Target:- study the classification of chest injuries;

study the features of the clinical picture of chest injuries;

study the features of diagnosing chest injuries;

know the tactics of providing surgical care for chest injuries.

Security questions:

General characteristics of chest injuries.

Classification of chest injuries.

Features of clinical manifestations in chest injuries.

Diagnostic program for chest injuries:

clinical and laboratory diagnostics;

X-ray diagnostics;

endoscopic diagnostics;

Principles of treatment and tactics for chest injuries.

Indications for surgical treatment, surgical methods and drainage methods for chest injuries.

Prevention of complications from chest trauma.

Ways to improve the results of treatment of patients with chest trauma.

Practical skills:

Be able to collect anamnesis and formulate a diagnosis.

Designate an examination plan.

Prescribe conservative treatment.

Know the principles of surgical treatment for chest injuries.

Forms of control:

Control of knowledge during examination and interview of victims.

Discussion of supervised victims.

Solving situational problems.

Test control.

Etiology and pathogenesis. The anatomical and physiological features of the structure of the chest create conditions for severe respiratory and circulatory disorders in the event of various injuries. The pathogenesis of these disorders is based on compression of the lungs and mediastinum by air or blood, the shockogenic pleuropulmonary zone, anemia, and pathological respiratory mechanisms. Chest injuries are very often complicated by shock, which is aggravated by hypoxia and hypercapnia.

The classification of chest injuries is shown in Figures 25.1 and 25.2.

Classification of chest injuries (E.L. Wagner, 1981).

Rice. 25.1. Classification of closed chest wounds.

Rice. 25.2. Classification of penetrating chest wounds.

Closed chest injuries

Closed chest injuries form a large group of mechanical injuries, observed in 2.5% of surgical patients. All closed chest injuries are divided into three main types: production, transport And household. The massive gross mechanism of traumatic impact, inherent in all closed chest injuries, first of all leads to a violation of the integrity of the bone frame of the chest. The main factors determining the nature and outcome of closed chest injuries include injuries to intrathoracic organs, fractures of the bone frame of the chest, and concomitant injuries in other areas of the body. Closed chest injuries are divided into two groups: without damage to internal organs and with damage.

Pulmonary tissue contusion usually occurs as a result of the direct impact of a damaging factor on a limited area of ​​the chest wall. At the same time, in some victims, especially in young people, short-term deformation of the ribs occurs without their fracture, as a result of which the mechanical continuity of the lung tissue, as a rule, is not disrupted. Nevertheless, in the cortical layer, and sometimes deeper, vascular damage occurs, accompanied by pinpoint, and with greater impact force, massive hemorrhages, ruptures of the interalveolar septa, etc. On the surface of the lung, small tears of the visceral pleura are sometimes observed, through which into the pleural cavity blood flows out and air enters (hemo- and pneumothorax). Often, lung damage due to a bruise is accompanied by atelectasis, predominantly of an obstructive nature. Such traumatic atelectasis can occur in the immediate hours after injury, sometimes involving a lobe and even the entire lung. Pneumonia sometimes develops in the area of ​​bruised lung tissue, and the hematoma suppurates, resulting in the formation of an abscess.

Of very significant interest is the rupture of large bronchi sometimes observed during compression of the chest. This occurs as a result of a sharp increase in pressure in the airways, and mechanical crushing of large bronchi against the spine is also possible. One way or another, as a result of a rupture of a large bronchus immediately after injury, mediastinal emphysema develops, and if the integrity of the pleura was simultaneously damaged, then pneumothorax, often with a valve mechanism.

Clinical picture with closed lung injuries, it depends mainly on three factors: severe damage to the chest wall, as a result of which the pulmonary ventilation mechanism is disrupted; severity of hemo- and pneumothorax; the degree and extent of damage to the lung tissue itself or the bronchi.

The main complaint of victims is usually pain in the area of ​​the bruise, which intensifies with deep breathing and movement. The main undoubted sign of damage to the lung tissue is hemoptysis, and in more rare cases, pulmonary hemorrhage. Serious disturbances in the general condition are noted (shortness of breath, cyanosis, tachycardia, hypotension), usually resulting from massive and, above all, valvular pneumothorax, or bleeding into the pleural cavity.

When examining the area of ​​the bruise, as a rule, abrasions, subcutaneous hemorrhages, or wounds of the chest wall that do not penetrate the pleural cavity are visible. In patients with a rib fracture and pneumothorax, local emphysema is found by palpation.

With compression of the chest, accompanied by damage to the lung tissue, the clinical picture is more severe. The victims complain of severe pain in the area of ​​injury, difficulty breathing, vertical body position, and shortness of breath. Sometimes wheezing can be heard from a distance, depending on the accumulation of fluid in the upper respiratory tract, which the patient cannot cough up. At the same time, bloody foam is visible on the lips. Victims are usually cyanotic, with many petechial hemorrhages visible on the neck, face and under the conjunctiva of the eyes. Blood pressure is reduced, pulse is increased. During physical examination, the first thing that attracts attention is multiple moist rales of different sizes in both lungs, signs of hemo- and pneumothorax.

Diagnostics. On X-ray examination, the lungs appear spotty due to multiple shadows with unclear contours, depending on alternating foci of hemorrhage, atelectasis and emphysema. The photographs show rib fractures, hemo- and pneumothorax.

