How to properly and quickly provide assistance for a wound in the stomach? Damage to the small intestine. duodenal injury

First aid. In MPP, bandages are corrected for those wounded in the stomach, antibiotics are administered, tetanus toxoid, analgesics, according to indications - cardiac drugs. In the cold season, the wounded must be warmed: overlaid with heating pads, wrapped in a blanket or sleeping bag. With penetrating wounds, especially in the case of life-threatening blood loss, the introduction of blood substitutes is necessary. Such wounded are subject to evacuation in the first place. After them, in the second turn, the wounded are evacuated, who, against the background of a relatively satisfactory state of health and a stable general condition, have a suspicion of a penetrating wound in the abdomen. At the MPP, only those who are agonizing are detained, who are treated symptomatically.

qualified health care. In omedb (omedo), the wounded in the stomach are divided into the following groups:

With symptoms of internal bleeding - immediately sent to the operating room in the first turn;

With penetrating wounds without signs of bleeding, as well as with clinically pronounced symptoms of peritonitis, they are sent to the anti-shock ward for intensive care and preparation for surgery in the second turn;

The wounded with a suspected penetrating nature of the wound of the abdomen are sent to the operating room in the second turn, where they perform progressive expansion of the wound or laparocentesis (laparoscopy). Depending on the result, either a laparotomy is performed for a penetrating wound of the abdomen, or, if necessary, only debridement is performed. abdominal wall;

Those who are agonizing are sent to the hospital department for symptomatic therapy.

In the event of a large number of wounded, when it is impossible to provide assistance within 3-4 hours qualified assistance all those wounded in the stomach, evacuation is permissible in the near future medical institution those with no signs of internal bleeding.

Preoperative preparation depends on the general condition of the wounded and the nature of the injury. For carrying out infusion-transfusion therapy, catheterization of the central veins is necessary. It is based on intravenous infusions crystalloid and colloid solutions with broad-spectrum antibiotics. The duration of preoperative infusion therapy should not exceed 1.5-2 hours. With continued internal bleeding, intense antishock therapy should be carried out simultaneously with the operation.

Laparotomy produced under endotracheal anesthesia with muscle relaxants. The incision of the abdominal wall should provide the possibility of a detailed examination of all parts of the abdominal cavity. The most convenient median approach, as it allows you to perform a complete revision of the abdominal cavity and retroperitoneal space, if necessary, can be extended in the proximal or distal directions, supplemented by transverse incisions.

The loops of the intestine that fell out through the wound or a strand of the greater omentum are washed with an antiseptic solution. The intact intestine is set into the abdominal cavity, expanding, if necessary, the wound of the abdominal wall. To prevent the outflow of intestinal contents, the intestinal walls penetrating into the lumen of the wound are closed with elastic intestinal sphincter, followed by their suturing. The modified area of the omentum is subject to resection.

After opening the abdominal cavity, the surgical aid is carried out in the following sequence: 1) identification of a source with a temporary or final stop bleeding; 2) systematic revision of the abdominal organs; 3) intervention on damaged organs; 4) intubation small intestine(according to indications); 5) sanitation, drainage of the abdominal cavity and retroperitoneal space; 6) closing the wound of the abdominal wall; 7) surgical treatment of entry and exit wounds.

Main principle surgical intervention regarding wounds of the abdomen with damage to the organs of the abdominal cavity and retroperitoneal space, the bleeding is stopped as soon as possible. Its most frequent sources are damaged liver, spleen, mesenteric and other large abdominal vessels, kidneys, pancreas. An important method treatment traumatic shock in these wounded, there is a reinfusion of blood that has poured into the abdominal cavity. Seemingly uncontaminated blood is collected by suction, after which it is filtered (perhaps through several layers of gauze) and reinfused. In case of damage hollow organs, kidneys and ureters, it is advisable to transfuse canned blood or its erythrocyte-containing components. In the absence of blood supplies and severe blood loss, reinfusion of autologous blood under the cover of antibiotics is justified even in the case of injury to hollow organs. A contraindication to reinfusion is massive contamination with the contents of hollow organs of blood poured into the abdominal cavity.

