Heart wounds. Clinic. Diagnostics. Conservative and surgical treatment. Open and closed injuries of the heart

The frequency of damage to the heart and pericardium with penetrating chest injuries is 10-12%.

The clinical picture, features of surgical tactics and treatment outcomes depend on the location, size and depth of the wound. There are small (up to 1 cm) and large (more than 1 cm) wounds of the heart. The larger the wound, the more dangerous it is for the victim. The results of treatment worsen when the wound penetrates into the cavity of the heart, damage to the coronary vessels, intracardiac structures, through the nature of the injury. The intensity and volume of blood loss is higher, and the immediate results of treatment are worse when the left heart is injured than the right. The most reliable signs of injury to the heart and pericardium are the localization of the wound in the projection of the heart (I.I. Grekov), the expansion of the boundaries of cardiac dullness, the dullness of the heart tones, the decrease in blood pressure, the paradoxical nature of the pulse, the development of symptoms of venous stasis on the face, neck, upper body due to cardiac tamponade. Intensive internal bleeding can also be manifested by massive hemothorax, significant suffocation. Gushing external bleeding is rarely observed in the emergency room.

A possible injury to the heart should be considered if the inlet wound opening is located in a zone bounded from above - by the II rib, from below - by the left hypochondrium and epigastric region, on the right - by the right parasternal line, on the left - by the middle axillary line. Although, exceptions to this rule are not uncommon - atypical localization of entry wounds on the back, abdomen, etc., especially with a gunshot wound. The general condition of the majority of victims is severe and extremely severe, sometimes terminal, progressively turning into clinical death during transportation. But there are also options for treating the victim "on their own feet."

Developing acute cardiac tamponade causes a forced sitting or semi-sitting position of the victim, accelerated, shallow breathing with the participation of auxiliary muscles, pale cyanotic coloration of the skin, puffiness of the face, increased venous pattern on the neck. The pulse is small, frequent, weak filling, sometimes disappears on inspiration (paradoxical). The disappearance of the apex beat, physical and radiologically detectable enlargement of the boundaries of the heart, smoothness of the left contours of the heart, the absence of heart pulsation during fluoroscopy complement the results of electrocardiography (decreased voltage of ECG waves, heart attack-like changes). Prolonged ischemia of the brain, liver, kidneys aggravates and diversifies the clinical picture, can lead to acute multiple organ failure, convulsive and other additional symptoms, and death of the victim.

Diagnostic in unclear cases, and with developed tamponade - an effective first aid is a pericardial puncture, most often performed according to Marfan or Larrey, less often - according to Pirogov-Delorme or Kurshman.

Marfan's method: in a half-sitting or reclining position on a couch with a padded roller, the patient under local infiltration anesthesia with a 0.25% solution of novocaine is punctured with a medium needle strictly along the midline immediately under the xiphoid process. The needle is directed from bottom to top, from front to back and penetrate into the pericardial cavity. With the Larrey method, the needle is injected into the angle between the base of the xiphoid process of the sternum and the attachment of the VII left costal cartilage to a depth of 1.5-2 cm, and then advanced upward and medially parallel to the chest wall for another 2-3 cm, getting into the pericardial cavity.

For general surgeons, reliable signs of injury to the heart and pericardium, as well as a reasonable suspicion of injury to the heart, are an indication for emergency hospitalization and emergency thoracotomy to stop bleeding, eliminate cardiac tamponade, and suture the wound of the heart. The extremely serious condition of the victim excludes various diagnostic measures and speeds up surgical intervention. In a state of clinical death, only immediate thoracotomy in combination with resuscitation on the operating table can give a chance to save the life of the victim.

In unclear diagnostic situations and in the condition of the wounded, which allows to deepen diagnostic measures, the above studies (ECG, radiography, fluoroscopy, echocardioscopy, measurement of CVP) can be used to identify hemopneumopericardium, measure heart pulsation, concomitant signs of intrapleural bleeding and disorders of position and mobility diaphragm.

In some difficult diagnostic cases, repeated X-ray examination of the victim for a comparative analysis of changes becomes important. The established cardiac tamponade is an indication for pericardial puncture followed by intravenous infusion of fluids to replenish the BCC during the operation. Until the tamponade is eliminated, jet intravenous infusions of fluids are contraindicated, tk. they aggravate disturbances of the central hemodynamics.

Thoracotomy is performed under intubation anesthesia in the IV or V intercostal space in the position on the right side - from the left edge of the sternum to the posterior axillary line. The pericardium is opened with a longitudinal incision up to 8-12 cm parallel to the phrenic nerve, retreating from it ventrally or dorsally 1.5-2 cm. The left palm is inserted into the pericardial cavity so that the heart rests on the palm with the back surface, and the thumb lies on its front surface and could, if necessary, temporarily stop bleeding from a heart wound by pressing. The wound of the heart is sutured with a round needle, nodal or mattress, more often nylon sutures, passing through all layers on the atria, on the ventricles of the heart through the thickness of the myocardium, without penetrating into the heart cavity. When cutting sutures on the myocardium, a piece of the pectoralis major muscle with fascia or a pericardial flap can be used as a lining, damage to the coronary vessels should be avoided. There is no need to rush to remove blood clots plugging the heart wound before a reliable suture is applied. It is useful to apply temporary holders to the edges of the wound of the heart to reduce blood loss (in order to temporarily bring the edges of the wound closer together). Be sure to make an audit of the heart for a possible penetrating injury. To improve the outflow of fluid from the pericardium in the postoperative period and prevent pericarditis, a window is cut out in the posterior inferior wall of the pericardium with a diameter of 2.5-3 cm, and the pericardial wound is sutured with rare (2-2.5 cm) single sutures. If necessary, a thoracotomy wound can be supplemented by transection of the sternum or even a contralateral thoracotomy. Access should be convenient for suturing the wound of the heart and saving the life of the victim. Fears of developing osteomyelitis of the sternum, etc. recede into the background. During the operation, the spilled pleural and donor blood is used for reinfusion, significantly reducing the need for donor blood. In many ways, the final results of the treatment of victims depend on the timeliness of delivery to the hospital and the speed of surgical intervention. With penetrating wounds of the heart with damage to intracardiac structures, patients need subsequent treatment by a cardiac surgeon.

History of cardiac injury surgery

The famous French surgeon René Leriche, in his book “Memories of a Past Life,” wrote: “I loved everything that was required in emergency surgery - determination, responsibility and inclusion completely and completely in action.” In the highest degree, these requirements are necessary in providing assistance to victims with heart injuries. Even the fulfillment of all these requirements does not always lead to positive results in case of heart injuries.

The first mention of the fatal consequences of wounding the heart is described by the Greek poet Homer in the 13th book of the Iliad (950 BC).

The observation of Galen makes a special impression: “When one of the ventricles of the heart is perforated, the gladiators die immediately on the spot from blood loss, especially fast when the left ventricle is damaged. If the sword does not penetrate into the cavity of the heart, but stops in the heart muscle, then some of the wounded survive for a whole day, and also, despite the wound, the following night; but then they die of inflammation.”

At the end of the 19th century, when the survival rate for heart injuries was approximately 10%, reputable surgeons, in particular, T. Billroth, argued that inexperienced surgeons without a solid reputation were trying to deal with surgical treatment of heart injuries.

For the first time, a suture on a stab-cut wound of the heart was imposed by Cappelen in Oslo on September 5, 1895, but the wounded man died 2 days later from pericarditis. In March 1896, Farina in Rome put stitches on the wound of the right ventricle, but six days later the wounded man died of pneumonia.

