Contusion of the anterior abdominal wall. Ruptures of the internal organs of the abdominal cavity. Other clinical signs

Abdominal injuries, which account for up to 4% of the total number of injuries received in peacetime, are classified as the most severe injuries, often associated with a real threat to the life of the injured person.

In the statistics of deaths from injuries, they occupy the third place (leading positions in it belong to craniocerebral and thoracic - with damage to the chest - injuries). The mortality rate for trauma to the abdomen ranges from 25-70%.

In peacetime, the structure of traumatic injuries of the abdomen is formed by cases of criminal injuries, falls from a height, natural disasters and traffic accidents.

Definition and reasons

Abdominal injury, in the language of physicians called abdominal, is characterized by all sorts of violations of the functional state or anatomical integrity of tissues and internal organs, localized in the abdominal cavity, retroperitoneal space and the pelvic area, resulting from external influences.

Abdominal injuries are primarily divided into open and closed. In the total mass of abdominal injuries, 85% are closed injuries and only 15% are open ones.

The culprits of the occurrence of open injuries are usually:

• all kinds of wounds: primarily gunshot and stab wounds;
• falling on sharp surfaces or objects.

Closed abdominal injuries are the result of:

• workplace accidents;
• car accidents;
• falls from any height;
• falls on blunt hard objects;
• accidental or intentional ingestion of objects with sharp corners and aggressive chemical substances (alkalis and acids);
• iatrogenic factors (risks arising from therapeutic effects on the patient's body).

In most cases, abdominal injuries are characterized by:

• the multiplicity and severity of injuries;
• high mortality rate;
• a large (up to 85%) number of postoperative complications.

The severity of the injuries received in open and closed abdominal injuries may be different; at the same time, closed-type injuries cause more problems for physicians.

Since the wound and associated external bleeding are absent in this case, and the affected person is often either in a state of traumatic shock or in an extremely serious condition, primary diagnosis can be difficult.

A person who is suspected of having an abdominal injury is subject to urgent hospitalization.

After an immediate examination, a series of therapeutic measures aimed at preventing or stopping internal bleeding and eliminating the risk of developing peritonitis (inflammation of the peritoneum). The life of the victim depends on the coherence and correctness of the actions of medical personnel at this stage. Further treatment of such patients is usually surgical.

Classification

The variety of abdominal injuries is so great that none of existing classifications unable to contain it. In the practice of domestic traumatologists, the classification proposed by V.S. Savelyev is most in demand.

Depending on the nature of the damaging agent, abdominal injuries are:

• mechanical;
• chemical;
• thermal;
• radiation;
• combined (combining the effects of two or more types of damaging factors).

Symptoms and signs

Separation mechanical injuries abdomen into open and closed emphasizes the fundamental difference between these injuries. The differences concern:

• receiving mechanism;
• diagnostic and treatment methods;
• the severity of the condition;
• final outcome.

That is why the symptoms of open and closed abdominal injuries are always considered separately.

Open abdominal trauma

Open injuries (wounds) can be caused by weapons (cold and firearms) and fragments of live or secondary projectiles.

• For cutting wounds, having a clear linear shape, considerable length and smooth edges, cold weapons (most often a knife or dagger) can be used. Since, as a result of incised wounds, many blood vessels, the affected person may experience severe external bleeding. When an extensive wound is received, eventration is sometimes observed - damage to the anterior abdominal wall, as a result of which depressurization of the abdominal cavity occurs, accompanied by prolapse of internal organs.
• For application stab wounds , characterized by the presence of a narrow wound channel, a narrow stylet, an awl, a thin knife, a table fork, a bayonet or scissors can be used. Bleeding from stab wounds may be minor, although significant damage to internal organs is possible due to the large depth of penetration. The main danger of such injuries is that the injured person, at the sight of a minor and almost non-bleeding wound, may not immediately seek medical help.
• Large chopped wounds , having uneven edges, accompanied by extensive dissection of soft tissues and severe bleeding, occur when exposed to an ax.
• lacerations, characterized by the presence of multiple injuries with ruptures and crushing of tissues, arise as a result of careless handling of mechanisms (in the event of an accident at work) or as a result of an attack by aggressive animals. characteristic feature lacerations is a very strong tissue contamination.
• Gunshot wounds to the abdomen are classified as extremely serious injuries because when they occur, not only a wound channel is formed, but also a serious (with a radius of damage three dozen times greater than the dimensions of a pellet or bullet) contusion of soft tissues. As a result of contusion, compression, stretching, delamination or rupture of the affected organs and tissues occurs. In some cases (with the location of the inlets in the lumbar region or in the side), gunshot wounds to the abdomen may be implicit.
• The culprits of the occurrence of lacerated wounds secondary projectiles can become (fragments of metal parts or glass fragments can act in their role). This type of abdominal injury can result from car accidents, man-made disasters, or industrial accidents.

Closed (blunt) abdominal trauma

AT international classification diseases of the latest version (ICD-10), blunt abdominal injuries are assigned to the XIX class, which combines injuries, poisonings and a number of other consequences caused by external causes.

Under the appropriate codes, you can find injuries in it:

• abdominal organs (S36);
• spleen (S36.0);
• liver or gallbladder (S36.1);
• pancreas (S36.2);
• stomach (S36.3);
• small intestine (S36.4);
• colon (S36.5);
• rectum (S36.6);
• several intra-abdominal organs (S36.7);
• other intra-abdominal organs (S36.8).

Since closed abdominal injuries are often accompanied by damage to internal organs, consider characteristics failure of each of them.

• With bruises of the anterior abdominal wall there is pain, local swelling of the damaged area, abrasions appear; development of hemorrhages is possible. When emptying the bowels, during coughing, sneezing, abrupt change body position pain increases.
• With rupture of the muscles and fascia of the abdominal wall similar symptoms occur, but the pain is more intense. The victim's body may respond to severe pain by developing intestinal obstruction caused by reflex paresis of the intestine (the so-called condition characterized by a gradual decrease in the tone of the intestinal walls with the subsequent development of paralysis of the intestinal muscles).
• Abdominal injuries with rupture small intestine , characterized by the presence of increasing pain, occur as a result of a direct blow to the stomach. The victim feels the tension of the muscles of the anterior wall of the abdomen; his pulse quickens and he may vomit. With such injuries, cases of the development of traumatic shock are not uncommon.
• Blunt abdominal trauma with colon rupture have a similar mechanism of occurrence and almost similar symptoms (as in cases with ruptures of the small intestine), however, due to the often occurring intra-abdominal bleeding, shock conditions are observed much more often.
• Closed abdominal injuries quite often accompanied by all kinds of damage to the liver (from subcapsular cracks to the complete separation of its individual fragments). Due to the large number of blood vessels penetrating this organ, any injury to the liver is associated with the development of severe internal bleeding. The condition of a person who has received such an injury is extremely difficult and is often accompanied by loss of consciousness. Victims who are conscious complain of severe pain in the area of ​​the right hypochondrium, radiating to the area of ​​the right collarbone. Breathing and pulse of the victims quicken, skin turn pale, and blood pressure drops. Many of them have severe symptoms of traumatic shock.
• Blunt trauma to the abdomen with damage to the spleen make up about a third of the total number of abdominal injuries, accompanied by trauma to the internal organs. Splenic ruptures can be either primary (in this case, the symptoms of the lesion appear from the first minutes of injury), and secondary (the appearance warning signs observed after several days or weeks). The occurrence of secondary ruptures of the spleen is typical for children. If the size of the gaps is insignificant, spontaneous cessation of bleeding is possible. Significant damage to the spleen leads to the development of hemoperitoneum - severe intra-abdominal bleeding, leading to accumulation of blood between the layers of the peritoneum. The clinical manifestations of hemoperitoneum coincide with the picture of hemorrhagic shock: the victim, who is in a semi-conscious state, is pale, drenched in cold sweat and complains of a sharp pain in the abdomen (in the region of the left hypochondrium with irradiation to left shoulder), severe dizziness and darkening of the eyes. He has tachycardia and arterial hypotension. To reduce pain, the victim can lie on his left side, bending and pulling his legs to his stomach.
• With a closed abdominal injury intraperitoneal or extraperitoneal rupture of the bladder may occur. This happens if the victim's bladder was full at the time of the injury. If the rupture of the bladder was extraperitoneal, the patient has severe pain, swelling of the perineum and a false urge to urinate. Sometimes a small amount of urine mixed with blood is excreted. With an intraperitoneal rupture of the bladder, the victim feels pain in the lower abdomen and frequent false urge to urinate. Urine that enters the abdominal cavity provokes the development of peritonitis. The patient's abdomen remains soft; on palpation, the patient feels moderate soreness; intestinal peristalsis is weakening.
• Injury to the pancreas occurs when receiving very severe abdominal injuries associated with damage to several internal organs at once. The pancreas may be jarred or bruised; sometimes trauma leads to its rupture. The victim, who is in serious condition, experiences a sharp pain in the epigastric region; his stomach swells, the muscles of the anterior abdominal wall are in a tense state, blood pressure drops, and the pulse quickens.
• Blunt abdominal trauma rarely results in kidney damage. located in the region of the retroperitoneal space and protected from all sides by other tissues and organs. When receiving concussions and bruises of the kidneys, the victim begins to complain of pain in the lumbar region; blood appears in his urine, his body temperature rises. The most severe abdominal injuries can be accompanied by ruptures or crushing of the kidneys and injury to other internal organs. In such cases, victims experiencing severe pain often develop a state of shock, develop tachycardia and arterial hypotension.