An individual approach is required to stop bleeding from large abdominal vessels(abdominal aorta and inferior vena cava, iliac vessels, portal vein, vessels of the kidney, spleen). After temporary compression, the aorta is isolated from the esophagus: the left triangular ligament is dissected, taken to right side left lobe liver, carry out the imposition of a vascular clamp or tourniquet on the abdominal aorta. For revision of the aorta and its branches, left iliac vessels, extraperitoneal parts of the left half of the colon, left kidney, adrenal gland and ureter, the parietal peritoneum is dissected along the left lateral canal along the outer edge of the descending and sigmoid colon, and sometimes the spleen. These formations are exfoliated in the medial direction along with the mesenteric vessels, and, if necessary, with the tail of the pancreas and mobilization of the splenic flexure of the colon. Access to the inferior vena cava, right iliac vessels, extraperitoneal sections of the right half of the colon, right kidney, adrenal gland and ureter is carried out by dissection of the parietal peritoneum along the right lateral canal. Then the blind, ascending and mobilized hepatic flexure of the colon is peeled off, and if necessary, mobilization is performed. duodenum according to Kocher.

After exposing the vessels and temporarily stopping the bleeding (cross-clamping, tight tamponade, applying tourniquets and vascular clamps), a vascular suture is applied, both lateral and circular anastomosis, and in case of a large defect, autovenous plasty. In the absence of ischemia or the impossibility of restoring the integrity of a large vessel, rigid clamps are applied with ligation or stitching of the damaged vessel. In a difficult situation (development terminal state) ligation of the inferior vena cava below the confluence of the renal veins, the superior mesenteric artery below the origin of the first small intestinal branch, as well as one of the ducts of the portal vein (superior, inferior mesenteric, splenic veins) is acceptable. When ligating two or more mesenteric arteries in all cases, it is necessary to control the state of the intraparietal circulation of the intestine. In case of development of necrosis, it is resected. Be sure to drain the damaged area.

Gunshot wounds of all abdominal organs are subject to surgical treatment. , which is mandatory and milestone operations. During surgical treatment of parenchymal organs, excision of visible necrosis is performed, removal foreign bodies, blood clots, since failure to do so leads to the development severe complications(repeated bleeding, formation of purulent foci). Stopping bleeding, suturing wounds of parenchymal organs is carried out using piercing needles and threads from absorbable material (polysorb, vicryl, catgut).

In case of gunshot defects of hollow organs (stomach, intestine), economical excision of wall tissues up to 0.5 cm around the wound is performed. When carrying out surgical treatment, it is taken into account that a sign of the viability of the wall of a hollow organ is a distinct bleeding from the edges of the wound. Failure to comply with this rule is accompanied by a high incidence of suture failure and the development of life-threatening complications. All hematomas of the wall of hollow organs are subject to mandatory revision to exclude damage penetrating into the lumen. Suturing and formation of anastomoses on hollow organs are performed in 2 rows. The first row of sutures is applied through all layers, using absorbable threads (Polysorb, Vicryl, Polydiaxonone, catgut), the second - serous-muscular - from non-absorbable material (Prolene, polypropylene, capron, lavsan).

At liver injury volume surgical interventions depends on the degree of its damage, while the general principles are a reliable stop of bleeding and a full-fledged surgical treatment of the wound of the liver. For peripheral ruptures, suturing with U- or Z-shaped sutures from absorbable material, plugging the liver wound, and omentohepatopexy are used. With deep, especially central damage to the organ, preference is given to atypical or anatomical resections with mandatory drainage biliary tract regardless of the presence or absence of bile leakage from the liver wound. With crushing of the lobe, as well as multiple ruptures of both lobes, liver resection or lobectomy is indicated. In critical situations, for the purpose of hemostasis, tight tamponade or compression of the liver with a bandage and tampons is used by fixing them to the ligamentous apparatus. The wound area should be drained with a tube brought out in the right hypochondrium.

