MINISTRY OF HEALTH OF UKRAINE
LVIV DANYLO HALYTSKY NATIONAL MEDICAL
UNIVERSITY
CHAIR OF GENERAL SURGERY
GUIDELINES
TO THE PRACTICAL LESSONS
for 3rd-year students of medical faculty
Module 1
INTRODUCTION TO SURGERY. EMERGENCY
SURGICAL CONDITIONS. FUNDAMENTALS OF
ANAESTHESIOLOGY AND RESUSCITATION.
Thematical module 4
TRAUMA AND INJURIES
Topic 16
Closed injuries of soft tissues, skull, thorax, abdominal organs
Academic discipline:
General surgery
3-rd year medical faculty
Specialty: 7.110101 - "Medicine"
7.110104 - "Pediatrics"
7.110105 - "Medical prophylaxis"
quantity of hours 4
Guidelines’ authors
Docent Matviychuk O.B.
Docent Kushta Yu.F.
Lviv-2014
Methodological guidelines were approved at the meeting of the
Central methodical commission of surgical disciplines of Lviv
Danylo Halytsky national medical university No.56 from
16.05.2014.
Editor - Professor V.P.Andryuschenko
Reviewer - Professor N.I.Boyko
Responsible for the issue - Academician M.R.Hzhehotskyy
© Matviychuk O.B., Kushta Yu.F., 2014
1. BACKGROUND.
At the stage of studying of the propaedeutic disciplines, the
need for students to master the basic skills of diagnostics and
emergency care in the pathology caused by trauma, is a purely
practical problem. During medical care, the fate of the victims
depends on physicians, general surgeons, emergency doctors,
neurologists, who are required to competently provide first aid
to injured patients. Since trauma is the third leading cause of
mortality after cardiovascular and oncological diseases and
common in all branches of pathology, it is natural that the study
of this topic is extremely important for physicians of all
specialties.
2. DURATION: 2 hours.
3. STUDY OBJECTIVE.
Know (theoretical questions):
- concept of trauma and traumatism;
- steps to aid the injured;
- basic terminology concepts that characterize trauma pathology;
- pathogenetic mechanisms that occur in the body during trauma;
- classification of traumas;
- classification of traumatism;
- the concept of combined trauma;
- general principles of examination of injured;
- principles of aid to injured;
- closed soft tissue injury (contusion, sprain, fracture): classification,
clinical picture, diagnostics, first aid and treatment guidelines;
- crush-syndrome - clinical picture, diagnostics, first aid and
treatment guidelines;
- craniocerebral trauma (concussion, contusion, compression of the
brain, skull fractures): classification, clinical picture, diagnostics,
first aid and treatment guidelines;
- trauma of facial skull: classification, clinical picture, diagnostics,
first aid and treatment guidelines;
- trauma of chest and its organs (concussion, contusion and
compression of the chest, rib fractures, pneumothorax, haemothorax,
cardiac injury): classification, clinical picture, diagnostics, first aid
and treatment guidelines;
- trauma of abdomen and its organs: classification, clinical picture,
diagnostics, first aid and treatment guidelines;
- traumatic shock: clinical presentation, diagnostics, first aid and
treatment guidelines.
Be able to:
- diagnose the closed soft tissue injury (contusion, sprain, fracture);
- diagnose the crush-syndrome;
- diagnose the craniocerebral trauma (concussion, contusion,
compression of the brain, skull fractures);
- diagnose the trauma of facial skull;
- diagnose the injury of the chest and its organs (concussion,
contusion, compression, rib fractures, pneumothorax, haemothorax,
cardiac injury);
- diagnose the injury of the abdomen and its organs;
- diagnose the traumatic shock;
- provide first aid in case of closed soft tissue injury (contusion,
sprain, fracture);
- provide first aid in case of crush-syndrome;
- provide first aid in case of traumatic brain injury (concussion,
contusion, compression of the brain, skull fractures);
- provide first aid in case of trauma of facial skull;
- provide first aid for injuries of the chest and its organs (concussion,
contusion and compression of the chest, rib fractures, pneumothorax,
haemothorax, cardiac injury);
- provide first aid in case of trauma of abdomen and its organs;
- provide first aid in case of traumatic shock;
- assess the condition of the victim and prognosticate the possible
consequences;
- evaluate the laboratory test results of the injured;
- put the diagnosis of trauma according to the classification
categories;
- outline the treatment plan.
