trauma ans

8/10/2019 Trauma Ans

1/31


2/31

8. Linked to this is the need to concentrate reserves surgical training, health and transport

equipment in the hands of health chiefs to maneuver. And these funds in places the greatest

losses. Despite the difficulties of full and complete implementation by the war of the modernprinciples of first aid and operate the wounded, the military surgeon should not make allowances

for field conditions and should not depart from firmly established in a peaceful surgery aseptic

and antiseptic. On the contrary, the rules of asepsis and antisepsis, surgical operating disciplinemust be observed in a war even stricter than in a peaceful manner, as a wartime injuryaccompanied by even more severe complications than injuries and diseases of the peace-time,

requiring surgical intervention.

Ans.3

Military doctrine

It supports an integrated health services system to triage, treat, evacuate, and returnsoldiers to duty in the most time efficient manner.

It begins with the soldier on the battlefield and ends in hospitals. Care begins with first aid (self-aid/ buddy aid), rapidly progresses through emergency

medical care (EMT) and advanced trauma management (ATM) to stabilizing surgery, andis followed by critical care transport to a level where more sophisticated treatment can be

rendered.

Ans.4

Medical support is an important part of military operations. The aim of war surgery is to achieve

the return of the greatest number of injured to combat and the preservation of life, limb, and

eyesight. War surgery is different from current traumatology because of many reasons. Because

hemorrhage is the most common cause of death in military trauma, airway preservation andeffective control of bleeding represent the highest priorities in war injuries. Wound excision (the

so-called debridement) is a significant part in the management of war injuries. It involves

excision of all foreign objects and contaminants and dead/nonviable tissue that--if not removed--would become a medium for infection. Broad-spectrum antibiotics should be administered and

tetanus prophylaxis measures should be taken, as indicated. Delayed wound closure (usually

after 4-5 days) is the standard procedure after wound excision. Recently, changes in the dogmaof war necessitated significant changes in the organization schema of military services

supporting modern military operations. The concept of highly mobile, easily deployed, forward

surgical facilities is the most important change in the philosophy of modern war injury. Military

surgeons are now facing new challenges; appropriate education is required to achieve success intheir mission.

Ans.5 ,6,7

RANEVOY PROCESS. MORPHOLOGY AND pathomorphology.


3/31

The structure of any gunshot wounds can be traced to a number-

ing morphological traits. (e) The mechanism of injury

tissues in wounds are distinguished: a zone of direct action hurt the

projectile (the wound defect, wound channel); area contusion (bruise)

or primary traumatic necrosis due to direct and

side impacts and runway; zone concussion (concussion) or zone can-

molecular tremors caused by side impacts.

Wound defect may be true (because of the pull-out

textiles - minus tissue) or false, due to retraction of the disconnector-

United tissues. Depending on the nature of the wound tissue defect can-

Jette manifest in the form of the wound cavity (walls and bottom), wound

channel (depth greater than the diameter) or the wound surface.


4/31

The walls of the wound defect covered, usually in the dead

time of tissue damage, forming a zone of primary trauma

kinetic necrosis. Wound cavity and the wound channel is usually filled

are satisfied by blood clots, shreds crush tissue, often

bone fragments and foreign bodies. Accumulates in the wound

cavity blood, increasing intralyuminarnoe pressure, promotes

spontaneous hemostasis. The walls of the wound defect covered by the convolution

nuvsheysya blood coagulated fibrin is fixed to the wound

surface. Microbes that fall into the wound, serve further research

source of infection.

In the area of contusion revealed foci of hemorrhages, diffuse


5/31

1. impregnation of tissues with blood, tears of the internal organs, fractures

bones, separation of tissue complexes foci denaturation of tissue.

Macroscopic (color, texture, turgor) and microscopic

(Kariopiknoz, karyorhexis, kariolizis, the disintegration of the fibers, coagulation

tion and transformation of detritus in the cytoplasm), signs of necrosis with

content of the wound defect is the material basis of pro-

processes, which in conditions of significant microbial contamination

accompanied by a purulent inflammation and provide the basis for compli-

tions of wound healing.

Zone of secondary traumatic process (molecular

concussion) is characterized by circulatory disturbance in the form

spasm with subsequent expansion of the small blood vessels and


6/31

stasis. This is accompanied by tissue hypoxia and the violation of pi-

Tania with the emergence of sites necrobiotic changes and

secondary foci of necrosis. The width of this zone in different sections

wounds and wounds in different varies, but is determined rather

well, after many hours or even days after the injury.

