Damage from piercing and cutting weapons. Mechanisms of occurrence and characteristic features of stab wounds. Possibility of identifying a specific operating weapon. Issues resolved by forensic medical examination. Wounds by method of occurrence

Wounds are damage to tissues and organs, accompanied by a violation of the integrity of the skin (mucous membrane), accompanying pain, bleeding, separation of damaged edges (gaping) and dysfunction of the damaged part of the body. Superficial wounds in which there is incomplete damage to the skin or mucous membrane are called abrasions. Depending on the presence of the inlet and outlet openings of the wound canal, wounds are called blind - with a wounding object stuck in the tissue, and through - when it passes through. In addition, there are soft tissue injuries (skin, subcutaneous tissue, muscles, tendons, blood vessels, nerves), bone injuries, as well as wounds that penetrate and do not penetrate body cavities. A penetrating wound is a wound when the object that caused it penetrates the pleural, abdominal, articular, cranial cavities of a person, the chamber of the eye, etc. With penetrating wounds of the chest and abdominal cavity, damage to the organs located in them is common. According to the mechanism of application, the nature of the wounding object and tissue damage, wounds are cut, punctured, chopped, bitten, torn, scalped, bruised, crushed, or gunshot.

Torn a wound is formed when a mechanical damaging factor impacts soft tissues in a way that exceeds their physical ability to stretch. Its edges always have an irregular shape, tissue detachments or tears and tissue destruction are noted.

Chopped wound - a wound caused by a heavy sharp object. It has greater depth and a larger volume of non-viable tissue than an incised wound.

Cut a wound inflicted by a sharp object (knife, glass, etc.) is characterized by a predominance of the length of the damaged area over its depth, smooth edges, a minimal amount of dead tissue and reactive changes around the wound. A scalped wound is characterized by complete or partial detachment of the skin, and on the scalp of almost all soft tissues, without significant damage. A bruised wound and a crushed wound are possible when struck by blunt objects and are characterized by crushing and rupture of tissue with a significant area of ​​primary and subsequently secondary traumatic necrosis with abundant microbial contamination of damaged tissue.

Stabbed a wound occurs when soft tissue is damaged by a needle, awl, nail, knife, bayonet and other sharp elongated objects. Such a wound is usually deep and blind, has a relatively small entrance hole and may be accompanied by damage to blood vessels and internal organs.

Bitten the wound, as a result of an animal or human bite, is characterized by abundant microbial contamination and frequent infectious complications, sometimes very dangerous (rabies, etc.). It may have signs characteristic of lacerated, bruised and crushed wounds, and is often infected with pathogenic flora contained directly in the saliva of the bite victim.

Firearms a wound is the result of exposure to damaging factors of a firearm (fragments, bullets, shot). It differs significantly from all other types of wounds in structure, the nature of local and general changes, and the course of healing processes. Gunshot wounds from explosive bullets and bullets with a displaced center of gravity are especially life-threatening. With a through-and-through gunshot wound, an entrance and exit opening are formed, and the entrance opening is always smaller than the exit opening. As a result of the direct action of a fragment or bullet, a wound channel appears. It, especially with shrapnel wounds, carries scraps of clothing, soil, and destroyed tissues that contaminate the wound, which, in cases of extensive crushing, blood accumulation, and damage to internal organs, contributes to the development of severe forms of purulent and other complications. The effect of the physical impact of gunshot factors on tissue depends, on the one hand, on their properties of damaging factors - size, shape, mass, flight speed, on the other - on the structure and physical properties of the affected tissues - their density, elasticity, water content, the presence of elastic, strong or fragile structures. Each such wound is contaminated with microbes. It is customary to distinguish between primary and secondary microbial contamination. Primary contamination occurs at the very moment of inflicting the wound; secondary contamination, as a rule, is associated with violation of the rules of asepsis during dressings and operations and manifests itself in the form purulent complications. First aid to the wounded includes immediate stoppage of bleeding using a tourniquet or pressure bandage, application of a primary aseptic dressing to the wound, administration of painkillers, immobilization of body parts for bone fractures, significant damage to soft tissue, large vessels and nerves. The primary aseptic dressing protects the wound from secondary infection, since it absorbs and provides a temporary delay of infectious agents, toxins and decay products of damaged tissue entering the wound, and prevents the development of wound infection and shock.

Open injuries (wounds)

Violations of the integrity of the skin, mucous membranes and the surface of internal organs, occurring as a result of mechanical or other impact, are called a wound. Damage to the skin is usually accompanied by damage to the integrity of deeper tissues. The cavity formed between tissues as a result of penetration of a wounding object deep into the body is called a wound canal.

Classification of wounds:

Depending on the nature of the wounding object, there are stab, cut, chopped, bruised, lacerated, gunshot, bite wounds. The sharper the object and the faster the damage is done, the less damage is done to the edges of the wound.

^ By degree of damage wounds are divided into superficial and deep. Deep wounds may be accompanied by damage to blood vessels, nerves, bones, tendons, and internal organs. Deep wounds that penetrate into the cavity (abdominal, chest, skull) are called penetrating. All other types of wounds, regardless of their depth, are called non-penetrating.

^ By the presence or absence of infection In the wound, aseptic and infected wounds are distinguished.

All wounds, except those caused by a sterile instrument under sterile conditions during surgery, should be considered infected. A wound that has been exposed to another factor (poison, chemical agents, radiation) is called complicated.

^ Characteristics of certain types of wounds.

Puncture wounds occur when exposed to a sharp weapon - an injection with a knife, bayonet, or needle. This type The wound is characterized by a small, smooth external opening and usually great depth. Since the wound channel is narrow, due to tissue displacement (muscle contractions, skin displacement), it becomes intermittent zigzag. This makes puncture wounds especially dangerous, since it is difficult to diagnose the depth of damage and possible injuries to internal organs. Unnoticed damage to internal organs can cause internal bleeding, peritonitis or pneumothorax.Very often, a piercing weapon, such as a needle, remains in the tissue, which in turn can cause later complications.

^ Incised wounds can be applied with a sharp cutting object (knife, razor, glass, scalpel). Incised wounds have smooth edges. Most accidental wounds during surgical treatment are converted into incised wounds, which ensures their rapid healing.

^ Chopped wounds occur when damage is caused by a sharp but heavy object (axe, saber, etc.). Since the wounding object is sharp, a wound appears that is similar in appearance to a cut, but since the wounding objects are quite thick, crushing of the edges of the wound always occurs to one degree or another.

^ Bruised Wounds is the result of the impact of a blunt object on tissue (hammer, stone, etc.). The edges of the bruised wounds are crushed, uneven, and soaked in blood. As a result of damage to blood vessels and their thrombosis, malnutrition of the wound edges and their necrosis quickly occur. Crushed tissue are an excellent breeding ground for microbes. Because of this, bruised wounds easily become infected.

^ Gunshot wounds are the result of injury from a firearm. Depending on the type of weapon, they are distinguished: bullet wound, shot wound, fragmentation wound (mine, grenade, shell). The least damage to soft tissue is caused by a bullet.

A gunshot wound can be through, when the wounding object passes through and has an entrance and exit opening; blind when an object gets stuck in the body; tangent, when the object caused superficial damage, passed next to the organ, only partially touching it. The entrance hole in a penetrating wound is always smaller than the exit hole. In a blind gunshot wound, the wounding object gets stuck in the tissues of the wounded person and becomes a foreign body. Fragments of damaged bone also become foreign bodies, which, necrotizing deep in the soft tissues, often lead to suppuration of the wound.

Gunshot wounds are often multiple and combined. Combined wounds are those in which the wounding projectile passes through a number of organs and cavities (for example, the abdominal cavity, diaphragm, pleural cavity) and causes dysfunction of several organs. Therefore, when treating gunshot wounds the main attention should be paid to the wound channel. By examining it, you can determine the depth of the wound, the degree of damage to internal organs and soft tissues, and detect a foreign body.

Shrapnel gunshot wounds are often multiple and always cause more extensive tissue damage, since the fragments have jagged edges, sometimes of significant size. Uneven edges cause the penetration of various objects into the wound (clothing, soil, skin), which enlarge and contaminate the wound. Extensive crushing of tissues and abundant accumulation of blood in the wound canals contribute to rapid infection and the development of severe purulent inflammation.

Symptoms of wounds.

Every wound is characterized by:

1. 
   pain,
2. 
   gaping
3. 
   bleeding.

Hiatus wound - the divergence of its edges - depends on the elasticity and ability of soft tissues to contract. The larger and deeper the wound, the greater the separation of the edges.

Bleeding from the wound depends on the type of damaged vessels (artery, vein, capillaries), the height of blood pressure and the nature of the wound. The less damaged the tissue (cut, chopped wounds), the more pronounced the bleeding. In crushed tissues, the vessels are crushed and thrombosed, so bruised wounds bleed little.

The nature of wound healing depends on the general condition of the victim (age, nutrition, concomitant diseases, vitamin deficiency, etc.), as well as on local conditions, i.e. the nature and type of the wound, the degree of its contamination, etc.

^ Wound healing.

Wounds can heal in two main ways - primary intention and secondary intention.

Wound healing, which proceeds quickly, without complications and ends after a few days with the complete restoration of tissue integrity with the formation of a thin linear scar, is called primary intention. The main condition for primary intention is the absence of dead and crushed tissue, blood clots (hematomas) and infection in the wound. In addition, for a wound to heal by primary intention, it is necessary that the edges of the wound fit tightly together and be viable.

Rice. Healing by first intention

In cases where the wound gapes, its edges are significantly damaged, there is dead tissue, blood clots, foreign bodies, an infection develops in the wound - healing proceeds slowly, by gradually filling the wound with granulation tissue with the release of pus and exudate. This type of wound healing is called secondary intention . The scar that appears after wound healing by secondary intention is rough, uneven, wide, and can subsequently wrinkle and cause contractures and stiffness of the joints.

Only incised and surgical wounds inflicted under aseptic conditions can heal by primary intention. All accidental wounds are infected to one degree or another and heal by secondary intention without surgery. Surgical intervention - primary surgical treatment - excision of the edges of the wound and wound channel, removal of dead and crushed tissue, foreign bodies followed by a closed suture of the wound, carried out in the first hours after injury, allows you to convert infected and crushed wounds into incised aseptic ones and, in a significant number of cases, achieve primary intention.

Healing under the scab observed with superficial damage to the skin (burn, abrasion, scratch). A scab arises from blood and lymph poured into the wound, which, when dried, form a crust - a scab. Under the scab, the epidermis is restored. The scab falls off on its own after the skin is completely restored. The scab should not be forcibly removed, as this will disrupt the restoration process of the epidermis and the development of granulation tissue at the site of the wound, which will delay healing. If skin restoration with primary intention occurs within 4-7 days, then with secondary intention - within several weeks or months. This implies the importance of primary surgical treatment of accidental wounds.

Rice. Scheme of wound healing by primary intention without scar formation.

Occurs without suppuration and formation of visible interstitial tissue with subsequent development of a linear scar. It occurs in wounds with smooth, viable edges that are no more than 1 cm apart from each other, in the absence of wound infection. A typical example of such healing is surgical wounds.

Rice. The pattern of delayed primary healing (healing by primary intention) is healing without suppuration with delayed closure of the wound with sutures.

Rice. Scheme of healing by secondary intention.

Occurs through suppuration with the formation of visible connective tissue and the subsequent development of a rough scar. Occurs with the development of a wound infection and the presence of extensive tissue defects that do not allow initial comparison of the wound walls.

^ Rice. Healing pattern under the scab.

Occurs without scar formation in superficial wounds with the germ layer of the skin preserved. Rapid regeneration of the epidermis occurs under a scab consisting of fibrin and blood cells.

^ Treatment of wounds. (for amateurs)

Primary treatment of wounds

First What needs to be done when injured is to stop the bleeding that occurs. If the bleeding is capillary and the wound is shallow, this step can be skipped.

Second- this is to anesthetize the victim (it is better to use injectable forms of painkillers, for example, intramuscularly inject ketarol or, in extreme cases, analgin). For shallow wounds and the absence of pain, painkillers may not be administered, but if the wound is at least somewhat serious, you should not refuse pain relief.

Third- This is the treatment of a wound with an antiseptic agent. Usually in such cases I use a solution of chlorhexidine bigluconate, sold in pharmacies. You can also use a 3% solution of hydrogen peroxide (at the same time it will help stop bleeding), but chlorhexidine still disinfects better. When washing the wound, you must carefully remove all foreign bodies - they will interfere with healing. It is advisable to treat the edges of the wound with 5% tincture of iodine, making sure that iodine does not get into the wound.

Fourth- applying a bandage. The dressing should be changed daily.

Fifth- introduction antibacterial drugs. In camping conditions, it is better to “protect” yourself with medications in any case, using them in the form of capsules from a camping first aid kit (cephalexin 2 capsules 3 times a day, ciprofloxacin 250-500 mg 2 times a day).

^ Treatment of purulent wounds

The main thing in the treatment of a purulent wound is to ensure normal outflow of pus and wound discharge from the wound. There will be normal outflow - the wound will heal normally. If pus accumulates in the wound, there will be no healing, despite all efforts.

That is why it is not recommended to suture wounds while traveling. During a hike, there is a high probability of wounds suppurating, and in a sutured wound, ideal conditions for the development of infection. Plus, there is a lack of oxygen, which can lead to an anaerobic infection. Of course, if you have a medical education and relevant experience, you will be able to suture the wound correctly, avoiding complications. However, for everyone else, we can only recommend treating the wound with an antiseptic and applying a bandage, and then repeating this procedure daily. It is good to use dressings with a 10% solution of table salt (not necessarily sterile) - they draw out fluid and pus. If the wound is narrow, and when applying a bandage the edges close tightly, it is advisable to place a thin strip of rubber or film (carefully treated with alcohol and available antiseptics) between the edges of the wound to give the pus a path for outflow.