Practical skills:
- master the technique of immobilization during transport depending
on the type of injury (head trauma, trauma of facial skull, trauma of
chest and its organs, trauma of abdomen and its organs, crushsyndrome, soft tissue injuries);
- master the techniques of first aid to the victim in traumatic shock;
4. BASIC KNOWLEDGE, SKILLS NECESSARY
FOR STUDYING THE TOPIC (INTERDISCIPLINARY
INTEGRATION)
Discipline
Received skills
Normal anatomy
Normal physiology
Histology
Pathological anatomy
Pathological
physiology
Pharmacology
Anatomical structure of human body
Functions of organs and systems of human
body
Histological structure of tissues and organs
Histopathological signs of oedema,
necrosis, inflammation, shock
Pathogenesis of shock, respiratory failure,
bleeding, intracranial hypertension, crushsyndrome
Medicines used in emergency
states (pain relievers, decongestants, antishock drugs)
5. TIPS FOR STUDENTS.
Emphasize (reveal) the value of the topic for further
study of the discipline and professional activity of doctor in
order to create motivation for targeted training. Acquaint
students with specific goals and lesson plan.
Perform the standardized control of initial level of
students' knowledge (written tests).
After studying this topic, students should have an
understanding of trauma, traumatism, traumatic shock,
hazards and clinical features of different types of trauma; be
able to aid the injured.
5.1. CONTENT OF THE TOPIC.
Trauma (acute) - a sudden traumatic effect on the body of an
external factor (mechanical, physical, chemical, psychological) that
causes the anatomical or functional disorders to the tissues or organs
and is accompanied by local and general reactions. Chronic trauma –
a permanent effect on the body of similar external factors.
Traumatism - repetitive injuries, specific to a certain group of
people who are in the same working conditions, life; there is
industrial, agricultural, household, sport, street, child traumatism.
Traumas are classified according to the nature of the injuring
factors: mechanical (contact damage by objects); physical (effect of
temperature, electricity, radiation); chemical (exposure to chemicals,
toxins, abnormal bodily excretions); mental (the influence of external
factors on the psycho-emotional sphere).
Open injury - an impaired wholeness of previously intact
skin or mucous membranes; closed – when damage to the outer
layers of body is absent. Penetrating injury develops when body
cavities are connected with the external environment through a
wound; non-penetrating – in case there is no connection between the
cavities of the body and the external environment. By localization,
injuries are classified into direct (at the site of traumatic factor) and
indirect (at a distance from the traumatic factor). By the clinical
course, trauma can be uncomplicated and complicated (at the
moment of injury; soon - from days to weeks after the injury, in the
late period).
Isolated (single) trauma - injury within a single organ or one
anatomical area.
Multiple trauma - several similar injuries to a single organ /
anatomic segment or injury to 2 or more organs within the same
cavity.
Combined trauma - injury to 2 or more organs in
different body cavities or simultaneous injury to internal organ
and elements of the musculoskeletal system under the effect of
one traumatic factor. Combined injury occurs under the
influence of multiple traumatic agents.
Medical care to injured patients consists of pre-hospital phase
(life-saving actions, prevention of worsening of injuries during
transportation to medical facilities), hospital phase (elimination
of trauma and its effects, restoration of body functions,
prevention of complications), rehabilitation phase (recovery of
lost functions).
Pre-hospital care of victim includes the following tasks:
- clarification of the circumstances of the injury;
- assessment of the severity of the victim’s condition;
- elimination of factors that directly threaten the life of the
injured patient, support the function of life-important systems:
cardiopulmonary resuscitation, haemostasis, pain relief,
immobilization, anti-shock measures.
Closed injuries include soft tissue contusion, sprain,
rupture, crush-syndrome.
Contusion (contusio) - closed injury of soft tissues or
organs without any apparent impairment of their anatomical
integrity: pain at the site of injury, which increases with
movement and palpation, dysfunction, swelling, bleeding and
bruises. Treatment: rest to the damaged area, local cold for the
first 2 days, since 2nd-3rd day - physiotherapy, puncture
evacuation of haemolyzate from large haematoma on day 5-7.
Sprain (distorsio) – injury to ligaments, muscles,
tendons without damage to their anatomical integrity under the
effect of force, which exceeds the limits of elasticity of tissues:
a strain occurs with haemorrhage into their thickness.
Manifestations: pain, swelling, bleeding, dysfunction.
Treatment: immobilization, pain-relief, local cold for 2 days
followed by local heat, massage, therapeutic exercises.
Rupture (ruptura) - injury to ligaments, muscles,
tendons with damage to their anatomical integrity. During
rupture, oedema, haemorrhage and joint reconfiguration
develop; muscle rupture presents as hollow area with
subsequent haematoma; tendon ruptures lead to disorders of
motor function. Treatment: immobilization, anaesthesia; in case of
complete rupture - surgery.
Crush-syndrome (positional trauma, compartment syndrome,
traumatic toxicosis) – is a general and local reaction to pain and
long-term (over 2 hours) compression of the soft tissues, which
causes impairment of microcirculation, ischaemia and tissue
necrosis. Pathogenesis includes the following processes:
compartment hypertension, ischaemia and necrosis of compressed
muscle, absorption of toxic products of abnormal metabolism into
the blood flow (potassium, myoglobin) and neuro-reflectory
traumatic disorders, loss of blood plasma. Clinical manifestations
depend on the area of injury, length of compression, timely and
proper first aid.