In the area of molecular tremors and disturbed physiological

FIR mechanisms (local tissue stupor) contusion with electron

polaron microscopy revealed a clear destructive changes

intracellular organelles, milliarnye foci of necrosis and small blood-

voizliyaniya. In general, the nature of the processes occurring in cells

framework of, poorly studied and evaluated as parabiosis.


7/31

Thus, we, the military doctors, it is important to know that

walls of the wound channel is found dead, the destroyed tissue, to

which are adjacent tissue with altered reactivity dramatically under-

zhennoy vitality, by which live and feed on micro-

Microorganisms.

In response to the traumatic effects of the organism occurs

and develops the wound process and (or) wound disease, characterized by

rizuyuschayasya myriad of interrelated changes

internal environment and phase over the healing wound.

Let me remind you know information about the wound healing process. By

IG Rufanova, it passes a phase hydration (redness, swelling,


8/31

stasis, thrombosis, degeneration). This phase transition gelatinous body

in the liquid, which accelerates the course of the process. The second phase of dehydration

tion and regeneration.

SS Girgolav identifies the following phases:

1) preparations;

2) regeneration;

3) the formation of scar.

Wound inflammation in VI Rusakov (1971) may be: ASEP-

cal, infectious, acute, chronic, superficial, deep

bokoe, alterative, exudative, proliferative, serous,

fibrinous, hemorrhagic, purulent.

In this regard, of great importance within gunshot


9/31

wound has microbial contamination wounds. Although this issue will be

devoted to lecture, tell that to distinguish between:

- Microbial contamination of the wound (ie, the presence of microbes in

wound, hit them in the wound at the time of injury and immediately after,

to the imposition of aseptic dressings) - primary, secondary;

- Wound microflora (bacteria that are "grafted" into the wound of

entered it;

- Wound infection - this is a painful process. As he wrote

IV Davidovsky: "Contact with microbes in the wound - the regularity and

development of infection in the wound - an event during the wound healing process. "

The presence of microbes in the wound, their activity, the relationship with organic


10/31

nism as a whole largely determines the ways of healing.

To clarify further remind you of the fundamental position of

tion of general surgery. There are two ways of wound healing: primary

nym tension (without abscesses); secondary intention (via Nag

noenie), which in turn may also develop in two

ways: by concentric scars to epithelialization. For the first time

described N. Krause (Surgery, 1944, N 4).

Some authors devote a third way - healing under

eschar, which may also be primary and secondary.

When a gunshot wound is not only local in-

change in the organs and tissues in the area of injury. Disrupted activities


11/31

sequence of the CNS, cardiovascular system, endocrine glands, metabolism. WHO-

arise toksikorezorbtivnaya fever, change of Immunobiology,

chemical reactions. Wound complicated by shock, blood loss, various

GOVERNMENTAL types of hypoxia. Wound develops a disease in which

domestic pathophysiology highlighted stage:

1) the mobilization and protection;

2) resistance;

3) exhaustion.

Of particular importance, this acquires a gradation in activity

medical service in the dry, hot climate and dehydration

smoothing the body, what will stop below.

Ans.8


12/31

Primary Surgical Wound Care

longitudinal incisions.

Debridement: Excision of foreign material and devitalized tissue. Irrigation. Reconstruction, drainage

LEAVE WOUND OPENNO PRIMARY CLOSURE.

Antibiotics and tetanus prophylaxis.

Splint for transport (improves pain control)

Gunshot wound

initial assessment of tissue viability

Color Contraction

Consistency

Circulation

Incision

debridement

Reconstruction drainage

Gunshot wound No Primary Closure of War Wounds.

Dressing.

Do not plug the wound with packing as this prevents wound drainage. Leaving the

wound open allows the egress of fluids, avoids ischemia, allows for unrestricted

edema, and avoids the creation of an anaerobic environment.

Place a nonconstricting, nonocclusive dry dressing over the wound

Wound Management After Initial Surgery

The wound undergoes a planned second debridement and irrigation in 2472 hours,

and subsequent procedures until a clean wound is achieved.

Between procedures there may be better demarcation of nonviable tissue or the

development of local infection.

Early soft-tissue coverage is desirable within 35 days, when the wound is clean, to

prevent secondary infection.


13/31

Delayed primary closure (35 days) requires a clean wound that can be closed

without undo tension. This state may be difficult to achieve in war wounds.

Soft-tissue war wounds heal well without significant loss of function through

secondary intention. This is especially true of simple soft-tissue wounds.

Definitive closure with skin grafts and muscle flaps should not be done in theater

when evacuation is possible. These techniques may be required, however, forinjured civilians or prisoners of war.