The first successful operation of this kind was performed on September 9, 1896 by L. Rehn, who demonstrated the patient at the 26th Congress of German Surgeons in Berlin (J.W. Blatford, R.W. Anderson, 1985). In 1897, the Russian surgeon A.G. The undercut was the first in the world to successfully close a gunshot wound of the heart. In 1902 L.L. Hill was the first in the United States to successfully suture a stab wound to the heart of a 13-year-old boy (on a kitchen table by the light of two kerosene lamps). However, with the accumulation of experience, the romantic coloring of this section of emergency surgery began to disappear, and already in 1926, K. Beck, in his classic monograph, which has not lost its significance to this day, wrote: “Successful suturing of a heart wound is not a special surgical feat” .

Classification.

Heart wounds are divided into non-gunshot (knife, etc.) and gunshot: penetrating into the cavity of the heart and non-penetrating. Penetrating, in turn, - on the blind and through. This is the localization of injuries in relation to the chambers of the heart: injuries to the left ventricle (45-50%), right ventricle (36-45%), left atrium (10-20%) and right atrium (6-12%). They, in turn - with damage and without damage to intracardiac structures.

Currently, heart injuries account for 5 to 7% of all penetrating chest injuries, including gunshot wounds - no more than 0.5-1%. With stab wounds of the heart and pericardium, isolated damage to the pericardium is 10-20%. By themselves, pericardial injuries do not pose a danger to the life of the victim, however, bleeding from transected pericardial vessels can lead to cardiac tamponade.

Cardiac tamponade is a condition in which blood penetrating into the pericardial cavity, as it were, “suffocates” the heart.

Acute cardiac tamponade occurs in 53-70% of all cardiac injuries. The degree of tamponade is determined by the size of the heart wound, the rate of bleeding from the heart into the cavity of the heart shirt, and the size of the pericardial wound. Small knife wounds of the pericardium quickly close with a clot of blood or adjacent fat, and cardiac tamponade quickly sets in. The accumulation of more than 100-150 ml of blood in the cavity of the heart shirt leads to compression of the heart, a decrease in myocardial contractility. The filling of the left ventricle and the stroke volume are rapidly falling, there is a deep systemic hypotension. Myocardial ischemia is exacerbated by compression of the coronary arteries. In the presence of 300-500 ml, in most cases, cardiac arrest occurs. It should be remembered that an extensive pericardial wound prevents the occurrence of tamponade, because. blood flows freely into the pleural cavity or out.

According to S.Tavares (1984), lethality in heart injuries is associated with the nature, size, localization of the heart wound, as well as concomitant injuries and the length of time from the moment of injury to the start of resuscitation and treatment. In recent years, there has been an increase in mortality, which is primarily due to the severity of heart damage.

The prognosis is also affected by rhythm disturbance. So, for example, with sinus rhythm, the survival rate is 77.8%. According to J. P. Binet (1985), only 1/3 of victims with a heart injury are admitted to the hospital, and the rest die at the scene or on the way to the hospital. Estimated causes of death at the prehospital stage, according to the observations of V.N. Wolf (1986), the following: 32.8% die from massive blood loss, 26.4% - a combination of massive blood loss and cardiac tamponade, 12.7% - isolated cardiac tamponade. In addition, factors such as the duration of acute cardiac tamponade, the degree of blood loss, and the presence of damage to the coronary arteries and intracardiac structures influence the level of mortality.

The highest mortality is observed in gunshot wounds.

Diagnostics.

According to the literature, in the diagnosis of heart injuries, the determining factor is the localization of the chest wound in the projection of the heart and the degree of blood loss. An important and reliable sign of a heart injury is the localization of an external wound in the projection of the heart, which, according to the observations of V.V. Chalenko et al., (1992) - met in 96%, M.V. Grineva, A.L. Bolshakova, (1986) - in 26.5% of cases.

Difficulties in diagnosis arise in the absence of typical clinical signs. According to D.P. Chukhrienko et al., (1989), cardiac tamponade occurs in 25.5% of cases of cardiac injuries. V.N. Wolf (1986) distinguishes two stages of cardiac tamponade: the first - blood pressure at the level of 100-80 mm Hg. Art., while the hemopericardium does not exceed 250 ml; the second, when blood pressure is less than 80 mm Hg. Art., which corresponds to a hemopericardium of more than 250 ml. J.Kh. Vasiliev (1989) believes that a sudden accumulation of 200 ml of fluid in the pericardial cavity causes a clinical picture of cardiac compression, an accumulation of about 500 ml leads to cardiac arrest.

The pneumopericardium may also be the cause of cardiac tamponade.

Beck's triad, according to A.K. Benyan et al. (1992), was observed in 73% of cases, according to D. Demetriades (1986) - in 65%, according to M.McFariane et al. (1990) - in 33%.

X-ray examinations in case of injury to the heart are carried out in 25% and 31.5%. On the basis of radiographs, one can judge the volume of blood in the pericardial cavity - the volume of blood from 30 ml to 85 ml is not detected; in the presence of 100 ml - there are signs of a weakening of the pulsation; with a blood volume of more than 150 ml, an increase in the boundaries of the heart with smoothing of the "arcs" is noted.

For the diagnosis of heart injury, additional research methods are used - ultrasound, pericardiocentesis [Chukhrienko D.P. et al., 1989; Demetriades D., 1984; Hehriein F.W., 1986; McFariane M. et al., 1990], pericardiotomy [Vasiliev Zh.Kh., 1989; Grewal H. et al., 1995].

It should be emphasized that when performing a puncture of the pericardium, false negative results were obtained in 33% [Chalenko V.V. et al., 1992] and in 80% of cases.

ECG is performed quite often: in 60%. At the same time, such signs of heart injury as large-focal lesions with changes in the T wave, a decrease in the RST interval were detected in 41.1%, rhythm disturbances - in 52%.

The diagnosis of heart injury before surgery was established in 75.3%.

According to the authors, progress in diagnostics is obvious, but mainly due to the "classical" clinical approach. This opinion is also shared by K.K. Nagy et al., (1995), they consider clinical signs of damage and active surgical intervention to be the most reliable diagnostic methods.

The following triad of symptoms should be considered as characteristic signs of heart injury:

1) localization of the wound in the projection of the heart;

2) signs of acute blood loss;

3) signs of acute cardiac tamponade.

When the wound is located within the following boundaries: above - the level of the second rib, below - the epigastric region, on the left - the anterior axillary line and on the right - the parasternal line, there is always a real risk of injury to the heart.

With the localization of the wound in the epigastric region and the direction of the blow from the bottom up, the wound channel, penetrating into the abdominal cavity, goes further through the tendon center of the diagram into the cavity of the heart shirt and reaches the top of the heart.

The classic clinical picture of cardiac tamponade was described by K. Beck (1926): deafness of heart sounds; low blood pressure with a small rapid pulse (and low pulse pressure); high venous pressure with swelling of the jugular veins.

If the patient's condition is stable, the diagnosis of heart injury can be confirmed by X-ray examination.

Currently, the most accurate and fastest method of non-invasive diagnostics is the method of echocardiography. At the same time, within 2-3 minutes, the divergence of the pericardial sheets (more than 4 mm), the presence of fluid and echo-negative formations (blood clots), akinesia zones in the area of the myocardial wound, and a decrease in myocardial contractility in the cavity of the heart shirt are clearly detected.

Recently, surgeons have sometimes begun to use such a minimally invasive method as thoracoscopy to diagnose a heart injury. It should be noted that indications for this method occur quite rarely, for example, in clinically unclear cases, when it is impossible to diagnose a heart injury with echocardiography, when, on the one hand, it is dangerous to continue monitoring and examination in dynamics, and on the other hand, it is dangerous to perform a classic thoracotomy (for example, in patients with decompensated diabetes mellitus).