As long as the wound is “flowing”, ointment preparations cannot be used - they impede the outflow of wound discharge. Ointments will be needed at the second stage, when the wound is cleared of pus and non-viable tissue, and the process of granulation formation begins (the growth of special tissue on the walls of the wound, which will subsequently fill the entire wound and become the basis for the scar). These granulations must be protected from damage, so it is good to lubricate them with ointments such as Levosin and Levomekol. Usually ointments can be used only for 3-4 days. At this time, suction dressings with saline solution no longer needed. When the wound is completely clean, you can try to tighten the edges of the wound with a bandage or narrow (3-4 mm wide) strips of plaster to speed up healing.

Rice. - Granulation tissue is a sign of an adequate healing process

^ Wound treatment (advanced)

Primary surgical treatment of the wound.

The main point of wound treatment is primary surgical treatment of the wound. Inflammatory phenomena in the wound develop quite quickly. After just 6 hours, you can observe the first signs of inflammation in the wound: swelling and hyperemia appear. Thanks to antibiotics and some sulfa drugs the possible period of initial treatment is 18-24 hours. However, the earlier the treatment is carried out, the greater the conditions for wound healing by primary intention. The main task of primary surgical treatment is to remove necrotic, contaminated and infected tissue and bring the edges of the wound closer together.

Each dressing must be carried out in compliance with the rules of asepsis. Objects in contact with the wound must be sterile, so all dressings are carried out with instruments - the so-called instrumental dressing. Instruments can only be used for one dressing, after which they are sterilized again.

Tweezers are used to remove the last layers of the dressing. Using the same tools, grasping balls moistened with ether or alcohol, treat the skin around the wound, and apply a new bandage with them.

The appearance of pain in the wound, redness and swelling of its edges, and an increase in temperature indicate developing suppuration of the wound. In such cases, it is necessary to remove the stitches and open the wound. If wound healing proceeds without complications, then after 5-7 days the sutures are removed and the wound is considered healed.

^ Treatment of purulent wounds.

Treatment of purulent wounds varies depending on the phase of the wound process. Developing inflammation creates a kind of protective barrier, ensures the rejection of dead tissue and their removal along with the embedded microflora. The early period of a purulent wound is characterized by the development of an acute inflammatory reaction (first phase). In this case, pronounced tissue swelling, redness, copious discharge tissue fluid into the lumen of the wound and the formation of pus (hydration stage) - Pus is an inflammatory exudate containing leukocytes (white blood cells), dead and living bacteria, an enzyme that has the ability to melt tissue. The process occurring during this period ensures the rejection of dead tissue and the formation of a protective wall of granulation tissue.

Rice. Spongy granulation tissue with inadequate wound healing

After rejection of necrotic areas, the wound is cleaned and quickly filled with granulation tissue (dehydration stage), which is gradually replaced by connective tissue (second phase).

The main task in the treatment of infected and purulent wounds in the first period is to create conditions for good outflow of exudate, pus and separation of necrotic tissue, as well as to take measures to prevent the penetration of infection from the wound into the body. A satisfactory outflow of pus can occur only with a wide opening of the abscess and the destruction of all pockets and leaks. This is achieved by applying additional incisions and mechanical removal of dead tissue, fragments, and foreign bodies. Outflow from the wound can be improved by the use of hypertonic solutions and ointments, which increase exudation and at the same time increase the flow of pus from the wound into the dressing. Antiseptic solutions injected into the wound have a certain influence on the course of the purulent process during this period. The destruction of microbes that occurs, slowing down their growth and reproduction, reduces the risk of infection and poisoning of the entire body and has a beneficial effect on the protective processes occurring in the wound. It is very important to increase blood flow to the wound during this period. This is achieved by using heat in the form of heating pads and dry-air hot baths. However, warming compresses should not be used, as they sharply disrupt the outflow of pus and increase the absorption of toxic products into the body. An equally important point is to create rest for the wound, including the use of immobilizing dressings (splints, plaster splints, etc.).

Treatment of wounds in the second phase mainly comes down to protecting granulations from damage and secondary infection. During this period, the use of hypertonic and antiseptic solutions is contraindicated, as they destroy granulations and slow down their growth. Wet dressings have an unfavorable effect, disrupting the process of replacing granulations with connective tissue. Protection of wounds and granulations is carried out by applying aseptic oil dressings (fish oil, Vaseline oil). It is necessary to achieve complete filling of the wound with granulations. The wound is considered healed when it is completely epithelialized.

^ Wound care.

Care for an infected and purulent wound must be carried out very carefully. When changing the dressing, washing the wound, inserting tampons, etc., the most important thing is to maintain asepsis. Particular attention should be paid to protecting the skin around the wound from infection. Pus entering the skin can lead to disruption of its integrity and the spread of the inflammatory process. The skin can be protected by applying a layer of fat, ointment or paste. In this regard, Lassara pasta is the best. Dressings should be made only with instruments (two tweezers), being careful not to contaminate the skin around the wound, as well as your own hands. It is better to protect your hands with gloves and wash them with soap and water after each dressing without removing them.

Removal of dried dressings, tampons and drains should be done carefully. To painlessly separate the dressing from the wound, in some cases you should moisten the dressing with hydrogen peroxide. Before you start cleaning the wound, you need to lubricate the skin with iodine tincture. Good action washes the wound with weak antiseptic solutions (hydrogen peroxide, furacillin, rivanol, potassium permanganate). Hydrogen peroxide in the wound quickly decomposes, releasing a large amount of foam, which carries with it pieces of necrotic tissue, pus and significantly reduces the unpleasant putrid odor.

Particular care must be taken to monitor the inserted drains (rubber tubes and strips). Their prolonged stay in the wound can lead to the development of bedsores of nearby organs (vessels, intestines, etc.). To reduce the possibility of the dressing getting wet, it is necessary to apply a sufficient layer of dressing material (gauze, cotton wool, lignin) to the wound.

Summarizing all of the above, the treatment of infected and purulent wounds can be presented schematically as follows. The wound is opened wide with the elimination of pockets, leaks and bridges. For the first 2-3 days, gauze swabs moistened with hypertonic solutions (10% sodium chloride solution, 25% magnesium sulfate solution) are inserted into the wound for better outflow. Tampons absorb wound contents well, which enter the upper layers of the dressing. Hypertonic solutions not only improve the release of pus, decaying tissue and blood clots from the wound, but also have a bactericidal effect, creating unfavorable conditions for the growth and reproduction of bacteria. After cleansing the wounds, they proceed to treatment with ointment dressings. At first, tampons are also used, but they are changed less frequently, after 3-5 days. When good granulations appear, the introduction of tampons is stopped, since they are already foreign bodies and impede healing. It is necessary to switch to tampon-free treatment with ointment dressings. The most common is Vishnevsky's ointment (Ol. Cadini 3.0; Xeformil 3.0; Ol. Ricini 100.0), which has a weak irritant and antiseptic effect and provides good drainage of the wound. It is possible to use ointments containing sulfonamides (streptocide, sulfadimezin), antibiotics (penicillin, streptomycin). The final stage of treatment is aimed at protecting granulations and the epithelium growing on them from damage, re-infection with simultaneous active therapeutic exercises.

For some types of infected wounds (burns, frostbite), open treatment is used to achieve drying of the wound surface under the influence of air and light. Drying the wound leads to the death of microorganisms. Protection of the wound from contamination and re-infection is achieved by placing the wound surface under a frame equipped with thermal reflectors (electric lamps).

Caring for patients with open injuries. Successful treatment the wounded depend largely on care. The main danger is the possibility of wound infection. Keeping the bed and skin in hygienic conditions helps prevent secondary infection. First of all, you need to monitor the applied bandage. The dressing should be dry and reliably cover the wound from the environment. Contact of urine, feces, water from heating pads and glaciers on the bandage can cause the wound to fester. This bandage must be changed immediately. If the dressing gets wet excessively with discharge from the wound, cotton wool should be placed on the dressing and bandaged. You need to be especially sensitive to the patient’s complaints about pain in the wound, the appearance of chills and increased body temperature. All this may indicate developing suppuration in the wound and necessitates control dressing,

During the first 3-5 days, it is necessary to create rest for the damaged organ.

Wound. Signs. Classification. First aid

Introduction

The study of wounds has a long history. As soon as a person appeared, he began to receive wounds in the process of his activities, and was forced to treat them. Wounds are one of the types of injuries that are extremely common both in peacetime and, especially, in wartime. In all wars, they are the main reason for the incapacitation of soldiers, as well as disability and mortality.

A wound is any mechanical damage to the body, accompanied by a violation of the integrity of the integumentary tissues - skin or mucous membranes. In this case, damage to deeper located tissues and internal organs is possible (injury to the brain, liver, stomach and intestines, kidneys, etc.), the clinical picture of wounds depends on their nature, the wounding projectile, the size of the wound, damage to cavities and internal organs, and violation of the integrity of blood vessels , nerves and bones. Proper treatment of the wound prevents the occurrence of complications and reduces its healing time several times. Therefore, every person is obliged to be able to provide assistance, both to himself and to any victim.

1. Signs of a wound

Each wound has more or less pronounced clinical signs: pain, gaping and bleeding. General symptoms, such as infection, shock, acute respiratory failure (ARF), acute anemia, etc., already characterize complications and are not mandatory signs of every wound.

The severity of pain depends on a number of reasons:

.Location of the wound. Wounds are especially painful in places where there are a large number of pain receptors (skin in the area of ​​the fingertips, periosteum, parietal peritoneum, pleura)

.Presence of damage to large nerve trunks

.the nature of the wounding weapon and the time of its impact on the formation of the pain impulse - the sharper the weapon, the less damage to the receptors and the less pain; the faster the impact occurs, the less pain syndrome.

.Neuropsychic state of the body. Pain sensations can be reduced when the victim is in a state of passion, shock, alcohol or drug intoxication. Pain is completely absent when surgery is performed under anesthesia, as well as with a disease such as syringomyelia (damage to the gray matter of the spinal cord).

The gaping of a wound depends on the length, depth and nature of its location in relation to the elastic fibers of the skin, the projection of which onto the skin is known as the Langer line pattern, and to the muscle fibers. Thus, wounds located perpendicular to Langer’s lines and to the course muscle fibers, are distinguished by the greatest gaping. For example, to reduce gaping during surgical interventions on the upper and lower extremities, longitudinal incision directions are preferably chosen rather than transverse. The direction of the incision is of particular importance in cosmetic and plastic surgery, when closing skin defects and excision of scars.

Bleeding and its intensity depend on the nature of the damage and the diameter of the vessel, the area of ​​damage and the number of damaged vessels (arterial, venous, capillary, parenchymal and mixed bleeding are distinguished). External bleeding does not present any difficulties for diagnosis at the prehospital stage, while internal bleeding requires a thorough examination of the victim with an assessment of the general condition (the appearance of the patient, his skin and mucous membranes, pulse rate, blood pressure). When wounded, blood can flow outward (external bleeding) and inward - into the tissue, into the interstitial space, into various cavities (internal bleeding). You should always remember the possibility of a combination of external and internal bleeding.

2. Classification of wounds

Wound is a violation of the anatomical integrity of the integumentary or internal tissues throughout their entire thickness, and sometimes also of internal organs, due to mechanical action.

According to the conditions of occurrence, they distinguishaccidental wounds (domestic and industrial), received in battle and in the operating room.

According to the mechanism of application, the type of wounding object and the nature of the damage, wounds are divided into:

Incised wound- a wound that is usually caused by a sliding movement of a sharp cutting object, such as a knife or glass. This wound can have either a patchy or linear appearance and is accompanied by loss of tissue. Incised wounds also include surgical wounds. Despite the variety of appearance and position, incised wounds have many common properties. Since the skin is elastic, the edges of the wound diverge (the wound gapes), it is possible to examine the deep parts of the wound and conclude whether there is damage to organs and tissues. The gaping of the edges of the wound depends on the location and direction of the wound; for example, wounds that are inflicted along the skin folds (transverse incisions on the neck) are least susceptible to gaping. This property of wounds is used in medicine during operations, so-called normal incisions, i.e. incisions along the folds of the skin. Due to good contact between the edges, such wounds heal with barely noticeable scars. In an incised wound, the edges of the cut tissues are slightly damaged, so the tissues almost do not lose their vitality and are able to respond to infection. The pain with such injuries is much less than with other types of injuries, due to minor damage to the nerve endings. Another important property of an incised wound is its tendency to cause significant bleeding.

Puncture wound.This type of wound can appear as a result of injury from a stabbing weapon or object (steel rod, awl). A puncture wound has a small area of ​​damage and smooth edges. The walls of the wound remain viable, bleed heavily, and are less susceptible to infection than others. Penetrating puncture wounds with a small area of ​​damage to the skin or mucous membrane can be of considerable depth and pose a great danger due to the possibility of damage to internal organs and the introduction of infection into them. However, this type of wound is quite rare and is most often combined with another type of wound (stab wound).

Stabbed- wounds resulting from exposure to a sharp object with cutting edges; such instruments not only pierce, but also cut tissue when immersed in them. They have a relatively small affected area, but can be quite deep. More often there are wounds that have an angular or slit-like shape, sharp ends and smooth edges. The depth of the wound channel does not always correspond to the length of the weapon blade. A stab wound poses a serious danger when it damages the heart and large blood vessels and other internal organs (liver, kidneys, spleen, etc.) due to the development of bleeding; the development of infectious processes is also dangerous, up to the possibility of blood poisoning.

Lacerationsarise from the rough mechanical impact of a blunt object directed at an acute angle to the surface of the body, are often accompanied by detachment of flaps of skin (the detached area of ​​skin may lose nutrition and become necrotic), damage to tendons, muscles and blood vessels, and are subject to severe contamination.

Bite wound.The peculiarity of this wound, formed as a result of an animal or human bite, is a high degree of infection, since a large number of pathogenic microorganisms are found in the saliva and oral cavity of animals. A bite wound is often complicated by the development of infection and suppuration, although the area of ​​damage is not particularly large. The danger of such a wound also lies in the possibility of infection with the rabies virus.