Ans.9

biology(pathogenesis) Gunshot wounds

Pathogenesis of wounds

Complete destruction of tissue structure, tears, crushing, bleeding = PRIMARY NECROSIS

Increased vascular permeability, tissue edema, fascial carrying cases, the disorder of intracellularredox processes, the development of circulatory and tissue hypoxia, metabolic disorders =

secondary necrosis

Changes in regional blood flow in the anatomical segment, the body of an organism,neurotrophic disorders arising as a result of activation of bioactive substances

Violation of the regulatory function of the central autonomic nervous and endocrine systems,

reducing the BCC, and therefore - hypoxia

Ans.10-13


14/31

MODERN MILITARY FIELD DOCTRINE Wound Healing

gunshot wound is the primary microbial-POLLUTED

The only method to prevent the occurrence of infectious complications in wound FIRE IS

- PRIMARY SURGICAL TREATMENT OF WOUNDS

Surgical treatment of wounds create optimal conditions for its healing

Debridement

(Surgical interventions, aimed at creating optimal conditions for HEALING DAMAGED

TISSUE)

PRIMARY

(FIRST AFTER INJURY OPER. INTERVENTION TO BE CARRIED ON INJURY, in

order to prevent complica-tions)

EARLY - UP TO 24 HOURSv

DEFERRED-to 48 hoursv

later - more than 48 hoursv

REASSESSMENT


15/31

(OPER. INTERVENTION TO BE CARRIED OUT ON EARLY WOUND ZHNENY Oslo

process, or is not limited to surgical-logical PRIMARY TREATMENT

SECONDARY

(OPER. INTERVENTION TO BE CARRIED OUT ON THE SECONDARY

COMPLICATIONS OF WOUND HEALING PROCESS

TECHNOLOGY IMPLEMENTATION PECVD INJURY INCLUDES 4 stages:

I-incision WOUNDS

II-excision of necrotic tissues, removal of foreign bodies, ETC.

III-REHABILITATION Anatomical functionally RELATIONSHIPS

IV-drainage of the wound

INDICATIONS debridement wounds

extensive destruction of tissuesv

gunshot fracturesv

CONTINUED BLEEDING WOUNDv


16/31

POLLUTION INJURY land and so on.v

Infected Wounds OB, PBv

penetrating wounds BODIESv

CONTRAINDICATIONS TO PD gunshot wounds

Traumatic shock (time - up to removal from a state of shock)

agonal STATUS

PECVD not be undertaken:

TANGENT INJURY TO THE EXTENT OF SKIN AND SUBCUTANEOUS TISSUE

SOFT TISSUE INJURY WITHOUT damage to bones, vessels and nerves

multiple shrapnel wounds SKIN AND SUBCUTANEOUS TISSUE

13 : indications and contraindications for the closure of gunshot wound?

Gunshot wounds are not sutured.wound must kept open except

Wound of hand (wrist)


17/31

Wounds of head

Wounds of face

Bcoz they have good blood supply.

Indications for primay suturing:

when no necrotized or dead tissue remained inside the wound.

When patient can be kept under observation for some time.

When wound can be sutured without excessive tension.

CONTRAINDICATIONS:

These are also mostly the indications for delayed primary suture. They are:

(1) Wounds more than 6 hours old, or with dirty or damaged tissue.

(2) All severe wounds, crush injuries, gunshot wounds and bites, either human or animal.

(3) Any wound in which immediate or delayed primary split skin grafting might be a better way

of providing skin cover, for example degloving injuries.

(4) Wounds in severely shocked patients whose peripheral circulation is so poor as to seriously

weaken wound repair

(5) All open fractures

(6) Most open joint wounds

(7) Wounds in anyone who is about to be sent on a long journey.

(8) Lack of antibiotics, so that you have nothing to give a patient if his wound does become

infected.

(9) ALL war wounds, especially all missile wounds

14:treatment of gunshot wounds?

Gunshot wounds should be treated as contaminated wounds.

1: control the bleeding


18/31


19/31

3. Tangents.

IV Relative to body cavities:

1. Penetrating.

2. Non-penetrating.

V to quantify the characteristics:

1. Single.

2. Multiple.

VI on localization:

1. Isolated (head, neck, chest, abdomen, pelvis, spine, limbs).

2. Co (2 anatomic areas and more).

VII As aggravating effects, accompanied by:

1. massive bleeding (including those with damage to large vessels);

2. acute regional ischemia of the tissues;

3. damage to vital organs, anatomical structures;

4. damage to bones and joints;

5. traumatic shock.

VIII On the clinical course of wound healing:

1. Complicated.

2. Uncomplicated.

16: Combined radiation injuries after nuclear explosion?