Diagnostics

If there is a suspicion of an abdominal injury, the victim should be urgently taken to a medical facility for immediate diagnostic procedures and treatment.

The primary task of medical personnel is to assess the severity and nature of the injuries received, as well as to identify bleeding that can pose a threat to the life of the victim. During a physical examination, doctors collect information about the presence of complaints and take an anamnesis.

• In victims admitted to the hospital in the order of emergency hospitalization, they must take blood and urine (general) for analysis (general and biochemical), establish the blood group and Rh factor.
• An electrocardiogram is mandatory.
• Using the radiography procedure of the abdominal organs, it is possible to establish the presence of ruptures of hollow organs, the location of pellets and bullets (in case of a gunshot wound), as well as confirm or refute the assumption of the presence of concomitant injuries of the chest and pelvic bones.
• More reliable information procedure can give ultrasound, allowing you to detect any intra-abdominal bleeding and damage to internal organs, soon fraught with the occurrence of such bleeding.
• For a detailed study of the state and structure of internal organs, a procedure is used that allows you to track the presence of even minor injuries and bleeding.
• If there is a suspicion of rupture of the bladder, a catheterization technique is used, consisting in the introduction of a soft or rigid catheter into the bladder. Isolation through the catheter of small portions of urine mixed with blood is a confirmation of the preliminary diagnosis. When in doubt, perform x-ray procedure ascending cystography, consisting in the introduction of a radiopaque preparation into the cavity of the bladder (through the urethra). When this organ breaks radiopaque agent will be found in the tissues of the perivesical tissue.
• The most effective diagnostic technique, which leaves no doubt about the correctness of the diagnosis, is the laparoscopy procedure. Having made a small incision, the specialist introduces a special device into the patient's abdominal cavity - an endoscope equipped with a video camera and connected to a monitor. The endoscope allows you to examine the internal organs and, having assessed the degree of their damage, outline the scope of the upcoming surgical intervention. With the help of laparoscopy, it is possible not only to clarify the diagnosis, but also to carry out a number of therapeutic measures aimed at stopping bleeding and removing blood that has accumulated in the abdominal cavity.

First aid

When receiving a serious abdominal injury, the correct and urgent provision of emergency care can not only preserve the health of the victim, but also save his life.

When providing first aid, you must:

• Give the patient the most comfortable position.
• Put something cold on his stomach.
• Wear an oxygen mask if you have breathing problems.
• Before performing an anesthetic injection, it is necessary to clarify the symptoms of the injury (this item does not apply to cases where there are signs of a penetrating wound). For pain relief, you can use a 50% solution of metamizole or ketorolac (intravenously). With open abdominal injuries, accompanied by eventration of the viscera, the use of narcotic painkillers (for example, trimeperidine) is allowed.
• Take the patient to the nearest hospital immediately.
• In no case should internal organs that have fallen out of it be inserted into the abdominal cavity. In case of heavy contamination, careful washing of the insides with a warm solution of an antiseptic agent and fixation with a bandage soaked and constantly moistened with the same solution is allowed.
• When an open wound is formed, a sterile dressing must be applied.
• In spite of intense thirst that occurs in the victim due to massive blood loss, it is impossible to drink it.
• If vomiting occurs, it is necessary to put the victim in such a way that the vomit does not interfere with his breathing.
• Drugs should not be given to the victim.
• It is not allowed to extract from the wound the injuring objects (sharpening, knife or awl) located in it. For additional fixation, you can use an adhesive plaster, as well as hold it with your hand.

Treatment in adults and children

When choosing a treatment strategy, the determining factor is the mechanism of injury, since the therapy of open and closed abdominal injuries has a number of cardinal differences.

• With open wounds emergency surgery is needed.
• Superficial non-penetrating injuries require primary surgical treatment and thorough washing of the wound cavity. After that, contaminated and non-viable structures are excised and sutured.
• When receiving penetrating wounds tactics surgical treatment depends on whether any internal organs are affected.
• Treatment of bruises and ruptures of fascia and muscles carried out by conservative methods. For the implementation of drug therapy, antibacterial drugs, analgesics, tranquilizers (anxiolytics) are used. Patients must comply with strict bed rest. In some cases, they are shown the use of infusion therapy and physiotherapy.
• In the presence of large hematomas(cavities containing liquid or coagulated blood) resort to opening them, performed under local anesthesia. Having made a small incision in the center of the hematoma, the surgeon frees the cavity from liquid blood and her clots. After washing the cavity with a solution of furacilin, a couple of sutures are applied and drainage is established using a rubber graduate or tube for this. final stage is the application of a sterile pressure bandage.
• In case of abdominal injuries with damage to hollow and parenchymal organs accompanied by intra-abdominal bleeding, perform immediate surgical operations requiring the use of general anesthesia. During the midline laparotomy, the surgeon carefully examines the condition of the abdominal organs. All detected damage is repaired. In some cases, a blood transfusion is performed during the operation.
• During the postoperative period further treatment of patients is carried out with the use of analgesics and antibiotics.

Penetrating injuries in children are much less common than the closed abdominal injuries they receive as a result of traffic accidents in which they participate as pedestrians or passengers.

• Therapeutic activities initial stage (first aid, diagnostics) in the treatment of children are no different from the treatment of adults. Some differences relate only to the size of the tubes used for intubation (the so-called insertion into the trachea of ​​a special tube that ensures the patency of the airways) of the trachea of ​​small patients: they are much narrower and equipped with a special cuff.
• Given the high immunological significance of the spleen for the child's body, priority in the treatment of this organ is given to conservative methods of therapy. If there is suspicion of damage to the spleen, laparotomy is performed only if it was not possible to stop the bleeding or there is reliable evidence of the presence of damage to hollow organs. During the operation, the surgeon takes measures aimed at eliminating damage to the spleen.
• Complex of therapeutic measures for the treatment of all other injuries of the abdominal organs received by children is almost identical to that in adults.
• In case of damage to parenchymal organs in children physicians resort to watchful waiting tactics.