The initial period presents as shock with prevalence of
cardiovascular failure as a result of entry of tissue destruction
products into the blood circulation due to release of the compressed
limb without prior tourniquet usage.
Toxic period - intoxication by tissue destruction products and
bacterial toxins, renal failure due to entry of myoglobin into renal
canaliculi (in acidic environment, it is transformed into insoluble
haematin hydrochloride).
Period of late complications and recovery - local signs of tissue
damage, septic complications, sepsis, immunodeficiency.
Based upon the severity, following forms of the clinical course are
distinguished:
- mild (compression up to 4 hours) - minor soft tissue lesions,
haemodynamic and renal disorders are not severe;
- moderate (compression up to 6 hours) - moderate renal
impairment without severe haemodynamic disorders;
- severe (compression 6-8 hours) - intensive haemodynamic
disorders and renal failure;
- extremely severe (compression over 6 hours, both limbs or
trunk) – cardiovascular and renal failure, likely fatal outcome.
Initial period (4-6 h after release): condition of the patient is
gradually deteriorating, subfascial swelling of the affected area
develops rapidly, purplish-bluish vesicles and bruises appear on the
skin; hypotension, arrhythmia, tachycardia, oliguria, pulmonary
oedema and encephalopathy. In toxic period, the patient is in stupor
or coma, pale, covered with cold sweat, marked oedema, necrosis,
suppuration and erosions in areas of compression; hypertension,
tachycardia, arrhythmia, oligo-anuria. Injured area is cold,
insensitive, not moving, tissue has “woody” density, pulse is not
detected. Laboratory findings: high haematocrit and haemoglobin,
hypoproteinaemia, increased potassium, urea, creatinine, blood
transferases; myoglobinuria, albuminuria, creatinuria, DIC.
First aid: before the release of the limb, tourniquet is applied
above the compression site, is bandaged tightly and immobilized,
anaesthetics are injected. Conservative therapy is aimed at combating
shock, supporting renal function, detoxification, restoring
homeostasis, maintenance of vital functions, prevention of septic
complications. Surgical intervention is aimed at eliminating of
compartment hypertension (decompressive fasciotomy), removal of
nonviable tissues (necrectomy, amputation).
All head injuries have common nomenclature – craniocerebral
trauma - pathological processes that occur inside and outside the
skull as a result of traumatic influence.
The contents of the skull are represented by nervous tissue,
meninges, CSF and blood vessels. In craniocerebral trauma, each of
these anatomical structures - in particular or in combination - can be
damaged. Thus, the determinants of pathogenesis are diffuse or local
changes in the nervous tissue (destruction, oedema, haemorrhage),
injury of skull, meninges and brain vessels. In diffuse brain lesions,
which accompany concussion, no macroscopic changes to
anatomical structures are observed. Leading pathogenetic mechanism
during concussion is swelling with increase of intracranial pressure
and subsequent clinical symptoms. In local injuries of the skull and
brain, the pathogenetic role is primarily played by compression or
destruction of separate sections of nervous tissue with impairment or
disappearance of the relevant functions. These pathogenetic
mechanisms are characteristical to the brain concussion, subdural and
epidural haematoma, compression fractures of skull. Immediate
threat to life of a patient with craniocerebral trauma is the
involvement of deep brain structures, in particular - the medulla. This
can occur either as a result of direct injury to the brain, or as a result
of oedema with subsequent herniation into the foramen magnum and
the impairment of vital functions - cardiovascular activity and
respiration.
Concussion develops under the influence of significant force on
the skull due to a hit or falling from height. Nervous tissue is
concussed, interrelationships between neurons become impaired and
oedema develops. Depending on the severity of the injury, the
following symptoms are observed: loss of consciousness of different
length, retrograde amnesia, headache and dizziness, tinnitus,
sweating, nausea, vomiting, nystagmus. In severe trauma,
additionally, excitation, inhibition or absence of reflexes,
bradycardia, constriction or dilation of the pupils and suppression of
their light response, divergent strabismus may occur. As a result of
cerebral oedema, intracranial pressure increases, which spreads to the
CSF pathways. During the diagnostic lumbar puncture, an increase of
CSF pressure can be detected.
The clinical picture of a brain concussion signs differ from
loss or impairment of its functions as a result of damaged nerve
tissue. Focal symptoms develop: paresis, paralysis, seizures,
impairment of reflexes, sensitivity, facial expressions, speech,
psychics etc. Brain concussion may be associated with cranial
fractures and intracranial haematomas with the appearance of
characteristic symptoms. For diagnostics of brain concussion, lumbar
puncture (blood in the CSF), craniography (roentgenological signs of
fracture of the bones of the skull), angiography, computed
tomography of the head (signs of damaged blood vessels and brain
tissue) are used.
Compression of the brain is the result of pressure by bone
fragments after fractures of the skull or blood due to intracranial
bleeding (subdural, epidural and intracerebral haematomas).