When a bronchial tube ruptures immediately after an injury, the clinical picture is dominated by the phenomena of rapidly growing emphysema of the mediastinum, spreading to the subcutaneous and intermuscular tissue of the neck, head and the entire upper half of the body, or valvular pneumothorax.

The most valuable information for establishing a diagnosis of rupture of large bronchi, both in the early and late periods, is provided by bronchoscopy, which allows one to accurately determine the nature and location of the damage.

Treatment with limited bruises of the lung tissue, as a rule, it is conservative. In milder cases, it is enough for the patient to be given rest for several days, painkillers and antibiotics to prevent pneumonia. To treat concomitant rib fractures, it is advisable to perform a blockade of the fracture site or paravertebral one. In order to prevent traumatic atelectasis and eliminate existing ones, bronchoscopy is necessary.

In the presence of hemo- and pneumothorax, pleural puncture is performed, and, if necessary, drainage of the pleural cavity with active aspiration.

In case of closed injury associated with rupture of large bronchi, treatment in the first hours should be aimed at relieving tense mediastinal emphysema and valvular pneumothorax, which pose an immediate threat to the life of the victim. The pleural cavity should be drained immediately and continuous suction from it should be ensured. In many cases, after drainage of the pleural cavity, mediastinal emphysema gradually decreases. Otherwise, a cervical mediastinostomy is required in the area of ​​the jugular fossa with insertion of a drainage tube into the pretracheal space behind the sternum.

Once the diagnosis of bronchial rupture is confirmed, a posterolateral thoracotomy is performed to provide the best access to the damaged bronchus. The defect of the latter is sutured, preferably with an atraumatic needle.

In case of complete separation of the bronchus, after economically refreshing the edges, a circular suture is applied. The pleural cavity is drained, and the patient is subsequently treated as after partial resection of the lung.

With timely and correctly provided assistance, the prognosis for the patient is favorable.

Treatment for closed injuries to the soft tissues of the chest wall is usually not difficult. Only sometimes are extensive exfoliating hematomas discovered on the lateral surfaces of the chest - when a car wheel hits the area “slippingly” or when it is compressed with blunt objects, during which the force was applied tangentially. At the site of peeling of the skin from the underlying tissues, blood accumulates, and ripples are clearly visible. The skin over peeling hematomas is often raw. During puncture, dark blood is usually obtained, which cannot be completely removed, since the needle is clogged with clots and crushed fragments of subcutaneous tissue. For peeling hematomas, their emptying is indicated using a large-diameter trocar or through a small incision with drainage. The prognosis is favorable.

Chest injuries– injuries that damage the bones that form the frame of the chest and/or organs located in the chest cavity.

Classification of chest injuries

All chest injuries are divided into two groups: closed and open.

A distinctive feature of closed injuries is the absence of a wound. Such damage is divided into:

• Concussions. Injuries in which there are no visible morphological changes in the chest.
• . This group includes ribs and soft tissues, cardiac contusion, vascular contusion, and lung ruptures, hemothorax and fractures of the sternum, ribs and thoracic vertebrae.
• Compression. This includes cases of traumatic injury, in which the patient's chest is compressed between two blunt objects, causing suffocation.

With open injuries, there is a wound in the chest area, which can be a knife wound, a gunshot wound, etc.

Open injuries (wounds) are divided into:

• Non-penetrating.
• Penetrating.
• Without damage to internal organs located in the chest cavity.
• With damage to internal organs located in the chest cavity.
• With bone damage (ribs, thoracic vertebrae or sternum).
• Without open pneumothorax or with its presence.
• Without open hemothorax or with its presence.
• Thoracoabdominal trauma (with simultaneous violation of the integrity of the chest cavity, diaphragm and abdominal cavity).

Taking into account the nature of the damage, through, blind and tangential chest wounds are also distinguished.

Causes of chest injuries

In peacetime, closed chest trauma occurs in traumatology much more often than open one. Its main causes are car accidents (70%), falls from a height (23%), work-related injuries, natural disasters, criminal acts (beating, fighting) or domestic trauma.

Most often, with closed trauma, injuries to the lungs (60%), ribs (45.4%), heart (8%) and spine (4.8%) are detected. Other organs are rarely affected. Damage to the lungs, intercostal vessels, pleura, bronchi and pulmonary vessels is often secondary in nature and develops as a result of trauma to these organs by the sharp ends of broken ribs.

Open injuries are rare in peacetime and usually result from wounds with edged weapons. The number of gunshot wounds increases sharply in wartime. Wounds caused by another object (for example, a sharp metal pin or piece of reinforcement) can occur as a result of a work-related injury, a man-made or natural disaster, or a domestic accident.

Fractures of ribs and sternum

Rib fractures usually occur in adult patients. They are observed very rarely in children and adolescents due to the extreme elasticity of bone structures. Taking into account the mechanism of injury, all rib fractures can be divided into three groups: indirect, direct and avulsion. The greatest displacement of fragments and, as a consequence, a high probability of damage to the organs of the thoracic cavity by the sharp ends of broken ribs occurs with avulsion, double and multiple fractures.

Fragments of the ribs can damage not only the lung and pleura, but also the intercostal vessels, resulting in internal bleeding into the pleural cavity and the formation of hemothorax. If the sharp end of the rib pierces the lung, air escapes into the pleural cavity and forms.

