiological characteristics of the face.
Let's consider the positive and negative sides these features.
Damage to the rich vascular network of the face is accompanied by severe bleeding, which in some cases can lead to the development of hemorrhagic shock. The passage of a wounding projectile near a large vessel causes it to vibrate along with the walls of the temporary pulsating cavity created by the wounding projectile. A very powerful shock wave of blood occurs inside the vessel. Spreading upward, it strikes the substance of the brain from the inside, which forms a picture of a brain contusion with all the ensuing consequences.

On the other hand, a rich blood supply is an excellent microcirculatory network, which ensures a high rate of complete reparative tissue regeneration. This cannot be explained only by the good saturation of the tissues with the necessary nutrients and oxygen for existing cells, supplying excess plastic material and energy sources for wound healing. Fabric builders needed. There is a direct relationship between the number of small vessels, the rate and quality of regeneration. The fact is that along these vessels there are inconspicuous, very elongated, spindle-shaped cells, the purpose of which is very for a long time remained unclear, and only relatively recently their role became known. After this, it became possible to scientifically substantiate the high regenerative potency of facial tissues in comparison with tissues of other areas of the body, with the possible exception of the genital organs.

These poorly differentiated cells are called pericytes, perivascular, pericapillary, adventitial, pluripotent, pluripotent cells, progenitor cells. Under the influence of morphogenetic proteins of destroyed tissues, progenitor cells undergo certain changes and through a series of transitional forms are transformed, depending on the situation in the wound (type of tissue, pO2 in the tissue, etc.) into fibro-, chondro- or osteoblasts. These skeletogenic cells take an active part in the healing of soft and bone tissue wounds.
It should be noted not only the rich microcirculatory network, but also the ability of the facial vascular network to quickly activate collaterals (reserve vessels), usually not involved in blood circulation and opening only in stressful situations. This feature was noted by surgeons of the last century. This explains the sometimes continued bleeding from a facial wound even after ligation of the external carotid artery, as well as the occurrence of repeated bleeding 4-5 days after ligation of the great vessels, i.e. when the organization of a blood clot in the damaged vessel has not yet completed.
The rich and varied innervation of the face also has two sides. The destruction of large areas of tissue is accompanied by damage to a huge number of sensory nerves and their endings, more than in other areas human body. This is accompanied by a large flow of pain impulses into the brain, which can lead to traumatic (painful) shock.
Damage to the branches or trunk of the facial nerve, even in the presence of a very small wound (d = 6-7 mm), is accompanied by paralysis of the facial muscles and distortion of the wounded person’s face, and if the motor branches of the trigeminal nerve are damaged, some imbalance of masticatory function.
And at the same time, a rich, well-balanced neural network provides a subtle correlation metabolic processes, which has a positive effect on the regenerative capabilities of facial tissues.
Anatomical structure lower jaw (arched shape) from the point of view of a gunshot wound is very unfortunate. The thickness of the jaw body ranges from 0.5 to 1.8 cm. Having a thick cortical layer, the lower jaw forms very strong fragments that have great destructive power.
In no other place in the human body is it possible to observe that fragments of the same bone are at the same time secondary projectiles destroying the bone from which they arose. Bone fragments and teeth of one half of the lower jaw, formed as a result of a gunshot wound, acting as secondary projectiles, destroy and crush the other half of the jaw. In this case, it is formed big wound bone and soft tissue, exceeding the entrance hole by 20-80 times.

: subtotal shooting of the body of the lower jaw with the formation of a flap wound 80 times larger than the entrance hole.