Complications

Abdominal injuries, accompanied by damage to internal organs, are fraught with the development of:

• Peritonitis - inflammation of the peritoneum (the serous membrane that lines the surface of the internal organs and inner walls abdominal cavity). Abdomen healthy person is sterile. Upon receipt of an abdominal injury, accompanied by a rupture of the intestine or stomach, the contents of these organs (represented by the microorganisms they contain, feces, gastric juice, food debris and digestive enzymes) enter this sterile environment, provoking the development of the inflammatory process.
• Internal bleeding that occurs when any organ is injured. Minor bleeding can stop on its own. The occurrence of serious bleeding is fraught with a sharp deterioration in the condition of the affected person: he becomes covered with cold sticky sweat, his blood pressure drops rapidly, and the skin turns pale. In this state, victims often lose consciousness and die from massive blood loss.
• Abdominal sepsis (the so-called systemic inflammatory reaction of the body that occurs in response to the occurrence of a pathological process in the abdominal cavity) and septic shock (a severe condition characterized by the simultaneous presence of both infection and a systemic inflammatory reaction of the body).
• Enteral insufficiency is a violation of the function of the small intestine, characterized by an insufficient degree of absorption of decomposition products of useful substances through the intestinal wall.

Video on how to provide emergency care for a stab wound to the stomach:

In the case of non-penetrating damage to the peritoneum, it is not always possible to determine the severity of the damage to health at first glance. With this type of injury, there are no visible signs violations. In this case, due to blunt trauma to the abdomen, vital organs can be damaged. Their rupture occurs, there is a possibility of infection with subsequent acute inflammation. If bruises and injuries of other parts of the body are fairly easy to diagnose, then in the case of damage to the abdomen, it is not always possible to determine the extent of violations and the risk of consequences for health and life.

AT medical practice Abdominal injuries are divided into open and closed. The latter make up 85% of all damage. More detailed classification possible injuries the abdomen implies their division into, radiation, thermal and chemical. Combined injury involves a combination of several factors.

The most dangerous are open injuries of the pelvis and abdomen with damage to internal organs. With these types of violations, the risk of irreversible changes is high. Knife and gunshot wounds provoke traumatization of the abdominal organs and cause extensive and rapid blood loss.

Due to severe bruising, vital organs can also be affected. With the external integrity of soft tissues, there are such hidden damage as a rupture of the liver, spleen, mesentery of the intestine. Closed abdominal trauma with damage to the parenchymal organ system is a common occurrence. At the same time, ZTZh is classified into:

• uncomplicated- only the zone of the anterior abdominal wall suffers. The bruise is amenable to conservative treatment, the risk of complications is minimal;
• involving organs- with a closed abdominal injury, hollow organs suffer - the stomach and intestines, and the injuries themselves are fraught with the rapid development of inflammation, which is associated with a violation of the sterility of the intra-abdominal space;
• with internal bleeding- with closed injuries, the spleen, kidneys, pancreas often suffer, and their traumatization provokes blood loss;
• combined- imply damage to both solid and hollow organs.

During pregnancy, any trauma to the abdomen poses a threat to the health of the mother and fetus. Abdominal injuries are grounds for immediate hospitalization.

ICD 10 injury code

The coding system according to ICD 10, the international classifier of diseases, assigns the code S39 to abdominal injuries. According to the classification, abdominal tendons (S39.0), injuries of intra-abdominal organs (S39.6) are isolated. Multiple injuries abdomen are coded S39.7.

The reasons

Penetrating abdominal injuries are usually the result of road accidents, hostilities, and criminal acts. The causes of closed abdominal injuries are natural disasters, extreme sports, carelessness in everyday life. When falling from a height, traumatic injury to the abdominal organs is often combined with or. due to accidents and natural Disasters several systems of the human body are involved in the pathological process at once.

Blows to the chest and abdomen often lead to disorders incompatible with life. With such injuries, retroperitoneal bleeding and the possible development of peritonitis cannot be ruled out. Blunt abdominal trauma in young children is considered less dangerous. Most of them are the result of negligence and are not associated with violent actions. Also get an abdominal bruise in childhood possible when falling from a bicycle or horizontal bar.

Symptoms

It is possible to determine the nature of the damage using clinical manifestations. Upon impact, hematomas, scratches, pain appear, which can radiate to other organs and tissues. Due to severe injury, loss of consciousness is possible. The main symptoms of blunt abdominal trauma are:

• swelling in the affected area;
• blood pressure is reduced;
• the muscles of the abdominal wall are strained;
• nausea and vomiting due to rupture of the small intestine;
• bloating due to the presence of free gases in the abdominal cavity - typical for trauma to the pancreas;
• pulse and respiration speeded up.

A victim with blunt abdominal trauma usually complains of pain throughout the abdomen. If the liver is injured, the pain radiates to the supraclavicular region. Rupture of organs is fraught with the development of peritonitis with characteristic symptoms, this includes fever, vomiting, and increasing pain.

Abdominal injuries vary in location, and therefore the symptoms have their own characteristics. When the abdominal muscles are torn, intestinal obstruction occurs. Rupture of the colon provokes. In case of damage to the abdomen in a child, the symptoms are intensified. With penetrating wounds, heavy bleeding occurs.

First aid

With an abdominal injury, emergency care plays an almost paramount role and allows you to save the victim's life. Medical care for open wounds is antiseptic treatment. In case of severe tissue contamination, the cavity is washed with chlorhexidine. The protruding organs are not set, but bandaged with a bandage or gauze bandage, after soaking the fabric with an antiseptic.

First aid for closed abdominal injuries involves cooling the injured area. You can put an ice pack on your stomach. This will help stop swelling, hemorrhage and bruising. In case of blunt abdominal trauma, it is recommended to lay the victim in a comfortable position, and the position of the body is determined by the nature of the injury. If the blow fell on the liver, it is more convenient to lie with bent legs on the left side. With vomiting and nausea, it is impossible to lie down.

It is recommended to transport the victim with a closed abdominal injury in a semi-lying position. Transportation is best entrusted to doctors. If the accident occurred far from civilization and doctors cannot quickly get to the victim, you can transport the person on your own, eliminating pressure on the abdomen. The position in which persons with abdominal injuries are transported depends on the location of the injury. Usually a person lies on his back with half-bent legs and a raised head.

Painkillers are included in the first aid list. Tablets are prohibited, anesthesia is carried out by injection. At open injury the abdomen, the clinic is extremely pronounced, the victim may be in post-traumatic shock. In this case, Ketorolac is administered intravenously. All manipulations necessarily require an assessment of the general condition of the victim.

First aid in case of damage to the abdomen and internal organs is aimed at maintaining life support functions. If breathing problems occur, wear an oxygen mask. With blood loss, a sterile bandage is applied. Is it possible to give drink to the victim with an abdominal injury? Since a person may have hidden bleeding, drinking is excluded.