When the heart or pericardium is injured, after opening the pleural cavity, it is clearly visible how blood shines through the walls of the tense pericardium. Further manipulations of the surgeon and his assistants, the entire team on duty, including the anesthesiologist, must be clearly coordinated. The surgeon puts two threads-holders on the pericardium, widely opens it parallel and in front of the phrenic nerve.

The assistant spreads the pericardial wound wide by the handles, and at the same time frees the pericardial cavity from liquid blood and clots, and the surgeon, guided by the pulsating blood stream, immediately plugs a small wound of the heart with the second finger of the left hand, or, if the size of the wound exceeds 1 cm, with the first finger, bringing the palm under the back wall of the heart.

In cases of more extensive wounds, a Foley catheter can be used to achieve temporary hemostasis. Inserting a catheter into the heart chamber and inflating the balloon with gentle tension temporarily stops bleeding. This task can also be accomplished by inserting a finger into the myocardial wound. The latter technique was successfully used by us in four observations. When suturing a heart wound, only non-absorbable suture material is used, preferably with an atraumatic needle. It should be remembered that thin threads are easily cut through when suturing a flabby wall, especially in the atrial region.

In these cases, it is better to use thicker threads and put under them patches cut in the form of strips from the pericardium. In cases of injury to the auricle of the heart, instead of suturing, it is better to simply bandage the ear at the base, after placing a fenestrated Luer clamp on it.

In order to avoid myocardial infarction when branches of the coronary arteries are dangerously close to the wound, vertical interrupted sutures should be applied with a bypass of the coronary artery.

Of no small importance for the postoperative course is a thorough sanitation and proper drainage of the cavity of the heart shirt. If this is not done, then postoperative pericarditis inevitably develops, leading to an increase in the duration of inpatient treatment, and, in some cases, to a decrease in the patient's ability to work.

Therefore, the cavity of the heart shirt is thoroughly washed with a warm isotonic solution, a section of about 2-2.5 cm in diameter is excised in the posterior wall of the pericardium, making the so-called “window” that opens into the free pleural cavity, and rare interrupted sutures are placed on the anterior wall of the pericardium for prevention of dislocation of the heart and "infringement" of it in a wide wound of the pericardium.

In cases of abdomino-thoracic injuries with damage to the heart from the bottom up, it is more convenient to suture the wound of the heart through a transdiaphragmatic-pericardial approach, without performing a lateral thoracotomy.

Noteworthy is the proposed Trinkle J.K. (1979) Subxiphoidal fenestration of the pericardium. It consists in dissection of soft tissues in the region of the xiphoid process, resection of the latter, reaching the pericardium, applying holders to it, opening and evacuating blood clots in an open way. This operation can be performed under local anesthesia and is life-saving in cases where time is needed and thoracotomy is not possible.

We studied the results of subxiphoid partial pericardectomy in 10 patients with heart injury. The operation ended with the installation of a silicone drainage tube with a diameter of 5 mm into the cavity of the heart shirt. To improve the outflow from the pericardial cavity, the distal end of the drain was attached to the aspiration system.

So, depending on the conditions for providing assistance, there may be various solutions to tactical problems in case of heart injuries.

REPORT TO THE MILITARY SCIENTIFIC SOCIETY MEETING: HEART WOUNDS

GENERAL PART - "HEART WOUNDS"

The problem of heart injuries has a long history. For the first time, Hellarius (1458-1502) expressed the idea of saving life when the heart was injured. It was practically the only voice that was lost among the ideas that existed since the time of Hippocrates, Galen, Aristotle, Avicenna about the unconditional death after an open heart injury. However, already at the end of the 15th - beginning of the 16th century, the first reports appeared about the possibility of more or less long-term survival after injury to this organ. Ambroise Pare (1509-1590) first described a case of a penetrating wound of the heart, when a man wounded in a duel with a sword, before falling dead, was able to pursue his opponent for a distance of 200 meters. In 1641, N. Muller published a message regarding a wound in the heart, when the victim lived for 16 days. In 1642 wolf describes a heart wound healed by independent scarring. In subsequent years, not only descriptions of individual cases of heart injury are published, but judgments are made regarding the causes of death and possible methods of treating the victims. Thus, in 1762 Morgagni points to the accumulation of blood in the pericardium during injuries of the heart, considering this the main cause of death in such damage. The number of observations of the wounded in the heart with a long survival gradually accumulates, and in the 18th century Dupuytren offers his own treatment regimen, which consists in complete rest, application of cold to the heart area and bloodletting. N.I. Pirogov in 1865, describing injuries to the chest, considered wounds in the heart as a curiosity and recommended in these cases cold on the chest and rest. Believing that wounds of the heart and blood vessels can be healed by fainting, N.I. Pirogov suggested profuse bloodletting. Thus, rest, cold and bloodletting were at that time the only means used for wounds of the heart. Nevertheless, even then more rational proposals were made. In the first half of the 19th century, a significant number of observations accumulated, and in 1868 Fischer published a collection of statistics covering 401 cases of heart injuries, which indicated examples of recovery as a result of conservative measures (10-12%). Summarizing the experience Fischer proposed the use of treatment aimed at stopping life-threatening bleeding, creating favorable conditions for the formation of a clot in the wound of the heart, and combating inflammation of the heart and pericardium. In addition to applying cold to the region of the heart and bloodletting, as a last resort, he proposed the artificial removal of blood from the pericardium by inserting a catheter into the wound or by puncturing the heart shirt. It was at this time that the prerequisites were laid that prompted surgeons to suture the wound of the heart in the future, but nevertheless, radical measures are recommended only in exceptional cases. The famous German surgeon T. Billroth stated in 1883 that a surgeon who tried to sew up a heart wound would lose all respect from his colleagues. Paracentesis with fluid accumulation in the pericardial cavity, he considered "surgical frivolity." Despite such a harsh assessment of one of the most prominent surgeons of that time, pericardial puncture finds an active supporter in the face of Rose (1884), who first introduced the term "cardiac tamponade". Operations to release the heart from compression Rose puts on a beneficial effect on a par with tracheostomy. In 1881 an American surgeon Roberts said that opening the pericardium and suturing the heart muscle would be considered as a radical method of treating wounds of the heart, and the time for this had already come. The first attempt at cardiac suture in humans was made almost simultaneously in 1896. Farina in Italy and Kappelen in Norway. Patients died as a result of postoperative complications, but the very fact of a bold operation was a turning point in the treatment of heart wounds. Somewhat later, in the same 1896, Ludwig Rehn performed the first successful cardiography in case of injury to the right ventricle, demonstrating at the 26th Congress of German Surgeons in Berlin the first recovered patient after suturing the wound of the heart. In 1897 Perrozzani performed a similar operation for wounding the left ventricle. Gunshot wounds of the heart soon became the object of active surgery. The first operation for a blind gunshot wound of the heart was performed by Russian surgeon A.G. Undercut in 1897. An original and daring operation performed on a 16-year-old girl is of exceptional interest. A.G. The incision suggested, in the event that a bullet was found in the muscle of the heart, to preliminarily apply two sutures to its wall, tightening which after removing the bullet would ensure a quick stop of bleeding. The original idea of A.G. The undercut on the imposition of provisional sutures has retained its significance to the present day. Many surgeons in Russia and other countries who have operated on the heart for foreign bodies have successfully used this technique. The first successful cardiography for a gunshot wound was performed Lannay in 1902. Operations performed for wounds of the heart served as an impetus for the study of the pathological anatomy and pathophysiology of the damaged heart. A lot of valuable information was contributed by Russian surgeons N.I. Napalkov - works on various methods of surgical access to the heart (1900), V.A. Oppel (1901), I.I. Grekov (1904). In 1927, the monograph “Wounds of the Heart and Their Surgical Treatment” by Yu.Yu. Dzhanelidze was published, covering a very large material - 535 observations available in domestic and foreign literature over 25 years. The richest experience in the treatment of chest wounds was acquired by Soviet surgeons during the Great Patriotic War. To a large extent, this was facilitated by the creation of specialized hospitals for those wounded in the chest. Of great interest are data on the experience of modern local wars. For example, during the South Vietnam War, penetrating chest wounds were noted in 9% of the wounded. Of these, 18% underwent urgent thoracotomy, including for heart injuries.