The muscles of the floor of the mouth and tongue, located in the path of flying fragments, are not only torn, but also stuffed (stuffed, filled) with these fragments. Secondary wounding projectiles tear off pieces of soft tissue and knock out sections of bone; they create long curved channels, sometimes reaching a length of 20 cm and ending in other areas of the body.
The results of long-term observations of several generations of surgeons are well known, indicating high tolerance of facial tissues to oral microflora. Therefore, inflammatory phenomena around fragments of teeth or bone infected with oral microflora do not always occur. However, fabrics lower section neck and upper shoulder girdle, where combined injuries occur quite often, react very painfully to the introduction of oral microflora. Here, rapidly occurring putrefactive-necrotic phlegmons arise with significant intoxication, high body temperature and extensive damage to fiber and muscle tissue. We observed 2 wounded: the first one was crushed by a bullet in the body of the lower jaw, and the second one was inflicted with a tangential wound to the first finger of his left hand. In the first wounded, after PSO and the application of CDA, the wound healed by primary intention, in the second, an abscess of the first finger arose, which turned into phlegmon of the hand, requiring several incisions and intensive antimicrobial therapy.
Lower jaw, being broken on both sides, under the influence of the muscles of the floor of the mouth, it moves back and contributes to the retraction of the tongue, which leads to dislocation asphyxia. When the body of the lower jaw is shot (traumatic amputation), the hyoid bone loses support from the mylohyoid muscle and ceases to hold the larynx at the required anatomical level. Both of them, the hyoid bone and the larynx, moving downwards, pull the remaining tongue along with them and cause dislocation asphyxia.
When the walls of the body are injured upper jaw , the thickness of which does not exceed 2 mm, cannot form fragments that can seriously damage tissue. Typically, with such wounds, several thin plates are found entangled in soft tissues or settled in the maxillary (maxillary) sinus. The exit hole turns out to be 1-2 mm larger than the entrance hole, which significantly distinguishes through wounds of the body of the lower jaw. However, if the formation of a temporary pulsating cavity occurs in the maxillary sinus, then it undergoes complete or almost complete destruction.
A completely different picture is observed when the alveolar process of the upper jaw is injured. Not only thick pieces of the alveolar process, but also the teeth located in it become secondary projectiles. With such wounds, large defects are always found bone tissue, combined with the formation of either large soft tissue flaps or a soft tissue defect.

: shooting of the left half of the upper lip and the entire left upper jaw, preserving only the bottom of the eye socket. On the right under the auricle you can see a probe inserted into the inlet, which is 80 times smaller than the outlet

The preserved part of the upper jaw can break off from the bones of the skull - a reflected fracture occurs due to shear.
Teeth knocked out of the sockets entirely or their fragments are the most powerful secondary wounding projectiles. Scattering when wounded, like billiard balls, they break bones and penetrate deeply into soft tissues, infecting them. Penetration of secondary wounding projectiles infected with oral flora into tissues of other areas of the body usually causes a violent inflammatory reaction. Moreover, the development of putrefactive flora predominates, accompanied by significant intoxication, high body temperature, very poor health, decreased blood pressure, sometimes a disorder of the gastrointestinal tract. When such abscesses are opened, gray-brown pus with a putrid odor and gas bubbles is released. Even tissues of the perioral area, which are well adapted to the oral flora, cannot always suppress it without mobilization defense mechanism- acute purulent inflammation. Abscesses of the peripharyngeal space and the root of the tongue are especially difficult.
However, there is a positive side to teeth.: they help to accurately carry out topical diagnosis of a jaw fracture. Even a slight displacement of a jaw fragment, sometimes invisible to the eye, is very clearly perceived by the wounded, who notes a violation of the closure of the teeth. The “mirror” symptom we described also facilitates the topical diagnosis of a jaw fracture. The role of teeth in immobilizing fragments of a broken jaw is enormous. During conservative treatment with dental wire splints, they serve to fix these splints, and then to stretch and secure fragments of the broken jaw. They can be used in post-treatment of a wounded person using lab-made dental or periodontal splints. During osteosynthesis, the correct alignment of fragments in the wound is controlled by restoring central occlusion.
Negative features of facial wounds include: anatomical or functional disorders of vital organs located nearby. Vital organs include those organs whose damage is incompatible with life. These are primarily the brain and spinal cord (cervical spine), large vessels, larynx and trachea. It is damage to these organs that causes the death of a wounded person at the advanced stages of medical evacuation.
The shock wave on the bone can travel a considerable distance. When the upper jaw is wounded, the shock wave along the bone spreads to the frontal and sphenoid bone(in the bottom and walls of the anterior and middle cranial fossae), and through them into the substance of the brain. This causes brain contusion, which is accompanied by the development of coma and loss of consciousness lasting from several hours to a week. In mild cases, a short-term (up to 30 minutes) loss of consciousness will be a sign of a concussion.
The lower jaw is connected to the base of the skull through a damping device - the temporomandibular joint and, moreover, its contact area is many times smaller than that of the upper jaw. Due to this, the force of the shock wave is significantly reduced and the brain injury is significantly less. That is why a wound to the lower jaw is accompanied by a concussion much more often than a bruise.
In addition, with total or subtotal destruction of the upper jaw, areas of the base of the skull are often broken out: the orbital part of the frontal bone, the ethmoid bone, including the cribriform plate, with the occurrence of liquorrhea. Moreover, liquorrhea can be so active that when a wounded person is admitted to the hospital a few hours after injury, intracranial pressure has time to drop by half.
The passage of a bullet near the cervical spine causes a concussion, which best case scenario is complicated by dysfunction of the upper extremities, and in the worst case, by the death of the wounded person due to ascending edema of the spinal cord and jamming of the medulla oblongata at the level of the fourth ventricle.
The role of blood vessels in the occurrence of brain contusion was described above. It should be noted here that injury to the wall of a large vessel (carotid artery, external and internal jugular veins) or its complete rupture is accompanied by severe, sometimes fatal bleeding. The formation of a closed dissecting hematoma of the neck, which can cause stenotic asphyxia, is also life-threatening. A traumatic aneurysm of a large vessel should also be considered a “delayed-action bomb”.
Injuries to the larynx and trachea are usually dealt with by otolaryngologists, but the fight against valve asphyxia for the life of the wounded often has to be carried out by a maxillofacial surgeon, since valves in the form of soft tissue flaps are usually formed when the upper jaw, tongue, cheek and side wall of the pharynx are wounded.
The facial muscles start from the bone and are woven into the skin. The efforts of these muscles of the left and right sides balanced by the skin. When the skin is damaged, this physiological balance is disrupted, and the edges of the wound diverge - creating the impression of a tissue defect that disfigures the face. There is a discrepancy between the volume of damage and the danger to the life of the wounded person.