Indicates a rib fracture sharp pain at the site of injury and pain when the chest is compressed in the anteroposterior direction. Breathing becomes shallow. It is easier for the patient to be in a sitting position than in a lying position. The main method of instrumental diagnosis is radiography of the ribs.

Treatment is in eliminating pain, preventing pneumonia and facilitating breathing.

For an uncomplicated fracture of one rib, the patient is under outpatient observation. A fracture of two or more ribs is an indication for hospitalization. Patients are also prescribed physical therapy and are recommended to remain in bed in a semi-sitting position. To prevent congestion in the lungs, breathing exercises are mandatory. In case of multiple rib fractures, they are surgically immobilized.

Fractures of the sternum are relatively rare. Accompanied by pain, aggravated by coughing and deep breathing. Palpation is sharply painful. To confirm the diagnosis, a lateral x-ray of the sternum is performed. Treatment is carried out in a hospital setting. For non-displaced fractures, rest and painkillers are prescribed. When displaced, reposition is performed on the shield.

Bruises, concussions and chest compressions

These chest injuries are less common than rib fractures and are caused by blunt force trauma or forced compression between two large blunt objects. Chest contusion is accompanied by small hematoma and moderate pain. Usually do not require special treatment. In some cases, with severe bruising, extensive hemorrhage may occur in the tissue or cavity of the chest, sometimes accompanied by rupture of organs and tissues. Such an injury is classified as severe, requires emergency hospitalization and can result in the death of the patient.

When the chest is concussed, there is extreme severe shock in the absence of anatomical changes. The patient's condition is serious, breathing is uneven, painful, and shallow. The pulse is rapid, uneven, barely perceptible. Extremities are cold, cyanotic. Immediate hospitalization, complete rest and inhalation of oxygen under pressure are required.

When the chest is compressed, breathing movements are disrupted. Blood flows from the shoulders, upper chest, neck and head. Choking develops. Possible disturbances of consciousness. The skin of the listed parts of the body turns blue, and numerous small hemorrhages (ecchymoses) form on it, as well as on the conjunctiva and oral mucosa. A symptom of décolleté is revealed - swelling and cyanosis of the upper body. Temporary loss of vision and hearing is possible due to hemorrhages in the optic nerve, retina, eyeball and inner ear.

The patient is hospitalized and recommended to remain at rest in a semi-sitting position. To eliminate pain, perform novocaine vagosympathetic blockades. They carry out sanitation of the respiratory tract, oxygen therapy and, in some cases, artificial ventilation.

Open chest injuries

With non-penetrating chest injuries, the condition of the patients is satisfactory. Treatment consists of applying a bandage or suturing the wound. With penetrating injuries, the condition of patients can vary significantly and depends on the absence or presence of hemopneumothorax and associated damage to internal organs and bone frame.

Hemothorax in such injuries develops due to bleeding into the pleural cavity from damaged vessels of the lung and chest wall, pneumothorax - due to the penetration of air from the injured lung into the pleural cavity. When the lung is injured, hemoptysis, hemothorax and subcutaneous swelling are observed. To clarify the diagnosis, a chest x-ray is performed.

Treatment is surgical.

Patients are hospitalized in a specialized department, where thoracic surgeons urgently perform surgery and suturing the wound. The extent of intervention depends on the nature of the injury.

Hemothorax

Hemothorax (accumulation of blood in the pleural cavity) is formed when bleeding due to damage to the intercostal vessels, lung or internal mammary artery. There are small (less than 500 ml), medium (from 500 to 1000 ml) and large (more than 1000 ml) hemothorax. If the condition is low, the patient does not suffer or suffers only slightly. Conservative treatment is possible. With average hemothorax, the patient's condition moderately or slightly worsens, breathing becomes more frequent. Both conservative treatment and pleural puncture may be required.

With large hemothorax, shock, hemodynamic disturbances, shrinkage of the lung and displacement of the mediastinal organs are observed. The patient's skin is cyanotic, the pulse is rapid, and breathing is also rapid and shallow. The body position is forced, sitting, supported by hands. A pleural puncture is required, or, if the hemothorax increases, a thoracotomy is required to identify and eliminate the source of bleeding.

All patients with hemothorax are required to be hospitalized. Observation includes repeated fluoroscopic or radiographic examinations to assess dynamics and determine further treatment tactics.

Pneumothorax

Pneumothorax is an accumulation of air penetrating into the pleural cavity from a damaged lung or from the external environment. There are three types of pneumothorax: closed, open and valvular. With a closed pneumothorax, the wound is closed with soft tissue. The amount of air is limited and does not increase. A small amount of air resolves on its own; moderate amounts may require pleural puncture.

Open pneumothorax occurs with chest injuries. Its distinguishing feature is the presence of communication between the pleural cavity and the external environment. During inhalation, air penetrates through the wound, and during exhalation, it leaves it. The lung gradually collapses. It is necessary to close the wound and puncture or drainage of the pleural cavity.

With increasing (valvular) pneumothorax, air enters the pleural cavity, but then does not leave it. The patient's condition is rapidly deteriorating. There is increasing respiratory distress, shortness of breath, suffocation, tachycardia, cyanosis of the mucous membranes and skin. Immediate drainage of the pleural cavity is required.