Bleeding from a wound spleen usually requires removal of the organ. Be sure to drain the left subdiaphragmatic space with drainage in the left hypochondrium.

When bleeding from a wound kidneys suturing small, non-penetrating wounds into the abdominal system. For more massive wounds, pole resection or wedge resection, supplemented by nephropyelo- or pyelostomy with penetrating into pelvicalyceal system wounds. Nephrectomy is performed with central ruptures or irreparable damage to the vessels of the leg, and you should first make sure that there is a second kidney. Be sure to perform drainage of the retroperitoneal space.

When ureteral injury its mandatory revision is carried out throughout its entire length. In this case, either a small (up to 1/3 of the circumference) wound defect is sutured, or the damaged edges are resected and the anastomosis is applied in the absence of tension. It is advisable to use a ureteral catheter (stent) for suturing and resection of the ureter. With extensive damage and the impossibility of restoring the integrity of the ureter, either the central end of the ureter is removed to the abdominal wall, or an unloading pyelo-, pyelonephrostomy is performed. In all cases, drainage of the retroperitoneal space is performed.

Bleeding from small superficial wounds pancreas stop stitching. In such cases, it is sufficient to drain the cavity of the stuffing bag with a tube, which is carried along the lower edge of the gland from the head to the tail, bringing it retroperitoneally under the splenic flexure or the initial section of the colon to the left side wall of the abdomen along the midaxillary line. For supply-and-flow drainage, a second tube is additionally inserted into the hermetically sutured omental bag, which is passed from the right hypochondrium towards the first, through the gastrocolic ligament. With extensive head injuries or the inability to stop bleeding from the pancreatic wound, tamponade and marsupialization are performed - suturing the gastrocolic ligament to the edges of the surgical wound. At complete breaks distal to the passage of the mesenteric vessels, resection of the body or tail of the pancreas is acceptable. You should always infiltrate the parapancreatic tissue with a 0.25% solution of novocaine with anti-enzymatic drugs (contrical, gordox, trasilol). With severe damage to the pancreas, the operation must be completed with nasogastrointestinal drainage and unloading cholecystostomy.

When injured stomach crushed edges of the wound are economically excised and the wall defect is sutured in the transverse direction. The operation ends with obligatory drainage of the stomach for the purpose of decompression within 3–5 days. AT rare cases with extensive damage to the organ, its marginal (atypical) resection is performed.

Wounds on the anterior wall duodenum, covered with peritoneum, sutured in the transverse direction; when suturing an extensive wound defect (up to ½ of the circumference of the intestine), an unloading gastrojejunostomy should be applied. If damage to the retroperitoneal part is detected, the intestine is mobilized according to Kocher, the wound opening is sutured, and the retroperitoneal space is drained with a tube. With a pronounced narrowing and deformation of the intestine as a result of suturing, the operation of choice is the operation of switching off (diverticulization) by flashing and peritonizing the outlet section of the stomach and applying a bypass gastroenteroanastomosis. Plastic surgery of an extensive defect of the duodenum with a loop of the small intestine (or Roux-en-y) is allowed; accordingly, an unloading entero-enteroanastomosis according to Brown is applied between the inlet and outlet sections of the intestinal loop, and with the Roux method, the continuity of the small intestine is restored using the “end-to-side” method. The retroperitoneal space is drained, and a nasogastroduodenal probe is inserted into the intestinal lumen.

For minor damage gallbladder after surgical treatment of the wound, the defect is sutured and cholecystostomy is performed. In case of extensive damage, cholecystectomy is performed, and with concomitant liver damage, it is necessary to use drainage of the choledochus through the stump. cystic duct according to Halsted. In all cases, the subhepatic space is drained with a tube.

For minor damage extrahepatic bile ducts after suturing the wound defect, a cholecystostomy is applied, or cholecystectomy and drainage of the choledoch through the stump of the cystic duct according to Halsted is performed, or external drainage of the choledoch with a T-shaped drainage is performed. Drainage of the subhepatic space is mandatory.