Chopped woundappears under the influence of a massive but quite sharp object (axe, shovel). Accompanied by bruises, unequal depth, crushing of soft tissues, wide gaping, and the development of massive necrosis. Significant pain, moderate bleeding, severe hemorrhage. For this type of injury, damage to the skeleton and opening of internal cavities is possible.

Crushed wound- a wound formed as a result of compression of tissues, mainly limbs, by solid massive objects. Characterized by a complex shape, uneven edges, and dead tissue over a significant area, such wounds create favorable conditions for the development of infection.

Bruised woundformed as a result of the impact of a blunt object. To overcome the resistance of relatively strong and elastic skin, a blunt object must damage less strong but fragile deep formations (muscles, bones). In the circumference of the wound, a wide zone of tissue damage occurs with its impregnation with blood and impaired viability (necrosis). With bruised wounds, pain is pronounced, and external bleeding is small (the walls of the vessels are damaged over a large area and quickly thrombose), but hemorrhages may occur.

Due to the presence of a large area of ​​damage and a large amount of necrotic tissue, bruised wounds are prone to healing by secondary intention.

Gunshot woundoccurs as a result of a bullet or shrapnel wound. A gunshot wound is more severe, and healing is much worse and longer than for wounds inflicted by knives. An important difference between a gunshot wound is the high speed of the wounding object. If the projectile stops in the tissues, then all or part of the energy is spent on damaging them, and since the speed of the bullet or projectile is high, the destruction of the tissues is enormous. When a projectile penetrates tissue, an area of ​​increased pressure is created, in which tissue compression occurs, spreading to the sides of the projectile in the form of a shock wave. The phenomenon of “side impact” occurs, as a result of which a temporary cavity is formed in the tissues, which seems to pulsate, and the tissues are compressed, separated, and mutually displaced at high speed. As a result of the direct action of the wounding projectile, a wound channel appears, which is an irregularly shaped penetrating gap filled with blood clots, foreign bodies, bone fragments when bones are damaged, as well as the projectile itself at the bottom of this gap if the wound was not through. The consequence of all impact factors is primary necrosis of tissue areas adjacent to the wound defect area. These tissues immediately lose their viability and must be completely excised and removed during primary surgical treatment. Secondary tissue necrosis is a process that actively develops over time, the extent of which depends on surgical treatment of the wound and treatment.

scalped woundis formed as a result of mechanical damage, which is accompanied by complete or partial tearing off large areas of the skin. These wounds usually occur when hair or folds of skin get caught in moving machine parts. Accompanied by shock and heavy bleeding. A serious complication is necrosis of the skin flap and the development of infection.

Surgical wound- a wound inflicted intentionally for therapeutic or diagnostic purposes in an operating room in compliance with the rules of asepsis. The main difference between such wounds is their sterility. They are applied with minimal tissue trauma, with pain relief, with careful hemostasis and, as a rule, with comparison and connection of dissected anatomical structures with sutures. Thus, with surgical wounds there is no pain, the possibility of bleeding is minimized, and the gaping is usually eliminated at the end of the operation by suturing, that is, the main signs of the wound are artificially eliminated. Due to their characteristics, surgical wounds tend to heal by primary intention.

Poisoned wound- a wound containing poison introduced as a result of an animal bite or human activity. A wound into which substances are introduced is poisoned. toxic effect. Usually these are bite wounds caused by poisonous animals; also, as a result of working with toxic substances, there is a possibility of their introduction into the wound; in wartime, wounds that have been exposed to chemical warfare agents.

Wounds are classified according to the depth of damage:

· Superficial are wounds in which the resulting wound channel does not communicate with any body cavity;

· Penetrating wounds are those in which the resulting wound channel communicates with any body cavity.

In relation to body cavities, wounds are divided into:

· Penetrating;

· Non-penetrating;

· With damage to internal organs;

· No damage to internal organs.

According to the shape of the defect:

·Linear;

Hole-shaped;

· Patchwork.

Depending on the anatomical substrate, injuries are distinguished:

· Soft tissue injury;

·Bone injury;

· Injury of large vessels and nerves;

· Tendon injury.

By anatomical localization:

Neck wound;

· Wounded thigh;

· Chest injury, etc.

By number of injuries per person:

· Single wound - injuries characterized by the presence of one wound channel;

· Multiple wounds are injuries to two or more organs (regions of the body) by several wounding projectiles, several blows from bladed weapons, etc.

According to the presence of microflora in the wound:

· Aseptic wounds inflicted under sterile conditions are characterized by a virtual absence of microflora in the wound and heal without manifestations of the infectious process;

· Bacterially contaminated wounds are characterized by the presence of various microorganisms in the wound. A distinction is made between primary microbial contamination, which occurs at the time of injury, and secondary, which occurs during treatment. In these cases, wound microflora refers to microorganisms that grow in the wound, but do not cause pathogenic effects;

· Infected wounds are characterized by the development of an infectious process, manifested by local signs of inflammation and often severe general reaction. During the treatment of an infected wound, additional pathogenic microflora (nosocomial, hospital) may enter it, causing secondary infection

By length:

· Isolated wounds located within one organ or anatomical area;

· Combined injuries mean simultaneous damage to several anatomical areas.

According to the presence of complications:

· Uncomplicated wounds with only soft tissue damage;

· Complicated wounds occur when a wounding projectile damages large blood vessels, nerve trunks and plexuses, bones, cavities and vital important organs. The nature of complications in these cases is determined by the degree of damage to these structures.

Based on the nature of the wound channel and the depth of damage, wounds are divided into:

· Through - wounds that have entry and exit wound openings, the latter having a large area of ​​tissue destruction;

· Blind - wounds in which the resulting wound channel does not have an exit hole;

· Tangent wounds - wounds in which a bullet or fragment, flying tangentially, damages the skin and soft tissues without getting stuck in them.

wound bleeding help pain

3. First aid

In case of wounds, first aid consists, first of all, of stopping the bleeding with any possible way. Blood loss is the cause of most deaths from wounds. The next step is to protect the wound from contamination and infection. A measure to prevent wound infection is the rapid application of an aseptic dressing to it, which prevents further entry of microbes into the wound. A bandage is a dressing material, sometimes containing medicinal and some other substances, that is used to cover the wound. Proper wound treatment protects it from complications and can also lead to faster healing. When applying a bandage to a wound, you must first treat the skin around the wound with gauze or cotton wool moistened with an antiseptic substance (alcohol solution of iodine, vodka, 3% hydrogen peroxide solution), while removing soil, scraps of clothing, and other foreign substances from the surface of the skin. In case of an extensive wound, it is unacceptable to wash the wound with any liquid containing alcohol: this can lead to increased traumatic shock and necrosis of the wound edges, followed by the development of severe complications.

There are strengthening, pressure, and immobilizing (immobilizing) bandages. The most common strengthening dressings are bandage, plaster and adhesive. Mesh, contour and specially prepared fabric bandages are increasingly coming into use. IN living conditions The most commonly used are strengthening bandages. Their main purpose is to protect the wound from external influences and hold the dressing material.

Bandaging rules:

Give the patient the most comfortable position, you must try not to cause unnecessary pain in the victim.

The head of the bandage should be held in the right hand, and the bandage should be done from left to right, while with the left hand you need to hold the bandage and smooth out the passages of the bandage. The bandage is not applied very tightly (except in cases where special pressure is required) so as not to interfere with blood circulation, and not very loosely so that it does not fall off the wound.

When applying a sterile dressing, you should not touch those layers of gauze that will be in direct contact with the wound;

Each subsequent turn of the bandage should cover half or two-thirds of the width of the previous one;

The bandaged part of the body, especially the limbs, should be in the position in which it will be after applying the bandage. For example, a bandage applied to the knee joint in a bent position will be unsuitable if the patient then begins to walk;

The end of the bandage should be tied or secured with a pin over a healthy part of the body.

A pressure bandage performs three functions: it prevents secondary infection, stops bleeding, and provides rest to the damaged surface.

Depending on the nature of the wound, weather and local conditions, the victim’s outer clothing is either removed or cut. First, remove clothes from the healthy side, then from the affected side. In the cold season, to avoid chilling, as well as in in case of emergency providing first medical care For victims in serious condition, the clothing is cut in the area of ​​the wound. You should not tear off any clothing that is stuck to the wound; it should be carefully cut off with scissors and then a bandage should be applied.

Conclusion

A wound is any damage to the integrity of the mucous membranes or integuments of the human body and underlying tissues. We can distinguish an immediate danger to the health and life of the victim, which arises immediately at the moment of injury and immediately after it, as well as later - after a certain period of time. In this regard, when providing first aid and during the treatment process, it is necessary to identify the most dangerous circumstances for a specific period of time and prevent possible complications. The immediate mortal danger after injury is caused by a violation of the anatomical integrity and functioning of vital organs and systems. In more late period The development of a wound infectious process, when secondary anatomical changes and functional disorders may occur, the development of gas gangrene, the breakthrough of the purulent contents of the wound into the bloodstream, and rabies, poses a huge danger to the successful healing of the wound and to the life of the wounded. Proper wound treatment prevents complications from occurring and reduces healing time several times. Protecting the wound from infection is best achieved by applying a bandage.

Bibliography

1.Artyunina G.P., Gonchar N.T., Ignatkova S.A. Fundamentals of medical knowledge: Health, illness and lifestyle. - Pskov, 2003 - 292 p.

2.Gogolev M.I., Gaiko B.A., Shkuratov V.A., Ushakova V.I. Fundamentals of medical knowledge of students: Prob. textbook for 0-75 avg. textbook institutions / Ed. M.I. Gogoleva - M.: Education, 1991. - 112 p.

3.#"justify">4. http://psyera.ru/klassifikaciya-ran-1467.htm

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A wound is damage to living tissues of the body caused by external influences, with a violation of the integrity of the skin or mucous membrane. In cases of deep wounds, not only the skin and subcutaneous tissue are damaged, but also nerves, muscles, tendons, bones, ligaments, and sometimes large blood vessels. Cases of penetration of a wounding object into any body cavity (abdominal, cranial cavity or other) are called penetrating wounds; they are often accompanied by damage to internal organs.

According to the method of occurrence, the following are distinguished: types of wounds:

mechanical injuries – caused by the action of a sharp or blunt object or instrument; the result of such wounds are puncture, cut, chopped, bruised, crushed, torn, bitten, and mixed wounds;

firearms– due to the use of firearms;

thermal– caused by excessive exposure to cold and heat; these are frostbite and burns;

chemical– arise due to exposure to chemically active alkalis and acids;

biological– caused by various kinds of bacteria and their toxic secretions;

mental- as a result of irritation nervous system And mental activity, for example, a feeling of constant fear or threats.

Also, injuries, depending on the severity, are classified into:

lungs– bruises, sprains, lacerations;

moderate severity- dislocations, fractures of small bones, such as phalanges of the fingers;

heavy– these include concussions, fractures of large bones (hips), and severe bleeding.

With mechanical and gunshot wounds, bleeding, pain and, in most cases, gaping of the wound - separation of its edges - will certainly occur. Wounds can be dangerous when an internal organ is injured, when there is bleeding from a large vessel, or when there is significant pain that causes shock. The main danger of wounds in other cases is the penetration through them of microorganisms that are causative agents of infectious complications (wound infection), and in some cases, the most dangerous general infectious diseases, such as rabies or tetanus.

Any wound, with the exception of the surgical operating room, is always contaminated with microbes right at the moment of injury. In the absence of properly provided first aid, pollution can continue in the future, this is the so-called secondary pollution.

As first aid for any type of injury, it is necessary to protect the wound from secondary contamination. The surrounding skin is treated with an alcohol solution of iodine, and a sterile bandage is applied, with obligatory observance of aseptic rules, avoiding touching the wound itself. In the case of a scalped wound, the flap of skin is often not completely torn off and can be tilted to the side, exposing the subcutaneous tissue to the outside. Then you should carefully lift the flap and lubricate its skin surface with iodine.

If the wound is bleeding profusely, first aid should begin with temporarily stopping the bleeding. In cases of severe wounds of the extremities, transport immobilization is required.

In cases of animal bites, both domestic and wild, even if the wound is minor, you should immediately consult a doctor for vaccinations against possible rabies infection.

Small, shallow wounds with slight divergence of edges and no visible contamination, in most cases heal under a bandage applied with correctly provided first aid. If, a day or two after the injury, pain in the wound resumes, this indicates the onset of an infectious complication and requires mandatory consultation with a surgeon. This especially applies to cuts and pricks of the fingers, which threaten the development of panaritium.

WOUNDS, INJURIES(syn. open damage); wound (vulnus) - damage to tissues and organs with disruption of the integrity of their covering (skin, mucous membrane), caused by mechanical impact; wound (vulneratio) - a mechanical effect (except for surgery) on tissues and organs, entailing a violation of their integrity with the formation of a wound. In the literature, both terms are sometimes used as synonyms (equivalents). Superficial wounds, in which there is incomplete (only the superficial layers) disruption of the skin or mucous membrane, are sometimes referred to as abrasions if the damage is caused by a flat object over a wide area, or as scratches if they are caused in a thin line by a sharp object. Separately, there are thermal, electrical, radiation and chemical damage to the skin and mucous membranes, which differ from wounds in etiology, pathogenesis, wedge, course and treatment (see Radiation damage, Burns, Frostbite, Electrical trauma). In these cases, we usually talk about the affected surface (for example, a burned surface) and only after rejection (excision) of charred, coagulated or necrotic tissue can we talk about a special type of wound (for example, a burn wound).

Classification

Rice. 1. Incised wound on the anterior wrist. Rice. 2. Chopped wound of the anterior forearm. Rice. 3. Bruised wound in the occipital region of the head. Rice. 4. Hand after traumatic amputation of the first and second fingers. Rice. 5. Multiple wounds to the face (a) and back (b) from grenade fragments.