Combined radiation injuries is the kind of defeats arising at simultaneous or consecutive

influence on an organism of ionizing radiation and non-radiation factors

Classification of combined radiation injures


20/31

According to radiation dose combined with other factors, combined radiation injures (CRI) can

be classified as:

thermal CRI :external/internal irradiation with thermal burns

mechanical CRI :external/internal irradiation with wound or fracture, or haemorrhage

thermal-mechanical CRI:external/internal irradiation with thermal burns and wound (fracture,haemorrhage)

chemical CRI :external/internal irradiation with chemical burns or chemical intoxication

Predicted distribution of injuries from nuclear explosion

Combined injuries: 65 % to 70 %

Irradiation, burns, wounds 20 %

Irradiation, burns 40 %

Irradiation, wounds 5 %

Wounds, burns 5%

Distinctive features of combined radiation injures:

presence at the victim of attributes two or more pathologies,

prevalence of one, heavier and expressed during the concrete moment of pathological process,so-called a leading component,

interference (mutual burdening) radiation and non-radiation factors, shown as heavier current ofpathological process, than it is peculiar to each component

Phases (periods) of combined radiation injuries:

The acute phase or the period of primary reactions to radiation and non-radiation traumas

The period of prevalence of non-radiation components

The period of prevalence of radiation components

The recovery phase or the period of restoration

Major burn injury results in a systemic responsecharacterized by an early period of shockwith hypovolemia, gastrointestinal ileus, and oliguria. After adequate resuscitation, the burn


21/31

patient converts to a hyperdynamic state characterized by increased cardiac output, diuresis, and

peripheral catabolism.

Causes of burn deaths

Direct results of accident 13 %

Sepsis 45 %

Organ /system failure

(burn shock, acute renal failure) 41 %

Yatrogenic intervention 1 %

Expected mortality from thermal injuries

Burn area, % of body surface area

> 30 ..EXPECTED MORTALITY 100 %

1030.. Survive possible with specific treatment

< 10 .. Survive even without treatment

Principles of burn therapy

Topical antimicrobials

Early grafting

Stimulation of the bone marrow and possibly of skin regeneration with cytokines

Treatment of contaminated burn injuries

Gentle decontamination after stabilization

Passive tetanus immunization even in previously immunized patients

Emergency procedures

First actions standard emergency medical procedures:

ventilation

circulation


22/31

stop haemorrhage

Decontamination after stabilization

Survivable radiation injury not acutely life threatening

Secondary assessment of combined injury

Primary surgical responsibilities:

stabilize

set surgical priorities

perform surgery

Secondary responsibilities:

manage post-operative course

assess radiation exposure in post-operative or post-stabilization period

17:Radiation influence in wound healing?

Wound colonization

Wound sepsis

Failed delayed primary closure

Delay in healing

Occasional amputation

Radioactive nuclides contaminated wound

18:combined chemical injuries

Combined chemical destruction. When using chemical weapons may be different combinations

of combined chemical damage: infected wound or burn the surface is accompanied by lesions ofthe skin, eyes, respiratory system, gastrointestinal tract, lesions of the skin, eyes and other organs

without getting agents (IA) into the wound, lesion skin, eyes, respiratory system, in combination

with a closed mechanical trauma. Combined chemical lesions characteristic syndrome of mutualaggravation. When injected into the wound with skin-resorptive agents actions (mustard gas,


23/31

lewisite) appear necrotic changes, which leads to the development of pus, or anaerobic infection,

while sucking QB from the wound they have a general effect on the body, healing is very long.

As a result of the defeat of the soft tissues of OM develop deep intermuscular cellulitis, zateki,fistulas, osteomyelitis, severe arthritis. Upon infection of wounds with mustard noted an odor

(garlic or mustard), fabric painted in a dark-brown color. With the massive penetration of

mustard gas from a wound he has re-zorbtivnoe action, manifested a common oppression,drowsiness, increase in body temperature to 39 C, the appearance of protein in urine,erythrocytes, and cylinders. In severe cases, pulmonary edema, and skin. Healing of such

wounds is slow, often formed ulcerate scars and ulcers. In case of infection of wounds lewisite

marked smell of geraniums and ashen-gray coloring of fabrics, there are congestion and swellingof skin, the deposition of the bubbles. By the end of one's days growing tissue necrosis.

Obscherezorbtivnoe effect is manifested by salivation, nausea, vomiting, agitation, shortness of

breath occurs, lowers blood pressure and cardiovascular activities, developing pulmonary edema.