In addition to compression of the lung on the side of the injury, pneumothorax causes mediastinal voting - a pendulum-like movement of organs during inhalation and exhalation. The heart and blood vessels are displaced, and blood flow to the heart decreases. This further aggravates the patient's condition.

All patients with pneumothorax are hospitalized. Emergency measures are taken to eliminate pneumothorax. Subsequently, dynamic observation is carried out, repeated fluoroscopy of the lungs or radiography is performed.

External violence (blow, compression, air wave) can cause a closed chest injury - not only damage to the pleura or lung, but also a fracture of the ribs, sternum, collarbone or scapula. Consequently, we are talking about closed injuries with or without disruption of bone integrity.

Severe compression of the chest often causes fractured ribs while simultaneously damaging the lung. The periosteum and costal pleura are ruptured, and fragments of broken ribs can also damage the lung. In rare cases, displacement of bone fragments causes rupture of the intercostal vessels and parietal pleura, which causes blood to flow into the pleural cavity. Intrapleural bleeding due to closed lung injuries is quite common.

When aircraft bombs and artillery shells explode at close range, the force of the blast wave is so great that the victim can die instantly. With a lower blast wave force, a wide variety of damage is possible. This includes closed explosive injuries, previously designated by the terms “general concussion” and “air concussion”. In such cases, the air wave causes damage to various organs and especially to the lungs. In addition to the direct action of air pressure, followed by a phase of negative pressure, there are often injuries caused by throwing the victim away, as well as compression of the body during the destruction of buildings, collapses, or being thrown into the ground.

Pathological data

Pathological changes in closed chest injuries depend on the severity of the injury. With very severe injuries, significant hemorrhages in the lungs are possible, even their ruptures with the appearance of hemothorax and pneumothorax.

Ruptures of large bronchi with closed injuries are rare. Then tension occurs with air leaking through the connective tissue of the lung (interstitial emphysema) or penetrating into it (mediastinal emphysema).

Closed lung injuries are often accompanied by damage to other organs and significant skeletal damage.

Symptoms of closed chest injury

pneumothorax.

The frequency of symptoms varies; Subcutaneous emphysema is most easily detected.

Blood accumulations up to 200 ml are not recognized clinically or radiologically. Therefore, every recognized hemothorax indicates significant or severe internal bleeding. A small accumulation of air can only be determined by x-ray examination.

With large hemothorax there are signs of acute hemothorax. In addition, the blood accumulated in the pleural cavity compresses the lung, gradually turning it off from the respiratory function. The diaphragm is somewhat pushed downwards. The mediastinum with its organs shifts to the healthy side. An inflection is created, compression of the vena cava, which disrupts hemodynamics. The larger the hemothorax and the faster it grows, the more severe the respiratory and circulatory disorders.

When examining a closed chest injury, it is important to take into account the nature of the violence, general condition, and the presence of lung damage. The combination of a rib fracture with hemoptysis and subcutaneous emphysema undoubtedly indicates a rupture of both layers of the pleura. In the absence of noticeable hemothorax and pneumothorax (which often happens), the patient's condition is usually satisfactory. On the contrary, in the presence of internal bleeding (hemothorax), the patient falls into a serious condition. He is exsanguinated, cyanosis, shortness of breath, rapid and small pulse are noted. A large pneumothorax also sharply aggravates the patient’s condition, and valvular pneumothorax causes severe shortness of breath and cyanosis, often leading to death due to severe respiratory failure.

In every doubtful case, a puncture of the chest wall should be made, using simultaneously a puncture to suction out fluid and intrapleural administration of drugs.

In the diagnosis of closed chest injuries, X-ray examination is of great importance. Using fluoroscopy and radiography, the presence of air can be accurately determined.

Complications

Complications from closed chest injuries are rare. Purulent pleurisy or suppuration of hemothorax is possible due to the penetration of microflora into the pleural cavity from ruptured airways. In older people, pneumonia is a danger. Pulmonary hemorrhages due to the breakdown of damaged tissues are a rare but dangerous complication of closed lung injuries.

Inflammation of the pleura and suppuration of hemothorax cause a deterioration in the general condition of the large and are accompanied by increased pain in the side, increased heart rate, increased temperature and changes in the peripheral blood pattern.

An important criterion for increased hemopleuritis is an increase in pleural effusion. Progressive accumulation of pleural exudate usually indicates infection of the pleura and the beginning of purulent changes in the leaked blood.

Then pleural puncture acquires great diagnostic significance.

Based on the changed color of blood obtained from the pleural cavity (dark or even brown), one can suspect that it is infected. Important data on early infection of hemothorax is provided by bacteriological examination. However, it must be emphasized that with moderate bacterial contamination of the hemothorax, repeated bacteriological examination is sometimes required to detect the microbial flora.

Efendiyev's test - several milliliters of pleural puncture are poured into a test tube, left for 3 hours or centrifuged. After settling or centrifugation, the formed elements of the punctate settle to the bottom of the test tube, and the liquid part remains at the top.

Normally, the ratio of sediment to liquid part (plasma) is 1:1. In other words, in a test tube the height of the columns of formed elements and plasma will be approximately the same. When hemothorax becomes infected, the accumulation of pleural exudate increases, which dilutes the blood poured into the pleural cavity. As a result, the liquid part of the punctate becomes larger in volume than the sediment. The ratio of sediment to liquid will be expressed by the ratio 1: 1.5; 1: 2. The more the ratio between the liquid part and the sediment is changed, the more diluted the blood is with exudate. In addition, in infected blood the mass of leukocytes increases, occupying the upper part of the blood sediment.