According to the conditions of occurrence, the following types of wounds are distinguished: operating wounds, inflicted during the operation; random, applied to different conditions domestic and industrial environment; received in battle. Surgical wounds are usually applied taking into account the anatomical and physiological characteristics of the tissues to be separated under conditions of anesthesia and the use of measures to prevent microbial contamination. Such wounds are called aseptic (sterile). Accidental wounds, and especially wounds received in combat, arise from exposure to a variety of damaging factors and differ from surgical wounds in bacterial contamination.

According to the mechanism of application, the nature of the wounding object and tissue damage, wounds are cut, punctured, chopped, bitten, torn, scalped, bruised, crushed, or gunshot. Their main distinguishing feature is the different amount of destruction of tissue elements at the time of injury.

Incised wound applied with a sharp object, characterized by a predominance of length over depth, smooth parallel edges (tsvetn, table, Fig. 1), minimal volume of dead tissue and reactive changes in the circumference of the wound.

Puncture wound differs from cut wound by a significant predominance of depth over width, i.e., a deep, narrow wound channel, often separated into a number of closed spaces (as a result of displacement of layers of damaged tissue). These features cause a high risk of inf. complications during wound healing.

Chopped wound(tsvetn, table, fig. 2), resulting from a blow with a heavy sharp object, has a great depth; the volume of non-viable tissue at the time of wound application and in the subsequent period may be slightly greater than in cut wounds Oh.

Wounds caused by a circular saw or band saw are characterized by finely flapbed soft tissue edges and frequent bone damage.

Laceration is formed when a damaging factor acts on soft tissues that exceeds their physical ability to stretch. Its edges are irregular in shape, there is detachment or separation of tissue (Fig. 1) and destruction of tissue elements over a significant extent.

The so-called are allocated into a separate group. scalped wounds(see Scalping), characterized by complete or partial detachment of the skin (and on the scalp - almost all soft tissues) from the underlying tissues without significant damage. Such wounds occur when long hair gets caught in moving mechanisms (rollers, gears) of machine tools and other machines, limbs get caught in rotating mechanisms, or under the wheels of vehicles. These wounds are usually heavily contaminated with soil, lubricating oils, industrial dust, and foreign bodies.

Bruised wound(tsvetn, table, Fig. 3), which occurs from a blow with a blunt object, as well as a crushed wound, in which crushing and tissue rupture are observed, have a large area of ​​primary and especially secondary traumatic necrosis with abundant microbial contamination. Sometimes, under the influence of great force, causing rupture and crushing of tissues (Fig. 2,3), a complete separation of the limb segment occurs, the so-called. traumatic separation (tsvetn, table, Fig. 4), an essential feature of which is the separation of the skin above the level of separation of the underlying tissues.

Bite wound occurs as a result of a bite by an animal or a person, characterized by abundant microbial contamination and frequent inf. complications. When bitten by an animal, infection with the rabies virus can occur (see).

Gunshot wounds occur as a result of exposure to a firearm. In this case, the damage is characterized by a complex structure, a wide area of ​​primary and secondary traumatic necrosis, and the development of various complications (see below “Features of wartime wounds. Staged treatment”). The variety of firearms and ammunition systems determines a wide variety of gunshot wounds, the classification of which, in addition to morphology, signs characteristic of all wounds, also takes into account the type of wounding projectile. Thus, a distinction is made between bullet and shrapnel wounds (tsvetn, table, Fig. 5, 6) and shot wounds (Fig. 4). For gunshot wounds of individual anatomical areas and organs of the body (for example, chest, abdomen, pelvis, joints, etc.), private classifications have been developed.

In addition, there are tangential, blind and through wounds; penetrating and non-penetrating; with and without damage to internal organs; single, multiple and combined; aseptic, purulent infected; poisoned; combined.

At tangential wound the resulting wound channel lacks one wall. At blind wound the wound channel has no outlet and ends in the tissues; at penetrating wound There are inlet and outlet openings.

Penetrating called a wound, in which the wounding object falls into any cavity human body(pleural, abdominal, articular, cranial cavity, chambers of the eye, paranasal sinuses, etc.) provided that it perforates the entire thickness of the wall of the corresponding cavity, including parietal leaf pleura, peritoneum, etc.

Multiple wounds occurs when two or more organs (areas of the body) are damaged by several damaging agents of the same type of weapon (for example, injury to the upper and lower extremities by two bullets).

At combined injury there is damage to two or more adjacent anatomical areas or organs caused by a single damaging agent (for example, a bullet wound to the stomach and spleen).

At combined wounds a wound occurs as a result of the action of a mechanical factor in various combinations with other damaging factors of modern weapons - thermal, radiation, chemical, bacteriological. Taking into account the damage by several factors, the term “combined wounds” fell out of use and was replaced by the corresponding term - combined lesions (see).

TO aseptic(sterile) include surgical wounds inflicted under conditions of strict adherence to the principles of asepsis and antisepsis. This name is arbitrary, because in reality, truly aseptic wounds are rare. However, the degree of bacterial contamination of surgical wounds, especially pathogenic or conditionally pathogenic microflora, as a rule, is significantly lower than the critical dose - the minimum amount that causes an infectious process.

Under bacterial(microbial) contamination of a wound is understood as the entry of microbes into the wound at the time of its occurrence (primary bacterial contamination) or during treatment if the rules of asepsis and antisepsis are violated (secondary bacterial contamination). The concept of “bacterially contaminated wound” is not synonymous with the concept of “infected wound”, because under the influence of the autoantiseptic properties of the tissues themselves, cellular elements of the blood, tissue fluids and other factors of the body’s natural defense developed in the process of phylogenesis (see), all bacteria or a significant part of them die into the wound. Only bacteria remain in the wound that are in a state of symbiosis (see) with the macroorganism, which retain the ability to develop and reproduce, but do not cause general disturbances in the body and do not aggravate the course of the wound process. This microflora plays an important role in wound healing by secondary intention. By participating in the destruction and transformation of necrotic tissue into a liquid state (see Pus), i.e., promoting suppuration of the wound, they accelerate its cleansing and healing (see Wound infections). A wound that heals by secondary intention, in which suppuration is an obligatory component of the wound process, is called purulent.

The symbiosis of bacteria and a macroorganism is possible only under certain conditions, the violation of which can lead to the spread of pathogenic microflora in the tissue beyond the wound, into the lymphatic and blood vessels. As a result, inf develops. process in the wound (see Abscess, Cellulitis), complicating the course of the wound process and worsening the general condition of the patient. This wound is called infected.

Poisoned wound- this is a wound into which poisonous chemicals have penetrated. substances. Substances that have predominantly local action(acids, alkalis, etc.) quickly cause tissue necrosis. Such wounds are usually complicated by infection and heal by secondary intention. If substances with a general toxic effect enter the wound, for example. organophosphorus compounds (see), general poisoning of the body occurs.

Pathogenesis

The wound process is a complex complex of general and local reactions the body in response to injury, ensuring wound healing.

In uncomplicated cases, general reactions occur in two phases. For first phase(1-4 days after injury) characterized by agitation sympathetic division autonomic nervous system (see), accompanied by an increased release of adrenaline into the blood (see), under the influence of which the vital activity of the body and basal metabolism increase, the breakdown of proteins, fats and glycogen increases, the permeability of cell membranes decreases, the mechanisms of physiology are inhibited. regeneration, the aggregation properties of platelets (see Aggregation) and the processes of intravascular coagulation are enhanced. The activity of the adrenal cortex (see), which secretes glucocorticoid hormones (see), which have an anti-inflammatory effect, reducing the permeability of the vascular wall and stabilizing cell membranes, also increases. Thus, in response to the injury, an adaptation syndrome develops, at the beginning of which the cells seem to tune in to a new nature of metabolism and the forces of the body as a whole are mobilized.

For second phase(4-10 days after injury) the predominant influence of the parasympathetic department is characteristic. n. pp., the action of mineralocorticoid hormones (see), aldosterone (see) and other hormones and mediators that activate regeneration processes. In this phase, metabolism, especially protein metabolism, is normalized, and wound healing processes are activated.

Local reactions occurring in damaged tissues (i.e., the wound process itself) were studied by N. I. Pirogov 1861), I. G. Rufanov (1954), S. S. Girgolav (1956), I. V. Davydovsky ( 1958), A. A. Voitkevich (1965), V. I. Struchkov (1975), House (1929), Merle (1968), etc. Researchers note that the wound process in its development naturally goes through several successively replacing phases . Various classifications of these phases have been proposed.

The classification proposed by M.I. Kuzin (1977) distinguishes the inflammation phase during the wound process (consists of two periods - the period vascular changes and the period of cleansing the wound from necrotic tissue), the regeneration phase (formation and maturation of granulation tissue) and the phase of scar reorganization and epithelization.

During the wound process, a number of natural cellular and humoral changes are observed, the combination and degree of severity of which determine its dynamics. In addition to morphol, changes, these include changes in microcirculation (see), the action of mediators (see) and other biologically active substances, changes in metabolism, etc.

Changes in microcirculation when injured, they are caused by reactive phenomena on the part of arterioles, capillaries and venules and their damage, as well as changes in the lymph and capillaries. The first reactive phenomena include vasospasm in the wound area, followed by paralytic dilation. At the same time, as a result of bleeding (see), hemostasis mechanisms are activated, in which the main role is played by blood coagulation processes with the formation of a blood clot inside the damaged vessel (see Thrombus). With the participation of the fibrin-stabilizing factor of blood plasma, fibrin threads appear on the surface of the wound, which has mechanical, bacteriostatic and sorption properties, and also plays an important role in the antibacterial protection of tissues and subsequent regenerative and reparative processes, the so-called. fibrinous barrier.

Rapidly growing traumatic edema is apparently the result of a two-phase process.

In the first phase, its development is based primarily on a reflex spasm of blood vessels with the occurrence of hypoxia (see) and acidosis (see) of tissues, which cause an increase in the permeability of the vascular wall and tissue osmolarity (see Osmotic pressure).

In the second phase, humoral mechanisms are activated. According to I.V. Davydovsky, the development of traumatic edema in this phase is associated with an increase in the permeability of capillary walls caused by the release and activation of intracellular enzymes in damaged tissues. Some importance is attached to degranulation mast cells and the release of substances (histamine, serotonin) on the surface of the endothelium, which increase its permeability, as well as the formation in damaged tissues of small peptides of endogenous origin, which increase the permeability of the vascular wall and cause vasodilation. The initial spasm of blood vessels is replaced by paretic dilation, and the acceleration of blood flow by its slowdown and the appearance of stasis (see), which further enhances hypoxia and tissue acidosis. Violations are essential local circulation associated with changes in the rheological properties of blood (increased plasma viscosity and hemoconcentration) and intravascular aggregation of its formed elements. Metabolic disorders with the accumulation of patol metabolic products in damaged tissues (see Metabolites) aggravate the progression of traumatic edema. Biol, and wedge, the significance of traumatic edema is that it promotes spontaneous stopping of bleeding from small vessels and cleansing of the wound by displacing rejected tissue sections, blood clots and small foreign bodies from the wound canal, thereby providing the so-called. primary wound cleansing. Thanks to traumatic swelling, the edges of the wound come closer together, which helps their consolidation. At the same time, causing a significant increase in interstitial pressure, traumatic edema increases microcirculation disorders and tissue hypoxia, which can contribute to the appearance of new foci of necrosis.

Chem. Mediators of the wound process regulate regenerative and reparative processes in the wound. All substances of this group are sharply activated in damaged tissues; they exhibit pronounced activity even in negligible concentrations. The ratio of mediators determines the nature of the wound process and the rate of wound healing. M.I. Kuzin (1981) et al. the following groups of mediators are distinguished: substances entering the wound from plasma (part of the kallikrein-kinin system, complement system, blood coagulation and fibrinolysis system); substances of local origin (biogenic amines, acidic lipids, leukocyte and lysosomal components, tissue thromboplastins); other substances that can be formed in the lesion and far from it (plasmin, biogenic amines).

The kallikrein-kinin system includes kallikreins - enzymes that break down the inactive kininogen molecule into active kinin, and kinins (see) - small peptides that cause vasodilation, increasing vascular permeability and contraction of smooth muscles (located in the plasma in the form of inactive kininogen). The main mediator of this system is bradykinin (see Mediators of allergic reactions), which stimulates the contraction of smooth muscle cells, increases the permeability of microvessels and their expansion.

The complement system (see) is a group of substances activated by a number of compounds, especially the antigen-antibody complex (see Antigen-antibody reaction). The system consists of AND proteins or 9 groups called complementary components. Functionally, this system is connected with the kinin system and the system of blood coagulation and fibrinolysis. Most complement components are enzymes that circulate in the blood under normal conditions in the form of inactive forms. When wounded, each component is activated by its predecessor and activates the next component. In this case, they are biologically released active substances, causing an increase in the permeability of the vascular wall, leukocyte chemotaxis, phagocytosis and immune reactions.

Mediators from the group of acidic lipids (see) include some fatty acids (see), for example, arachidonic, linoleic, etc. and their derivatives - prostaglandins (see), involved in the regulation of the exchange of cyclic nucleotides in cells (see Nucleic acids ). Mediators of this group influence the inflammatory response in damaged tissues, platelet aggregation and cause a general increase in body temperature (fever). Under the influence of prostaglandins, the sensitivity of pain receptors to mechanical and chemical irritations increases. By interacting with bradykinin, acidic lipids contribute to the development of edema, and accumulating in the wound, they have a pronounced effect on microcirculation, the vital activity of leukocytes and other cells.