Symptoms occur immediately after the injury – a time ("light gap") is
needed for the compression of nerve tissue and the development of
corresponding clinical picture: common manifestations of contusioncommotion syndrome and focal symptoms depend on the location of
the pathological focus and manifest by paresis and paralysis,
convulsions, impaired reflexes, sensitivity, facial expressions,
speech, psychics.
For the diagnostics of brain compression, lumbar puncture
(blood in the CSF), craniography (roentgenological signs of fracture
of the bones of the skull), angiography, ultrasound, computed
tomography (signs of damaged blood vessels and brain tissue,
localizing haematomas) are used.
Fractures of the skull base are often accompanied by damage
to the dura mater and development of liquorrhea from the ears or
nose; likely to be is the appearance of haemorrhage in the region of
the orbits ("symptom of glasses").
Injury of the facial skull - soft tissue contusion, sprains and
broken bones. Nasal trauma manifests by bleeding nose and nasal
deformity. Injury of eye and orbit followed by pain, haemorrhage,
oedema, increased tear flow. When the mandible is sprained - pain,
absence of movement; when it fractures - pain and limited or
impossible opening of mouth.
First aid for craniocerebral trauma. Crucial value is not only
the accurate diagnosis of the type of craniocerebral trauma, but also
the fact of its presence in the patient. In case of respiratory arrest and
cardiac activity, cardiopulmonary resuscitation is of first importance.
When vital functions are compensated, it’s necessary to control the
airways. If the patient is unconscious, he/she is laid on side or on
back. Head is to be returned to the side to prevent asphyxia as a
result of retraction of the tongue or vomiting. Unconscious victim is
should not to be given liquids to drink, as this may cause mechanical
asphyxia.
Basic principles of treatment of patients with craniocerebral
trauma. Regardless of the type of trauma, patient should be
immobilized and stay in bed regime.
Reduction of intracranial pressure is achieved by: infusing of
hyperosmotic solutions (40% glucose, 25% magnesium sulfate, 10%
sodium chloride, 40% hexamethylenetetramine), corticosteroids
(dexamethasone, hydrocortisone, prednisone), diuretics, protectors of
hypoxia (piracetam, Aminalon, Cerebrolysin, sodium oxybutyrate),
hyperbaric oxygenation. Lumbar puncture determines the pressure of
the CSF and the pathological contents therein (blood, pus, bacteria) careful removal of 5-8 ml of CSF improves patient’s condition if
increased intracranial pressure is diagnosed.
In case of increase in symptoms of brain compression,
surgery is indicated - decompressive craniotomy, haematoma is
removed, bleeding vessels tied; bone fragments in depressed
fractures are also removed.
The goal of antibacterial therapy in craniocerebral trauma prevention of septic complications both in the brain and other organs.
Correction of other parts of homeostasis involves the introduction of
saline, haemodynamic, detoxicative drugs and blood substitutes,
parenteral and enteral nutrients, drugs that improve the function of
impaired organs.
Thoracic trauma can be isolated or as part of combined
trauma. At the same time, thoracic trauma may be closed
(concussion, compression) and open (penetrating, non-penetrating),
with / without bone fracture, with / without organ damage,
complicated / uncomplicated. Pathophysiological mechanisms of
injury of chest (blood loss, pain, reduction of respiratory surface of
the alveoli, direct damage to organs) because of hypovolaemia and
hypoventilation cause hypoxia and acidosis. Life-threatening
conditions that are diagnosed at the initial examination of the patient
include the following manifestations of chest trauma: airway
obstruction, tension and open pneumothorax, massive haemothorax,
floating rib fractures, cardiac tamponade, damage to major blood
vessels. Potentially life-threatening conditions that may be diagnosed
later during inspection, include concussion of lungs, heart, ruptures
of the trachea, bronchi, oesophagus, aorta, diaphragm. Among
internal organs, lungs and pleura are often damaged, rarely - heart,
bronchi, major vessels. Injury of the diaphragm is an attribute of
thoracoabdominal trauma.
Thoracic trauma may be limited to soft tissue injury
(concussion, bruising, pain and swelling at the site of impact) or be
accompanied by damage to internal organs and broken ribs.
Chest concussion causes functional disorders without
apparent anatomical changes: traumatic shock, hypotension,
bradycardia; due to the severity of the injury, the victim needs
hospitalization, strict bed regime; symptomatic treatment (two-way
vago-sympathetic blockade, anti-shock measures).
During compression of the chest, sudden outflow of blood
from the lungs and congestion in the system of superior vena cava
happen, traumatic asphyxia develops. The victim should be treated in
ICU.
Rib fractures occur in almost 70% of all cases of closed
thoracic trauma. Isolated rib fractures are characterized by a clinical
picture of stingy pain that worsens during breathing, coughing,
movement; multiple rib fractures pose danger because of potent
injury to internal organs, severe respiratory and circulatory failure.
First aid includes anesthesia, immobilization, anti-shock therapy.