S T A T I S T I C A

Statistical data on the number and outcomes of treatment of open heart injuries are far from always homogeneous, as they reflect the experience of different periods of time, different medical institutions, and largely depend on the equipment and scientific and practical orientation of clinics, as well as on the contingent of patients.

During the Second World War, the rarity of clinical observations of heart injuries is due to the fact that patients usually remain on the battlefield. So, according to Vasiliev, among the dead on the battlefield, 5.2% of autopsies found damage to the heart. Sauerbruch believed that this percentage was higher - from 7 to 10, and V.L. Bialik reports 9.8%.

Yu.Yu.Dzhanelidze collected and published general information about heart injuries in various countries: by 1927 there were 535 of them in 25 years (57 of them during the First World War), by 1941 the number of such observations had increased to 1000. 1000 cases of heart injuries, the structure of injuries of its various departments has the following picture - see table 1.

TABLE #1

CSTRUCTURE OF HEART WOUNDS BY DEPARTMENTS

In our time, the proportion of damage to the heart and pericardium among patients admitted to the hospital with penetrating wounds of the chest ranges from 5.1% (Kabanov A.N. et al., 1982) to 13.4% (Gilevich Yu.S. and others, 1973)

Over a ten-year period of emergency surgical care

In the city of Krasnoyarsk, out of 1140 victims with penetrating chest wounds who were admitted to hospitals, there were 106 cases of damage to the pericardium and heart, which amounted to 9.3%.

Thus, we see that heart injuries in peacetime occur in 7-11% of victims with penetrating chest wounds.

To the emergency surgical department of the emergency hospital in Engels for 6 years (1992-

1998) admitted 21 patients with a heart injury: 19 men (90.4%) and 2 women (9.6%) aged 15 to 57 years. (See table 2.)

TABLE #2

>
STRUCTURE OF HEART WOUNDS BY GENDER

All injuries were caused by a knife during a deliberate attack, or quarrels, most often while intoxicated (62%). This is the so-called "criminal injury". Victims, as a rule, were delivered to the hospital in the first 6 hours from the moment of injury. In 45% of patients, heart injury was accompanied by hemothorax, in 38% by pneumothorax, 38% of the victims were admitted with cardiac tamponade, 47.6% (i.e. almost every second victim) were admitted in a state of shock. (See table 3.)

TABLE #3

COMPLICATIONS IN ENTRY WITH A HEART WOUND

All victims with a heart injury needed immediate resuscitation and operational assistance. It is known that the outcome mainly depends on the time from the moment of injury to the operation and the coherence of the medical staff. Of the 100% of the victims, 86% were operated on within the first hour from the moment of admission, after the first hour 14% of the patients were operated on. The structure of injury to various parts of the heart in these patients is as follows. ( c see table 4.)

TABLE #4

STRUCTURE OF WOUNDS OF THE HEART DEPARTMENTS

In some cases, heart injury was combined with damage to the abdominal organs. The frequency of thoracoabdominal injuries among penetrating chest wounds in peacetime is quite high and amounts to 13.5%. According to our data, wounds of the heart with damage to the organs of the abdominal cavity and diaphragm were observed in 8 patients (38%) and in 1 patient without damage to internal organs. The most common injury was the liver (62.5%) and the transverse colon (50%). The small intestine and gastrocolic ligament were damaged in 12.5%. ( c see table 5.)

TABLE #5

FREQUENCY OF DAMAGE TO INTERNAL ORGANS IN THORACOABDOMINAL WOUNDS

C L A S I F I C A T I O

R A N E N I A S E R D C A

THROUGH-THROUGH

NON-PENETrating MULTIPLE PENETRATING

WITH HEMOPERICARDUS

WITH HEMOTHORAX

WITH HEMOPNEUMOTHORAX

WITH DAMAGE TO THE CORONARY VESSELS

WITH DAMAGE TO THE SEPTEMBER OF THE HEART

WITH DAMAGE TO THE CONDUCTING SYSTEM

WITH DAMAGE TO THE VALVE DEVICE

K L I N I C A

Wounded in the heart usually note pain and other subjective sensations in the chest and heart area, are in a state of anxiety, experience a feeling of fear, anxiety. Victims with symptoms of severe shock may not complain, and with a combined injury, they often pay attention to other injuries. On the other hand, patients with severe cardiac tamponade, as a rule, note a feeling of lack of air, and with damage to the coronary arteries and multiple injuries, significant pain in the heart.

Of the objective symptoms, attention is drawn to a sharp pallor of the skin, a frequent thready pulse, arrhythmia, expansion of the boundaries, deafness of heart sounds, a decrease in arterial and an increase in venous pressure above 15 cm of water. Art., which is very significant for tamponade, especially in patients with trauma and blood loss, in which, in other situations, venous pressure should be low. With a large hemopericardium, the so-called paradoxical pulse occurs - the weakening or disappearance of the pulse wave at the moment of inspiration. Thus, clinically acute cardiac tamponade is manifested by the so-called Beck's triad, which includes a sharp decrease in blood pressure, a rapid and significant increase in central venous pressure, and the absence of a heart pulsation on chest x-ray. According to the literature, a complete triad of signs occurs in 53% of cases.

COMPLICATIONS

1. Pneumothorax - occurs when the chest wall is damaged, through which air can relatively freely enter the pleural cavity. An open pneumothorax with a large opening in the chest can be fatal in a short time. Of particular danger is the so-called valvular pneumothorax, when a wound in the lung, bronchus or chest wall forms a valve that allows air to enter the pleural cavity, but prevents it from escaping. Spreading through the fiber, the air compresses the heart, large vessels, even the trachea, which leads to very severe cardiorespiratory disorders.

2. Hemothorax - the presence of blood in the pleural cavity. As blood enters the pleural cavity, the lung is compressed until it is completely or almost completely turned off from the act of breathing.

3. Hemopericardium - the presence of blood in the pericardial cavity, as the amount of which increases, cardiac tamponade occurs. According to G.V. Lobachev, already with the accumulation of 200 ml of blood in the pericardium, symptoms of cardiac tamponade are expressed, and at 500 ml death occurs. But there is data for the years of the Second World War on the operated wounded with an accumulation of up to 1.5 and even 3 liters of fluid in the pericardium

4. Cardiac tamponade is a very formidable complication that occurs as a result of filling the pericardial cavity with blood and blockade of atrial filling, a sharp reduction in venous return due to atrial compression.

DIAGNOSTICS

At visual the study of the possibility of injury to the heart makes one think about the presence of a wound in the chest and its localization in the area of the projection of the heart or in the precordial zone. The zone dangerous in terms of possible damage to the heart with penetrating wounds of the chest was determined by Grekov I.I. (1934) and limited to:

Above - the second rib;

Bottom - left hypochondrium and epigastric region;

On the left - the middle axillary line;

Right - parasternal line.

Despite the fact that most wounds are located on the anterior surface of the chest wall in the projection of the heart, there are often cases of atypical location of inlets, which can lead to diagnostic and tactical errors. Here is a rare diagnostic case.