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Weapon injuries in peacetime are even more varied than in wartime. Gunshot wounds are inflicted intentionally or through careless handling of a machine gun, machine gun, hunting rifle, gas pistol, or self-propelled gun. This group also includes injuries caused by non-firearms: pneumatic guns, crossbows, spearguns, etc.

The peculiarity of such lesions is that the entrance holes are often pinpoint, with a small diameter (2-3 mm), and the gunshot wound often occurs with entry into cavities.

In addition, there are several point injuries, for example, when hit by shot, which makes it difficult to provide assistance. When the shot occurs from a short distance or at point-blank range, the damage is wider and deeper.

Brief first aid instructions

First aid for a gunshot wound is provided urgently, regardless of what part of the body is damaged and what damaging element caused the damage: buckshot, shot, bullet, shell fragment.

Before providing assistance, it is necessary to correctly assess the condition of the victim, the seriousness and severity of the wound, the nature of the injury, and the type of gunshot wound. The course and outcome of the injury will depend on how quickly and correctly the assistance was provided.

First aid for a gunshot wound includes the following:

Wait for the medical team, constantly talking with the person, if the ambulance arrives no earlier than half an hour later, ensure that the victim is transported to the hospital on your own. Next, we will consider in detail some of the types of gunshot wounds: bullet wounds of the arms and legs, chest, head, spine and neck, and abdomen.

First aid for injured arms and legs

The main thing to pay attention to with gunshot wounds to the extremities is the presence of bleeding.

If the femoral or brachial artery is damaged, a person loses consciousness in 10-15 seconds, death from blood loss occurs in 2-3 minutes - therefore immediate first aid is necessary.

It is important to determine the type of bleeding: bright, scarlet, gushing from the wound in a pulsating stream. the blood is dark, burgundy in color, flowing out of the wound with less intensity. When blood seeps out of the wound in drops, resembling a sponge.

First aid actions for gunshot wounds to the arms and legs:

• In case of bleeding from the arteries, apply a twist above the wound indicating the exact time;
• If there is heavy bleeding from a vein, you can either twist it below the wound or apply a pressure bandage.

Features of applying a pressure bandage

In case of a gunshot wound to the extremities, when applying a pressure bandage, you must:

• In place of the hearth you need to put a 4-layer napkin;
• Secure the fabric to the limb with three rounds of gauze bandage;
• Use a pressure pad, place it on top so that it covers the edges of the wound;
• Fix the roller with a bandage; the bandage must be applied with a tight pressure so that the bleeding stops;
• The pressure pad should be in the form of a dense, tight roller; if it is absent, use any available means;
• If the wound contains foreign object, a bandage cannot be applied until it is removed.

The injured person must be given a body position in which the limbs are above the level of the heart.

In some situations, with bullet wounds, tamponade is used to stop bleeding. For this manipulation, the wound hole is filled with sterile dressing material using a thin long object.

The second important circumstance for any injuries to the arms or legs is the presence of fractures. When a fracture is present, any movement of the limbs should be excluded until doctors arrive, since the sharp edges of the bone further damage soft tissues and blood vessels.

How to transport a victim?

If you plan to deliver the victim to a medical facility on your own, you must transport immobilization limbs, for this purpose any available means are used.

The splint is applied, covering two adjacent joints, and secured with bandages or any fabric.

Similar articles

When arms and legs are shot, rest of the limbs is ensured not only in case of fractures, but also in case of severe damage to tissues with a large surface area - this is considered an anti-shock measure.