Diagnostics

If an abdominal injury occurs, delay in diagnosis is fraught with dangerous complications. At the same time, the nature of the damage itself does not matter, since it is visually impossible to detect rupture of organs, internal bleeding, etc. The method of examining patients with abdominal injuries implies:

• X-ray examination- is not the main diagnostic method, but allows you to determine the integrity of the bones in case of damage to the ribs and pelvis;
• ultrasound- determines the state of internal organs, reveals hidden bleeding, is considered informative and reliable method research;
• CT- a detailed diagnostic tool that detects minor injuries and hemorrhages that are difficult to detect during ultrasound. To diagnose hemoperitoneum (bleeding), tomography of the abdominal and retroperitoneal space is performed.

The chest, pelvis and abdomen require detailed examination. Diagnostic measures are carried out taking into account the clinical picture. If a bladder rupture is suspected, diagnostic catheterization is recommended. Evaluate the functionality of the internal organs of the abdomen allows laparoscopy. It can be both diagnostic and therapeutic at the same time. In the second case, it is possible not only to examine the organs, but also to remove excess blood during internal bleeding.

Treatment

Therapy for open and closed abdominal injuries will vary. If available open wounds, their sanitation is carried out, antibiotic therapy is carried out. Conservative methods are suitable for the treatment of uncomplicated blunt abdominal trauma. Bed rest is prescribed. To prevent extensive hematomas cold is used. In traumatology, minimally invasive methods of hematoma drainage are practiced. Opening the cavity is necessary in case of impossibility of self-resorption of the hemorrhage zone.

Further treatment of the injury is to control intra-abdominal pressure and normalization of metabolic processes at the tissue level. To do this, it is sufficient to provide adequate nutrition, the emphasis in therapy is on physiotherapy, taking analgesics and anxiolytics.

Due to rupture of the bladder, both intraperitoneal and extraperitoneal complications occur. If urine enters the sterile space of the peritoneum, peritonitis develops, requiring surgical intervention. For mild bladder injury acute delay urine is catheterized. The method is not used for injuries urethra and bleeding.

Surgical treatment

Complicated abdominal injuries with damage to solid and hollow organs are treated surgically. In case of damage to the bladder and ureters, intestines, liver and kidneys, use conservative methods impractical. The surgeon prescribes an emergency operation for internal bleeding and suspected peritonitis.

Injuries with rupture of hollow organs - the stomach, intestines, almost always require surgical intervention. Operations are prescribed for stab and gunshot wounds of the abdomen, as well as in case of rupture of the bladder and peritoneal organs. In general surgery, abdominal trauma is repaired through a median laparotomy.

The revolutionary methods of treatment for abdominal injuries include regenerative medicine. It stimulates recovery processes and returns the lost functions of the body. It is a transplantation of healthy cells. Currently, it is not widespread, but it has great prospects.

Rehabilitation

If the abdominal injury was detected and treated in time, then you will not have to follow a special diet after leaving the hospital. Severe patients are prescribed enteral nutrition until the condition stabilizes. After surgical treatment, attention is paid to the prevention of intestinal obstruction. It usually occurs due to trauma to the intestine, but may be the result of unsuccessful surgical intervention. In this case, the doctor prescribes drugs that stimulate peristalsis and facilitate the process of digestion.

Restrict physical exercise. Return to the usual way of life gradually. Recovery period may be delayed due to heavy internal violations. Vitamin therapy, therapeutic exercises, physiotherapy are distinguished as rehabilitation measures.

Complications and consequences

If abdominal injuries were detected in time, then the risk of complications is minimal, with the exception of penetrating wounds. Blunt trauma to the abdomen with damage to the internal organs can lead to the development of insufficiency of some of them. The most common side effects are:

• inflammation of the peritoneum Medically known as peritonitis. Under the influence of microorganisms that enter the abdominal cavity from a damaged intestine or stomach, an acute inflammatory process develops. Delay in treatment can lead to death;
• sepsis or septic shock- is a consequence acute reaction to an infection that entered the body when the internal organs were ruptured. When the process is generalized, it leads to death;
• enteral insufficiency- pathology of the small intestine, preventing the absorption of nutrients during food processing;
• internal bleeding- massive blood loss leads to death. Timely detection of the area of ​​bleeding can save the victim's life.

Damage to the peritoneum is always difficult to tolerate, especially if there is damage to the internal organs. Their insufficiency further leads to a deterioration in the quality of life and requires maintenance therapy.

Dear readers of the 1MedHelp website, if you have any questions on this topic, we will be happy to answer them. Leave your feedback, comments, share stories of how you survived a similar trauma and successfully coped with the consequences! Your life experience may be useful to other readers.

Article author:| orthopedic doctor Education: Diploma in the specialty "Medicine" received in 2001 in medical academy them. I. M. Sechenov. In 2003, she completed postgraduate studies in the specialty "Traumatology and Orthopedics" in the City clinical hospital No. 29 im. N.E. Bauman.

- an extensive group of severe injuries, in most cases posing a threat to the patient's life. They can be both closed and open. Open most often arise due to knife wounds, although other causes are possible (falling on a sharp object, gunshot wound). Closed injuries are usually caused by falls from a height, car accidents, industrial accidents, etc. The severity of injury in open and closed abdominal trauma can vary, but closed injuries are a particular problem. In this case, due to the absence of a wound and external bleeding, as well as due to the traumatic shock associated with such injuries or the patient’s serious condition, difficulties often arise at the stage primary diagnosis. If an abdominal injury is suspected, urgent delivery of the patient to a specialized medical facility is necessary. Treatment is usually surgical.

Colon rupture the symptomatology resembles ruptures of the small intestine, however, this often reveals tension in the abdominal wall and signs of intra-abdominal bleeding. Shock develops more often than with ruptures of the small intestine.

Liver damage occurs with abdominal trauma quite often. Both subcapsular cracks or ruptures, and complete detachment of individual parts of the liver are possible. Such liver injury in the vast majority of cases is accompanied by profuse internal bleeding. The patient's condition is severe, loss of consciousness is possible. With preserved consciousness, the patient complains of pain in the right hypochondrium, which can radiate to the right supraclavicular region. The skin is pale, the pulse and respiration is rapid, blood pressure is reduced. Signs of traumatic shock.

Spleen injury- the most common injury in blunt abdominal trauma, accounting for 30% of the total number of injuries with a violation of the integrity of the abdominal organs. It can be primary (symptoms appear immediately after the injury) or secondary (symptoms appear days or even weeks later). Secondary ruptures of the spleen are commonly seen in children.

With small tears, bleeding stops due to the formation of a blood clot. With major injuries, profuse internal bleeding occurs with accumulation of blood in the abdominal cavity (hemoperitoneum). Severe condition, shock, pressure drop, increased heart rate and respiration. The patient is concerned about pain in the left hypochondrium, irradiation to the left shoulder is possible. The pain decreases in the position on the left side with the legs bent and pulled up to the stomach.

Damage to the pancreas. Usually occur when severe injuries abdomen and are often combined with damage to other organs (intestines, liver, kidneys and spleen). Perhaps concussion of the pancreas, its injury or rupture. The patient complains of sharp pains in the epigastric region. The condition is severe, the abdomen is swollen, the muscles of the anterior abdominal wall are tense, the pulse is quickened, the blood pressure is reduced.

Kidney damage blunt abdominal trauma is rare. This is due to the location of the organ, which lies in the retroperitoneal space and is surrounded on all sides by other organs and tissues. Injury or concussion causes pain in lumbar region, gross hematuria (urine with blood) and fever. More severe kidney injuries (crushes or ruptures) usually occur with severe abdominal trauma and are combined with damage to other organs. Characterized by shock, pain, muscle tension in the lumbar region and hypochondrium on the side of the damaged kidney, falling blood pressure, tachycardia.