Surgical tactics for wounds of the small and large intestines depends on the nature of the injury, the severity of blood loss, the presence and phase of peritonitis.

When injured small intestine suturing wounds or resection of the intestine is used. An indication for suturing is the presence of one or more wounds located at a considerable distance from each other, when their size does not exceed the semicircle of the intestine. Resection of the small intestine is indicated for defects in its wall greater than a semicircle, with crush and bruises of the intestine with a violation of the viability of the wall, with separation and rupture of the mesentery with impaired blood supply, with multiple wounds located in a limited area and complete rupture of the intestine. The imposition of a primary anastomosis after resection of the small intestine is permissible in the absence of peritonitis, as well as after resection of the small intestine, when the danger to the life of the wounded person from the formation of a high small bowel fistula exceeds that in the event of failure of the anastomotic sutures. In conditions of diffuse peritonitis in the toxic or terminal phase, anastomosis is not applied to the small intestine, and the leading and abducting ends of the small intestine are brought to the abdominal wall in the form of fistulas. The operation after interventions on the small intestine (suturing several wounds or resection) is completed by its obligatory drainage with a two-channel silicone probe. Preference should be given to nasogastrointestinal intubation, retrograde drainage of the small intestine is preferred when removing a caudal enterostomy.

When injured colon the presence of a wound more than ½ of the circumference of the intestine, the destruction or disruption of the blood supply to the segment of the intestine serve as an indication for resection of the damaged segment and the formation of a single-barreled unnatural anus from the leading section of the intestine; the discharge end of the intestine is muffled according to Hartmann, or it is brought to the abdominal wall in the form of a colonic fistula. The presence of diffuse peritonitis is a contraindication to suturing even a small wound defect; in such cases, either crossing the lumen of the intestine and its mesentery at the site of injury and performing the Hartmann operation, or removing the movable damaged area in the form of an unnatural anus of the “double-barreled” type, is permissible. Suturing is permissible only in the presence of an isolated small (up to 1/3 of the circumference of the intestine) wound, the absence of massive blood loss, as well as severe damage to other organs and anatomical regions; if there is doubt about the final outcome or a larger size of the wound defect (up to ½ of the circumference of the intestine), extraperitonization of the movable part of the colon with a sutured wound is indicated. Under extraperitonization understand the temporary removal through a separate incision of the abdominal wall of the loop of the colon with a sutured wound, which is placed under the skin; with a successful postoperative course, after 10 days, the bowel loop is immersed in the abdominal cavity; with the development of insolvency of the intestinal sutures, a colonic fistula is formed. If the mesoperitoneal section is damaged, either the wound is sutured and an unloading proximal abduction colostomy is applied, or the intestinal lumen and its mesentery are crossed at the wound site, mobilization and the Hartmann operation is performed. With extensive wounds of the right half of the colon, it is permissible to perform a right-sided hemicolectomy: the imposition of a primary ileotransverse anastomosis is indicated in the absence of pronounced inflammatory changes in the abdominal cavity, characteristic of the toxic or terminal phase of peritonitis and stable hemodynamics; in other situations, the operation ends with the removal of the ileostomy. The removal of the damaged segment of the colon with an extensive wound on the abdominal wall is not recommended because of the highest mortality.

When injured intra-abdominal rectum There are 2 operating options available. With a small wound the wound defect is sutured, and from a separate incision of the abdominal wall in the right iliac region, an unnatural anus is applied to the sigmoid colon (in the form of a "double-barrel"). With extensive wounds of the rectum resection of the non-viable area and removal of the adducting end of the intestine to the anterior abdominal wall in the form of a single-barreled unnatural anus are performed; the outlet end is sutured tightly (Hartmann's operation). Injury to the extraperitoneal rectum impose unnatural anus(in the form of a "shotgun") on the sigmoid colon. The outlet part of the rectum is washed with an antiseptic solution, after which the ischiorectal space is opened with perineal access; if possible, the wound opening is sutured or the sphincter is restored; drainage of the pararectal space in case of extraperitoneal injury is mandatory. It is better to use a double-lumen tube, which is brought to the damaged area.