Patient V., 17 years old, was delivered to the clinic in a critical condition, unconscious, with signs of pronounced anemia. There is moderate bleeding from the rectum. When examined with the help of mirrors, a wound of the rectum was found, penetrating into the abdominal cavity. An emergency laparotomy was performed under general anesthesia. There are two liters of blood with clots in the abdominal cavity, multiple wounds to the large and small intestines, stomach, a wound in the diaphragm, from which a blood clot hangs. The wound of the diaphragm was enlarged, a wound of the pericardium and the left ventricle of the heart was found. Despite the jet blood transfusion, cardiac arrest occurred. Resuscitation measures were not effective. Subsequently, it was found out that a metal rod was introduced into the victim's rectum with a hooligan purpose.

At X-ray a study for which the rapidly deteriorating condition of the patient with cardiac tamponade often does not leave time, but which, with an unclear diagnosis and the slightest opportunity, should be resorted to, an increase in heart volume, smoothing of the cardiac waist, a triangular or spherical shape of the heart shadow are noted. Sometimes you can see the level of fluid and air in the cavity of the heart shirt or pleura - hemopericardium or hemopneumopericardium. With a blind shrapnel or blind bullet wound, an x-ray examination determines the localization of a foreign body. However, not all cases show the classic (above) signs of cardiac tamponade. Apparently, this is due to the presence of hemopneumothorax, which distorts the x-ray picture of tamponade.

At electrocardiographic a study that has little diagnostic value, but gives an idea of the functional changes in the heart dynamics during surgery and in the postoperative period, when analyzing electrocardiograms, it was found that an indirect sign of hemopericardium may be a decrease in the voltage of ECG waves. Infarction-like changes in the ECG occur with injuries of the ventricles, while there is a monophasic nature of the ST-T complex followed by a decrease in the interval ST to the isoline and the appearance of a negative T wave. In case of violation of intraventricular conduction, serration and expansion of the complex are noted QRS.

A valuable diagnostic technique should be recognized as a puncture of the pericardium, which makes it possible to detect blood in its cavity.

TREATMENT

Operations for wounds of the heart.

In case of gunshot wounds of the heart, especially with ongoing bleeding, urgent suturing of the wound (cardiorrhaphy) is always indicated. It should be remembered that before introducing into anesthesia a patient with signs of hemopericardium or cardiac tamponade, a preliminary puncture of the pericardium is required, which has diagnostic and therapeutic value. Pericardial decompression is needed because intrathoracic pressure changes during induction of anesthesia and tracheal intubation, the effect of tamponade increases, which often causes cardiac arrest at this very moment. Removal of even a very small (20-30 ml) amount of blood from the pericardial cavity improves hemodynamic parameters and prevents asystole.

C There are several ways to perform a pericardial puncture:

1. Morfan method

2. Lorrey method

3. Pirogov-Delorme method

4. Kurshman method

1. Under local anesthesia with a 0.25% solution of novocaine in the position of the patient half-sitting, a puncture is made under the xiphoid process strictly along the midline of the body, then the needle is advanced from below obliquely upward to a depth of about 4 cm and somewhat posteriorly and penetrate into the pericardial cavity. After the needle enters the pericardial cavity, blood is aspirated.

2. The patient is in a semi-sitting position. The needle is injected into the angle between the attachment of the left 7th costal cartilage and the base of the xiphoid process to a depth of 1.5-2 cm; then it is directed upward parallel to the chest wall and, advancing another 2-3 cm, enter the pericardial cavity.

3. The puncture is carried out at the very edge of the sternum, on the left, at the level of the fourth or fifth intercostal space (according to A.R. Voynich-Syanozhentsky - in the sixth intercostal space), directing the needle behind the sternum somewhat inward to a depth of 1.5-2 cm into the anterior wall of the pericardium.

4. The puncture is carried out in the left fifth intercostal space, retreating 4-6 cm from the edge of the sternum. The needle is advanced obliquely inward, almost parallel to the chest wall.

It should be noted that the last two methods are hardly acceptable, since blood accumulates in the lower parts of the heart sac. It is also important to note that the absence of blood in the syringe does not always rule out hemopericardium, since it is not uncommon for a blood clot to form in the heart sac.