Treatment of closed chest injury

Mild lung injuries are treated conservatively. In case of hemoptysis due to a ruptured lung, the patient should be prescribed bed rest and hemostatic agents (calcium chloride, blood plasma) should be prescribed.

Patients with minor hemorrhages into the pleural cavity should be administered intrapleurally to prevent inflammation of the pleura.

For large hemothoraxes, pleural puncture and removal of spilled blood are necessary. Blood is suctioned even on the first day of injury, if, of course, there is confidence that the bleeding has stopped. Postponing punctures for several days for fear of recurrence of bleeding from a ruptured lung is unjustified.

If the patient tolerates the removal of fluid (blood and exudate) well, one should try to suck it out entirely from the pleural cavity, trying to completely expand the lung. In any case, immediate suction of fluid up to 1 liter or more is often possible without the patient’s complaints. After removal of blood and exudate from the pleural cavity, antibiotics should be administered intrapleurally to prevent the possible development of pleurisy.

It goes without saying that in the first hours of injury, a vigorous fight against traumatic shock is required (warming the victim, administering cardiac drugs, vagosympathetic blockade, blood transfusion, administration of anti-shock fluids).

Surgical treatment of closed chest injuries is rarely used. The indication is severe, life-threatening intrapleural bleeding. This danger is created when large vessels of the lung rupture or when the arteries of the chest are damaged (aa. intercostales, a. mammaria interna, a. subclavia).

The chest not only contains vital organs and protects them from the harsh influences of the external environment, but is also an active organ, damage to which leads to disruption of the function of external respiration.

Chest injuries. Classification

If we classify chest injuries, it is necessary to distinguish between closed (blunt injuries) and open injuries (for example, wounds).

Closed chest injury

You can get a closed chest injury during road traffic accidents, falling from a height, and also if you are injured with a blunt object, as is often described in a criminal situation. Closed chest trauma often occurs in the rubble of destroyed houses or underground communications of mines, less often in sports.

The severity of damage to internal organs is of decisive importance for clarifying the diagnosis, choosing treatment tactics and prognosis. Among closed-type chest injuries without violating the integrity of internal organs, a distinction is made between chest injuries when bones are damaged (meaning the chest and ribs, because spinal fractures are an independent nosological category) and without bone damage.

Closed chest injuries without fractures of the ribs or sternum, as well as injuries to internal organs, are considered minor injuries that do not require special treatment. Sometimes there are still victims with large subcutaneous and intermuscular hemorrhages, which causes the patient’s serious condition even without fractures or injuries to the intrathoracic organs.

Closed chest injuries accompanied by rib fractures can cause catastrophic consequences regardless of whether internal organs are damaged:

• firstly, multiple, and especially bilateral, rib fractures lead to a gross disruption of the pulmonary respiration mechanism, resulting in severe hypoxia;
• secondly, with rib fractures (even in the case of a fracture of only one rib), rupture of the intercostal artery and parietal pleura may occur, followed by the development of massive hemothorax and accumulation of more than 1.5 liters of blood in the pleural cavity.

Blunt injuries to the chest, accompanied by damage to internal organs (lungs, heart, trachea, bronchi and great vessels) are considered severe, regardless of the condition of the bone frame of the chest.

According to the classification, there are closed chest injuries with damage to internal organs, accompanied or not accompanied by fractures of the ribs or sternum. Both may be complicated by pneumothorax and/or hemothorax. It may also be that there will be no hemorrhage and/or air will not accumulate in the pleural cavity. Pneumothorax can occur due to rupture of the trachea, lung, or even bronchus during a sharp increase in intrathoracic pressure immediately at the time of injury. And at the time of fracture - due to damage to the lung tissue and visceral pleura by the sharp ends of bone fragments.

Massive hemothorax in blunt trauma is caused by bleeding from ruptures of the lung, main blood vessels and heart, and intercostal vessels. Pneumothorax and hemothorax, regardless of the genesis and source of air and blood entering the pleural cavity, greatly complicate the condition of the victim, which worsens the prognosis.

Open chest injury

A mandatory component of an open chest injury is a wound to the chest wall. Such a wound can be caused by bladed weapons and firearms, fragments of devices that have exploded, sharp and blunt objects, as well as hard objects. Chest injuries can occur in wartime, as well as in peacetime, in everyday life and in criminal situations, during mass injuries and accidents. If the chest wound does not penetrate deeper than the pectoral fascia and the parietal pleura remains intact, then the wound is non-penetrating. If the parietal pleura is damaged, the wound is regarded as penetrating. Penetrating and non-penetrating wounds can be blind or through. This grouping is especially important for characterizing spherical, fractional and fragmentation wounds, because when a blind wound occurs (as opposed to a through wound), the object that wounds remains inside the victim, and the surgeon must weigh all the indications and contraindications for its removal.

First aid for chest injury

Based on the large number of types of chest injuries, it is quite difficult to immediately determine the nature and severity of the injuries, which causes problems when providing first aid for chest injuries. Because it is difficult to immediately tell exactly what has been damaged, you should pay close attention to the signs and symptoms of damage and act on the assumption of the worst.