Bladder rupture may be extraperitoneal or intraperitoneal. The cause is blunt trauma to the abdomen with a full bladder. Extraperitoneal rupture is characterized by false urge to urinate, pain and swelling of the perineum. It is possible to excrete a small amount of urine with blood.

Intraperitoneal rupture of the bladder is accompanied by pain in the lower abdomen and frequent false urge to urinate. Because of the urine poured into the abdominal cavity, peritonitis develops. The abdomen is soft, moderately painful on palpation, there is swelling and weakening of intestinal motility.

Diagnosis of abdominal trauma

Suspicion of an abdominal injury is an indication for the immediate delivery of the patient to the hospital for diagnosis and further treatment. In such a situation, it is extremely important to assess the nature of the damage as soon as possible and, first of all, to identify bleeding that may threaten the patient's life.

Upon admission, in all cases, blood and urine tests are mandatory, blood group and Rh factor are determined. Other research methods are selected individually, taking into account the clinical manifestations and severity of the patient's condition.

With the advent of modern, more accurate methods of examination, radiography of the abdominal cavity in case of abdominal trauma has partially lost its diagnostic value. However, it can be used to detect ruptures of hollow organs. Holding x-ray examination also indicated for gunshot wounds (to determine the location of foreign bodies - bullets or shots) and for suspected concomitant fracture of the pelvis or damage to the chest.

accessible and informative method research is an ultrasound that allows you to diagnose intra-abdominal bleeding and detect subcapsular damage to organs that can become a source of bleeding in the future.

If the appropriate equipment is available to examine a patient with an abdominal injury, computed tomography is used, which allows you to study in detail the structure and condition of the internal organs, revealing even minor damage and minor bleeding.

If a bladder rupture is suspected, catheterization is indicated - the diagnosis is confirmed by a small amount of bloody urine released through the catheter. In doubtful cases, it is necessary to conduct an ascending cystography, in which the presence of a radiopaque solution in the paravesical tissue is detected.

One of the most effective methods Diagnosis for abdominal trauma is laparoscopy. An endoscope is inserted into the abdominal cavity through a small incision, through which you can directly see the internal organs, assess the degree of their confirmation and clearly determine the indications for surgery. In some cases, laparoscopy is not only diagnostic, but also medical technique, with which you can stop bleeding and remove blood from the abdominal cavity.

Treatment of abdominal injuries

Open wounds are an indication for emergency operation. For superficial wounds that do not penetrate the abdominal cavity, the usual primary surgical treatment is performed with washing of the wound cavity, excision of non-viable and heavily contaminated tissues, and suturing. With penetrating wounds, the nature of the surgical intervention depends on the presence of damage to any organs.

Bruises of the abdominal wall, as well as ruptures of muscles and fascia, are treated conservatively. Bed rest, cold and physiotherapy are prescribed. Large hematomas may require puncture or opening and draining of the hematoma.

Ruptures of parenchymal and hollow organs, as well as intra-abdominal bleeding are indications for emergency surgery. Under general anesthesia median laparotomy is performed. Through a wide incision, the surgeon carefully examines the abdominal organs, identifies and eliminates damage. In the postoperative period, with an abdominal injury, analgesics are prescribed, antibiotic therapy is performed. If necessary, blood and blood substitutes are transfused during the operation and in the postoperative period.

Features of abdominal trauma in children.

Closed abdominal trauma accounts for 3% of all injuries in children.

Isolated ruptures of the organ are most often observed, less often multiple (simultaneous injury to several abdominal organs) or combined injuries (simultaneous damage to the abdominal organs and other anatomical parts of the body). Depending on these injuries, one or another clinical picture is observed and the choice of medical tactics is determined. When collecting an anamnesis, attention should be paid to the circumstances of the injury, the strength and localization of the blow. However, children and parents are not always correctly oriented in the circumstances of the trauma.

clinical picture. One of the most frequent, constant and leading symptoms in case of damage to the internal organs of the abdominal cavity in children is pain, and its localization often indicates the source of damage. When a hollow organ is damaged, children complain of severe pain in all parts of the abdomen without strict localization. With an injury to the parenchymal organ, mild localized pain is noted in the right (liver) or left (spleen) hypochondrium. In cases where blood spills throughout the abdominal cavity, the pain becomes diffuse in nature, but still remains more pronounced in the area of ​​\u200b\u200bthe damaged organ. Children often note the irradiation of pain in one of the shoulder girdle (phrenicus symptom), the shoulder blade. Pain and its irradiation sometimes increase with deep inspiration and movements. Girdle pain occurs when the pancreas is damaged. Of certain importance is the presence of external traces of trauma: abrasions, bruises and their localization.

Vomiting, nausea are not permanent signs of damage to the parenchymal organ, but sometimes they occur immediately after the injury or after a few hours. With a rupture of a hollow organ, vomiting is frequent, with bile, very painful. An active, energetic child becomes adynamic after an injury. Having accepted comfortable position, he reluctantly changes it, and in case of damage to the liver or spleen, he tries to lie on the side of the same name. When trying to get the child out of this position, he seeks to immediately take the previous position, which provides peace and unloading for the injured area (a symptom of "roll-up").

Dynamic monitoring of blood pressure often does not allow determining the severity of intra-abdominal bleeding, since for a long time the child's blood pressure may remain at the border age norm. A very rarely observed drop in blood pressure is possible with profuse, significant or prolonged undiagnosed bleeding. More revealing is the change in heart rate; with an increase in the observation period, the pulse rate sometimes increases even with satisfactory filling.

With isolated damage to the liver, spleen, the rigidity of the muscles of the anterior abdominal wall is usually weakly expressed and is often limited to the left or right half. epigastric region depending on the location of the damage. With the spread of blood in the abdominal cavity, rigidity can capture the entire anterior abdominal wall. The symptom of peritoneal irritation (Shchetkin-Blumberg symptom) with ruptures of parenchymal organs is usually mild and is associated with the reaction of the peritoneum to the blood that has poured into the abdominal cavity. With subcapsular or intraorgan hematomas (ruptures), the Shchetkin-Blumberg symptom is often negative. With intra-abdominal bleeding, palpation of the abdomen often reveals a discrepancy between severe pain and slight tension in the muscles of the anterior abdominal wall - a positive symptom of Kulenkampf.

If the spleen is damaged, a positive sign of Weinert is noted: the rescuer covers the upper part of the lumbar region with four fingers on both sides and with the first fingers in the hypochondrium region on the right determines tissue compliance, while on the left he encounters resistance in the form of rigidity, soreness. Damage to the liver is characterized by a "symptom of the navel" when pressing on the navel, a sharp pain occurs due to tension of the round ligament of the liver.

Percussion of the abdomen with intra-abdominal bleeding reveals dullness of percussion sound in sloping places, moving with a change in body position and often increasing in size due to ongoing bleeding. During auscultation, in some cases, intestinal peristalsis is not audible (the result of reflex post-traumatic atony of the intestine).

When examining a child with damage to the hollow organ of the abdominal cavity, pointed facial features, moderate pallor, sometimes with an earthy tint, and a dry, thickly furred tongue are noted. The abdomen is flattened, does not participate in the act of breathing, the tension of the muscles of the anterior abdominal wall is expressed, the symptoms of peritoneal irritation are clearly defined. With the increasing phenomena of peritonitis, toxicosis, exsicosis, the patient's condition progressively worsens.

Body temperature rises, but not much (within 37.5-38°C). With peritonitis, there is a growing discrepancy between the pulse and temperature: at a relatively low temperature, the pulse quickens by 20-30 per minute.

Help at the pre-hospital stage.