In all cases, colon surgery should end with decompression. gastrointestinal tract. Preference should be given nasogastrointestinal intubation using double lumen silicone probes. When applying an ileo- or cecostomy, retrograde drainage of the small intestine is performed through the removed intestinal fistula. It is mandatory to simultaneously drain the colon through the anus with a silicone probe (single or double lumen), especially in cases of suturing a defect in the intestinal wall or applying a primary anastomosis. At the end of the operation, devulsion of the anus is performed.

At small intraperitoneal bladder injury after surgical treatment of the wound, it is sutured with double-row sutures without capturing the mucous membrane. After that, bladder drainage is established with a permanent catheter. In the case of extensive and multiple wound defects, cystostomy and drainage of paravesical tissue are performed according to Buyalsky-McWorter (through the obturator foramen) or Kupriyanov (under the pubic symphysis). At extraperitoneal bladder injuries produce extraperitoneal access to the bladder, if possible, suturing wound defects. The operation is completed with the imposition of a cystostomy and drainage of paravesical tissue.

An important point surgical stage treatment is sanitation of the abdominal cavity. Allocate primary and final sanitation. The primary is carried out after the evacuation of the exudate, intestinal contents from the abdominal cavity, the final - after the elimination or delimitation of the source of peritonitis. The best bactericidal properties are oxygenated (0.06% -0.09%) or ozonated (4-6 mg / l) isotonic solution sodium chloride, however, depending on the equipment and capabilities of the military medical institution for lavage of the peritoneal cavity, you can use a sterile saline or antiseptic solutions: furatsilina (1:5000), chlorhexidine (0.2%).

Each laparotomy for a penetrating abdominal injury should end with drainage of the abdominal cavity. Drainages are carried out through separate incisions (punctures) of the abdominal wall, while one of them must be installed in the cavity of the small pelvis.

Surgical wounds of the anterior abdominal wall after laparotomy are sutured tightly. In the case of laparotomy against the background of diffuse peritonitis, severe intestinal paresis, the need for repeated sanitation of the abdominal cavity, the aponeurosis is not sutured, but only skin sutures. After that, surgical treatment of input and output wounds is performed.

After the operation, the wounded are placed in the intensive care unit to continue treatment with the participation of an anesthesiologist-resuscitator, and after waking up, without an endotracheal tube and with restored natural breathing, they are transferred to the hospital ward. In the first 2-3 days of the postoperative period, parenteral nutrition is carried out by intravenous administration protein solutions (plasma, albumin), concentrated solutions glucose (20–40%) with insulin and vitamins with a total volume of up to 4–6 l / day. In the following days, the volume of infusions is reduced and gradually switched to enteral nutrition. With intestinal paresis, constant aspiration of gastric and intestinal contents through probes is provided, epidural anesthesia is performed, and intestinal function is stimulated.

Antibiotics are administered intramuscularly, intravenously, endolymphatic and additionally intraperitoneally through established drains.

In some cases, it becomes necessary to perform an early (in 12–24 hours) programmed relaparotomy, the purpose of which is to check internal organs and sanitation of the abdominal cavity. The indications for such an operation are: the performance of a primary operation against the background of diffuse purulent peritonitis, the forced use of methods for temporarily stopping bleeding, high probability failure of the imposed intestinal sutures.

After the operation, the wounded in the stomach are not transportable for 7-10 days if the evacuation is carried out by road, and up to 3-4 days - by air.