Especially dangerous are floating fractures when fragments form a
valve: paradoxical respiration develops, immediate fixation of
floating segments and surgery are indicated.
Complications of chest trauma are divided into early: pleural
- haemothorax, haemopneumothorax, pneumothorax, pulmonary
haemorrhage, haematoma, atelectasis, air cavities, mediastinal emphysema, haemorrhage, subcutaneous emphysema, flotation of
sternum, traumatic asphyxia, shock, and late - post-traumatic
pneumonia, post-traumatic pleuritis, pleural and lung diseases, septic
processes.
Pneumothorax - air accumulation in the pleural cavity; types
of pneumothorax: open, closed, valve (tension) and limited
(compression of lung to 1/3 of its volume), medium (compression of
lung to 1/2 of its volume), large (over 1/2 volume), total (fully
collapsed lung). The clinical picture is characterized by severe
dyspnea, cyanosis, tachycardia, development of shock.
Roentgenological diagnostics of pneumothorax is performed on the
exhalation: in vertical position of the patient, air collects in the apical
areas of visceral pleura, presented on X-ray film by a white line with
no pulmonary shadow above; in horizontal position - the air is seen
in front of costo-phrenic sinus, apex of the heart is contoured.
First aid is to convert valve pneumothorax to the open type
and anti-shock measures. Surgical treatment is used in open and
valve pneumothorax (stitching of damaged lungs and pleura), also
pleural cavity is drained (thoracostomy).
Haemothorax - accumulation of blood in the pleural cavity,
with / without ongoing bleeding; roentgenologically and by blood
loss volume it is classified into small (dimming of pleural sinus, 200500 ml of blood, almost invisible), medium (dimming to angle of
blade, 500-1000 ml of blood), high (dimming above the angle of the
blade, over 1000 ml of blood). In the clinical picture of haemothorax,
acute blood loss on a background of growing respiratory distress
prevail. In case of medium and massive haemothorax, repeated
punctures for blood evacuation and injection of antibiotics are
indicated.
The clinical picture of cardiac trauma depends on the
mechanism of injury (blunt trauma, wound): pain, severe weakness,
shortness of breath, signs of shock. Cardiac tamponade is diagnosed
by Beck’s triad: hypotension, muffled heart tones, increased central
venous pressure. When heart is wounded or in case of tamponade immediate surgical intervention should be done; concussion observation and treatment of ischaemic disorders.
When thoracic trauma is combined with abdominal trauma,
primarily correct the disorders caused by damage to the chest (given
above) and temporarily stop the bleeding; the second stage is done
"below the diaphragm" - injuries of the abdomen and
retroperitoneum.
Abdominal trauma is divided into open and closed (blunt),
with / without penetration into the abdominal cavity, with / without
organ damage (parenchymal or hollow), with / without
retroperitoneal injuries. In case of severe blunt blow to the epigastric
area where solar plexus is injured, shock may develop even without
damage to internal organs. Diagnostic difficulties in victims with
abdominal injuries is caused by the fact that 70% of them have
extraabdominal traumas, clinical picture is masked by shock, alcohol
or drug intoxication. In blunt abdominal trauma, spleen is frequently
affected - almost in quarter of cases.
Clinical picture of closed abdominal trauma depends on the
degree of damage. If only anterior abdominal wall is injured, the
victim feels pain in the area of impact, which increases during
movement, some swelling and haemorrhage can be seen; sometimes
due to a defect in torn muscles, traumatic hernia may form.
In case of damage to internal organs, clinical picture depends
on the organ injured: in injuries of parenchymal organs, signs of
internal bleeding prevail, if hollow organs are injured – peritonitis
develops. The most severe course is seen when bleeding is combined
with peritonitis or when retroperitoneal space is injured.
Among auxiliary diagnostic measures, important are the
laboratory examination of blood and urine, ultrasonography of the
abdomen, radiological studies, computed tomography, laparocentesis,
laparoscopy. An important component of the diagnostic program is
the intubation of stomach for aspiration of blood, decompression and
antacid infusion. If a lesion of urinary tract is suspected,
catheterization is required for all victims, as well as for assessment of
urinary function in further.
If in 1 mm3 of peritoneal more than 100.000 erythrocytes,
5.000 of leukocytes, fiber, bile acids, amylase are revealed immediate laparotomy is indicated. Laparotomy in trauma victims is
done in case of peritonitis, unexplained shock, dull sounds on
percussion of abdomen (except the area of right subcostal region),
evisceration of omentum or an internal organ, presence of blood in
the stomach, urinary bladder or rectum, pneumoperitoneum,
dislocation of internal organs are seen on roentgenological study.
