THORACOABDOMINAL DAMAGES

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THORACOABDOMINAL DAMAGES (Greek thorax, thorakos breast, thorax + lat. abdomen, abdominis a stomach) — damages, at to-rykh in connection with wound of a diaphragm arises the message between chest and belly cavities.

According to different researchers, in the conditions of peace time approximately in 90% of cases Other is been a consequence of the getting wounds of a breast and stomach and in 10% — the closed injury. Among total number of patients with the getting wounds of a breast patients with Other make 10 — 15%. About 90% of these damages result from use of the pricking and cutting weapon of willows of 10% — fire; in 70% of cases of wound happen left-side, in 28% — right-hand, in * 2% — bilateral. Inlet openings of wounds are located more often between VI and XI edges, and at the longitudinal course of the wound channel (gunshot wounds) even in the third or fourth mezhreberye and in subcostal areas; in most cases outside wounds are localized between sredneklyuchichny and back axillary lines. On clinical manifestations the getting thoracoabdominal wounds subdivide into 4 groups. In the first (apprx. 22%) damages of bodies of a chest cavity, in the second prevail (apprx. 36%) — vnutribryush-ny bodies, in the third (apprx. 32%) there are equivalent damages of bodies of a breast and stomach, in the fourth (apprx. 10%) only the isolated wounds of a diaphragm are noted (see). From bodies lungs, then a liver, a stomach, heart and large vessels are more often injured.

Closed Other most often (50%) result avtodorozh-


from Fig. Roentgenograms (a direct projection) of a thorax of patients with torakoabdomi-nalny damages: and — at right-hand damage; in the right pleural cavity a shadow of the moved liver (it is specified by an arrow); — at left-side damage; in the left pleural cavity a shadow of the contrasted stomach (it is specified by an arrow).

ny injuries, in 25% — falling from height, 20% —. - of injuries and 5% — as a result of a prelum a load. Ruptures of a diaphragm are more often observed at the left.

Wedge, a picture of torakoabdominal-ny wounds develops of symptoms of an internal injury, moving of abdominal organs to a pleural cavity and acute blood loss (see). At such wounded characteristic symptoms of the getting wound of a breast — a pneumorrhagia (see), a podsasyvaniye of air through a wound, loss in a wound of a breast of an epiploon, hypodermic emphysema (see), a hemothorax (see), pheumothorax (see), a hemopericardium can odnovremenko be observed (see) and the complex of abdominal symptoms — a coffee-ground vomit (see the Hematemesis), the expiration of contents went. - kish. a path in a wound of a breast, availability of free gas or liquid in an abdominal cavity, morbidity and a muscle tension of a front abdominal wall with irradiation of pains in a shoulder and a shovel, etc. In some cases signs of massive blood loss come to light. Wedge, a picture closed Other can be shaded by symptoms of often accompanying injuries of a breast, head, a basin, extremities.

Diagnosis Other is complicated. According to D. A. Arapov and

N. V. Horoshko (1970), the correct preoperative diagnosis was established at 66,7% of wounded with T. and. Diagnosis are open * Etc. it is facilitated by existence of wound openings a little, to-rye can sometimes serve as a reference point for definition of the course of the wound channel. In these cases a reliable sign Other are symptoms of the getting wound of a breast at localization of a wound in a stomach and a complex of abdominal symptoms at localization of a wound in a breast. Even more difficultly diagnosis closed Other. Essential help in diagnosis is given by data rentge-nol. researches, at Krom come to light signs of a prolapse of abdominal organs in a pleural cavity (fig.), availability of gas under a dome of a diaphragm, restriction of mobility and high standing of a diaphragm, etc.

According to indications apply contrasting of hollow bodies, a sple-noportografiya (see), administration of gas in an abdominal cavity (see the Pneumoperitoneum), radionuclide methods (see. Radio isotope diagnosis), a laparocentesis, a torakolaparoskopiya (see Peritoneoskopiya, Torakoskopiya), etc.

Treatment Other consists in an urgent operative measure with simultaneous compensation of blood loss and correction of a hypovolemia. For completion of blood loss, in addition to hemotransfusion, in the absence of contraindications use as well reinfusion of an autoblood (see Hemotransfusion). From methods of anesthesia the endotracheal anesthesia with a separate intubation of bronchial tubes is optimum (see. Inhalation anesthesia). Surgical access should be chosen differentially: the laparotomy (see) is obligatory at the wounds which are followed by damage of hollow bodies and bleeding in an abdominal cavity; a thoracotomy (see) — at the proceeding bleeding in a pleural cavity, a massive hemothorax, a cardiac tamponade (see), ruptures of bronchial tubes, the isolated rupture of a diaphragm (the thoracotomy is carried out from side access through the seventh or eighth mezhre-berye that allows to get free access to bodies of a chest cavity, it is easy to process a wound of a diaphragm, and if necessary to carry out a transphrenic laparotomy); the thoracolaparotomy (see the Laparotomy) is shown to hl. obr. at gunshot right-hand wounds with damage of hardly accessible departments of a liver. The volume of operation depends on the nature of damage and on what body is damaged; most often carry out bandaging of the bleeding vessels (see Bandaging of blood vessels) or a vascular seam (see), mending of gaps or a resection (see) hollow bodies, removal of a spleen (see the Splenectomy), kidneys (see Pefrek-tomiya), etc. Wounds in a diaphragm are located in the tendinous center with transition to a pericardium more often; these wounds sew up with noose sutures. The pleural cavity is drained one, and at injury of airways — two drainages (see Drainage).

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Postoperative complications — an empyema of a pleura (see Pleurisy), sepsis (see), peritonitis (see), a pericardis (see) — occur more than at V3 of patients that emphasizes weight of these damages and complexity of their treatment.