The most common complication (more than 60% of their total number) in those wounded in the stomach in the postoperative period is peritonitis. Postoperative peritonitis most often develops due to the failure of intestinal sutures or anastomoses, local delimited peritonitis (abscesses) as a result of inadequate sanitation or inadequate drainage of the abdominal cavity. Diagnosis of peritonitis in those wounded in the abdomen is difficult and responsible, since the outcome often depends on the early detection of complications. The basis of diagnosis is the deterioration of the general condition, the progression of intoxication and intestinal paresis, which are often supported by x-ray and laboratory data (increased leukocytosis and shift leukocyte formula to the left). Laparoscopy is highly informative in terms of diagnosing this complication, while one should not forget about adhesive process and the possibility of additional iatrogenic injury. If peritonitis is detected, urgent relaparotomy is performed and its source is eliminated with full range detoxification measures (forced diuresis, peritoneal and intestinal lavage, enterosorption, endolymphatic administration of antibiotics, drainage thoracic duct). In some cases, after relaparotomy, there is a need for program sanitation of the abdominal cavity, the indications for which are the impossibility of performing a single thorough intraoperative lavage. This situation, as a rule, occurs when there is significant fecal content in the abdominal cavity. In such cases, after sanitation of the abdominal cavity, only skin sutures are applied to the edges of the surgical wound. These wounded, after stabilization of hemodynamic parameters in the immediate postoperative period, should be transferred to a specialized hospital in the first place.

The next severe postoperative complication in those wounded in the abdomen is early adhesive intestinal obstruction, occurring, as a rule, for 3-5 days. Clinical picture obstruction is characterized by the appearance of cramping pains in the abdomen, nausea, vomiting, bloating, cessation of gas, stool or intestinal contents, a change in the shape of the abdomen (Val's symptom). In these cases, the first conservative therapy: drainage and gastric lavage, enema, warming compress on the abdomen, sacrospinal, and even better epidural blockade at the level of the lower thoracic spine. If these procedures do not lead to the desired effect and intoxication increases, they resort to relaparotomy and removal of the obstacle that caused difficulty in the passage of intestinal contents, drainage of the small intestine with a nasogastrointestinal probe.

At eventrations, the causes of which are most often peritonitis, suppuration of the surgical wound and errors in suturing the abdominal wall, the wounded person needs urgent surgical intervention. Under general anesthesia the prolapsed intestinal loops are set into the abdominal cavity, the small intestine is intubated, the abdominal cavity is sanitized and drained. To prevent re-eventration, the wound is sutured through all layers with mattress sutures, a wide bandage of a towel or sheet is applied to the abdomen. With diffuse purulent peritonitis, the surgical wound of the abdomen is closed only with skin sutures.

For prevention pneumonia the wounded should be in bed with a raised head end, systematically carried out breathing exercises and vibration massage after administration of analgesics.

Specialized medical care wounded in the stomach is in hospitals intended for the treatment of wounded in the chest, abdomen and pelvis (VPTAG). At this stage of evacuation, the wounded are mainly delivered, who have already been provided with qualified surgical care.

One of the main tasks in providing specialized care is the treatment of emerging postoperative complications: diffuse peritonitis, intra-abdominal abscesses, early adhesive intestinal obstruction, secondary bleeding, eventration of internal organs, phlegmon of the abdominal wall and retroperitoneal space, intestinal fistulas and urinary streaks. In the conditions of modern warfare, the wounded in the stomach or pelvis, who need urgent operations and anti-shock treatment, can be delivered to a specialized hospital directly from the centers of mass destruction, bypassing the stage of providing qualified medical care.

In TTMZ, the treatment of the wounded continues due to complications that have arisen in them: adhesive disease, intestinal and urinary fistulas, etc.

Guidelines for military surgery

Surgical intervention, performed no later than 10-12 hours from the moment of injury, can save a person with a penetrating wound to the abdomen and damage to internal organs. If the patient is not provided with full-fledged surgical care in a timely manner, then death becomes almost inevitable. It is important for a gunshot wound to the abdomen to quickly and correctly assess the nature of the wound and provide first aid.

Symptoms of non-penetrating wounds

In some cases, gunshot non-penetrating wounds of the abdomen without extraperitoneal damage to organs are classified as minor injuries. The lightest - with a trajectory of a bullet or projectile or their fragments at the end, perpendicular to the surface of the abdomen. In this case, the foreign body can get stuck in the abdominal wall without damaging the peritoneum. With oblique wounds of the abdominal wall, which can be caused by shells or their fragments, there may be severe bruises of the small or large intestine, followed by necrosis of a section of their wall and perforative peritonitis. With gunshot wounds to the abdominal wall, symptoms of shock and symptoms of a penetrating wound of the abdomen can be observed. Therefore, any wound should be considered as potentially penetrating. Wounded with non-penetrating wounds require urgent evacuation to a medical facility in order to establish the true nature of the injury.