Treatment of wounds of the heart can only be operative. If a wound of the heart and pericardium is suspected, the indications for surgical treatment become absolute. The correctness of this concept has been confirmed in practice by thousands of similar operations performed in the world over the 80-year period. At the same time, the experience of numerous medical institutions has shown that suturing a heart wound, performed on an emergency basis, saves the life of most patients and reduces mortality. In addition, delaying the operation in such cases is a violation of the general surgical rules for helping with bleeding. Many different approaches have been proposed to expose the heart. Patchwork methods, as well as median dissection of the sternum, are too traumatic and complicated; currently they are used only for special indications. Lost its value and transdiaphragmatic access with combined wounds of the chest and abdominal cavity, allowing you to take in the wound of the apex of the heart. At one time, the variant of the left-sided thoracotomy according to Wilms-Spangar-Le Fort was quite widely used. This method involves an incision along the fourth intercostal space from the left edge of the sternum to the axillary line and perpendicular to it the second - along the left edge of the sternum, crossing the cartilages of the 4th and 5th, and sometimes the 3rd rib. At the Institute. N.V. Sklifosovsky somewhat changed this method (S.V. Lobachev, 1958), giving the access a crescent shape in order to prevent tissue necrosis at the intersection of the incisions. In recent years, most surgeons during operations for heart injuries prefer the standard left-sided anterolateral thoracotomy along the fourth or fifth intercostal space with an incision from the edge of the sternum (1.5-2 cm back) to the mid-axillary line. This is the most convenient and rational approach that provides manipulations on the heart and does not require the intersection of costal cartilages. It is usually performed within an extremely short time and provides a good approach to almost all parts of the heart, with the exception of the right atrium and the orifices of the vena cava. If necessary, the surgical wound can be significantly expanded by crossing one or two costal cartilages or transversely crossing the sternum. After inserting the expander into the wound, in order to prevent rib fracture, it is recommended to additionally dissect the intercostal muscles along the incision to the posterior axillary line. This technique makes it possible to widen the wound of the chest, freely navigate and carry out the necessary measures. Having opened the pleural cavity, a significant amount of blood is usually found in it. If the pericardium is distended with accumulated blood, tense, it is immediately possible to detect a wound. The integrity of the pericardium is sometimes only apparent and, therefore, does not exclude damage to the heart. If the wound of the heart is not penetrating, hemorrhage into the pericardial cavity is rarely large. With such injuries, a clot may hang from the pericardial wound, through which blood flows in frequent drops into the pleural cavity. Less often, with small defects, pulsating bleeding is observed. With wide and low-lying wounds of the pericardium, blood does not form large accumulations in it, since it flows quite freely into the pleural cavity. This fact prevents the occurrence of cardiac tamponade. Usually, the wounds of the pericardium are small, and to examine the heart, the pericardium has to be opened with a longitudinal incision along the entire length (up to 8-10 cm), leading it at a distance of 1 cm anterior or posterior to the phrenic nerve. At the moment of opening the pericardium, liquid blood and clots are ejected from its cavity under pressure. Without wasting time on their removal, you need to start examining the heart. To do this, you must quickly enter the left hand into the pericardial cavity so that the heart with its back surface, as it were, lies on the palm, and the thumb holds it in front. If the wound is located on the anterior or lateral surface of the heart (most often in the region of the left ventricle) and blood erupts from it as a fountain, then the wound is covered with the same finger before suturing. When the damage is small, bleeding may be absent due to blockage of the wound opening by a thrombus. This means that under any conditions the most careful examination of the naked heart is necessary. We must not forget about penetrating wounds, in which most often there are tragic mistakes. Be sure to remember the possibility of multiple injuries of the heart in the presence of one wound in the pericardium, which can occur when a wounding foreign body is found in the cavity or in the wall of the pericardium. For revision of the posterior surface of the heart, it is advisable to use the method according to F.L. Lezhar - the heart must be carefully and for a short time lifted and removed from the pericardial cavity. The heart does not tolerate changes in position, especially rotations along the axis, which can cause fibrillation and reflex stop due to kinking of the vessels. Dangerous and too vigorous sipping down, leading to a decrease in the lumen of the pulmonary veins and the desolation of the cavities of the heart, which also threatens to stop it. Before this manipulation, the heart and pericardium should be irrigated with a 0.5% solution of novocaine (10-15 ml). The pericardium, epicardium, and pleura are very sensitive to desiccation. Therefore, they are periodically moistened, carefully limiting the site of intervention with gauze napkins soaked in warm saline. If during the revision myocardial damage is found that does not penetrate into the cavity of the heart, then even in cases where the wound seems to be completely superficial and does not bleed at the time of exposure of the heart, it should be sutured in order to prevent secondary bleeding and aneurysm. Performing cardiography on a beating heart is often associated with significant technical difficulties, especially with massive bleeding. In such cases, the most widely used technique is to simultaneously fix the heart and stop the bleeding. To do this, four fingers of the left hand are placed on the back wall of the heart, fixed and slightly raised, at the same time, the thumb is pressed against the wound, stopping the bleeding. The wound of the heart is first stitched in the middle with one wide suture, by crossing the threads of which it is possible to achieve a significant reduction or stop of bleeding (do not pull hard on the ligatures, since when cutting through the wound takes on a cruciform appearance, the bleeding intensifies). After that, nodal, U-shaped or mattress permanent sutures are applied to the wound with the right hand, they are tied very carefully (so as not to cut through the muscle) immediately after removing the finger from the wound. Then the holder is removed. When suturing large lacerated wounds of the heart, it is advisable to apply a wide circular purse-string or U-shaped suture. When suturing thin-walled atria, preference should be given to a purse-string suture, which has good sealing properties. In this case, the wound of the atrium is preliminarily captured in the fold with a soft fenestrated or triangular clamp. When the ear of the heart is injured, a circular ligature is applied to its base. In the case of suture eruption, despite their careful and gradual contraction, until the wound edges approach each other, Teflon pads with U-shaped sutures are used as a reinforcing material. C fibrin film, autotissues (muscle, pericardium) are fixed to the wound as a hemostatic target, cyacrine glue is used. When suturing the wall of the heart near intact large branches of the coronary arteries, they should not be sutured, as this can lead to myocardial infarction and even cardiac arrest. In these cases, it is best to apply mattress sutures under the coronary artery. It is desirable to tighten the seams at the time of systole. To reduce tissue damage, it is best to suture the wound of the heart with round atraumatic, thin or medium thickness needles. Injection and excision is made at a distance of 0.5-0.8 cm from the edges of the wound. The needle is passed through all layers. However, it is desirable not to pass the thread through the heart cavity for a long distance, since the piece of thread facing into the heart cavity is quickly covered with a layer of fibrin. A rough seam leads to a significant disruption of the blood supply to the myocardium. Superficially applied sutures can cause an aneurysm, in addition, blood clots can form in the gap remaining from the side of the endocardium, which is fraught with the risk of thromboembolism. As a suture material, silk, lavsan, kapron are more acceptable, because the time of resorption of catgut, as experience has shown, is insufficient to ensure reliable fusion of the heart wall. After suturing the wound of the heart, the pericardial cavity is carefully freed from blood and clots with soft swabs and must be washed with warm saline. The pericardium is sutured with rare interrupted sutures with nylon or silk No. 3-4 to create sufficient outflow with the possible formation of inflammatory exudate. If the pericardium was opened anterior to the phrenic nerve, it is advisable to form a counter-opening on its posterior surface. The operation is completed with a revision of the pleural cavity and suturing the chest wound tightly in layers, leaving drainage in the pleural sinus and for aspiration of air in the second or third intercostal space along the midclavicular line. The drains are connected to an active aspiration system.

CONCLUSION

Thus, the search for new and improvement of existing methods for diagnosing and treating heart injuries is not only a purely medical problem, but also an important economic and social task, since we are talking about the lives of people of the most able-bodied age.

L I T E R A T U R A:

1. “Penetrating chest wounds” E. A. Wagner, Moscow “Medicine” 1975, pp. 44-46; 71-74.

2. “Military field surgery” Vishnevsky A.A. Shraiber M.I., Moscow “Medicine” ed. 3rd 1975 pp. 242-246.

3. “Emergency surgery of the heart and blood vessels”, ed. DE BEKI M.E. (USA), Petrovsky B.V., Moscow “Medicine” 1980, p. 75-87.

4. “Military field surgery”, ed. Lisitsyna K.M. Shaposhnikova Yu.G., Moscow “Medicine”, 1982, p.265-267.

5. “Emergency surgery of the chest and abdomen” (mistakes in diagnosis and tactics). Kutushev F.Kh. Gvozdev M.P. Filin V.I. Libov A.S., Leningrad “Medicine” 1984, pp. 78-81; 87-90.

6. “Wounds of the heart” Nifantiev O.E. Ukolov V. G. Grushevsky V. E., Krasnoyarsk ed. Krasnoyarsk University 1984

7. “Surgical treatment of gunshot injuries of the chest” Kolesov A.P., Bisenkov L.N., Leningrad “Medicine” 1986, p.90-92.

8. “Wounds of the heart” Bulynin V.I. Kosonogov L.F. Wolf V.N., Voronezh ed. Voronezh University 1989

9. “Experience in the diagnosis and treatment of heart injuries” Mereskin N.A. C Vetlakov V.I., Military Medical Journal No. 8, 1991, Moscow“Red Star” c.27-29.

10. “Operative surgery and topographic anatomy” ed. Kovanova V.V., ed. 3rd, Moscow “Medicine”, 1995, p.128-131;302-311.

11. “Selected lectures on military surgery” (military field and military urban surgery) Petrovsky B.V., Moscow “Medicine” 1998, p.80-84.

12. “Operative surgery and topographic anatomy” Ostroverkhov G.E., Bomash Yu.M. Lubotsky D.N., Rostov-on-Don "Phoenix" Kursk KSMU 1998 pp. 423-433; 462-467.

HEART

The heart is a hollow muscular organ. Cardiac muscle combines the properties of both striated and smooth muscles and stands out as a separate type of muscle. The heart muscle is called the myocardium. In the chest, the heart is located somewhat to the left and is surrounded by a pericardial sac, which is called the pericardium. It is said that the size of the heart corresponds to the size of the fist of each person. The average weight of the heart is 500 g. However, individual fluctuations can be very significant. It largely depends on the lifestyle of the person. With a sedentary lifestyle, the heart decreases. the muscle becomes flabby. During physical training, the heart muscle is strengthened and the mass of the heart increases. The average heart weight is 500 g, in an adult, the heart weight is 0.5% of body weight, and in a newborn, 0.9%. The size of the heart along the vertical axis is 13-15 cm, along the horizontal axis - 8-11 cm. The normal volume of the heart in a healthy person is 600-750 ml. The volume of an athlete's heart can reach 800-1600 ml. The volume of the heart of the famous cyclist Edi Merzha is 1660 ml.

In men, the mass of the heart after 30 years increases annually by 1 g, in women by 1.4 g. The heart reaches its peak of productivity by the age of 58.