The forecast at Other in connection with existence of the multiple and combined damages serious. Many victims die on the spot incidents. The postoperative lethality at open Other reaches 20%, at closed it is even more considerable.

Torakoabdominalny damages of wartime arise preferential at fire, generally fragmental, wounds and are among especially heavy. Right-hand wounds during the Great Patriotic War were observed at 59,7%, left-side — at 39,6%, bilateral — at 0,7% of wounded. Inlet opening was located below the sixth mezhreberye between sredneklyuchichny and back axillary with lines more often. The direction of the wound channel generally kosofrontalny, is more rare — kosopoperechny and longitudinal.

Use sovr. types of weapon (see Firearms, Nuclear weapon) will undoubtedly increase quantity of severe torakoabdominal-ny wounds in combination with the multiple closed injuries of bodies of a chest and abdominal cavity and other areas of a body.

First aid (see) and pre-medical help (see) is given as well as at the isolated wounds of a breast (see) and a stomach (see). The main attention is paid to recovery of external respiration (introduction of an air duct), a stop of outside bleeding (compressing bandage), prevention of shock (anesthetics, a transport immobilization) and secondary infection of a wound; wounds of a breast with open pheumothorax close an occlusive (occlusal) dressing.

During the rendering the first medical assistance (see) carry out antishock actions (analgetics, novocainic blockade, introduction of blood substitutes of hemodynamic action), a puncture of a pleural cavity at valve pheumothorax (see), etc. Evacuations first of all are subject wounded with internal bleeding and damage of hollow bodies.

During the rendering the qualified medical care (see) first of all operate wounded with the proceeding bleeding, with widely open pheumothorax which is not pressurized by an occlusive bandage with the getting wounds of a stomach. The wounded who are in state of shock are sent to antishock chambers. An operative measure shall be most sparing. Quick access (a thoracotomy or a laparotomy) is chosen depending on in what area there are big damages. In cases of massive bleeding in a pleural cavity, reasonable suspicion of wound of heart, the main vessels, a gullet, a trachea and large bronchial tubes operation is begun with a thoracotomy. After unwinding on bodies of a chest cavity expand a wound of a diaphragm for audit of an abdominal cavity. The transphrenic laparotomy allows to execute necessary intervention and at injury of a liver, spleen, stomach, intestines. In the presence of multiple injuries of abdominal organs resort to the subsequent laparotomy. If operation is begun with a laparotomy, then if necessary drainage of a pleural cavity shall precede it, and the drainage tube is connected to a sterile can (see Drainage). This measure prevents development of a tension pneumothorax during operation and gives the chance in the absence of contraindications to collect blood for reinfusion.

Specialized medical care (see) is provided in hospital for wounded in a breast, a stomach and a basin of GB of the front (see. Hospital base); it consists hl. obr. in treatment of complications, carrying out various reconstructive operations.

Bibliography: Blackamoors D. A. and

Huo Roche to about N. V. Surgical tactics at thoracoabdominal wounds of peace time, Hirurgiya, No. 8, page 73, 1970; Wagner E. A. Hirurgiya of injuries of a breast, M., 1981; Kupriyanov P. A.

About perspectives of rendering the radical surgical help at gunshot wounds of a breast, Vestn. hir., t. 73, No. 3, page 11, 1953; Treatment of victims with injuries of a breast and stomach at stages of medical evacuation, under the editorship of V. D. Komarov and A. P. Kuzmichev, M., 1979; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 12, M., 1949; Sketches of field surgery, under the editorship of Yu. G. Shaposhnikov, M., 1977; P e t -

r about in with to and y B. V., To and N sh and N of H. N and Nikolaev N. O. Hirurgiya of a diaphragm, L., 1965; R and to and N And. X. and Akperbekov A. A. Radiodiagnosis of diseases and damages of a diaphragm, M., 1973; The Guide to treatment of the combined radiation defeats at stages of medical evacuation, under the editorship of E. A. Sherbin, M., 1982; Sh e l I x about in with to both y M. V. and e is scarlet about in V. A. Objem of medical care at stages of evacuation at the closed injuries of a breast, Voyen. - medical zhurn., No. 6, page 9, 1974; Sh e l I x about in -

with to and y M. V. and Lunin M. M. Organization of treatment of victims with the getting wounds of a breast at stages of medical evacuation, in the same place, No. 9, page 13, 1973; And 1 b of e h t M. Iskustva americke ratne hirurSke sluzbe u Vyetnamu, Vojno-sanit. Pregl., sv. 27, s. 167, 1970,

bib liogr.; Byerly W. G. a. P e n else P. D. War surgery in a forward surgical hospital in Vietnam, Milit. Med., v. 136, p. 221, 1971; Dickson J. F. a. H o r n b e r g e r H. R. The operative management of thoracic and thoracoabdominal wounds in the combat zone in Korea, J. thorac. cardiovasc. Surg., v. 41, p. 318, 1961; G a n z o n i N. Die Schuss-verletzung im Krieg, Wesen, Behandlung, Prognose, Bern, 1975; G 1 i n z W. Tho-raxverletzungen, Diagnose, Beurteilung, Behandlung, B. u. a., 1978; Miiller-Farber J. u. Katthagen B. D. Die Zwerchfellruptur nach stumpfer Gewal-teinwirkung, Unfallchirurgie, Bd 7, S. 147, 1981; Naclerio E. A. Chest injuries, N. Y. — L., 1971; Pop about vie i Z. Traumatismele diafragmului, Bucuresti, 1970; Rich N. M. Missile injuries, Amer. J. Surg., v. 139, p. 414, 1980.

E. A. Wagner.

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