If hollow organ is damaged and peritonitis is developing,
sanitize the abdominal cavity, localize and close the defect, perform
ostomy if indicated. In victims with significant liver damage, for a
temporary stop of bleeding (60 min), use the Pringle’s method –
compress the hepatoduodenal ligament (hepatic artery, portal vein); if
unsuccessful (or hepatic veins bleed) - tamponade and compression
with “towels” above and below by the intraperitoneal method. In
spleen trauma, organ-saving surgery gained popularity, but due to the
instability of the patient, extensive fragmentation of organ, damage
of blood vessels, it is impossible to achieve complete haemostasis by
splenectomy. Treatment of pancreatic trauma is surgical. In
intraperitoneal injury of urinary organs, the clinical picture is
dominated by signs of peritonitis, emergency laparotomy is
indicated. Immediate operative treatment is carried out in case of
extraperitoneal kidney injury when retroperitoneal haematoma
rapidly increases. Both intra- and extraperitoneal rupture of urinary
bladder cause peritonitis and can lead to septic complications, thus
are treated only surgically.
Traumatic shock is a serious impact on organism (mismatch
of perfusion to the needs of tissues) due to injury. By pathogenesis, it
is divided into hypovolaemic (blood loss) and peripheral vascular (no
bleeding). Shock has 2 phases: erectile (psychomotor agitation,
hypertension, tachycardia, tachypnea, skin color is normal or
hyperaemic) and torpid (weakness, stupor or coma, pallor, frequent
superficial or pathological breathing, hypotension, tachycardia,
hypothermia, oligo-anuria). The severity of the shock is determined
by Algover index (the ratio of heart rate to the value of systolic
pressure). The clinical course of shock consists of the following
periods: compensated (blood pressure within normal limits),
uncompensated (hypotension), irreversible (multiple organ failure).
First aid for shock includes: restoration of airway and
breathing, stopping of bleeding, restoration of haemodynamics, pain
management, immobilization, correction of hypovolaemia.
Treatment is aimed at interrupting of shock impulses (pain
relief), correction of circulating blood volume and acidosis,
improvement of microcirculation and blood rheology, symptomatic
treatment of dysfunction of organs and systems.
5.2. QUESTIONS FOR SELF-CONTROL.
1. Definitions of trauma, traumatism, polytrauma; classification of
injuries; basic terminology concepts that characterize trauma
pathology.
2. Pathogenetic mechanisms that occur in the body during trauma.
3. General principles of inspection of injured.
4. Principles and steps to aid the injured.
5. Closed soft tissue injury (contusion, sprain, fracture):
classification, clinical picture, diagnostics, first aid and treatment
guidelines.
6. Crush-syndrome - clinical picture, diagnostics, first aid and
treatment guidelines.
7. Traumatic brain injury (concussion, contusion, compression of the
brain, skull fractures): classification, clinical picture, diagnostics,
first aid and treatment guidelines.
8. Craniocerebral trauma: classification, clinical picture, diagnostics,
first aid and treatment guidelines.
9. Definition of thoracic trauma, classification, etiology, pathogenetic
mechanisms. Diagnostics of thoracic trauma. Life-threatening
manifestations of thoracic trauma.
10. The clinical picture of thoracic trauma (concussion, contusion,
compression). First aid, principles of treatment.
11. Pneumothorax: types, clinical picture. Diagnostics. First aid and
treatment options.
12. Haemothorax, the clinical picture. Diagnostics. First aid and
treatment.
13. Broken ribs. Diagnostics. First aid and treatment.
14. Definition of abdominal trauma, classification, etiological and
pathogenetic features. Examination of victims of abdominal trauma.
15. Peritonitis – injury to hollow organ in abdominal trauma.
16. Internal bleeding - damage of parenchymal organs in abdominal
trauma.
17. Injury to retroperitoneum.
18. First aid and treatment guidelines in trauma of abdominal cavity
and retroperitoneal space.
19. Traumatic shock: etiology, pathogenesis, diagnostics, clinical
course, first aid, principles of treatment.
5.3. TABLES FOR SELF-CONTROL
Fill a table of characteristic symptoms and principles of first
aid in pneumothorax.
Signs
Valve
Open
Closed
pneumothorax pneumothorax pneumothorax
Presence of wounds
Bleeding
Compression of the
lungs
Dislocation of
mediastinum
Shortness of breath
Tachycardia
Roentgenological
picture
Presence of
emphysema
First Aid
Treatment
Fill a table of characteristic symptoms and principles of first
aid in case of damage of parenchymatous and hollow organs of
the abdominal cavity.