The blood coagulation system (see) and fibrinolysis (see), providing hemostasis, are included in the wound process at its earliest stage and do not lose their importance until complete epithelization of the wound. Many factors of the coagulation system (fibrinogen, tissue thromboplastin, Hageman factor, fibrin-stabilizing factor, antiplasmins, heparin) are chemical. mediators of the wound process involved in its regulation. When vascular damage occurs, the Hageman factor is activated, which interacts with mediators, causing an increase vascular permeability. The Hageman factor triggers the activity of the blood coagulation system, promotes the activation of the fibrinolytic system and, through the activation of prekallikrein, causes the formation of active kinins, i.e., it performs a trigger function (see Trigger mechanisms) in the initial phases of the wound process and inflammation. Activation of plasminogen causes fibrin to melt and thereby promotes wound cleansing. In addition, some other proteases (see Peptide hydrolases), for example, contained in neutrophil leukocytes, can also, like an activated plasmogen (plasmin), take part in the breakdown of fibrin clots.

A group of leukocyte and lysosomal enzymes - proteases, phosphatases (see), cathepsins (see), etc. participate in the intracellular breakdown of microstructures phagocytosed by leukocytes and macrophages. Entering the extracellular environment during the breakdown of leukocytes, they activate and catalyze the hydrolysis of biopolymers, ensuring the melting of particles of dead cells and bacteria located in the wound, and contribute to its cleansing. In addition, lysosomal hydrolytic enzymes and substances contained in the granules of neutrophil leukocytes catalyze the transition of inactive forms of other enzymes (plasminogen, Hageman factor, kallikreinogen) into active ones and determine the formation of products that stimulate repair.

Adrenaline and norepinephrine (see) released during tissue damage cause spasm of small vessels, decrease the permeability of their walls and promote increased formation (under the influence of proteolytic enzymes) of histamine, peptides and surfactants. Histamine (see), which causes hyperemia, exudation, fibrin loss and migration of leukocytes, has the opposite effect on tissue. The effect of histamine is short-lived; it only plays the role of a triggering mediator of inflammation, since it is quickly destroyed by histaminase and blocked by heparin.

Serotonin (see) has an effect close to histamine.

To other chem. mediators of the wound process, which have not yet been studied enough, include tissue breakdown products.

Mediator systems function in close interaction; the leading significance of any of them has not yet been determined. Schematically, the action of mediator systems can be represented in this way. As a result of tissue damage, biogenic amines, tissue thromboplastin are released, Hageman factor is activated, and then kallikreinogen, a plasma precursor of thromboplastin and lysosomal components. Then plasmin, prostaglandins and the complement system are turned on. Tissue thromboplastin triggers the hemostasis system. As a result of activation of kallikreinogen, active kallikreins are formed, which catalyze the formation of kinins, causing a persistent and long-term increase in vascular permeability and influencing other factors in the initial stage of the wound process. Subsequently, due to impaired microcirculation and the development of hypoxia, prostaglandins accumulate, the complement system is activated, and lysosomal enzymes appear that help cleanse the wound and heal it.

Changes in metabolism (see Metabolism and energy) in the wound affect all types of metabolism; They are especially clearly manifested in the development of local acidosis, as well as in the accumulation of products of impaired metabolism in the tissues.

Acidosis in the wound occurs in two phases. The first phase (decrease in pH to 6.0) develops within a few seconds after injury as a result of local acid formation - primary acidosis. The second phase (decrease in pH to 5.0 and below) is the result of metabolic changes, chap. arr. activation of anaerobic glycolysis - secondary acidosis.

Initially, acidosis is compensated and is manifested only by a decrease in the level of standard bicarbonate and an increase in excess bases. With purulent-demarcation inflammation, especially insufficient outflow of wound fluid, buffer systems are depleted, and uncompensated (true) acidosis develops, in which the concentration of hydrogen ions in tissues can increase 50 times or more. Moderately expressed local acidosis is a secondary pathogenetic factor of the wound process, since it promotes the development of infiltrative-exudative phenomena in the wound, increases capillary permeability, enhances the migration of leukocytes and stimulates the activity of fibroblasts. When severe, acidosis causes the death of tissue structures and has an inactivating effect on chemical reactions. mediators of the wound process.

In purulent wounds, the concentration of hydrogen ions varies widely. According to M.I. Kuzin et al. (1981), in 30% of the examined wounded the reaction of the wound environment was neutral or alkaline. In the cytograms of wound discharge in an acidic environment, polyblasts, macrophages predominated, and young fibroblasts were found, i.e., there were clear signs of repair, while in an alkaline reaction, neutrophilic leukocytes in the decay stage were found in large numbers. From these data it follows that both acidic and alkaline hydrolases are involved in the wound process and that by changing the acidity of the wound environment, it is possible to regulate their activity, promoting wound healing.

Simultaneously with the change in the acid-base state of the tissues, the concentration and quantitative ratios of electrolytes in them change (for example, the number of potassium ions increases compared to the number of calcium ions), products of incomplete oxidation accumulate (lactic and oil acids, etc.), the composition changes cellular colloids, etc., which leads to an increase in osmotic pressure, edema and swelling of tissues, and in severe cases- to their secondary necrosis.

When purulent-demarcation inflammation occurs, a large number of enzymes of both endogenous origin (from decaying leukocytes, lymphocytes and other cells) and exogenous ones appear in the wound. Among exogenous enzymes, enzymes are of particular importance bacterial origin- hyaluronidase (see), streptokinase, bacterial deoxyribonuclease (see), collagenase (see), etc., causing proteolysis of dead tissue and promoting biol, wound cleaning. According to M.F. Kamaev, V.I. Struchkov and others, the activity of enzymatic systems reaches a maximum at the height of the development of the inflammatory process and decreases as the granulation tissue matures.

According to V. V. Vinogradov (1936), B. S. Kasavina et al. (1959), from the moment fibroblastic proliferation occurs in the wound, the synthesis and accumulation of sulfate-containing acid mucopolysaccharides (see), as well as hyaluronic acids (see), the concentration of which decreases as the collagen fibers mature, increases. The main role in the formation of collagen, so necessary for wound healing, is played by the biosynthesis of collagen protein, which occurs in fibroblasts. The final formation of collagen fibers is completed by the formation of collagen complexes with mucopolysaccharides, hyaluronic acid, chondroitin sulfate (see Chondroitinsulfuric acids) and other components of the intercellular substance.

The level of protein and vitamin supply to the body has a significant impact on the course of the wound process, since proteins and vitamins, in addition to their general effect, help to increase the functional activity of cells that ensure wound cleansing, the development of granulations and collagenogenesis.

When studying the resulting preparations, the phagocytic ability of neutrophils (microphages) and macrophages and the nature of phagocytosis are first assessed. With normal immunol. resistance of the body, phagocytosis ends with the lysis of pathogens in the cytoplasm of phagocytes, and the prints contain phagocytes at different stages of phagocytosis. If the body's resistance is insufficient, neutrophils with incomplete phagocytosis appear in the prints, in which the cytoplasm of the phagocyte is destroyed with the release of pathogens contained in it, but not subjected to lysis, into the environment. In the complete absence of a phagocytic reaction (for example, in sepsis), neutrophils find themselves surrounded on all sides by microorganisms without signs of their phagocytosis.

Next, the nature of the cells of the reticuloendothelial system located in the prints is assessed (see). Polyblasts and macrophages appear in wound exudate somewhat later than neutrophils, and their number increases as reactive processes develop. Appearance degenerative changes in the cytoplasm of polyblasts or a violation of their maturation (the predominance of young forms for a long time) is a sign of reduced body resistance or high virulence of pathogenic microflora of the wound. Intensive maturation of polyblasts into Mechnikov macrophages, which differ from polyblasts in the presence of digestive vacuoles and high phagocytic activity, is an indicator of a good protective reaction of the body and indicates the beginning of biol, wound cleaning; their disappearance in prints during the dehydration stage is associated with the formation of healthy granulation tissue. During the wound healing phase, polyblasts mature into profibroblasts, and then into fibroblasts, which, multiplying, gradually displace microphages.

The appearance of Unna plasma cells in the prints, distinguished by a characteristic spotted nucleus and a darker color of the cytoplasm, is significant. These cells do not transform into any other elements; they die during the healing process of the wound, and their massive appearance in the print indicates unfavorable changes in the regenerative and reparative processes and the failure of the treatment.

Other cells that can be found in prints, for example, eosinophils and so-called. giant cells of foreign bodies are not significant for assessing the course of the wound process.

At the same time, it is advisable to take into account the number of microorganisms found in wound prints and the dynamics of microbial contamination. I. I. Kolker et al. (1976) believe that such control must be supplemented by counting the number of microbes in 1 g of tissue that makes up the wound surface.

M. F. Kamaev (1970) recommends taking for cytol. research, scraping the surface layer of the wound, which is transferred to a glass slide in the form of a thin uniform layer, fixed and stained. This material contains not only cells of the wound discharge, but also newly formed cells of the surface layer of the wound, the composition and nature of which serve as additional material for assessing the state of regenerative and reparative processes in the wound.

Clinical picture

A fresh accidental wound is characterized by pain (see), the intensity and nature of the cut depend on the location and type of wound, as well as on the condition of the wounded (in a state of passion or deep alcohol intoxication pain is less pronounced or absent). There are also disturbances or limitations in the function of the damaged part of the body, minor in case of superficial wounds and abrasions and sharply expressed in case of damage to nerve trunks, tendons, blood vessels, muscles, bones, joints. A characteristic feature of the wound is its gaping, that is, the divergence of the edges associated with the elastic properties of the tissues, more pronounced in the wound located perpendicular to the course of the scallops of the skin, muscle and fascial fibers. There is bleeding (see) from damaged vessels of the wound wall, usually mixed, of the capillary type, which stops on its own or after applying a bandage. If major blood vessels are damaged, it can be life-threatening. Blood can soak into tissues (see Hemorrhage) or accumulate in interfascial spaces, subcutaneous, retroperitoneal, and perinephric tissue (see Hematoma). In some cases, the hematoma, communicating with the lumen of the damaged artery, forms the so-called. pulsating hematoma. With penetrating wounds, blood can flow into the corresponding cavity and accumulate there (see Hemarthrosis, Hemoperitoneum, Hemothorax). From a penetrating wound, depending on its location, intestinal contents, bile, pancreatic juice, as well as cerebrospinal fluid, urine, etc. can be released.

When injured, the general condition of the body is disrupted to varying degrees. With superficial wounds without significant bleeding, these disturbances are minor. With extensive laceration, crush and gunshot wounds, complicated by significant blood loss (see), hemodynamic disturbances occur, manifested by a decrease in blood pressure, general weakness, dizziness, nausea, pallor of the skin and mucous membranes, and tachycardia. In severe cases, a wedge develops, a picture of traumatic shock (see).

Wedge, the course of the wound process depends on the nature, location and size of the wound, the degree of microbial contamination, the adequacy of the treatment, as well as the immunological characteristics of the body.

When a wound heals by primary intention pain in the wound decreases or disappears by the end of the second day, pain on palpation or movement persists longer. Wedge, signs of reactive inflammation (hyperemia, swelling of the wound edges, local increase in temperature) are weakly expressed and disappear by the end of the first week. By this time, epithelization is completed and a delicate skin scar is formed (see). In the deep layers of the wound, scar formation occurs more slowly, which must be taken into account when determining the work schedule and physical activity of the patient. General phenomena are also less pronounced: low-grade fever, slight leukocytosis, acceleration of ROE are observed only in the first 3-4 days, and then disappear without special treatment. The occurrence of these changes is associated with the resorption of decay products of damaged tissue from the wound, physical inactivity and impaired pulmonary ventilation in weakened patients.

Healing of a wound under a scab takes longer, but the general phenomena are expressed as insignificantly as with healing by primary intention.

Wedge, course of wounds, healing by secondary intention, is largely determined by the development of inf. complications, the severity of purulent-demarcation inflammation and, therefore, largely depends on the developing relationship between the macroorganism and the microorganisms located in the wound. In uncomplicated cases, when the microflora of the wound is one of the components normal course wound process, many researchers identify in the wedge, during the wound process, periods of incubation, spread and localization of microbes.

The incubation period, usually coinciding with the first period of the first phase of the wound process, during which the wound microflora is formed, can last from several hours to 2-3 days. During this period, the condition of the wound is determined by the nature of tissue damage, and the general reactions of the body are determined by the severity of the injury and blood loss.

The period of microflora spread is clinically manifested by the development of purulent-demarcation inflammation (the second period of the first phase of the wound process), during which microbes penetrate deeper (especially damaged) tissues and multiply in them. Local symptoms of inflammation and signs of changes in the general condition of the body appear (deterioration of health, increase in body temperature, the appearance of leukocytosis, etc.), caused by Ch. arr. resorption of microbial waste products and decay products of dead tissue in the wound. The appearance of the wound changes: its edges are swollen, covered with fibrinous-necrotic plaque, the wound discharge takes on the appearance of serous-purulent exudate. If the course is favorable, this period lasts on average approx. 2 weeks

Then comes a period of microflora localization, during which it is suppressed, and wound healing processes develop (the second and third phases of the wound process). The wound is gradually cleared of necrotic tissue and filled with juicy bright red granulations. Wedge, signs of inflammation decrease and then completely disappear, wound discharge becomes thicker and loses its purulent character. Body temperature normalizes, the appetite and well-being of the wounded improve.

Despite the fact that during this period small bone sequesters (see Sequestration, sequestration), foreign bodies (ligatures, metal fragments, pieces of clothing, etc.) may depart from the depths of the wound, the process of delimiting dead tissue and their elimination can be considered mainly finished. The period of localization of infection can last a long time until the damaged integument - skin or mucous membranes - is restored; Until this moment, the wound or part of it remains filled with granulation tissue.

Complications

During the incubation period of infection complications associated with Ch. arr. with the nature and location of the wound. The most dangerous of them are shock and acute blood loss. Bleeding into confined spaces (cranial cavity, pleura and pericardium, spinal canal, etc.) can cause compression of vital organs. Penetrating wounds of the skull are often accompanied by liquorrhea (see), chest - hemopneumothorax (see Hemothorax); abdomen - the development of peritonitis (see).