If the wounded person has significant blood loss associated with arterial bleeding, the victim should be taken immediately to the operating room. Existing shock and bleeding from a vein are indications for transporting the wounded to intensive care.

Gunshot wounds to the chest

A gunshot to the chest refers to difficult circumstances and is accompanied by shock and complications. Fragments and ricochet bullets cause destruction of the ribs, sternum, shoulder blades, and damage the lungs and pleura.

Bone fragments penetrate deeply into the lung tissue, and pneumo- and/or hemothorax is possible.

When organs inside the chest are damaged, blood fluid does not always flow out; sometimes it accumulates there, so it is difficult to judge damage to blood vessels from gunshot wounds.

Hemothorax

When blood enters the chest cavity, hemothorax occurs, the blood interferes with breathing, disrupts the functions of the heart, since the volume of the chest has a limit, and blood occupies the entire volume.

Pneumothorax

Air leaks into the pleura through the wound, and the presence of constant communication with the atmosphere causes open pneumothorax. Sometimes the entrance hole of the wound is clamped, then the open pneumothorax turns into a closed one.

Pneumothorax with a valve also occurs, when air freely enters the chest cavity, but the valve, which was formed as a result of a gunshot wound, prevents its return from exiting.

When providing first aid for a gunshot wound to the chest, you need to take into account the person’s condition and the nature of the wound:

If the bullet hit the heart, we can assume the most worst option . By external signs the victim - the person quickly loses consciousness, the face takes on an earthy tint - it immediately becomes clear what happened, but death does not always occur.

Quick delivery of the victim to doctors, where he will undergo drainage and suturing of the heart wound, can save a life.

Help with a head wound

When a person loses consciousness with a gunshot wound to the head, there is no need to revive him from fainting; time cannot be wasted on this. All actions should be aimed at stopping the bleeding; to do this, you need to put a piece of sterile bandage, folded in several layers, on the wound and tape it tightly to the head.

At heavy bleeding head wound, the bandage should be compressive, using a dense pad that presses the soft tissue to the skull.

Then you should give the person supine position on a solid surface, ensure peace and wait for the arrival of doctors.

With a gunshot to the head, respiratory and cardiac arrest often occurs. In such situations, the victim must undergo chest compressions and artificial respiration; taking the victim to a medical facility on your own is highly discouraged.

Gunshot wound to the spine and neck

When the spine is damaged by a weapon, a brief loss of consciousness occurs. Help for wounds of the spinal column consists of stopping the bleeding and providing rest for the person. It is not advisable to move the victim or transport him to a medical facility yourself.

Bullet wounds of the neck are often accompanied by a violation of the integrity of the larynx, as well as damage to the cervical arteries.

If you are wounded in the neck, you must immediately stop the bleeding, the carotid artery is pressed with fingers, or a pressure bandage is applied using the victim’s hand, which is raised up, then wrapped around the neck along with the hand.

Sometimes the neck, larynx, and spine are simultaneously affected. Help in these situations comes down to stopping the bleeding and providing peace to the victim.

First aid for a stomach wound

Abdominal gunshot includes three pathologies:

• Bleeding;
• Perforation of hollow organs (stomach, bladder, intestines).

If organs have fallen out, they cannot be put back into the abdomen; they are covered with fabric rolls, then bandaged. The peculiarity of the bandage is that it must always be kept wet; for this it needs to be watered.

To reduce pain, cold is applied over the bandage to the wound. When the bandage is soaked through and blood begins to ooze out, the bandage is not removed, but a new bandage is applied over the old one.

If you are wounded in the stomach, you must not give the victim food or water, and you must not give him medicines through the mouth.

All gunshot wounds in the abdomen are considered to be primarily infected; antiseptic treatment of the gunshot wound and primary debridement, which is done in the first hours after injury. These measures provide a better future prognosis.

When the abdomen is injured, parenchymal organs, such as the liver, are sometimes affected. The victim experiences shock; in addition to blood, bile leaks into the abdominal cavity, and biliary peritonitis occurs. The pancreas, kidneys, ureters, and intestines are also affected. Often, nearby large arteries and veins are damaged along with them.

After first aid is provided, the victim is taken to a medical facility, where he is provided with qualified and specialized medical care.