At the scene of an open injury to the abdomen - an aseptic bandage. The internal organs that have fallen out cannot be set - they must be covered with a sterile napkin, abundantly moistened with furacillin or saline, after which a circular bandage is fixed. With open and closed injuries at the scene of the incident, and subsequently at the stages of evacuation (if necessary), a comprehensive antishock therapy. The patient is forbidden to take water and food. Urgent hospitalization.

SHOCK STATES DURING A RTA.

Shock is a phase-developing pathological process resulting from neurohumoral regulation disorders. of cardio-vascular system caused by extreme effects (pain, toxins, dehydration), and characterized by a sharp decrease in blood supply to tissues, hypoxia and inhibition of organ functions.

Shock is primarily a clinical diagnosis. Shock symptoms develop as a result of a critical decrease in capillary blood flow in the affected organs, which leads to insufficient oxygen supply to tissues, disruption of nutrient inflow and outflow of metabolic products. This results in the loss or loss normal function cells, in extreme cases- cell death.

More N.N. Burdenko emphasized that shock should not be regarded as a stage of dying, but as a reaction of an organism capable of living.

A creature of shock like defensive reaction organism, is the inhibition of most functions, the development of hypothermia, a decrease in energy costs.

Initially, such conditions were classified as shock, in the pathogenesis of which a powerful afferent impulse, primarily pain, nociceptive, had a leading role as a trigger mechanism. Then, taking into account the fact that injuries are always accompanied by intoxication, toxemia was also considered the trigger of shock. Subsequently, the loss of blood, plasma and dehydration was added as an etiological factor of hypovolemia. Therefore, at present, the etiopathogenetic classification of shock considers the following options:

traumatic (including shock in case of burn injury, electrical injury, etc.),

endogenous pain (abdominal, nephrogenic, cardiogenic, etc.),

hypovolemic, including anhydraemic and hemorrhagic,

post-transfusion,

infectious-toxic (septic, toxic),

anaphylactic.

In the clinical course of shock, N.I. Pirogov distinguished between erectile, torpid and terminal stages, thus characterizing shock as a phase-developing process. The first of these stages is short and rarely detected in clinical setting. It is characterized by the excitation of the victim, the activation of the heart, breathing. In the torpid phase, there is a pronounced inhibition of the functions of organs and systems. terminal stage coincides with the agonal state of patients.

At present, most authors divide shock according to severity into grades 1, 2, and 3, reflecting mainly the level of hemodynamic disorders that naturally develop during shock. There are proposals to divide the shock according to the degree of compensation of these disorders into compensated, subcompensated and decompensated variants.

The main links in the pathogenesis of shock are:

inhibition of the reticular formation of the brain, midbrain, thalamus, which prevents the flow of afferent impulses to the cortex, reducing its activity;

decrease in BCC, centralization of blood circulation, increase in total peripheral resistance to blood flow, decrease in cardiac output, sharp deterioration tissue perfusion;

at the height of severe shock, the concentration of adaptive hormones and vasopressor biologically active substances in the blood decreases - biologically active substances (ACTH, cortisol, catecholamines, insulin, renin, etc.), accumulate antidiuretic hormone, aldosterone, which prevent urination, as well as vasodepressor biologically active substances (histamine, kinins, etc.), proteolytic enzymes that paralyze the metabolic function of small vessels;

a sharp deterioration in the rheological properties of blood, due to its thickening, increased viscosity, agglutination of blood cells, activation of the blood coagulation system, thrombogenesis in the terminal vascular bed;

tissue hypoxia, energy deficiency against the background of a sharply increased need for macroergic compounds in cells, blockade of metabolism, mixed acidosis, hypercapnia;

"shock" damage to organs (shock kidney, shock lungs, shock liver, etc.) with the development of multiple organ failure.

In general, the whole variety of shock triggers is leveled at the cell level. Here the pathological process proceeds universally, the same for all types of shock. Therefore, there is one of the common names for shock - the “sick cell” syndrome, and hemodynamic disturbances in shock are called “microcirculation crisis” not without reason.

The unfavorable development of the pathological process in shock is due to the tendency to form many vicious circles of pathogenesis.

As a result, the first damage involves other organs and systems in the pathological process that are far from the main focus of damage, resembling an avalanche or a landslide in its progressive development. Ultimately, shock leads to the development of circulatory ischemia of the tissue and its necrosis - the morphological substrate of the irreversibility of the process.

As a result of circulatory damage to organs and systems, as well as their toxic damage during severe forms shock naturally develops multiple organ failure (MON). Circulating immune complexes, complement, and biological active substances, accumulating in shock in large quantities, metabolites, products of incomplete cellular metabolism. For example, the so-called "middle molecules" are well known, the pool of which in high concentrations causes pronounced damage to the heart, kidneys, brain and other organs.

If hemodynamic phenomena of severe shock persist for more than 4 hours, shock lung syndrome almost always develops ( respiratory distress syndrome adults - ARDS), shock kidney with a clinic of acute renal failure (ARF), shock liver with a clinic of acute liver failure, disseminated intravascular coagulation (DIC) with pronounced manifestations of bleeding, marking a manifestation of the syndrome of multiple organ failure.

The development of PON significantly worsens the prognosis of victims of road accidents. It is believed that if there is a lesion of one organ, the lethality of the victims reaches 20-30%, two organs - 40-60%, three or more organs - 90-100%.

The morphological substrate of organ damage in shock is ischemic tissue necrosis, the size of which depends on each specific case. Most often, against the background of severe shock, cortical necrosis of the kidneys, centrilobular necrosis of the liver, areas of necrosis in the myocardium and lung tissues develop.

Multiple organ failure syndrome (MOS) in children with shock is a self-deepening pathological process, a variant vicious circle, the starting point of which is most often acute cardiovascular and renal-hepatic insufficiency.

For the first time, the term "multiple organ failure" entered clinical practice after the publication of the work of N. Tylney et al. (1973) "Consecutive systemic failure after ruptured abdominal aortic aneurysm. An unresolved problem in postoperative management." Later, A. Baue (1975), and then B. Eisman (1977) and D. Fry (1980-1982) finally formed the features of this condition and its definition.

In our country, E.S. Zolotokrylina, Yu.N. Shanin, A.P. Zilber, V.L. Kassil, V.A. Gologorsky, B.R. Gelfand, O.A. Dolina, R.N. Lebedeva and others.

Today we understand PON as a severe non-specific stress response of the body, insufficiency of two or more functional systems, universal damage to all organs and tissues of the body by aggressive mediators of a critical state with a temporary predominance of symptoms of one or another organ failure - pulmonary, cardiac, renal, etc. The main feature of PON is the unstoppable development of damage to a life-support organ or system to such a depth, after reaching which one has to state the inability of the organ to function in the interests of maintaining vital functions in general and preserving its structure, in particular. The direct factors that determine the severity of multiple organ dysfunction are the different ability of organs to withstand hypoxia and reduce blood flow, the nature of the shock factor and the initial functional state the organ itself.

There are three main phases in the development of PON syndrome:

The induction phase, which results in the synthesis of a number of humoral factors that trigger the systemic inflammatory response;

The cascade phase, accompanied by the development of acute pulmonary injury, activation of the cascades of the kallikrein-kinin system, the arachidonic acid system, the blood coagulation system, and others;

The phase of secondary autoaggression, extremely pronounced organ dysfunction and stable hypermetabolism, in which the patient's body loses the ability to self-regulate homeostasis;

The initiating factor that triggers the release of systemic inflammatory mediators can be very different in origin - it is trauma, ischemia, blood loss, burns. The above effects transfer polymorphonuclear nuclei (neutrophils, basophils, granulocytes) and endotheliocytes into a state of "oxygen explosion", the result of this transformation is a powerful chaotic release by these cells into the bloodstream huge amount substances that have multidirectional effects and are mediators of PON.