During the period of spread of infection observed inf. complications of the wound process. In an infected wound, unlike a purulent wound, suppuration is a complication and not a natural component of the wound process. The emergence of inf. complications are facilitated by massive contamination of the wound with pathogenic microflora, accumulation of wound discharge due to insufficient drainage, the presence of foreign bodies, impaired blood supply to tissues in the damaged area (segment), reduction and distortion of the general reactivity of the body (nutritional dystrophy, hypovitaminosis, exposure to ionizing radiation, etc.). Depending on the type of pathogen, the wound process can be complicated by purulent, anaerobic and putrefactive infection (see Anaerobic infection, Putrefactive infection, Purulent infection). With a purulent infection in the wound area, it can develop purulent inflammation in the form of an abscess (see), phlegmon (see), purulent streaks (see), erysipelas (see Erysipelas), lymphangitis (see), lymphadenitis (see), thrombophlebitis (see), etc. As a result of purulent processes, arrosive bleeding is possible. The entry into the body of tissue decay products and toxic substances of microbial origin causes a febrile state, which I. V. Davydovsky defined as purulent-resorptive fever (see). Long-term suppuration and delayed wound healing, local and general disorders immune processes can lead to traumatic exhaustion (see) of the body or generalization of infection - sepsis (see).

During the healing period secondary infection is possible, which is usually provoked by injury or superinfection. Complications in this period are associated with hl. arr. with disruption of regenerative and reparative processes in the wound. Such complications include separation of the edges of the wound after removal of the sutures in the absence of suppuration, prolonged non-healing of the wound, the formation of ulcers (see Ulcer), fistulas (see), keloid scars (see Keloid), various deformities. General complications this period are often caused by prolonged intoxication, immunological and metabolic disorders(protein wasting, amyloidosis). In long-term non-healing wounds (ulcers), purulent fistulas, massive ulcerating scars, a malignant tumor can develop (see Tumors).

A special group of complications are therapeutic diseases, often arising or passing into the active phase due to injury: pneumonitis (see), pneumonia (see), gastritis (see), exacerbation peptic ulcer(see), hepatitis (see). According to N. S. Molchanov, E. V. Gembitsky and others, the course of these diseases has features associated with the location of the wound and the phase of the wound process.

Disorders of the cardiovascular system in the early period after injury, they are predominantly functional in nature and are expressed in increased heart rate and respiration, decreased blood pressure, pallor or cyanosis of the mucous membranes and skin, pain in the heart area, and general weakness. They are usually easy to treat. However, with injuries, for example, to the brain and spinal cord, chest, accompanied by difficult to eliminate hypoxia, such disorders are persistent and require long-term treatment.

With massive injuries to soft tissues, acute renal failure often develops (see Traumatic toxicosis), with injuries to large tubular bones - kidney stones, in case of acute blood loss - hypochromic Iron-deficiency anemia(see), with infected wounds - infectious toxic nephrosis (see Nephrotic syndrome), focal and diffuse glomerulonephritis (see), wound psychoses, etc.

Wound psychoses

Wound psychoses are a type of symptomatic psychoses (see). Most often they develop with injuries to the lower and upper extremities, chest and maxillofacial area, complicated by acute or chronic wound infection, especially osteomyelitis. Just like other symptomatic psychoses, they can be acute and protracted (protracted).

Acute wound psychoses develop in the first 2-3 weeks. after injury in the presence of an acute wound infection with a suppurative process in soft tissues and bones. In the etiology and pathogenesis of such acute psychoses, an important role is played by the infectious-toxic factor. With suppuration of soft tissues wedge, the picture is limited mainly to exogenous type reactions (see Wongeffer exogenous types of reactions). Psychosis is preceded by asthenia (see Asthenic syndrome), a feature of the cut is severe sleep disturbances and sometimes hypnagogic hallucinations (see). Delirium is the most common of the clouded consciousness syndromes (see Delirious syndrome). The characteristic content of delirium among the wounded in a combat situation is military themes. In more severe cases, amentia develops (see Amentia syndrome), often with motor agitation, less often with stupor. Amentive syndrome often begins with delirium of ordinary content, reflecting the real situation. It is also possible to develop twilight stupefaction in the form of epileptiform excitation. Acute wound psychoses last several days and usually end with mild asthenia. Psychosis acquires a more complex wedge and picture when the wound process is complicated by osteomyelitis.

In this case, after amentia, transient Vic syndromes may develop (see Symptomatic psychoses) in the form of hallucinatory-paranoid and depressive-paranoid symptom complexes, and the psychosis ends with asthenia of a more complex nature with hypochondriacal and hysterical disorders. This variant of wound psychoses occupies an intermediate position between acute and delayed psychoses.

Protracted wound psychoses develop with chronic wound infection after 2-4 months. after injury. In their etiology and pathogenesis, a significant place is occupied by the phenomena of hypoxia, prolonged intoxication, anemia, pronounced electrolyte imbalance, and in severe cases - dystrophic changes, and areactivity of the body. A psychogenic factor also takes part in the formation of protracted wound psychoses. Repeated injuries contribute to the development of wound psychoses. intoxication, infection. Wedge, the picture of affected wound psychoses is characterized by transitional Vic syndromes, often in the form of depression, depressive-paranoid and hallucinatory-paranoid syndromes with delusions of self-blame, hypochondriacal statements. An apathetic stupor and paralysis-like state with euphoria and foolishness are also possible. States of darkened consciousness occur much less frequently. With wound exhaustion, a prognostically unfavorable apathetic stupor, a paralysis-like and anxious-melancholy state with unaccountable anxiety, melancholy, fear, agitation and suicidal attempts develop, as well as states of obliteration of consciousness (see Stunning) with disorders of the body diagram. Protracted wound psychoses end in deep asthenia; development of psychoorganic syndrome is possible (see).

Treatment of acute wound psychoses possible in a surgical hospital setting, since it primarily involves treatment of the underlying disease. To relieve agitation, neuroleptics are used (aminazine, tizercin, haloperidol, triftazine). Protracted wound psychoses require treatment in a psychiatric hospital. Along with general strengthening, detoxification and anti-infective therapy, psychopharmakol is used carefully, taking into account the characteristics of the somatic condition. drugs - neuroleptics (see Neuroleptic drugs) and tranquilizers (see).

Treatment

Treatment of wounds is a system of measures, including first aid, surgical treatment of the wound, a set of measures aimed at increasing the body’s immune forces, preventing infections and combating it and other complications, the use of physiotherapy methods, treatment. physical education, etc. The extent of use of these activities. their sequence and execution time are determined by the nature and location of the wound and the condition of the wounded, and in wartime - by the combat and medical situation at the medical stages. evacuation.

When providing first aid, the edges are usually carried out at the site of the wound, first of all stopping external bleeding (see) by digitally pressing a blood vessel outside the wound, giving an elevated position or forced flexion of the limb, applying a pressure bandage, tourniquet (see Hemostatic tourniquet ) or twists from improvised material. The wound circumference is freed from clothing (shoes) and, if conditions permit, the skin around the wound is treated with 5% alcohol solution of iodine, after which an aseptic bandage is applied to the wound.

For small superficial skin wounds (abrasions and scratches), the role of the primary dressing can be performed by a protective film of film-forming preparations applied to the wound (see) such as plastubol, etc., which have antiseptic properties.

For bone fractures, injuries to joints, large blood vessels and extensive damage to soft tissues, transport immobilization(see) using tires (see Tires, splinting) or available material, after which the victim should be urgently taken to the hospital. institution.

In hospital conditions, the wounded person is brought out of the state of shock, antitetanus serum and tetanus toxoid are administered to him (see Tetanus) and measures are taken to prepare for the operation (see Preoperative period). In particularly severe cases, the use of hyperbaric oxygenation is indicated (see), which helps to normalize hemodynamic parameters and has a positive effect on the condition of the wound.

Surgical treatment is the main method of wound treatment. It involves surgical treatment - primary and secondary (repeated) and surgical methods for closing the wound defect - the application of primary, primary delayed, secondary early and late sutures and plastic surgery (see Primary suture, Secondary suture, Plastic surgery, Surgical debridement).

Primary surgical treatment of wounds performed until wedge and signs of wound infection appear. Its goal is to prevent wound infection and create the most favorable conditions for wound healing. It is achieved by radical excision of all dead and non-viable tissue. Hemostasis is performed and the wound is drained. The walls of the wound channel should be living, well-vascularized tissue. Primary surgical treatment performed in the most optimal time (up to 24 hours after injury) is called early. Modern means of antibacterial therapy make it possible to delay the development of wound infection and, if necessary, delay surgical treatment for up to 48 hours. (delayed primary surgical treatment of wounds). Primary surgical treatment performed after 48 hours is called late. In the practice of modern surgery, there has been a tendency to carry out primary surgical treatment of a wound as a one-stage primary reconstructive operation, widely using primary and early delayed skin grafting (see), metal osteosynthesis (see), reconstructive operations on tendons, peripheral nerves (see Nervous suture ) and blood vessels.

Secondary (repeated) surgical treatment of wounds is performed in the presence of a wedge, manifestations of a wound infection in order to eliminate it. This goal is achieved by excision of the walls of a purulent wound within healthy tissues (complete surgical debridement of a purulent wound), if this is not possible, they are limited to dissection of the wound, opening of pockets and leaks and excision of only large necrotic, non-viable and pus-impregnated tissues (partial surgical debridement of a purulent wound). Secondary surgical treatment of wounds, if indicated, can be performed at any phase of the wound process; It is especially advisable in the inflammation phase, since it ensures the fastest removal of dead tissue and transfer of the process to the regeneration phase.

In the practice of surgical treatment of wounds, secondary surgical treatment can be both the first operation for a wounded person, if for some reason primary surgical treatment was not performed, and the second, if the purpose of the primary treatment - prevention of wound infection - has not been achieved.

Primary surgical suture used as the final stage of primary surgical treatment in order to restore the anatomical continuity of tissues, prevent secondary microbial contamination of the wound and create conditions for healing by primary intention. The wound can be sutured tightly only if it is possible to perform radical primary surgical treatment. The application of primary sutures is permissible only if such conditions are met as the absence of excessive contamination of the wound, excision of all non-viable tissue and removal of foreign bodies, preservation of the blood supply to the wound area, the possibility of bringing the edges of the wound together without gross tension and, if the condition of the wounded is not aggravated by blood loss, fasting, inf. disease. The wounded person should be under the supervision of a surgeon after the initial treatment until the sutures are removed. Failure to comply with any of these requirements leads to serious complications. Therefore, primary sutures are most often applied to shallow musculocutaneous wounds. These, in particular, include cut, chopped, sawn, some bullet wounds, etc. Deep blind wounds, especially those accompanied by a bone fracture, after surgical treatment are temporarily left open and packed. In the surgical treatment of extensive crushed, bruised, and especially gunshot wounds, it is almost impossible to guarantee compliance with the above conditions (primarily the radicality of the surgical treatment). In this regard, the so-called delayed primary suture, which is applied 5-7 days after surgery (before granulation appears) in the absence of signs of wound suppuration. It can be used in the form of provisional sutures, which are applied during surgery, but tightened after a few days, making sure that there is no danger of wound suppuration.

In the practice of peacetime surgery, the possibility of applying a primary suture during the surgical treatment of abscesses, phlegmons, and after secondary surgical treatment of festering wounds is being studied. The success of such operations is achieved only under the condition of complete excision of necrotic tissue, adequate drainage of the wound, followed by prolonged washing with solutions of antiseptics, proteolytic enzymes and rational antimicrobial therapy.

Early secondary sutures applied to a granulating wound that has been cleared of pus and necrotic tissue (2nd week after surgical treatment). If scar tissue has formed in the wound, preventing the edges of the wound from approaching each other, they are excised and late secondary sutures are applied (3-4 weeks after surgical treatment).

A prerequisite for the success of the operation is the creation of unimpeded outflow of wound fluid using various drainage methods (see). The most effective methods are active aspiration of wound fluid using various vacuum systems (see Aspiration drainage).

To prevent wound infection, primary surgical treatment of the wound is combined with the use of antibiotics (see), which are administered in the form of solutions directly into the wound or surrounding tissues by intramuscular injection; The most effective is the combined administration of long-acting antibiotics. Sulfonamides and other antibacterial agents are also used.

If after the initial surgical treatment, completed with a primary suture, healing proceeds by primary intention, the bandage is changed on the 2-3rd day and the wound is no longer bandaged until the sutures are removed (usually on the 7-10th day). When the wound suppurates, the sutures are removed partially or completely and the necessary treatment is applied. Events; if a seroma is present, it is opened and the festering ligatures are removed. Such wounds heal by secondary intention.

Treatment of wounds that heal by secondary intention is much more difficult. In the phase of hydration and biol, cleaning such a wound, treat. measures should contribute to the rapid rejection of non-viable tissues and suppression of pathogenic microflora. To improve the rejection of necrotic tissue and reduce the resorption of toxic components of wound exudate in this phase, suction dressings (see) with hypertonic solution of sodium chloride and certain antiseptics are widely used, as well as powdered substances (for example, Zhitnyuk’s powder) and sorbents ( e.g. activated carbon). Effective for the purposes of biol, wound cleaning are proteolytic enzymes (see Peptide hydrolases) of pancreatic, for example, chymotrypsin (see), and bacterial origin, which, along with a necrolytic effect, have anti-inflammatory and anti-edematous properties, significantly reduce the duration of the wound hydration period. Enzyme preparations in some cases enhance the effect of antibiotics, making their combined use advisable.

Antibacterial therapy for wounds carried out taking into account immunol. state of the body, the nature of the microflora of the wound, individualization of chemotherapeutic agents. If there are staphylococci in the wound, usually resistant to the most widely used antibiotics (penicillin, streptomycin, tetracycline, etc.), antibiotics with higher antistaphylococcal activity (erythromycin, novobiocin, ristomycin, oleandomycin, polymyxin, etc.) are used, as well as drugs nitrofuran series (furacilin, furazolin, furazolidone, solafur). To increase the effectiveness of antibacterial therapy and reduce drug resistance of microflora, V. I. Struchkov et al. (1975) recommend the combined use of antibacterial drugs with different mechanisms and spectrum of action. Antibacterial drugs are used locally in the form of solutions and ointments, as well as intramuscularly and intravenously.