After age 90, heart mass begins to decline ("Road to Longevity"). It is known that it is never too late to start strengthening the heart muscle. You can start doing this at any age.

Experiments were carried out on pregnant rabbits: one group lived in familiar conditions, in another group the rabbits were restricted in movement, and the third was forced to constantly move. As a result, in newborn rabbits in the second group, the heart size was less than the control, and in the third group it was significantly larger than in the control. Consequently, the physical activity of pregnant women has a positive effect on the heart of the fetus.

The human heart has four chambers: left and right atria and left and right ventricles. The left atrium receives oxygenated blood from the lungs and passes into the left ventricle. From there, it enters the aorta, which branches into arteries, arterioles, and arterial capillaries. The other end of the capillary is called the venous end. The venous capillaries merge into venules, veins, and finally the inferior and superior vena cava. Venous blood flows into the right atrium. From there to the right ventricle. From the right ventricle, blood enters the lungs. The movement of blood occurs due to the contraction of the heart muscle. The contraction of the heart muscle on the walls of the arteries is reflected as an arterial wave or pulse.

In an adult, the number of such contractions is 70 per minute, in a child - 140.

For 5 contractions, the heart pumps 1 liter of blood, 7-9 thousand liters per day. Hard work increases the volume of blood circulation by 2500 liters per hour. There is evidence that in the aorta the speed of the blood push is 4 km / h, in the capillaries it moves in millimeter steps. For 60 years of a normal, not very stressful and agitated life, the human heart makes more than 2 billion contractions and performs the same work that a tractor would do if it lifted a huge boulder weighing 65 tons from sea level to a height of 5500 m (almost the height of Elbrus). During this time, the heart pumps 224 million liters of blood, which is equivalent to the flow of a river like the Seine in 10 minutes.

Impulses that cause contraction of the heart muscle come from the so-called pacemakers, capable of working in the autogeneration system, located in the atrial muscle and passing through the muscle fibers of the entire heart. The activity of these centers does not depend on our will. Soviet intelligence officer Richard Sorge was captured and hanged by the Japanese in 1944. His heart worked automatically after the execution, without support from the brain for almost 29 more minutes.

Even 400 years ago, people thought that blood was "boiled" in the heart and thus warmed the entire body.

In 1551, the "holy" church fathers ordered the 42-year-old Miguel Servet to be burned at the stake for his various ideas, including the one that blood circulates in the lungs.

In Norway, 8-year-old boy Jonas Bjorns with a congenital heart defect, doctors transplanted a donor heart into the right side of his chest. The doctors left the patient's own heart in the same place, it contracts, and causes the donor heart to contract. Now there is a person in the world with two simultaneously functioning hearts.

Knowledge about the human body was accumulated not only in European but also in other countries. However, when studying the history of science, we usually refer mainly to the discoveries of European scientists, and, in a later period, to American scientists. But already in 7 AD. the Chinese described the systemic and pulmonary circulation. In the West, this discovery is attributed to the Englishman Harvey, which he made much later, having previously been in China.

It was found that the state of the circulatory system is subject to seasonal and daily fluctuations. The lumen of capillaries is smaller in the morning than in the evening.

In the period between September and January, spasms of capillaries are observed. It is believed that it is this phenomenon that underlies the seasonal manifestation of diseases, in particular hypertension.

Much attention is paid to cardiovascular diseases and their prevention in society. Very often, new recommendations appear that refute previously established ideas. So, it was believed that alcohol is the number one enemy for the cardiovascular system. But recently, more and more often they began to talk about the benefits of small amounts of grape wine and cognac for the heart. For example, a report was published in the journal Medical News that an inverse relationship was found between wine consumption and coronary heart disease.

In 1959, Stefan Fagar from Prague showed in an experiment that a person, by an effort of will, can cause another person's blood pressure to rise.

Douglas Dean of the Newark College of Engineering found that long-term persistent thoughts about a friend lead to the fact that the latter's blood pressure rises no matter where he is ("Romeo's mistake").

American psychologist Michael Argyle believes that cynics are more likely to suffer from cardiovascular disease. Potential "cores" are distinguished by the desire for success at any cost, competitiveness, a tough, aggressive course of action, a desire to do everything at an accelerated pace, and high efficiency.

These individuals, according to Michael Argyle, are twice as likely to be at risk of heart attacks ("Diena" Riga).

Norman Kanzis, in The Healing Heart, wrote how he survived after a heart attack: faith, hope, love, determination to survive, good spirits, a sense of humor, the need to believe, the ability to fool around - all these qualities are valuable for health. They excite positive emotions, help to survive and maintain health.

Man is a social being. But communication is not in chatter, but in actions. A person leading a secluded lifestyle quickly worsens his condition, both mentally and physically. People who are less sociable are more likely to develop diseases of the cardiovascular system.

As already mentioned, constant stress is very dangerous for people. Scientists have found that up to 80% of people in developed countries are in a state of chronic stress (depression). With depression, the level of endorphins in the blood turned out to be incredibly low. Economists in the US have found that massive stresses undermine the US economy and cost firms $150 billion a year. The same applies to Japan. According to the WHO, by the end of the 80s, Japan came out on top in the world in per capita drug purchases, which is $116 per year, and in the United States, people spend $110 per year on drugs per inhabitant, regardless of age.

This information should be a desktop for the editors of most Ukrainian publications: they should think what is more important than easy success from publishing hot facts, or the health of the nation.

Help relieve stress: pets, cats, dogs, parrots, fish; art therapy: drawing, sculpture, collecting, calligraphy. It has been established that when writing out hieroglyphs, the pulse rate decreases.

The doctor and artist Nikolai Tokmanov offered 250 watercolor miniatures. With different colors. Laid out in front of the patient in a certain order, they help relieve fatigue.

To eliminate the cause of stress, P.V. Simonov suggests "unswaddling a head of cabbage", reaching the root cause, looking for a chain of events that led to stress, and as soon as the root cause is found, it will become clear what needs to be eliminated.

Physical activity, in particular running, can transform a person, relieve stress. Under stress, endorphins are released into the blood, and this gives a sharp improvement in both the mental and physical condition of a person.

Acupuncture can also be used to combat stress. A good specialist knows the "magic points" on the human body. It is often possible to observe how, after the introduction of needles at certain points, the patient falls asleep almost instantly. It has been shown that acupuncture leads to the release of endorphins into the blood. Therefore, it can be an effective tool in the prevention of stress and cardiovascular diseases.

Many problems can be solved by avoiding petty conflicts. Get out without loss - do not get involved. Develop a sense of humor. You should not rush, and without finishing one, take on another. You have to learn to say "NO".

Compared to people who are balanced, people who react violently to a stressful stimulus have 4 times more heart attacks. Valerian root tincture helps to calm the nervous system. It contains substances that slow down the transmission of nerve impulses to the central nervous system, which allows you to calm down.

To prevent situations leading to a heart attack, you need to use psychological tests and use these tests to determine what needs to be done at the moment. Do auto-training. Very effective in the prevention of cardiovascular disease for all sleepy effects on the subconscious: suggestion at the time of going to sleep or waking up.

You can influence emotional states with the help of facial expressions, as well as cause certain psychophysiological states in yourself by imagining them.

You can regulate your own state with the help of color, Yu.A. Andreev. You need to imagine a lettuce leaf translucent in the sun. Its color, veins, etc. Then imagine a red tulip petal with all the details, veins, shades.

Compare what was easier for you to imagine. If the salad, then you are tired, if the tulip, then you are dominated by excitement. But in any case, it is necessary to imagine what is difficult for you to imagine now. If it was easier for you to imagine a salad, then you need to cheer up the nervous system.

And for some time you have been trying very carefully to imagine a tulip flower with a red to black transition at the bottom of the petal, stamen, etc.