Signs
Leading syndrome
Pain
Fatigue
Tachycardia
Hypotension
The tension of the
abdominal wall
Blumberg’s symptom
Injury of
parenchymatous
organ
Injury of
hollow organ
Roentgenological picture
Complete blood count
First aid
Treatment
5.4. TESTS FOR SELF-CONTROL
1. Brain concussion is characterized by all, except:
A. Short-term consciousness disorder
B. Transitional cerebral symptoms of autonomic disorders
C. Vegetative disorders
D. Asthenia
E. Stable focal neurological symptoms
2. Mild focal symptoms during brain concussion can long for:
A. From a few hours to 3-4 days
B. 7 days
C. 24 days
D. 1-2 hours
3. Vital disorders during severe brain concussions are caused by:
A. Haemorrhage
B. Hypovolaemic shock
C. Direct trauma of basal-stem parts of the brain or dislocation of
stem part of the brain
D. Intoxication
4. Non- penetrating and penetrating head traumas differ by injury of:
A. Dura mater
B. Aponeurosis
C. Bone
D. Skin
5. Which of the following states belong to life-threatening in thoracic
trauma:
A. Floating rib fractures
B. Haemothorax
C. Haemoperitoneum
D. Pneumothorax
6. What haemothorax should be interpreted as medium:
A. 100 ml of blood
B. 200 ml of blood
C. 500 ml of blood
D. 1000 ml of blood
7. Roentgenodiagnostics of pneumothorax is made in:
A. Supine position
B. Sitting position
C. Standing position
D. Lying on side
E. Inhalation phase
F. Exhalation phase
8. Subcutaneous emphysema complicates thoracic trauma if the
following are injured:
A. Lungs, pleura, intercostal muscles
B. Airways
C. Lungs, skin, subcutaneous tissue
D. Respiratory muscles, subcutaneous tissue and skin
9. Tympanitis during percussion of liver indicates on injury of:
A. Spleen
B. Right kidney
C. Liver
D. Intestines
10. Penetrating abdominal trauma is distinguished by injury of:
A. Skin
B. Aponeurosis
C. Peritoneum
D. Stomach
E. Liver
5.5. SITUATIONAL TASKS.
1. As a result of falling and hitting head on the asphalt, the patient
lost consciousness for 5 minutes. The patient does not remember the
circumstances immediately before and during the injury. What's the
pathology ? What symptoms should the doctor look for?
2. After cranial trauma, the patient presented with seizures,
psychomotor agitation, involuntary urination, stiffness of neck,
hemiparesis. Put the diagnosis. What should be used further to make
a more accurate diagnosis ?
3. Patient after skull injury had noticed the excretion of light-yellow
fluid from the ears and nose, bruises around the eyeballs. What kind
complication occurred ? What should be used further to make a more
accurate diagnosis ?
4. After the falling on the street and hitting his head on the asphalt,
the patient is unconscious. There was vomiting; 2 hours later the
consciousness recovered. No evident organic symptoms during
neurological examination were found. Suddenly, coma, respiratory
failure, anisocoria developed in patient. What can it be ? What
should be done to save the patient's life ?
5. After a blow in the chest, the patient complains of difficulty to
breathe because of a sharp pain in the right half of the chest that
increases with movement, coughing, breathing. Visually, no chest
injuries were found.
6. Victim of a gunshot wound to the chest is in a serious condition,
dyspnea increases, tachycardia, hypotension, subcutaneous
emphysema. Chest is asymmetrical, one part is not involved in
breathing, a small wound without evidence of ongoing bleeding is
seen.
7. Person was stabbed in the abdomen. On the anterior abdominal
wall in the left mesogaster, there is a small wound hole with no signs
of ongoing bleeding, tension of the anterior abdominal wall is
detected, sharp pain on palpation, positive signs of peritoneal
irritation.
Literature.
1. Turney S.Z., Rodriguez A., Cowley R.A. Management of
cardiothoracic trauma. Williams & Wilkins. 1990. 417 p.
2. doCarmo P.B. Basic EMT skills and equipment: techniques and
pitfalls. C.V. Mosby Co. 1988, 387 p.
3. Alexander R.H., Proctor H.J. Advanced trauma life support.
American College of Surgeons. 1995. 396 p.
4. Петров С.П. Общая хирургия. Санкт-Петербург, 1999.
5. Методика обстеження xipypriчнoro хворого / під. ред.
М.О.Ляпіса. Тернопіль, 2000.
6. Черенько М.П., Ваврик Ж.М. Загальна хірурія // Київ,
"Здоров'я", 2004.
7. Мокшонов И Я., Гарелин П.В., Дубовин О.И. и др.
Хирургические операции // Минск, 2004, 413с.
8. Чен Г., Соннендэй К.Дж., Лилремо К.Д. Руководство по
технике врачебных манипуляций (2-е издание). Перевод с
английского // Москва.: Медицинская литература. - 2002. 384 с.
9. Хірургія. Т.І / За ред. Я.С.Березницького, М.П.Захараша,
В.Г.Мішалова,
В.О. Шідловського. – Дніпропетровськ:
РВА «Дніпро-VAL», 2007. – 445 с.
Supplement 1.
GLOSSARY
Retrograde Amnesia - amnesia retrograda - temporary loss of
memory for facts prior to loss of consciousness.
Anisocoria - anisocoria - uneven pupil diameter.
Brain herniation - impactio cerebri - bulging areas of the brain in the
skull orifices or dura mater due to a sharp increase in intracranial
pressure.
Brain contusion - contusio cerebri - closed brain injury with areas of
destruction of its tissue specific local neurological and
psychopathological symptoms.