Page 17 of 83

Gunshot wounds to the neck are often non-penetrating. However, they may be accompanied by damage to hollow organs, blood vessels, nerve trunks, as well as the hyoid bone and vertebrae. X-ray examination for gunshot wounds of the neck begins with radiography (electroradiography) of this area in two mutually perpendicular projections.
To further clarify the data obtained and determine the location of the foreign body (in case of blind and especially multiple wounds), fluoroscopy and targeted photographs are performed in normal conditions, as well as with the use of water-soluble contrast agents (vulnerography, esophagography). Wherein Special attention are devoted to the study of organs and tissues of the neck located along the wound channel or in the area of ​​the injury.
For fresh neck wounds X-ray examination used to determine the location of the lesion, its nature and extent, as well as to detect foreign bodies and determine their location. At the same time, attention is paid to the condition of the adjacent parts of the head and chest, which are often also damaged.
At a later date after a gunshot wound or neck injury, an X-ray examination is carried out according to the usual technique. If necessary and if practical, it is supplemented special techniques(tomography, fistulography, contrast study larynx, trachea, bronchi, pharynx, esophagus, etc.). The X-ray data obtained in this way acquires great importance for timely detection of inflammatory complications in the soft tissues of the neck and mediastinum, as well as the trachea and bronchopulmonary system (periesophagitis, mediastinitis, deep abscess, pneumonia, etc.).
Fractures of the hyoid bone are recognized by disruption of its integrity and displacement of fragments. Fractures of the large horns are more common, fragments of which are usually displaced upward and medially.
In case of wounds of the pharynx and cervical esophagus, radiological signs of deep emphysema of the neck and infiltration of its tissue (expansion of the retrovisceral space), as well as the release of water-soluble contrast agent beyond the examined organ, are revealed. If damage to the esophagus is combined with injury to the trachea or larynx (also accompanied by emphysema), then the contrast agent flows through the wound channel from the esophagus into the airways, causing whooping cough. IN similar cases it is necessary to exclude paresis or paralysis of the pharynx, damage to the trunk of the vagus nerve and its branches, and the epiglottis, which may also cause a disturbance in the act of swallowing and the throwing of a contrast agent into the trachea.
Rice. 88. X-ray and tomogram of the neck in direct projection. Blind gunshot wound with damage to the larynx.
a - radiograph. The foreign body is located in the area of ​​the right aryepiglottic fold; b - tomogram. In addition to the localization of the foreign body, damage to the cartilage of the larynx is well expressed.

With a small wound hole and a narrow wound channel, as well as with combined wounds of the neck and face with extensive damage to the skeleton, soft tissues and facial organs, wounds of the pharynx and esophagus in acute period often not clinically recognized. In order to detect them in a timely manner and take the necessary measures to prevent infectious complications, X-ray examination of such wounded people should be carried out as early as possible.
For injuries to the larynx and trachea, it is advisable to perform radiography using a softer than usual x-ray radiation(in the so-called soft tissue mode) or use electroradiography. On soft photographs and electro-radiographs of the neck, deformation of the larynx and trachea, displacement of cartilage fragments, disruption of the integrity of the epiglottis, hematomas, as well as accumulations of gas that have penetrated from the damaged organ into the surrounding soft tissues of the neck are better visible. If appropriate conditions exist, they resort to tomography, which allows one to obtain valuable information about the condition of the larynx and trachea (Fig. 88).
In case of blind gunshot wounds of the neck, X-ray examination of the damaged area is of great importance in order to determine the relationship between the foreign body and large vessels, since the foreign body is often located directly against the wall of the damaged vessel. To do this, when analyzing survey photographs, you can use the diagram proposed by D.N. Balasenko (1950), which shows a projection image of the main vessels of the neck in relation to the bony landmarks of the facial skull and cervical vertebrae, visible on direct and lateral radiographs (Fig. 89). If the data obtained indicate that the foreign body is located in close proximity to vascular bundle neck or the wound channel passes next to the latter, then the possibility of changes in the vascular wall is always allowed. In order to prevent cerebral complications or secondary bleeding, such wounded people are prescribed strict bed rest before the end of the critical period (organization of a blood clot).

Rice. 90. Carotid electroroentgenogram in direct projection. Blind shrapnel gunshot wound to the neck. The topographic-anatomical relationship of the metal fragment with the main vessels is clearly expressed.
Rice. 89. Location on the neck of the common (1), external (2) and internal (3) carotid arteries in relation to bone landmarks (diagram) [Balasenko D. B., 1950].

A more accurate diagnosis is facilitated by carotid angiography, which allows you to quickly and accurately determine the location of metal foreign bodies in relation to the great vessels (Fig. 90).
In case of combined wounds of the neck and face, which are usually among the complex and severe wounds, external damage and initial clinical manifestations do not always correspond to the severity and volume of true destruction hidden in the depths of the altered tissues. Combined injuries may be accompanied by damage to the organs of the neck, as well as communication of the wound channel with the oral, maxillary and nasal cavities or with the hollow organs of the neck. In all these cases, X-ray examination makes it possible to most accurately determine the volume and nature of the damage, as well as determine their location.