To activate nonspecific factors immunol. body resistance (opsonins, phagocytosis, bactericidal activity of leukocytes and serum) highest value has normalization and stimulation of protein metabolism (high-calorie nutrition, intravenous infusion of plasma, protein hydrolysates, protein, albumin, etc.), saturation of the body with all vitamins (see), administration of pyrimidine and purine derivatives (see Pyrimidine bases, Purine bases) etc. To stimulate anabolic processes, anabolic hormones are prescribed - retabolil, nerobol (see Anabolic steroids). For the purpose of detoxification and combating anemia, a transfusion of freshly citrated blood (250-500 ml with an interval of 1-2 days) is indicated. Prodigiosan (see) and other polysaccharides of bacterial origin increase the bactericidal properties of blood, activate the complement system and enhance the effect of antibiotics. When chemotaxis and complement values ​​are low, the phagocytic-bactericidal activity of leukocytes and serum bactericidal activity are reduced, fresh plasma is transfused. Low levels of T- and B-lymphocytes in the blood are compensated by transfusion of fresh leukocyte suspension.

To stimulate the processes of regeneration and wound healing, mineralocorticoid hormones (see), thyroxine (see), somatotropic hormone (see), sex hormones (see), etc. are used.

Specific immunoprophylaxis is aimed at creating passive (using hyperimmune serum and plasma, gamma globulin) or active (using vaccines) immunity against a specific pathogen of wound infection. For the purpose of active immunization, staphylococcal toxoid is most widely used (see Toxoids). When a wound infection develops, immunotherapy is performed (see).

Due to the widespread and often incorrect use of antibiotics, the ecology of wound infection pathogens and the reactivity of the human body to it have changed - antibiotic-resistant and antibiotic-dependent strains of microbes have emerged that are not sensitive to existing antibacterial agents. In this regard, the possibilities of treating wounds in a controlled abacterial environment are being studied, for which they use general isolation wards with a laminar flow of sterile air (see Sterile ward) and local isolators to create abacterial conditions around damaged areas of the body, mainly on the extremities (see Controlled abacterial environment). In general isolation wards, an optimal microclimate is created, the patient is isolated from the environment, communication with the patient is carried out through special gateways. Attendants work in sterile underwear and shoes.

Local sealants are plastic bags that are glued to the wound area. There are three treatment options using local isolators: in a controlled environment, in conditions of local gnotobiological isolation (biolysis) and in a controlled abacterial environment.

A controlled environment treatment method has been proposed for the treatment of sutured wounds following limb amputation. The stump without a bandage is placed for 10-15 days in a plastic isolation chamber, into which sterile air is supplied; temperature and air pressure are regulated. Carrying out treatment. There are no manipulations in the camera. According to the creators of the method, its use helps prevent hospital-acquired infection, helps reduce swelling and improve blood and lymph circulation in the wound area.

The method of local gnotobiological isolation was proposed by Yu. F. Isakov et al. (1976). Its essence lies in the fact that the wounded limb, without preliminary surgical treatment and without a bandage, is placed for the entire duration of treatment (10-20 days) in a special chamber with an abacterial air environment. The chamber has special sleeves with gloves and a gateway for supplying tools and material, which allows manipulation and surgical interventions. During the entire treatment period, sterile air is blown through the isolator; The camera does not have devices that regulate the microclimate. the main objective treatment - suppression of microflora in the wound and preparing it for plastic closure. According to S. S. Belokrysenko et al. (1978), the sudden or complete disappearance of pathogenic microbes in the wound during this treatment occurs mainly due to the drying effect of the blown air.

A treatment method in a controlled abacterial environment, developed at the Institute of Surgery named after. A.V. Vishnevsky of the USSR Academy of Medical Sciences (1976), allows you to combine surgical treatment with local gnotobiological isolation of the wound. Sterile air is supplied to the chamber, it is possible to regulate many environmental parameters (temperature, humidity) and create optimal conditions for wound healing. The limb without a bandage is placed in a sterile plastic isolator immediately after surgical treatment for the entire duration of treatment. Improvement in the general condition of the wounded and the condition of the wound itself occurs within the first 2-3 days after the start of treatment.

In the phase of wound dehydration, characterized by a gradual decrease in the inflammatory response and the development of regenerative-reparative processes, the goal of treatment is preservation of granulation tissue and elimination of obstacles to wound epithelization. This is achieved by proper care of the wound and surrounding skin, gentle dressings and other manipulations. Instead of dressings with antiseptic substances and hypertonic solutions, which damage granulation tissue, they use dressings with ointments and emulsions that have antibacterial properties and have a positive effect on tissue trophism (for example, solcoseryl, sea buckthorn oil, Shostakovsky balm, colanchoe, etc.). In this phase, operations are often performed that can sharply shorten the wound healing period (delayed skin grafting, secondary sutures, etc.).

Physiotherapy used in the treatment of wounds in all phases of the wound process in order to combat infection and intoxication, as well as to improve local blood circulation and stimulate regenerative and reparative processes.

During the surgical treatment of extensive and complex wounds, the wound is treated with a pulsating stream of an antiseptic solution or a sterile isotonic sodium chloride solution, which is supplied by oxygen pressure. Vacuum treatment of wounds is also used under conditions of constant irrigation with an antiseptic solution. Both methods help remove microflora, blood clots, wound detritus from the wound and provide the possibility of deeper penetration medicines to the lesion site. The effectiveness of ultrasound is being studied (tsvetn, table, Fig. 9), which helps to suppress wound microflora (by increasing its sensitivity to antibiotics) and accelerating reparative processes in tissues (see Ultrasound, Ultrasound therapy).

Wound sanitation is facilitated by irradiation with short UV rays (2-3 biodoses). In the first days after surgical treatment, the wound surface and surrounding skin are irradiated with UV rays (1 - 2 biodoses); in the presence of inflammation in the wound circumference and damage to deep-lying tissues, a UHF electric field is used (10-15 minutes, up to 10-12 procedures). When necrotic tissue or flaccid granulations appear, UV irradiation is adjusted to 6-8 biodoses and iodine electrophoresis, darsonvalization or aeroionization (for 10-20 minutes) of the wound area are added while changing the dressing. To suppress the microflora of the wound, electrophoresis of antibacterial drugs (antibiotics, sulfonamides, nitrofuran derivatives, etc.) is used.* During the period of biological cleansing of the wound, electrophoresis of proteolytic enzymes (trypsin) can be used.

If wound healing is delayed, electrophoresis of zinc iodine and peloidin (see) is prescribed for 20-30 minutes. daily for 10-12 days, ultrasound in pulse mode, microwave therapy. In more late dates slow wound healing in the presence of degenerative changes in granulations or signs of ulcer formation, mud and paraffin applications on the wound surface, spark darsonvalization around the circumference of the wound, sinusoidal modulated and diadynamic currents, general UV irradiation, local exposure to infrared radiation can be used. To stimulate reparative and regenerative processes, low-frequency alternating magnetic fields and laser radiation are also used (see Laser).

Physiotherapy in case of wounds, it helps to mobilize the vital forces of the body and create optimal conditions for blood circulation and reparative processes in the tissues of the damaged area.

Indications for exercise therapy for wounds are very wide. Moderately severe suppuration and low-grade body temperature with good outflow of pus and no spread of infection to the veins, tendon sheaths and joints are not contraindications to the use of exercise therapy. Exercise therapy is especially important for slow-healing wounds. Contraindications to such activities are the general serious condition of the wounded, high body temperature, severe pain in the wound and the risk of bleeding.

In the phase of wound hydration, exercise therapy is limited mainly to breathing exercises, changing body position in bed, movements of uninjured limbs, etc.

Targeted exercises begin with the beginning of wound regeneration (I period of exercise therapy). During this period, general tonic exercises are used. Stimulation of wound healing is facilitated by exercises for the distal segments of the injured limb and exercises for symmetrically located muscles.

When the formation of scar tissue begins (II period of exercise therapy), active muscle contractions in the damaged area are used to influence locally occurring processes. By improving blood supply and stimulating healing, they slow down the development and reduce the severity of contractures (see), and help maintain the interchangeability of the skin, muscles and tendons. A variety of movements should be repeated many times throughout the day. To avoid injury to the granulations when performing exercises, the bandages are loosened or removed. After suturing the damaged tendon, active movements begin from the 3-4th day in order to cause slight displacements of the tendon in relation to the surrounding tissues and especially to the tendon sheath. After applying delayed or secondary sutures, movements in the damaged segment are resumed after 3-4 days, but their amplitude is limited, taking into account the danger of suture dehiscence.

After the wound has healed, but in the presence of residual effects - scars, contractures, muscle weakness (III period of exercise therapy), treat. gymnastics should help restore the function of the damaged organ. During this period, active movements are performed along all axes of the joints with a gradually increasing amplitude. As the scar matures, exercises to lightly stretch it are included; slight pain during movement is not a contraindication. You can use clubs, gymnastic sticks, medicine balls, etc. Great attention must be paid to restoring the strength and endurance of the muscles of the damaged segment (see also Gymnastics, Physical therapy).

Features of wound treatment in children

Treatment of wounds in children is carried out mainly according to generally established rules of surgery.

During primary surgical treatment of a wound, tissue excision is performed more economically than in adults; preference is given to complete excision of the wound edges followed by a closed suture. Contaminated wounds are pre-washed with a jet antiseptic solution or hydrogen peroxide. Uncontaminated wounds of the soft tissues of the face and head are sutured with rare sutures without excision of the edges after treating the skin with alcohol and 3% alcohol solution of iodine; small wounds are covered with a sticky plaster. For extensive scalp and patch wounds with detachment of the skin and subcutaneous tissue, surgical treatment is performed using the Krasovitov method (see Skin grafting). The dressing is applied to the wound with special care, because due to the high mobility of children, it can slip off and there is a risk of infection of the wound. If the wound is located in the joint area, a fixing plaster splint is applied. Antibacterial therapy is administered according to indications. If the postoperative period is smooth, the sutures are removed on the 7th day, and in places where the skin is subject to constant mechanical stress, immobilization and sutures are maintained for another 3-4 days.

For any wounds, unvaccinated children are given prophylactic dose antitetanus serum, and vaccinated - tetanus toxoid in accordance with the instructions.

For the treatment of extensive infected, long-term non-healing wounds and open fractures in pediatric practice, the method of local gnotobiological isolation is used, as well as wound treatment with ultrasound and helium-neon laser, the combined use of which accelerates skin regeneration and the elimination of marginal lysis in transplanted skin autografts and reduces the time treatment of long-term non-healing wounds.

Hyperbaric oxygen therapy in children is especially effective in the first hours and days after injury. As a result of its use, the wound heals 1.5-2 times faster than under normal conditions.

Features of wartime wounds. Staged treatment

The nature and severity of injuries depend on the weapon used. In the wars of the 19th and early 20th centuries. bullet wounds predominated, relatively many wounds were from bladed weapons, the proportion of the most severe - fragmentation - wounds was small. With the improvement of military equipment and weapons, the proportion of gunshot (especially shrapnel) wounds increased and the number of wounds with edged weapons decreased. During the Great Patriotic War of 1941-1945. 99.98% of all injuries were caused by bullets or fragments of mines, aircraft bombs, artillery shells, etc.; wounds with bladed weapons averaged 0.02%. In this regard, the severity of injuries has increased compared to previous wars.

In local wars in recent years, there has been a further increase in the severity of gunshot wounds. The arsenal of foreign armies now includes ammunition specifically designed to destroy manpower - ball aerial bombs, artillery shells filled with arrow-shaped and ball elements, and others. When these munitions explode, a large number of damaging elements are scattered at a high initial flight speed, causing multiple severe injuries.

According to wound ballistics (the study of the movement of a wounding projectile in organs and tissues and the processes of transferring its energy to tissues), a gunshot wound is formed as a result of the impact on the tissue of the wounding projectile itself, the head shock wave, the energy of the side impact and the vortex wake.

The destructive force of a wounding projectile depends on its mass, shape, size and speed of movement at the moment of contact with tissue. Thus, fragments that have an irregular shape and a large area of ​​​​contact with tissues quickly transfer their kinetic energy to them and cause extensive destruction. The same is observed when wounded by ricocheting, deformed or changing stability in flight (tumbling) bullets.

The nature of destruction also depends on the anatomical and physiological characteristics of the tissues and their physical properties (elasticity, density, resilience, etc.), which determine the braking effect of the wounding projectile, i.e. the rate of transfer of kinetic energy to them. For example, when a wounding projectile comes into contact with a bone, the braking effect, and therefore the rate of energy release and the degree of tissue destruction, is much higher than when it comes into contact with muscle-elastic structures.

Due to the characteristics of the wounding projectile and the differences in the physical properties of the affected tissues, the wound channel may have different shapes, sizes and directions in individual areas. Curvature of the wound channel (deviation) is often observed, which is caused by a change in the direction of movement of the wounding projectile (primary deviation) or subsequent displacement, mutual movement of damaged tissues (secondary deviation).

Rice. 6, c. Diagram of the distribution of zones of mechanical stress that occurs in the bone tissue of the femur during the destructive effect of a bullet depending on its flight speed: a - at a bullet flight speed of 871.5 m/sec, most of the bone diaphysis is damaged; b - at a bullet speed of 367 m/sec, only the central part of the diaphysis is damaged (arrows indicate the bullet impact points); c - color codes indicate the sizes of mechanical stress zones in kg/cm 2. The vertical scale is given to determine the size of the mechanical impact zones in cm.