It turned out that the heart and blood vessels are very sensitive to music, and different music can cause different effects.

Just like the heart, the stomach cannot stand loud, hard music. It is shown that pop musicians often suffer from cardiovascular diseases and stomach ulcers. One US newsletter cited data that sounded wheat contained 20 times more vitamin A, 5 times more vitamin C and B6 compared to control. The total yield of alfalfa green mass is increasing. The leaves of plants respond well not only to music, but also to the chirping of birds. Music and birdsong can be used to treat cardiovascular disease. However, the forest is a forest of strife. It has been established that many cores perceive the neighborhood of pine forests poorly. This is apparently due to the presence of a large amount of ozone in the air of the pine forest.

According to the research of the chief cardiologist of the Volgograd region Yuri Lopatin, 5 people live in the region with a heart located on the right side. It does not affect their health. Lopatin believes that 1 in 10,000 people are born with this arrangement of the heart.

One of the most important indicators of the state of the cardiovascular system is the value of blood pressure. However, it should be noted that this is a dynamic indicator that is constantly changing. Even when a person talks, their blood pressure goes up, and when they listen, it goes down (Sciens News).

The tone of blood vessels and the work of the heart determine the amount of blood pressure. The amount of blood pressure in the body is monitored by the neuro-endocrine system. It has recently been found that not only the endocrine glands, but also the heart itself, in which the hormone that regulates blood pressure is produced, takes part in the production of regulatory hormones (DPA Agency, Hamburg). The receptors for this hormone are concentrated in the filtering apparatus of the kidneys - the glomeruli. The main function of the hormone is to enhance the filtering ability of the kidneys, i.e. increase the excretion of water from the body, and with it sodium ions. The hormone is released into the blood when the pressure in the atria rises. After the onset of its action, urine output increases and blood pressure decreases ("J. of Biological Chemistry").

An increase in blood pressure (hypertension) sharply worsens the supply of tissues with oxygen, a person's health deteriorates, and performance deteriorates. But the worst thing is that everything can end in a stroke or heart attack.

American researchers have shown that in young people who are predisposed to hypertension, after they drink black coffee in plasma, cortisol levels increase, which ultimately contributes to the development of hypertension.

American cardiologists have found that people of short stature (up to 154 cm) are more prone to heart attacks than people taller than 183 cm. Moreover, the situation is worse for people whose growth slowed down in childhood due to poor living conditions.

If oxygen were dissolved in the blood, and not bound by hemoglobin in red blood cells, then the heart, in order to ensure tissue respiration, would have to beat 40 times faster than it beats (Secret wisdom of the human body).

The issue of revitalization of organs has become especially important today. So, the isolated heart of a frog can be revived after several tens of hours. The calf heart can be revived after 6 hours. This issue has become relevant in connection with the development of organ transplantation. But it is just as important in cases of human resuscitation. The clinic managed to start the heart of twenty-year-old Canadian Jean Jobone, which was without movement for 3 hours 32 minutes before its work was restored by a medical team consisting of 26 people from the Winnipeg Medical Center (Guinness Book of Records).

Sometimes it happens that when the heart is injured, a person remains alive. It is known from history that one duelist who was wounded in the heart chased his opponent for 200 meters.

A 12-year-old schoolboy turned to one of the regional hospitals and complained of weakness and dizziness. During the examination, it was found that the boy had a gunshot wound to the heart. During the operation, it was found that the bullet passed through the right lung, wounded the right ventricle of the heart, and pierced the cardiac septum, ended up in the left ventricle. A stream of blood carried the bullet into the aorta. Moving with blood, the bullet hit the carotid artery, where it stopped.

In the history of medicine, about 30 cases are described when a wounded heart ejected foreign bodies that got into it. They were later found in various parts of the body.

Grigory Olkhovsky received a penetrating bullet wound to the heart during World War II and survived.

Front-line soldier Vasily Alekseevich Bryukhanov was wounded in the heart. Doctors determined that the bullet was in the heart, but they could not remove it. For several decades after the war, Bryukhanov lived with a bullet in his heart.

Mikhail Mizanov lives 50 years with a German bullet in his heart. The bullet lodged in the muscle of the left ventricle. Mikhail was wounded at the age of 19. After that, he repeatedly went to the hospital, but the matter did not come to the operation ("Working Newspaper").

The bullet can travel through the body even if it hits other parts of the body that do not have large arteries.

For 44 years, a bullet wandered in the body of the Chinese Gao Rong. By chance, he discovered it near the ankle. Gao was wounded in the groin during the war, but then the doctors did not find the bullet.

I knew the Russian soldier Moisei Vasilyevich Tarasenko, who for 30 years after World War II had a bullet palpated in different parts of the body until it was removed.

Grigory Ivanovich Chetkovsky Hero of the Soviet Union was wounded in the heart during World War II. Considered dead.

Cherz 20 years after the Victory saw his name in one of the museums among the dead Panfilov. However, back in 2001 he was alive and lived in a village in the Luhansk region (Ukraine).

at the Moscow Institute of Emergency Medicine. Sklifasovsky, it was estimated that in the event of a heart injury and timely medical assistance to the victim, only 22% of the victims die, more than 2/3 of these wounded survived. This is due to the high vitality of the human heart.

The main questions of the topic.

History of surgery for cardiac injuries.
Frequency of heart injuries.
Classification of wounds of the heart.
Clinic of heart injuries.
Diagnostic methods.
Differential diagnosis.
Indications and principles of surgical treatment.

The first mention of the fatal consequences of wounding the heart is described by the Greek poet Homer in the 13th book of the Iliad (950 BC).

The first successful operation of this kind was performed on September 9, 1896 by L. Rehn, who demonstrated the patient at the 26th Congress of German Surgeons in Berlin (J.W. Blatford, R.W. Anderson, 1985). In 1897, the Russian surgeon A.G. The undercut was the first in the world to successfully close a gunshot wound of the heart. In 1902 L.L. Hill was the first in the United States to successfully suture a stab wound to the heart of a 13-year-old boy (on a kitchen table by the light of two kerosene lamps). However, with the accumulation of experience, the romantic coloring of this section of emergency surgery began to disappear, and already in 1926, K. Beck in his classic monograph, which has not lost its significance to this day, wrote: “Successful suturing of a heart wound is not a special surgical feat.”

Classification.

Wounds of the heart are divided into non-gunshot (knife, etc.) and gunshot: penetrating into the cavity of the heart and non-penetrating. Penetrating, in turn, - on the blind and through. This is the localization of injuries in relation to the chambers of the heart: injuries to the left ventricle (45-50%), right ventricle (36-45%), left atrium (10-20%) and right atrium (6-12%). They, in turn, with and without damage to intracardiac structures.

Cardiac tamponade is a condition in which blood entering the pericardial cavity, as it were, “suffocates” the heart.

Acute cardiac tamponade occurs in 53-70% of all cardiac injuries. The degree of tamponade is determined by the size of the heart wound, the rate of bleeding from the heart into the cavity of the heart shirt, and the size of the pericardial wound. Small knife wounds of the pericardium quickly close with a clot of blood or adjacent fat, and cardiac tamponade quickly sets in. The accumulation of more than 100-150 ml of blood in the cavity of the heart shirt leads to compression of the heart, a decrease in myocardial contractility. The filling of the left ventricle and the stroke volume are rapidly falling, there is a deep systemic hypotension. Myocardial ischemia is exacerbated by compression of the coronary arteries. In the presence of 300-500 ml in most cases, cardiac arrest occurs. It should be remembered that an extensive pericardial wound prevents the occurrence of tamponade, because. blood flows freely into the pleural cavity or out.