With delayed treatment death occurs during the first 2 days. Appearance of wounds infected withorganophosphorus compounds (FOV) is not changed, necrotic and inflammatory changes are

absent, is characterized by fibrillary twitch muscle fibers in the wound. As a result, the suction

FOV of the wound developed tonic and clonic convulsions, miosis, bronchospasm, coma,asphyxia. Burns, infected skin-resorptive agents of action, characterized by a peculiar smell and

dark brown spots. With the defeat of mustard gas on the periphery of the burn develop swelling

and redness. After one day, there are bubbles. After contact with lewisite, these events are

developing rapidly. In case of infection of burns FOV observed the same features as in contactwith them in the wound. Clinic General poisoning FOV, infiltrated through a burn wound, the

same as in the FOV gets into the body in other ways.

19: Primary surgical debridgment of wound with chemical and radiation injuries?

Combined chemical destruction. The main method of treating wounds infected with agents ofskin-resorptive effect, is the primary surgical treatment in early (3-6 h after the lesion) as

possible. Dressings are burned. Surgical treatment of wounds infected with RH cutaneous re-

zorbtivnogo action has some special features. Primarily produce

degassing skin around the wound and the wound itself 5% aqueous solution of chlorine bleach.

After removal of nonviable tissue is widely excised subcutaneous fatty tissue and muscles ofinfected agents. Bone fragments are removed and the ends of broken bone opilivaem within

healthy tissue. Naked vessels ligated, and the nerve trunks treated with an aqueous solution of

chloramine. Seams do not overlap.

When you close an open pneumothorax and wound after laparotomy them sewn to the

aponeurosis. May be imposed by secondary sutures. In case of late receipt of the affected with

the combined damage and inflammation in the wound can restrict its dissection.

In the case of penetrating wounds of the skull exposing the brain to produce washing wounds 1%solution of bleach, 0.1% sodium lactate ethacridine (rivanola or isotonic sodium chloride).


24/31

With the massive defeat of the joint may require a primary resection arthroplasty or amputation

of limbs.

Primary surgical treatment of wounds infected with the FOV, produce after the removal of

agents, which predstvlyaet danger to the life of wounded. In the provision of skilled and

specialized surgical care necessary to carry out detoxification of the body and decreasing thedamage caused by chemical agents.

Q60. Types of pneumothorax. Treatment

Pneumothorax is a collection of air or gas in the pleural space of the lung, causing the lung tocollapse. Pneumothorax may be the result of an open chest wound that permits the entrance of

air, the rupture of an emphysematous vesicle on the surface of the lung, a severe bout of

coughing, or it may occur spontaneously without evident cause.

The major types of pneumothorax are:

Open pneumothoraxresults when a penetrating chest wound enables air to rush in and causethe lungs to collapse.

Closed pneumothorax results when the chest wall is punctured or air leaks from a ruptured

bronchus (or a perforated esophagus) and eventually ruptures into the pleural space.

Spontaneous pneumothoraxoccurs in a previously healthy individual with no prior trauma.

This is thought to be due to rupture of a bleb (a blister containing air) on the surface of the lung.This spontaneous pneumothorax is most frequent in people under the age of 40.

Pulmonary barotraumaoccurs when a patient whose lung function is being maintainedmechanically may have air forced into the lungs, which may rupture the pleural space.

Other things can cause pneumothorax. Air can enter the mediastinum (the space in the center of

the chest between the lungs), especially during an asthmatic attack, and then rupture into thepleural space, causing a pneumothorax. When a lung biopsy specimen is taken at the time of

bronchoscopy or during thoracentesis (removal of fluid from the pleural space), the pleura lining

the lung may be penetrated, causing a leak of air which may then cause a pneumothorax.

Symptoms of Pneumothorax

There may be no symptoms if the pneumothorax is small (a small amount of air in the pleuralspace) or there may be shortness of breath if a large amount of air is in that space. If a physician

suspects a pneumothorax, a chest x-ray may be taken to confirm the diagnosis and to determinethe amount of air present.

Treatment for Pneumothorax


25/31

If the lung is less than 20 to 25 percent collapsed, the physician may choose to watch the

progress by a series of chest x-rays until the air is completely absorbed or the lung completely re-

expands.

If collapse of the lung exceeds 25 percent or if you are short of breath at rest, the physician may

recommend removing the air through your chest wall. This can be done with a needle, but isbetter performed by inserting a tube and applying constant suction for 24 hours or more. The

latter procedure also helps to prevent recurrence of pneumothorax.

Medical aid for pneumothorax

For this, the plural wall must be punctured at the second intercostal space. For more

effectiveness, thoracosynthesis and drainage of the pleural cavity must be performed pn the 2nd

intercostal space on the mid-axillary line.

Steps to perform thoracosynthesis: 1) cut the ches wall in the side, 2) place a drainage tube inside

the cavity, 3) direct the the drainage from the pleural cavity

Q61) Hemothorax, classification, treatment.