PON mediators:

Cytokines

Interleukin 1

Interleukin 2

Interleukin 6

platelet activating factor

Thromboxanes

tumor necrosis factor

Eicosanoids

Prostaglandins (E1, E2)

Leukotrienes

Mediator amines

Histamine / Serotonin

Octopamine

Opioids / neurotransmitters

Enkephalins

beta endorphins

Hormonal amines / peptides

thyroxine

A growth hormone

Glucagon

Complement

fibronectin

growth factors

Proteases

Lysosomal Enzymes

Nitric oxide (NO)

LPO products

superoxide radicals

Hydroxy radicals

Peroxides

Currently, about 200 such mediators are known. The main ones are:

Cytokines are low molecular weight proteins that biological activity carried out through specific receptors located on cell membranes. The most significant are tumor necrosis factor (TNF) and interleukins 1, 6, 10. They are able to have both local and distal effects (on distant organs and tissues). Common to the entire group is increased adhesion and aggregation of leukocytes, as well as hypercatabolic and hyperdynamic effects. It is cytokines that are the mediators of the first row, which themselves are able to cause cascades of humoral reactions. The main cytokines responsible for stimulating the systemic response in the acute phase are interleukin-1, interleukin-6 and tumor necrosis factor, with interleukin-6 playing a dominant role. The primary action of cytokines is aimed at changing the gene response. TNF and interleukin-1 have been shown to have a direct transcriptional effect on the production of interleukin-6. In other cases, a synergistic effect of interleukin-1 and 6 was noted, leading to the development of a maximum response to damage. Under the influence of high concentrations of tumor necrosis factor cytokines, interleukins 1 and 6, interferon-gamma in experimental animals, significant changes occurred in the total pool of free plasma amino acids. alanine - as well as the severity of catabolism, oxygen transport disorders, functional disorders in vital organs.

Eicosanoids are degradation products of arachidonic acid. These include thromboxanes, leukotrienes, epoxides. The cumulative effects are characterized by the development of bronchoconstriction, increased membrane permeability, microthrombosis, adhesion, aggregation, and degranulation of leukocytes.

Nitric oxide (NO) is an endothelial-relaxing factor, a vasodilator that acts through the guanylate cyclase system and causes vasoplegia, which often accompanies the clinic of refractory shock.

Interferons - low molecular weight proteins that activate the endothelium, contribute to the release of other cytokines, the formation of growth factors.

Platelet activating factor - increases the aggregation of platelets and neutrophils. It promotes the release of oxidants, the formation of cyclo- and lipoxygenase products in the metabolism of arachidonic acid. Direct exposure leads to vasoconstriction and dilatation, increased permeability of the pulmonary and systemic vessels.

Fibronectin is a protein that exists in two main forms. Tissue - provides impermeability of fibers and cell connections. Circulating - causes adhesion of particles to be destroyed to macrophages and endothelium.

Oxygen radicals - damage the endothelial membrane, cells of the pulmonary interstitium, participate in the formation of a chemotactic lipid that attracts leukocytes.

The main factors aggravating the "mediator-cytokine storm" are hypoxia and dysoxia, deep microcirculation disorders, abnormally high concentrations of intermediate and final metabolic products, circulating immune complexes, biogenic amines, and peroxidation products.

The cumulative effects of damage mediators form a generalized systemic inflammatory response or systemic inflammatory response syndrome - SIRS (SIRS). clinical criteria development of SIRS are the following:

Body temperature is more than 38 o C or less than 36 o C;

Heart rate more than 90 per minute;

Respiratory rate more than 20 per minute or arterial hypocapnia less than 32 mm Hg. st;

Leukocytosis more than 12,000 mm or leukopenia less than 4,000 mm, or the presence of more than 10% immature

forms of neutrophils;

There are three stages in the development of SIRS:

Stage 1. Local production of cytokines in response to injury.

Stage 2. Release of a small amount of cytokines into the systemic circulation. Even small amounts of mediators can activate macrophages, platelets, and growth hormone production. The developing acute phase reaction is controlled by pro-inflammatory mediators and their endogenous antagonists, such as interleukin-1, 10, 13 antagonists; tumor necrosis factor. Due to the balance between cytokines, mediator receptor antagonists and antibodies in normal conditions prerequisites are created for wound healing, destruction pathogenic microorganisms maintaining homeostasis.

Stage 3. Generalization of the inflammatory response. In the event that the regulatory systems are unable to maintain homeostasis, the destructive effects of cytokines and other mediators begin to dominate, which leads to impaired permeability and function of the capillary endothelium, the formation of distant foci of systemic inflammation, and the development of mono- and multiple organ dysfunction.

SIRS is a symptom complex characterizing the severity of the inflammatory response in the endotheliocyte system, and, consequently, the direction of the inflammatory response to damage.

A number of studies have confirmed that the basis of the pathogenesis of PON is precisely a disseminated inflammatory reaction, accompanied by activation and release a large number biologically active compounds.

PON syndrome should be considered as the most severe degree SIRS is generalized inflammation causing damage to organ function.

In the light of modern ideas about the systemic inflammatory response, two main pathways for the development of PON are distinguished. Primary PON is a direct result of exposure to a certain damaging factor of any etiology. At the same time, signs of organ dysfunction appear early. An example of this type of PON can be multiple organ dysfunction in polytrauma, severe burns.

Secondary PON develops after the latent phase and is the result of a generalized systemic response of the organism to a damaging factor. The septic variant of MOF can be considered as a classic secondary organ failure, a manifestation of an extremely severe systemic response to infectious invasion.

The studies carried out in our country and abroad made it possible to reveal the general pattern of the formation of the PON syndrome. In most cases, in the most general form, the sequence of system involvement in PON is as follows: respiratory distress syndrome - encephalopathy - renal dysfunction syndrome - hepatic dysfunction syndrome - stress ulcers of the gastrointestinal tract.

Research recent years proved that the intestine plays a central role in the pathogenesis of the development of multiple organ failure in critical conditions. The intestine is not just an organ responsible for providing the body with essential nutrients. To maintain the integrity of the intestinal mucosa itself, the presence of nutrients is necessary. The intestine performs endocrine, immune, metabolic and mechanical barrier functions. Many factors are involved in maintaining the integrity and regeneration of the mucosal layer of the gastrointestinal tract. These are gastrointestinal peptides, enteroglucagon, thyroxine, fatty acids, growth hormone, Peyer's patches, lymphocytes, macrophages, immunoglobulin A in the bile secretion. The intestinal wall is richly filled with lymphoid tissue, which interacts with the bacterial flora of the intestine and nutritional factors; normal bacteria and toxins from the intestinal lumen to a small amount penetrate the system portal vein to the liver, where they are cleared by Kupffer and reticuloendothelial cells.

Closed (blunt) abdominal trauma is an injury that is not accompanied by a violation of the integrity of the abdominal wall. These injuries are also called "non-penetrating". However, the absence of visual pathologies is not evidence of the preservation of internal organs. Closed abdominal injuries are accompanied by damage to the pancreas, spleen, liver, intestinal tract, bladder and kidneys, which affects the patient's health and can be fatal.

Etiology

A blow to the stomach is considered the main cause of damage to internal organs. Most of the patients affected in this way were relaxed at the time of the injury. The muscles are at rest, which provokes the penetration of the impact force deep into the tissues. This mechanism of damage is typical for the following cases:

• criminal incidents (a blow to the stomach with fists or kicks);
• falling from height;
• car crashes;
• sports injuries;
• indomitable cough reflex, accompanied by a sharp contraction of the abdominal muscles;
• industrial disasters;
• natural or military disasters.