Studying the action of the head shock wave, side impact energy and wake vortex became possible using pulsed high-speed X-ray photography, which makes it possible to record the movement of the projectile within one millionth of a second. For the first time in our country, this method was used by S. S. Girgolav (1954). It turned out that at high projectile flight speeds (close to 1000 m/sec), the main role in the formation of the structure of a gunshot wound, including in bone tissue, belongs to the speed, and not the mass of the projectile (tsvetn, table, Fig. 6c ). This position is decisive in the improvement of small arms; it led to the creation of small-caliber combat systems (caliber 5.6 mm or less), providing a high initial velocity of the bullet and a resulting increase in the size of the destructive impact.

The head shock wave is a layer of compressed air. It has a destructive effect on tissue during the penetration of a wounding projectile into them, which has the character of an interstitial explosion; it is also involved in the formation of the effect of the release of wound detritus through the entrance and exit openings of the wound.

The integrated action of the shock wave, side impact energy and vortex movements causes the formation of a temporary pulsating cavity along the wound channel (the so-called cavitation effect), the pressure in the cut can reach 100 atm or more. According to L.N. Aleksandrov, E.A. Dyskin and others, the diameter of this cavity can exceed the diameter of the wounding projectile by 10-25 times or more, and the duration of the pulsation can exceed the time of passage of the projectile through tissue by 2000 times or more. As a result of the pulsating nature of cavitation, extensive and severe tissue damage occurs at a considerable distance from the wound channel (bruises, ruptures of muscles, fascia, hollow organs, blood vessels, nerve trunks, etc.) and conditions are created for the penetration of microflora into the wound channel already at the moment of wound formation , equally intense from both the inlet and outlet sides.

The extent of the zone of morphology and changes outside the wound channel can exceed the diameter of the wounding projectile by 30-40 times. As one moves away from the wound channel, these changes are increasingly determined by circulatory disorders (hemorrhages, thrombosis, microcirculation disorders), which are the main cause of subsequent focal necrosis. Physical phenomena, arising outside the wound canal, are determined by Ch. arr. hydrodynamic effect, the severity of which largely depends on the water content in the tissues and the mass of the organ.

Rice. 6. Multi-fragmentation wounds: the right foot with tissue crushing (a) and the soles of both feet (b). Rice. 7. View of the entrance hole (a) on the skin of the leg when wounded by a small-caliber bullet with high flight speed, which is accompanied by extensive tissue destruction in the area of ​​the bullet channel; X-ray (b) of the same wound shows comminuted bone fractures. Rice. 8. Multiple wounds on the skin of the thigh caused by arrow-shaped elements. Rice. 9. Treatment of wound edges with ultrasound using the UZUM-1 apparatus.

Wounds inflicted by modern types of small arms differ from wounds observed in previous wars in the extent and depth of damage to tissues and organs, the presence of multiple and combined wounds, and the widespread injury to personnel. Particular concern should be caused by injuries from arrow-shaped elements and small-caliber bullets, in which the entrance hole may be barely noticeable (tsvetn, table, Fig. 7, 8), and damage to deeper tissues is extensive and severe. In modern warfare, nuclear and chemical weapons can be used, which will lead to the occurrence of combined injuries (wound and burn, injury and damage by penetrating radiation, wound and damage by chemical agents, etc.), the course and outcomes of which are determined by the strength of the impact of each damaging factor and phenomenon their mutual aggravation (see Combined lesions). Significantly aggravate the course of the wound process such factors that are inevitable during war, such as overwork, hypothermia or overheating, fasting, hypovitaminosis, water-electrolyte imbalance, etc. Wartime wounds are accompanied by a more severe general reaction of the body (shock, collapse and etc.), are more often complicated by infection, have longer healing times and are more often fatal.

The massive nature of combat injuries requires a clear and well-coordinated system for providing medical care and treating the wounded.

The main task first aid(see First aid), which is a set of simple measures using individual standard and available means, is to save the life of a wounded person (for example, in case of bleeding from a wound, open pneumothorax, asphyxia, etc.) and prevent life-threatening complications. First medical aid is provided on the battlefield in the order of self-help and mutual assistance (see), as well as by a sanitary instructor (see) and an orderly (see). First of all, a temporary stop of external bleeding is carried out. To apply the primary dressing, use an individual dressing package (see Individual dressing package). Immobilization for bone fractures, joint injuries, large blood vessels and extensive soft tissue wounds is carried out using a scarf, improvised materials or table-top means (splints). To prevent wound infection, victims are given tableted antibiotics. For injuries accompanied by shock, analgesics are administered subcutaneously (see Analgesics).

After first aid is provided, the wounded are evacuated to the battalion medical center (see) or enlarged nests of the wounded, where the paramedic provides them with pre-hospital medical care (see First aid). The main tasks of pre-hospital medical care are the fight against asphyxia (see), the administration of respiratory and cardiovascular analeptics, control and correction of primary dressings, hemostatic tourniquets, immobilization with transport tires, and the administration of analgesics for severe wounds.

To provide first aid(see) the wounded are sent to the regimental medical station (see), and the first to be evacuated are the wounded with applied hemostatic tourniquets, in a state of shock, sudden bleeding, with breathing problems, as well as with penetrating wounds, closed abdominal injuries and wounds, infected with OV or RV. Here, a primary medical card is filled out for the wounded (see). All wounded are injected with antitetanus serum (3000 IU) and tetanus toxoid (0.5-1 ml) with a separate syringe. First of all, the wounded with suspected internal bleeding, with penetrating wounds of the abdomen, skull, chest and with hemostatic tourniquets are evacuated to the stage of providing qualified medical care.

Qualified medical care(see) wounded in wartime end up in the MB, OMO and military field surgical hospitals. In these institutions after medical triage(see Medical triage) surgical treatment of wounds, final stop of bleeding, treatment of shock, operations for penetrating abdominal wounds, open pneumothorax, decompressive craniotomy for cerebral compression syndrome, application of a suprapubic fistula for injuries of the spinal cord and urethra, as well as operations are performed for anaerobic wound infection. The operated patients are sent to the hospital department, where their treatment continues until transportability is restored, after which they are evacuated to specialized or general surgical hospitals at the front hospital base.

In specialized (see Specialized medical care) and general surgical hospitals, treatment is carried out until the wound heals and the outcome of the injury is determined. The wounded, who require long-term (up to several months) treatment, and who have no prospect of returning to duty after treatment, are evacuated to treatment. institutions of the country's home front.

Determination of the degree of loss of combat capability (work ability) of a wounded person or change in the category of fitness for military service is carried out upon completion of treatment on the basis of current legislation.

In the civil defense system, first medical aid to the wounded is provided by the personnel of the sanitary squads (see Sanitary squad) and in the order of self-help and mutual assistance, the first medical assistance- in the first aid unit (see), specialized medical care - in medical treatment. hospital facilities (see).

Wounds and wounds in forensic terms

At court medical During the examination of wounds, their localization, shape, size, features of the edges and ends, extraneous overlays and penetrations, the condition of the surrounding tissues and other features reflecting one or another specificity of this injury are carefully studied and described. This often makes it possible to determine the type of weapon, the wound inflicted, the mechanism of its formation, how long ago it occurred, the severity of the injuries, etc.

Wounds caused by a blunt object arise both from direct blows from hard objects of various configurations, and when struck by them, and are found in household injuries, falls from a height, transport injuries, etc. As a rule, bleeding from these wounds is insignificant. Bruised wounds have raw, often jagged edges with bruises; when moving the edges of the wound apart, connective tissue bridges are observed in the corners and at the bottom, and everted hair follicles can be seen in its walls. The appearance of the wound depends on the shape and area of ​​the striking surface of the weapon, for example, when struck by a cylindrical object (metal rod), linear wounds are more often formed, and with an object with a flat surface (board), star-shaped wounds are more often formed. When struck by a blunt, hard object with great force (for example, during a transport injury), wounds are often combined with damage to internal organs. With lacerations and related bite wounds, extensive damage to soft tissues is noted; the edges of the wound are uneven and patchy.

Wounds caused by a sharp weapon are often characterized by heavy bleeding, relatively minor damage to the edges, and gaping. Incised wounds typically have sharp ends and smooth edges. The length of the wound always prevails over the width; at the end of the wound, superficial additional cuts-notches are sometimes observed, which occur when the blade is removed. Puncture wounds are small in size and have a more or less deep wound channel. The edges of the wound are often even, smooth, and a band of subsidence usually forms around them. The shape of the wound depends on the configuration of the cross-section of the weapon and is determined by the number of edges on it. In most cases, the wound is slit-shaped or oval. Penetrating puncture wounds are often accompanied by damage to internal organs and bones, which may display the cross-sectional shape of the weapon. Puncture wounds have smooth, smooth edges. When exposed to a double-edged weapon (dagger), the shape of the wound approaches an oval with pointed ends. When exposed to a weapon with a one-sided sharpening of the blade (Finnish knife), one end of the wound is sharp, the other (from the butt side) is sharp or rounded (with a butt thickness of less than 1 mm), rectangular in shape or with additional tears in the corners (with a butt thickness of more than 1 mm) . Chopped wounds are caused by heavy chopping tools (axe, hoe, saber, etc.). They have a rectilinear or spindle-shaped shape, smooth and smooth edges, often sharp ends; You can often see signs of sedimentation at the edges of wounds. Unlike cut wounds, chopped wounds are usually accompanied by bone damage.

On the planes of bone cuts, one can almost always find individual signs of the blade of a chopping tool - traces of unevenness, notches, which are used in forensic identification of the tool. Sawn wounds are characterized by uneven, jagged, finely patchy edges. With them, damage to bones is often observed, the cutting surface of which is usually relatively flat, with arched marks from the action of the saw teeth.

Cut, stab, and stab wounds are more often found in everyday life; chopped and sawing wounds are found both in everyday life and in industrial accidents.

Gunshot wounds occur as a result of exposure to bullets (military and sporting weapons), pellets (hunting rifles) and fragments of grenades, bombs, shells, etc. Occasionally, everyday wounds inflicted by defective (sawed-off shotguns) and homemade (homemade) weapons occur.

The tasks of the examination of gunshot injuries include establishing the entrance and exit openings of wounds, the direction of the wound channels, the distance from which the shot was fired, the type and type of weapon used to cause the wound, as well as resolving other issues related to the characteristics of a particular case .

The entrance hole of a gunshot wound, depending on the type of weapon, the wounding projectile and the distance from which the shot was fired, can be cruciform, star-shaped, round or oval. General signs of the wound entrance are the presence of a tissue defect at the site of bullet penetration, a band of abrasion on the skin (1-2 mm wide) due to the tearing off of the epidermis by the side surfaces of the projectile, a rubbing band (up to 2-2.5 mm wide) resulting from rubbing the bullet on edges of the wound, traces of components accompanying the shot (gases, soot, unburned powder, flame burns), detected when wounded at close range. The entrance bullet hole is clearly defined when flat bones are damaged: it has the shape of a cone, with its base facing the direction of the bullet’s flight. The diameter of the entrance hole, as a rule, almost corresponds to the diameter of the bullet, which allows us to draw conclusions about the caliber of the weapon used.

The exit hole of a gunshot wound has a slit-like or irregular shape, its edges are often turned outward, there are no tissue defects and traces of components accompanying the shot. When bones, especially tubular bones, are damaged, their fragments can cause additional damage in the area of ​​the wound outlet, the edges take on a torn appearance.

The direction of the wound channel is determined by the location of the entrance and exit openings of the wound or the entrance opening of the wound and the location of the bullet in a blind wound.

Of significant importance is the question of the distance at which the shot was fired. There are three main shot distances: point blank, close range (within the detection range of components accompanying the shot) and non-close range (beyond the detection range of these components). A point-blank shot is characterized by a cruciform shape of the wound entrance, the presence in its area of ​​an imprint of the muzzle, a tissue defect and traces of components accompanying the shot along the wound channel. When shot point-blank at an angle, deposits of soot and powder particles in the form of an oval are visible on the skin from the side of the open corner. When fired at close range, scorching of vellus hair and deposition of the epidermis (parchmentation) are observed at a shooting distance of 1-3 cm, soot deposition - up to 35-40 cm, grains of unburnt powder - up to 1 m and more. Soot particles also settle on the outer surface of clothing and occupy a significant area. When fired from a hunting rifle, the components accompanying the shot spread over a longer distance. When shot from a short distance, the entrance hole of the wound has a round or slit-like shape; There are no traces of shot components. Since the bullet loses its kinetic energy at the end, it acquires a concussive effect and leaves a bruise and sedimentation on the skin. Sometimes, when fired from a short distance, when the speed of the bullet exceeds 500 m/sec, soot particles are transported over considerable distances and settle around the bullet hole on the second and subsequent layers of clothing (more often under conditions where the wet layers of clothing are not tightly adjacent to each other), and also on the skin in the form of a radiant corolla up to 11/2 cm wide, sometimes with the formation of a peripheral ring spaced 1-11/2 cm away from it (Vinogradov’s phenomenon). This circumstance should be taken into account when differentiating a shot at point-blank range or at close range from a shot at a short distance, which is an extremely difficult expert task.

Damage caused by an exploding shell, grenade, etc. is characterized by multiple wounds caused by fragments of the shell and objects caught in the explosion zone. The wound canals of such wounds are usually blind.

When examining wounds to establish the lifetime of their occurrence, histol and histochemical are performed. studies to study the characteristics of the edges and ends of the wound - stereoscopy, to detect metal particles in the wound area - study of color prints, radiography and spectrography; to identify soot and powder on fluffy fabrics and hair covered in blood, photographs are taken in infrared rays(see Infrared radiation); UV rays are used to detect the presence of gun lubricant, etc.

When examining and hospitalizing the wounded, the doctor must carefully describe the wounds, indicating their characteristics. Areas of tissue excised during surgical treatment of the wound are subject to fixation in 10% formalin solution and subsequent transfer to the investigative authorities for laboratory research.

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M. I. Lytkin; V. P. Illarionov (medical physic.), Yu. L. Melnikov (court), V. P. Nem-sadze (det. surgeon), D. S. Sarkisov (pat. an.), M. A. Tsivilno (psychiatrist), V. A. Romanov (tsvetn, Fig. 1-4).