A hemothorax(or haemothorax) is a condition that results from blood accumulating in

thepleural cavity.

Classification

1)mild ( in pleural sinuses) 2) moderate(until angle of shoulder blade), 3)severe(upto the thelevel of middle of shoulder blade) 4) total ( with continuous internal bleeding)

Treatment

A hemothorax is managed by removing the source of bleeding and by draining the blood alreadyin the thoracic cavity. Blood in the cavity can be removed by inserting a drain (chest tube) in a

procedure called a tube thoracostomy. Usually the lung will expand and the bleeding will stop

after a chest tube is inserted. The blood in the chest can thicken as the clotting cascade is

activated when the blood leaves the blood vessels and is activated by the pleural surface, injuredlung or chest wall, or contact with the chest tube. As the blood thickens, it can clot in the pleural

space (leading to a retained hemothorax) or within the chest tube, leading to chest tube clogging

or occlusion. Chest tube clogging or occlusion can lead to worse outcomes as it prevents

adequate drainage of the pleural space, contributing to the problem of retained hemothorax. Inthis case, patients can be hypoxic, short of breath, or in some cases, the retained hemothorax can

become infected (empyema). Therefore adequately functioning chest tubes are essential in the

setting of a hemothorax treated with a chest tube. To attempt to minimize the potential forclogging, the surgeons will often place more than one tube, or large diameter tubes. Maintaining

an adequately functioning chest tube is an active process, usually for the nurses, that often

requires tapping the tubes, milking the tubes, or stripping the tubes to minimize potential forclogging in the tube in the setting of a hemothorax. When these efforts fail a new chest tube must


26/31

be placed, or the patient must be taken to the operating room by a surgeon to open the chest and

remove the blood clot, and re insert adequately functioning chest tubes.

Thrombolytic agents have been used to break up clot in tubes or when the clot becomes

organized in the pleural space, however this is risky as it can lead to increased bleeding and the

need for reoperation.[2] Therefore, ideally, the tubes maintain their function so that the bloodcannot clot in the chest or the tube.

In some cases bleeding continues and surgery is necessary to stop the source of bleeding. Forexample, if the cause is rupture of the aortain high energy trauma, the intervention by a thoracic

surgeon is mandatory.

Q62 Peculiarities of the development of pleuropulmonary shock development and clinical

course.

Plevropulmonalny shock

The most frequently plevropulmonalny shock observed at an open pneumothorax with an

outer diameter of a significant injury as a result of air into the cavity. pleura (especially cold

air in winter),'abscission of the lung, mediastinal shift and its fluctuations at the timeof inhalation and exhalation. When plevropulmonalnomshocked marked pallor

of integuments, cyanosis of lips, difficultybreathing and sudden shortness ofbreath, painful cough, coldextremities. Pulse is sometimes delayed due to stimulation of thevagus nerve or frequent, small, barely noticeable, drop in bloodpressure.

89. External fixation, indications, main techniques.

Ans. external fixation Is a technique for safe transportation of a wounded soldier with a

long bone fracture this method is acceptable for initial treatment of a patient who will be

evacuated out of theater. indications for external fixator When the soft tissues need to be

evaluated while en route, such as with a vascular injury; when other injuries make use of

casting impractical, such as with a femur fracture and abdominal injury; or when the

patients have extensive burns. Advantages of external fixation it allows for soft tissueaccess, can be used for polytrauma patients, and has a minimal physiologic impact on the

patient. Disadvantages are the potential for pin site sepsis or colonization and less soft

tissue support than casts.main techniques General technique: The surgeon should be

familiar with four types of standard constructs of external fixation for use in the initial care

of battle casualties: femur, tibia, knee, and ankle. External fixation can also be applied for

humerus and ulna fractures as needed.


27/31

1.understanding of the anatomy of the lower extremity is essential for application of the

pins in a safe corridor.

2. The external fixator for military purposes should be modular and allow for building upor down as healing progresses.

3.Application of the external fixator may be done without

The use of plain films or fluoroscopy.

4.Pins can be inserted by hand using a brace without power Instruments.

5.Enough pins should be used to adequately stabilize the

fracture for transport. This is usually two per clamp, but

three may occasionally be required.

6.The present external fixation system (Hoffmann II) allows

for the use of either single pin clamps or multipin clamps.

Both clamps are acceptable to use in standard constructs.

7. Multipin clamps provide geater stability and are the

current fixators fielded. Dual pin placement (with multipin

clamps) is described here. The technique for single pin placement is similar.