1. If a rib is broken, it is necessary to give the victim pain medication, since such injuries are very painful. After this, you need to apply a tight fixing circular bandage. In case of air penetration into the pleural cavity (pneumothorax), it is necessary to make a sealed bandage (apply a layer of polyethylene to the wound, and then bandage the damaged area). When transporting a casualty, the patient should sit and not lie down. If there are complex fractures, the patient is hospitalized.
2. Compressions, concussions and bruises are less severe chest injuries, although they are no less painful. First, you need to eliminate the pain with painkillers, then quickly call an ambulance. If pneumothorax is observed, apply an insulating bandage, then urgently take the patient to the hospital. In this case, surgical intervention is necessary.

Transportation of victims with chest trauma should be carried out by specialists.

Consequences of chest injuries and complications of chest injuries

Chest injuries may be accompanied by damage to internal organs. At first glance, the possibility of injury to internal organs when a non-penetrating injury occurs may seem paradoxical. However, this happens if the object that wounds does not penetrate the pleural cavity, but at the time of injury causes a concussion of the chest, a sharp increase in intrathoracic pressure and rupture of internal organs, most often the lungs. This insidious option causes diagnostic errors, because the surgeon, having convinced himself of the non-penetrating nature of the wound, excludes damage to internal organs. The antipode of damage to internal organs with a non-penetrating wound is the so-called lucky through wound, when the internal organs remain unharmed.

The presence or absence of pneumothorax, hemothorax, emphysema and mediastinal hematoma, and pericardial tamponade is of decisive importance in assessing the severity of the condition, treatment tactics and prognosis. These complications occur during various chest injuries. They cause severe, sometimes catastrophic, breathing and circulatory disorders. The organization of first aid and the treatment program depend on understanding the essence of the pathophysiological disorders that occur during complications.

Chest injuries account for about 10% of all peacetime injuries. Depending on the mechanism of injury, the nature and intensity of the force of the acting factor, various injuries may occur.

There are closed (when the integrity of the skin is not broken) and open injuries (wounds) of the chest, and there are open ones that do not penetrate into the chest cavity (when the integrity of the parietal pleura is preserved), and those that penetrate into the pleural cavity.

Closed and open injuries can be with or without fracture of the ribs or sternum, without damage and with damage to the chest organs.

With all types of chest trauma, the depth and rhythm of breathing and normal coughing are disrupted, which leads to hypoxia and possible complications.

Closeddamage occur as a result of a blow, concussion or compression of the chest. The nature and severity of injuries depend on the mechanism and intensity of the injury.

Chest contusion

More common are ordinary chest bruises, which are sometimes accompanied. When the soft tissues of the chest are struck, local swelling and pain appear, and sometimes a subcutaneous fluctuating hematoma (with a tangential blow). Due to hemorrhages in the muscles, the patient breathes shallowly, and taking a deep breath increases the pain. To clarify the diagnosis, be sure to percussion and auscultation examine the condition of the lungs and take an x-ray of the injured half of the chest.

Treatmentsick consists of prescribing painkillers (analgesics, novocaine blockade), puncture of the hematoma, and after 3-4 days - thermal procedures, breathing exercises. Sometimes blood from a hematoma that has not resolved is removed through a skin incision. Antibiotics are not prescribed to prevent complications. Performance is restored in 2-3 weeks.

Chest concussion

A mild concussion may not be clinically apparent. The patient only feels a change in the depth and rhythm of breathing, lack of air. Severe chest concussions are accompanied by hemorrhage into the lungs and resemble a state of severe shock. The general condition of the patient is serious; cyanosis, cold and wet extremities, rapid, arrhythmic pulse, rapid, shallow and uneven breathing. Severe concussions sometimes result in the death of the patient. Such patients require intensive care, sometimes resuscitation, and then symptomatic therapy.

Rib fractures

Single rib fractures, as a rule, occur as a result of direct trauma - at the point of application of force (impact, pressing against a certain object). Double rib fractures occur. When the chest is compressed in the anteroposterior direction, several ribs break along the axillary line, and in the lateral direction, along the paravertebral and midclavicular lines. Multiple bilateral rib fractures occur in severe road traffic injuries, rubble, etc. Sometimes a sharp fragment of a rib can damage intercostal vessels, perforate the parietal pleura and even injure the lung.

Symptoms. The patient complains of sharp pain at the fracture site, which increases with inhalation. The general condition of the patient depends on the severity of the injury (number of damaged ribs, degree of lung failure, blood loss, pleuropulmonary shock, etc.).

With single rib fractures, the patient's general condition remains satisfactory. The patient spares the chest and breathes shallowly. Due to the pain, he cannot cough up the mucus that accumulates in the upper respiratory tract, and therefore gurgling appears, and over time, pneumonia can develop. Hemoptysis indicates lung damage.

During palpation, the points of maximum pain are determined. If you squeeze the chest lightly, local pain increases, and the patient points to the fracture site. With double fractures of the ribs (fenestrated fracture), when inhaling, this area sinks, and when exhaling, it levels out. Such flotation of the chest wall with each breath is very painful, which affects the nature of breathing, the function of the organs of the mediastinum, which also floats, and the general condition of the patient.