At the time of exposure to a detrimental factor that causes bruising of the abdominal wall, the presence of obesity and, conversely, depletion or weakness of the muscular apparatus increase the risk of damage to internal organs.

Frequent clinical cases are connecting blunt injuries of the abdomen with fractures of the bones of the limbs, pelvis, ribs, spine, craniocerebral trauma. This mechanism causes the development of large blood loss, aggravates the patient's condition and accelerates the onset of traumatic shock.

For any minor injury, go to the nearest emergency room. Working around the clock, employees will provide first aid, deciding on further hospitalization and the presence of internal injuries. Note! In the case of a serious condition of the victim or with any suspicion of a rupture of the internal organ, independent movement of the patient is contraindicated. Be sure to call an ambulance.

Classification

Blunt abdominal injuries are divided according to the following principles:

1. Without the presence of damage to organs (bruises, ruptures of muscle groups and fascia).
2. With the presence of damage to internal organs located in the peritoneal space of the spleen, sections of the intestinal tract, bladder).
3. With damage to the retroperitoneal organs (rupture of the pancreas, kidney).
4. Pathology with intra-abdominal bleeding.
5. Injuries accompanied by the threat of peritonitis (traumatization of hollow organs).
6. Combined damage to parenchymal and hollow organs.

Pain syndrome

Closed abdominal trauma is characterized by the first and main complaint from the victim - the appearance of pain in the abdomen. It is important to remember that the erectile phase of shock may be accompanied by suppression of the pain syndrome, which complicates the diagnosis of pathology. In the case of combined injuries, pain from a fracture of the ribs or bones of the limbs, the pelvis can push the symptoms caused by the blunt abdominal trauma into the background.

The torpid stage of the shock state depresses the brightness of painful conditions due to the fact that the patient is disoriented or unconscious.

The nature of the pain syndrome, its intensity and irradiation of sensations depend on the location of the damage and the organ involved in the process. For example, a liver injury is accompanied by a dull aching pain that radiates to the region of the right forearm. Rupture of the spleen is manifested by irradiation of pain in the left forearm. Damage to the pancreas is characterized by girdle pain, which responds in the region of both collarbones, lower back, and left shoulder.

Spleen rupture, the consequences of which are severe for the patient due to excessive blood loss, accompanies a third of all closed abdominal injuries. Frequent cases are damage to the spleen and left kidney. Often the doctor has to re-operate on the patient if he did not see the clinical picture of one of several injured organs.

Traumatization of the upper part of the intestinal tract, accompanied by rupture of the walls, is manifested by a sharp dagger pain resulting from the penetration of intestinal contents into the abdominal cavity. From the brightness of the pain syndrome, patients may lose consciousness. Injuries to the colon are less aggressive in manifestation because the contents do not have a strong acidic environment.

Other clinical signs

Blunt abdominal trauma is manifested by reflex vomiting. In cases of rupture of the walls of the small intestine or stomach, the vomit will contain blood clots or have a color coffee grounds. Similar discharge with feces indicates trauma to the colon. Injuries to the rectum are accompanied by the appearance of scarlet blood or its clots.

Intra-abdominal bleeding is accompanied by the following symptoms:

• weakness and drowsiness;
• dizziness;
• the appearance of "flies" before the eyes;
• skin and mucous membranes acquire a bluish tint;
• reduced blood pressure;
• weak and frequent pulse;
• frequent shallow breathing;
• the appearance of cold sweat.

Damage to hollow organs causes the development of peritonitis. On the similar pathology the body of the victim responds with a rise in body temperature (with severe blood loss - hypothermia), indomitable vomiting, and stopping the peristalsis of the intestinal tract. Character pain constantly changing, severe pain alternates with its temporary disappearance.

Traumatization of the urinary system is accompanied by the absence or violation of urine output, gross hematuria, pain in the lumbar region. Later, swelling develops in the perineum.

Injuries without trauma to internal organs

The contusion of the anterior abdominal wall is manifested by local visual changes:

• puffiness;
• hyperemia;
• soreness;
• the presence of bruises and abrasions;
• hematomas.

The pain that accompanies a bruise is aggravated by any change in body position, sneezing, coughing, defecation.

Blunt abdominal trauma may be accompanied by ruptures of the fascia. The patient complains of severe pain, a feeling of bloating. There is a dynamic paresis of the intestinal tract, and, accordingly, the dynamic nature of the obstruction. Rupture of muscle groups is accompanied local manifestations in the form of small-point hemorrhages or large hematomas, which can be localized not only at the site of injury, but also far beyond it.

The final diagnosis of "damage to the anterior abdominal wall" is made in case of confirmation of the absence of internal pathologies.

Diagnostic measures

Differential diagnosis of the patient's condition begins with the collection of anamnesis and trauma. Further, the determination of the condition of the victim includes following methods examinations:

1. General analysis of peripheral blood shows all signs acute blood loss: decrease in erythrocytes and hemoglobin, hematocrit, leukocytosis in the presence of an inflammatory process.
2. A general urinalysis determines macrohematuria, and if the pancreas is damaged, the presence of amylase in the urine.
3. Of the instrumental methods of examination, catheterization of the bladder and the introduction of a probe into the stomach are used.
4. Ultrasound examination.
5. Computed tomography with intravenous contrast agent.
6. Radiography.
7. Other examinations if necessary (cystography, rheovasography, ERCP).

Differentiation of pathology

The study of the abdominal cavity and the organs located there should be multilateral, since concomitant injuries can suppress the symptoms of one injury, bringing to the fore the clinic of another injury.

Emergency room, 24 hours a day medical care, unable to carry out all of these diagnostic methods, therefore, after the initial examination, the victim is sent to the hospital of the surgical department.

First aid for abdominal trauma

If damage to internal organs is suspected, the following rules should be followed:

1. The patient is placed on hard surface provide a state of rest.
2. Apply ice to the injury site.
3. Do not give the victim food or water.
4. Do not take medicines until the ambulance arrives, especially analgesics.
5. If possible, provide transportation to a medical facility.
6. In the presence of vomiting, turn the patient's head to the side so that aspiration of vomit does not occur.

Principles of medical care

Blunt abdominal trauma requires immediate intervention by specialists, since a favorable result is possible only with timely diagnosis and initiation of treatment. After stabilization of the victim's condition and anti-shock measures, surgical intervention is indicated for patients. Closed injuries require compliance with the following conditions during operations:

• general anesthesia with adequate muscle relaxation;
• allowing access to all areas of the abdominal cavity;
• simple in technique, but reliable in terms of the result of the event;
• intervention is short in time;
• uninfected blood poured into the abdominal cavity should be used for reinfusion.

If the liver is damaged, stop bleeding, excision of non-viable tissues, and suturing are necessary. Rupture of the spleen, the consequences of which can lead to the removal of the organ, requires a thorough revision. In the case of a minor injury, bleeding stop with suturing is indicated. With severe damage to the organ, splenectomy is used.

The tract is accompanied by the removal of non-viable tissues, stopping bleeding, revision of all loops, if necessary, bowel resection is performed.

Damage to the kidneys requires organ-preserving interventions, but with severe crushing or separation of the organ from the supply vessels, nephrectomy is performed.

Conclusion

The prognosis of traumatization of the abdominal organs depends on the speed of seeking help, the mechanism of damage, and the correct differential diagnosis, professionalism of the medical staff of the medical institution providing assistance to the victim.