90. Extremities amputation, primary and secondary indications, techniques.

Ans. Introduction-Battle casualties who sustain amputations have the most severe

Extremity injuries. Historically, one in three patients with a major amputation (proximal

to the wrist or ankle) will die, usually of exsanguination. Though amputations are visually

dramatic, attention must be focused on the frequently associated life-threatening injuries.

Goals for initial care are to preserve life, prepare the patient for evacuation, and leave the

maximum number of options for definitive treatment.

The following are indications for amputation.(1)Partial or complete traumatic amputation

2. Lrreparable vascular injury or failed vascular repair with an ischemic limb.3. Life-

threatening sepsis due to severe local infection including clostridial myonecrosis. 4.Severe

soft-tissue and bony injury to the extremityprecluding functional recovery.

Technique of Amputation 1.Surgical preparation of the entire limb, because planes of


28/31

injury may be much higher than initially evident.2.Tourniquet control is mandatory. If a

tourniquet was placed in the prehospital setting for hemorrhage control, it is prepped

entirely within the surgical field.3 Excise nonviable tissue. a Necrotic skin and

subcutaneous tissue or skin without vascular support.b Muscle that is friable, shredded,

grossly contaminated, or noncontractile. (This muscle is usually at the level of the

retracted skin.) c.Bone that is grossly contaminated or devoid of soft tissue support. Bone is

transected at a level at which it has the potential for coverage. (This is usually at the level of

the retracted muscle.)4 Identify and securely ligate major arteries and veins to prevent

hemorrhage in transport.5 Identify nerves, apply gentle traction, and resect proximally to

allow for retraction under soft tissue. Ligate the major nerves. 6 Preserved muscle flaps

should not be sutured, but should be held in their intended position by the dressing.7 Flaps

should not be constructed at the initial surgery, to facilitate later closure.

In blast injuries, particularly landmine injuries, the blast forces drive debris proximally

along fascial planes. It may be necessary to extend incisions proximally parallel to the axisof the extremity to ensure adequate surgical decontamination of the wound.

85. Main principals and methods of bone fractures treatment.

Ans. With pathoanatomical and clinical points of view fracture is a combination of bone

lesions in violation of its integrity and simultaneous damage to the surrounding soft tissue.

The extent and nature of damage can be quite varied. Most often in closed fractures, there

are small breaks muscles and small vessels, and in some cases are more severe.

complications: damage to major vessels, nerves, etc.

Treatment of fractures has a gap to save the life of the victim, to prevent possiblecomplications, and as soon as possible to restore the integrity of bones, limb function and

work capacity of the patient. To achieve these goals, treatment should be based on the

following principles.

1. 1. Treatment should begin at the scene.The main objectives for the provision of

first aid are: the struggle with respiratory and cardiac activity, the shock and pain,

bleeding, prevention of secondary contamination of wounds, immobilization of the

damaged limb and preparation for emergency evacuation, gentle transport the

victim to the hospital to provide skilled specialist surgical care . At the scene the

wound closed protective sterile bandage.

2.

2. In open fractures is rarely necessary in the application of hemostatictourniquet (it overlaps with a significant external bleeding from a major artery).

Tourniquet imposed without adequate evidence, causes significant damage to tissues

damaged limbs.

3. 3. Temporary immobilization of limbs should be taken immediately after the

imposition of aseptic dressing. Bad immobilization or transportation without a good

pre-limb immobilization can cause a number of complications (extra trauma of skin,


29/31

muscle, blood vessels and nerves) and cause amplification of bleeding, pain, shock,

embolism occurrence and spread of infection

4. 4. In cases where the scene first aid rendered by the ambulance immediately and

in the way of transportation conducted (Activities aimed at prevention and control

of shock (the introduction of anesthetics and cardiac facilities, if necessary,

novocaine blockade of the fracture site or futlyarnaya above the fracture site forWisniewski , transfusion of blood products, blood, gas-oxygen anesthesia, etc.).

5. 5. The treatment of victims based on Principles of emergency surgery in the firstplace should be on saving lives. The facility should be implemented and

protivoshokovym resuscitative measures. In the absence of specific

contraindications clinical, laboratory and radiological examinations. Among the

urgent measures also include the fight against hemorrhage. Emergency surgical

care shown in injuries of the abdominal cavity open and tense pneumothorax, as

well as pronounced signs of compression of the brain and intracranial hematoma.

6. 6. Choice of treatment of fractures depends on the general condition of thepatient, age, etc. 5. Prevention of wound infection is a major challenge: treatment of

open fractures. The main method of prevention is an urgent and thorough initialdebridement. 6. Reduction of bone fragments at the fracture and all subsequent

manipulations should be painless

7. 7. Reposition of fragments should be in the immobilized state until bone union.8. 8. To prevent and treat wound infections, These tools include blood transfusions,

gamma globulin, antibiotics, anabolic hormones, thyrocalcitonin, vitamins, etc.