Multiple and especially bilateral rib fractures cause severe respiratory distress, hypoxia and traumatic pleuropulmonary shock. The examination of the patient includes chest x-ray, percussion and auscultation to identify rib fractures and possible complications - pneumothorax, etc.

Treatment for uncomplicated rib fractures

If individual ribs are damaged, treatment is limited to pain relief, improvement of breathing conditions and prevention of pneumonia.

The patient is placed in a semi-sitting position in bed. A local or paravertebral blockade is performed with a 1% novocaine solution, and analgesics are prescribed. After anesthesia, chest excursion improves, and breathing becomes smooth and deep, the patient can even cough up sputum, which prevents the occurrence of pneumonia. The blockade is repeated 2-3 times. In addition, patients are prescribed breathing exercises and symptomatic therapy. Fractured ribs heal in 3-4 weeks, performance is restored in 5-6 weeks.

In case of multiple rib fractures (four or more), complex treatment is carried out, which is determined by the severity of the patient’s condition. In order not to disturb a seriously ill patient with repeated blockades and to maintain constant pain relief, a thin tube (vascular catheter) is inserted into the paravertebral area through a needle, which is left, glued with an adhesive plaster to the chest wall, and its second end (catheter cannula) is brought out to the shoulder girdle. When pain occurs, without moving the patient, 15-20 ml of a 0.5% novocaine solution is injected into the catheter (4-5 times a day).

Patients with severe breathing disorders are also treated with cervical vagosympathetic blockade according to A.V. Vishnevsky and undergo intensive therapy, and sometimes resuscitation measures (, mechanical breathing, etc.).

In case of double fenestrated fractures of the ribs, in order to eliminate flotation, under local anesthesia, the ribs are fixed with Kirschner wires passed percutaneously, or they are applied to the sinking area of ​​extraction (stitching behind the soft tissues and periosteum of the middle rib with a coarse Mylar thread or using bullet forceps). Ribs fixed using the following methods fuse in normal time. Open osteosynthesis of ribs is used extremely rarely.

Complextreatment also includes oxygen therapy, suction of mucus from the trachea, antibiotic therapy, etc.

Complications of rib fractures

Rib fractures, especially multiple ones, are often complicated by hemothorax, closed and valve pneumothorax, and subcutaneous emphysema.

Hemothorax

Hemothorax called the accumulation of blood in the pleural cavity, which leaked from damaged muscles or intercostal vessels, when wounded by fragments of the rib of the parietal pleura. There is less bleeding when the lung parenchyma is damaged, but then, as a rule, hemothorax is combined with pneumothorax, i.e. hemopneumothorax occurs. Depending on the degree of bleeding, hemothorax can be small - it occupies only the pleural sinus (100-200 ml of blood), medium, it does not reach the level of the lower angle of the scapula (300-500 ml). Total hemothorax (1-1.5 l) is extremely rare.

Levelhemothorax determined by percussion and x-ray with the patient sitting in an upright position. During percussion, the upper limit of dullness of the percussion sound is especially clearly demarcated against the background of the box sound of pneumothorax. On the radiograph, the hemothorax area is darkened with a pronounced horizontal upper border. Under local anesthesia, the diagnosis is clarified by puncture of the pleural cavity. If the hemothorax is small, sometimes it is not possible to suck the blood out.

Symptoms. A small hemothorax has no special signs, and the clinical symptomatology is dominated only by signs characteristic of rib fractures. But the dynamics of hemothorax need to be monitored, since it can increase. Moderate, especially total, hemothorax compresses the lung, hypoxia, shortness of breath, sometimes hemodynamic disturbances, etc. appear. With hemothorax, body temperature predominantly increases (38-39 ° C).

Treatment. Considering that hemothorax is one of the complications of rib fractures, the patient is treated comprehensively. As for hemothorax, with minor hemorrhage into the pleural cavity, the blood gradually resolves, although puncture is done to minimize the amount of blood. Due to reactive inflammation of the pleura and blood residues, the pleural cavity becomes obliterated over time.

In case of significant hemothorax, blood from the pleural cavity is immediately sucked out with a puncture needle, since after some time it can settle into a clot, and then it is necessary to perform an operation.

If after the puncture blood appears again, which should be regarded as unstoppable bleeding from damaged vessels, the patient undergoes surgery to stop the bleeding. But before that, a puncture and Ruvilois-Gregoire test are performed to determine whether the blood is fresh. Fresh blood obtained in a test tube in air quickly settles into a clot, but stale blood does not settle. Then you can limit yourself to repeated puncture.

There are cases when exudative pleurisy develops after hemothorax. Then the diagnosis is clarified by puncture and conservative treatment is carried out (repeated punctures, drug therapy, etc.).

Closed and valve pneumothorax

If the visceral pleura and parenchyma are damaged during inspiration, air from the lung enters the pleural cavity, where normally there is negative pressure (0.039-0.078 kPa,
4 8 mm water. V.).

The elastic lung tissue contracts and the lung collapses - a closed lung is formed. If, in addition to air, blood from damaged intercostal vessels or lung parenchyma enters the pleural cavity, hemopneumothorax is formed.

There are cases when the lung is injured so that pleural or lung tissue hangs over the rupture site. Then, when you inhale, air enters the pleural cavity, and when you exhale, this tissue, like a valve, closes the opening to the lungs and does not allow the air to escape - a valve pneumothorax is formed.