Epidural haematoma - haematoma epidurale - accumulation of blood
between the bones of the skull and dura mater.
Encephalitis - encephalitis - inflammation of the brain.
Divergent strabismus - strabismus divergens - strabismus in which
one eye periodically or continuously deviates outward.
Liquorrhea - liquorrhoea - leakage of cerebrospinal fluid through a
defect in the dura mater.
Meningitis - meningitis - inflammation of the membranes of the
brain and (or) the spinal cord.
Cerebral oedema - oedema cerebrale - accumulation of fluid in the
brain.
Nystagmus - nystagmus - involuntary trembling movements of the
eyeballs.
Paralysis - paralysis - complete absence of voluntary movements due
to lesions of the motor centers or the peripheral nervous system.
Paresis - paresis - a disorder of motor function characterized by
weakness and decrease in muscle strength due to the impaired
innervation.
Concussion - commotio cerebri - closed brain trauma, which is
accompanied by temporary disorders of consciousness, vomiting,
changes in heart rate, breathing etc.
Subdural haematoma - haematoma subdurale - accumulation of
blood under the dura mater.
Lumbar puncture - punctio spinalis - puncture of subarachnoid space
of the spinal cord.
Decompressive cranial trepanation - trepanatio cranii decompressiva
- removal of part of the cranial vault to reduce intracranial pressure.
Supplement 2
Diagnostic and therapeutic algorithm in closed
craniocerebral trauma
the determination of craniocerebral trauma history (if possible), wounds and
soft tissue contusion of the head, evident impairment of vital functions and
neurological symptoms
evaluation of vital functions
heart and lung arrest
vital functions are saved
Primary diagnostic and therapeutic measures
CPR
Diagnostics of craniocerebral trauma
choice of treatment strategy
Contusion
Concussion
Conservative treatment: hyperosmotic solutions,
diuretics, corticosteroids, anti-hypoxic drugs,
oxygenation, spinal puncture
Compression
Surgical treatment
(decompressive
craniotomy)
+
conservative treatment

Breathing disorders – freeing of airways, intubation,
artificial lung ventilation

Bleeding, hypotension – correction of circulating blood volume
Supplement 3
Algorhythm for thoracic trauma
Restitution and maintaining of airway passability
Anti-shock measures / pain relief
Early and adequate pleural drainage
Fast spreading of lung
Sealing and stabilization of thorax
Final haemostasis, correction of circulating blood volume
Infusion, antibacterial, supporting therapy
Supplement 4
Thoracic trauma (roentgenological suggestions)
Fracture of any rib(s)
Pneumothorax
Fracture of ribs 1-3
Injury of airways or large vessels
Fracture of ribs 9-12
Nasogastric tube in the
chest
Abdominal trauma
Rupture of the diaphragm or oesophagus
The level of the liquid/air in Haemothorax or rupture of the diaphragm
the chest
Fracture of sternum
Contusion of heart, craniocerebral trauma,
trauma of cervical spine
Gas in the mediastinum
Rupture of the oesophagus, trachea,
pneumoperitoneum
Injury of airways or large vessels or lung
contusion
Rupture of hollow abdominal organs
Rupture of the bronchus, oesophagus
Fracture of scapula
Gas under the diaphragm
Persistent large
pneumothorax
after tracheostomy
Supplement 5
Indications for laparoscopy in polytrauma:
- Dull consciousness / fainting
- Combination of spinal cord injury and abdominal trauma
- Fracture of the pelvis
- Hypotension, low haematocrit
- Injury of the lower parts of the chest
Conditional contraindications:
- Pregnancy (puncture is done above the navel)
- Previous abdominal surgery
- Gunshot wounds of the lower part of the chest or abdomen
- Stab wounds of back
Supplement 6
Algorhythm for tensiom pneumothorax
Assess the breathing
Provide oxygen inhalation
Identify 2nd intercostal space on midclavicular line
Desinfection of skin
Local anaesthesia
Patient is in sitting position if cervical spine is not injured
Puncture in upper edge of the rib, drainage
in 5-6 intercostal space on midaxillar line
Buelau drainage, evacuation of needle from 2nd intercostal space
X-ray of chest
Supplement 7
X-ray signs of rupture of diaphragm:
1) high standing and uneven contour
2) dim area above the diaphragm
3) gas bubbles above the diaphragm (prolapse of colon
through the rupture)
4) displacement of the mediastinal shadow to the side,
opposite of the pathological process
5) widening of the heart’s shadow
6) fluid in the pleural cavity
7) shadow of nasogastric tube in the thoracic cavity
Supplement 8
Algorhythm of pleural drainage
5-6 intercostal space, slightly frontally from midaxillar line
desinfection of skin
local anaesthesia
cut the skin 2-3 см along intercostal space, dilating the
muscles by the clip
puncture the pleura by the clip
introduce the clipped tube towards the apex of pleural cavity
Buelau drainage, check the air flow
sew the tube to skin, apply sterile bandage
X-ray