9. 9. With proper treatment, in most cases achieved complete anatomical and

functional restoration of limbs

95. Ankle fractures, clinical presentation, diagnosis and treatment.

The ankle helps support the whole weight of the body,Fractures are the most commontypes of ankle injuries healthy ankles are crucial to The list of signs and symptoms

mentioned in various sources for Ankle injuries includes the 5 symptoms listed below:

Swelling, Pain , Weakness, Difficulty walking, Paresthesia

History and physical examination.1 Ankle, foot, and lower leg examination 2.Always

evaluate neurovascular status, including pulses, color, and capillary refill 3.Observation of

bones and soft tissues, color, swelling 4.Anterior/posterior drawer test: Ankle is held in one

hand and the lower tibia is pushed and pulled to evaluate for instability 5.Range of motion

should be evaluate both actively and passively Ottawa ankle rules are used to determine

whether an X-ray of the ankle is necessary following trauma 1.Tenderness of the distal 6

cm of the fibula or tibia 2.Tender navicular area 3.Tender proximal fifth metatarsal

4.Cannot bear weight (at least four steps) Standard three-view ankle X-rays, stress views

(inversion or eversion), and consider foot series or lower leg series Lateral X-rays in

plantar- or dorsiflexion may help evaluate for anterior or posterior impingement CT or

MRI may be indicated to clarify findings on plain films and to evaluate cartilage, nerves,

tendons, ligaments Muscle strength and range of motion testing Treatments of Ankle

injuries PRICE 1.Protection from additional strain/injury 2.Relative rest (stretching is


30/31

okay) crutches 3.Ice for initial 2448 hours after trauma 4.Compression (elastic wrap or

ankle support) 5.Elevation of foot (higher than the pelvis). Casting is often indicated for

fractures and significant ankle sprains Short-term bracing may reduce risk of reinjury

Surgery may be indicated (e.g., bimalleolar fracture, trimalleolar fracture) Physical

therapy referral to improve strength, range of motion, and proprioception NSAIDs or

other analgesic

92. Fractures of the distal part of the radius, diagnosis and treatment.

Ans.A distal radius fracture is a common bone fracture of the radius in the forearm.Because of its proximity to the wrist joint, this injury is often called a wrist fracture.

Treatment is usually with immobilization, although surgery is sometimes needed for

complex fractures.Specific types of distal radius fractures are Colles' fracture; Smith's

fracture; Barton's fracture; Chauffeur's fracture. Diagnosis may be evident clinically when

the distal radius is deformed but should be confirmed by x-ray.Occasionally, fractures

may not be seen on x-rays immediately after the injury. Delayed x-rays, CT scan, or MRI

will confirm the diagnosis. Articular surface The articular joint surface must be smooth forit to function properly. Irregularity may result in radiocarpal arthritis, pain, and stiffness.

Lateral articular angle The lateral articular angle is the angle on an x-ray film between the

axis of the radius and the articular cup. Normally, the angle is turned down toward the

thumb. Radial length Radial length is an important consideration in distal radius fractures.

When the fracture begins to shorten, there is relative lengthening of the ulna because this is

usually not fractured. Classification Eponyms such as Colles', Smith's, and Barton's

fractures are discouraged. Though the Frykman system has traditionally been used, there

is little value in its use because it does not help direct treatment. The Universal system is

descriptive but also does not direct treatment. Universal codes include:Type I: extra

articular, undisplaced.Type II: extra articular, displaced.Type III intra articular,

undisplaced.Type IV: intra articular, displaced The system that comes closest to directingtreatment has been devised by Melone: I Stable fracture II Unstable "die-punch" III

"Spike" fracture IV Split fracture V Explosion injuries

However, an anatomic description of the fracture is the easiest way to describe the fracture,

decide on treatment, and make an assessment of stability.

Articular incongruity, Radial shortening, Radial angulation

Comminution of the fracture (the amount of crumbling at the fracture site Open

(compound fracture) or closed injury Associated ulnar styloid fracture, Associated soft

tissue injuries Treatment..Non-operative. For torus fractures a splint may be sufficientand casting may be avoided. Surgery..Contemporary surgical options have developed that

really have revolutionized treatment of this common injury. Generally, techniques include

Open Reduction Internal Fixation (ORIF), external fixation, percutaneous pinning, or

some combination of the above. The greatest recent advances have been with operative

open reduction and internal fixation ORIF.


31/31

trauma ans

Documents