With each inhalation, the amount of air in the pleural cavity increases, its pressure rises sharply (tension pneumothorax), which leads to compression of the lung and displacement of the mediastinum. Disorders of gas exchange and hemodynamics appear quite quickly. The general condition of the patient becomes severe, severe shortness of breath, cyanosis of the skin and mucous membranes, and tachycardia occur. As a result of sudden suffocation, the patient develops fear and severe psychomotor agitation.

The presence of pneumothorax is determined by percussion by the characteristic box sound, comparing it with the healthy half of the chest. On auscultation, breathing is weakened, and with a collapsed lung, it cannot be heard. The radiograph shows a clear contour of the collapsed lung against the background of clearing of the pneumothorax area. Puncture of the pleural cavity clarifies the diagnosis; moreover, with valvular tension pneumothorax, air comes out through the needle under pressure.

Treatment. In case of closed pneumothorax, regardless of its degree, air is immediately sucked out from the pleural cavity. This, firstly, improves the general condition of the patient, and, secondly, with prolonged pneumothorax the lung becomes rigid, and then it is more difficult to straighten it.

If for hemothorax the chest is punctured in the lower section, then for pneumothorax - in the upper, mainly in the second intercostal space along the midclavicular line. The air is sucked out using a Janet syringe or a triampulle system. If the pressure in the pleural cavity becomes negative, then the triampulle system is excluded. Lung expansion is controlled by percussion and x-ray.

The general condition of a patient with a closed valve pneumothorax is so severe that he should immediately, directly at the scene of the accident, perforate the chest wall (with a thick injection needle) - convert the closed pneumothorax into an open one. After the puncture, air is immediately released from the pleural cavity under pressure. And then the pressure in the cavity is equalized with atmospheric pressure, and the patient’s general condition improves. Choking is significantly reduced. After a few hours, with collapsed lungs, the “valve” may stick, and a regular closed pneumothorax will form. In these cases, the air from the pleural cavity is sucked out using a triampulle system. If the lung has expanded, then the triampulle system is not excluded, but negative pressure is maintained in the cavity and monitored for a day or two. The system is turned off only when they are sure that the valve has closed and there is no air in the pleural cavity. This is confirmed by percussion, auscultation and x-ray.

If the amount of air sucked out exceeds the nominal volume of the pleural cavity, this indicates that air continues to flow from the damaged lung. In this case, the pleural cavity drained according to the Bulau method.

Execution technique. A finger of a surgical glove is hermetically secured to one end of a sterile rubber tube (diameter 5 mm and length 60-70 cm), the top of which is cut along the length by 1.5-2 cm. Thoracentesis is performed and the second end of the tube is inserted into the pleural cavity, fixed, sealed skin wound with suture. The finger is dipped into a sterile jar filled with an aqueous solution of an antiseptic substance (furacilin (1: 500), etacridine lactate (1: 1000), etc.).

During inhalation, the tip of the finger collapses in the solution and closes the hole in it, preventing the solution from being sucked into the tube. When you exhale, the chest collapses and air escapes through the tube into the jar. This is how suction drainage works. After a day or two, when the valve in the lungs closes, negative pressure is created in the pleural cavity, and the lung expands, the drainage stops working, and after a day it is removed.

If the valve does not close after a few days, this indicates significant damage to the lung, and the patient is operated on. After elimination of pneumothorax, patients with rib fractures are treated according to general principles.

Subcutaneous emphysema

If there is pneumothorax and damage to the parietal pleura or mediastinum, then air from the pleural cavity through the wound enters the soft tissues of the chest or mediastinum, moves through the interfascial spaces into the subcutaneous tissue of the shoulder girdle, neck and face. Subcutaneous emphysema is especially pronounced with valvular pneumothorax.

Characteristic signs subcutaneous emphysema: swelling in the area of ​​air accumulation, and upon palpation - a specific crunch in the subcutaneous tissue (“walking in the snow”) due to the rupture of bubbles and movement of air. By percussion you can feel the difference in the percussion sound above the emphysema. Air in the soft tissues is also visible on a chest x-ray.

Subcutaneous emphysema gradually decreases, the air is absorbed and no special treatment is required. Only in case of excessive emphysema, when air accumulated under the skin of the neck compresses the veins or trachea, small fasciocutaneous openings with drainage are made above the collarbone, through which the air escapes.

Sternum fractures

They usually occur as a result of direct trauma. Most often, a fracture occurs at the junction of the manubrium and the body of the sternum, less often - the xiphoid process and the body of the sternum. The displacement of the fragments is insignificant.

Symptoms. The patient complains of local pain, which intensifies during deep inspiration and coughing. By palpation, local fluidity and the degree of displacement of fragments are determined.

The diagnosis is clarified by radiography in the lateral projection of the sternum.

Treatment. 10 ml of 1% novocaine solution is injected into the fracture area. For fractures without displacement of the fragments, no special treatment is required. The sternum grows together in 3-4 weeks. If there is a posterior displacement of the body of the sternum, the patient is placed on a bed with a shield and a cushion is placed under the thoracolumbar region to achieve sufficient reclination. After comparison of the fragments, reclination can be reduced.

After 3-4 weeks the patient is discharged. The average period of incapacity for work is 6 weeks.

Surgical treatment for sternal fractures is indicated only when, after reposition, pain or dysfunction of the mediastinal organs remains.