Symptoms of penetrating wounds

In most cases, penetrating wounds of the abdomen are accompanied by injuries of the abdominal organs (liver, spleen, stomach, intestines, mesentery, bladder, combined with a wound of the spine and spinal cord).

The clinic and symptoms of penetrating gunshot wounds of the abdomen are determined by a combination of three pathological processes: shock, bleeding and perforation or through violation of the integrity of the wall of the cavity or tubular organ(intestine, stomach, bladder), as a result of which a communication is established between the cavity of the organ and its environment. In the first hours after the injury, the clinic of blood loss and shock dominates. After 5-6 hours from the moment of injury, peritonitis develops.

Symptoms of penetrating wounds of the abdomen: prolapse of the viscera from the wound or outflow from the wound canal of fluids corresponding to the contents abdominal organs. In such cases, the diagnosis of a penetrating wound of the abdomen is established at the first examination.

First aid

In order to perform the correct first aid actions for wounding the abdomen, it is necessary to correctly assess the severity and nature of the injury. . Bullet or shrapnel wounds, penetrating the body, cause damage to the latter, which have certain differences from other body injuries: the wounds are usually deep, often contaminated with tissue fragments, shells, bone fragments, and the injuring object often remains inside the body. These features of a gunshot wound should be taken into account when providing first aid to the victim. The severity of the injury should be assessed by the location and type of the inlet, the behavior of the victim and other signs.

In case of injuries of the abdominal organs, the victim is seated on the floor sitting position. Warning wound infection: disinfect the edges of the wound, apply a sterile napkin. At severe blood loss- anti-shock therapy.

At the slightest suspicion of the penetrating nature of the wound, it is necessary:

Inject morphine.
Close the wound with a dry aseptic bandage.
Give the wounded absolutely no drink and no food.
To ensure the fastest and smoothest possible transportation.

In case of loss of entrails:

Cover the entire abdominal wall, immobilizing (especially when bowel loops, omentum fall out of the wound) with a wide aseptic bandage moistened with a solution of furacilin or vaseline oil. It is impossible to set the fallen organs into the abdominal cavity.
Place a roll of gauze bandages around the fallen organs. Apply an aseptic bandage over the rollers, trying not to press the fallen organs. Bandage the bandage to the stomach.
Apply cold to the bandage.
Introduce analgesics, cardiac agents, tetanus toxoid and morphine hydrochloride.
If necessary, wrap the wounded in a warm blanket.
Provide gentle transportation of the wounded on a stretcher.
Call " ambulance”, ensuring the delivery of the victim in a supine position with bent knees, under which a roller from a blanket should be placed.

Important! It is forbidden to drink or feed the wounded. To quench the feeling of thirst, you need to moisten your lips.

Treatment

Most frequent complications in postoperative period in the wounded in the stomach - peritonitis and pneumonia. The main signs of peritonitis are abdominal pain, dry tongue, thirst, pointed facial features, tachycardia, chest type of breathing, muscle tension in the anterior abdominal wall, widespread and severe pain on palpation of the abdomen, positive symptoms irritation of the peritoneum, the absence of noises of intestinal peristalsis.

Treatment includes repeated operations about peritonitis and subsequent conservative treatment, opening of abscesses of the abdominal cavity, surgery intestinal fistulas and others recovery operations on the gastrointestinal tract.

With combined radiation injuries surgical treatment of gunshot wounds of the abdomen begins at the stage of qualified medical care and is necessarily combined with the treatment of radiation sickness. Operations should be simultaneous and radical, since as radiation sickness develops, the risk increases sharply infectious complications. In the postoperative period, a massive antibiotic therapy, transfusion of blood and plasma substitutes, administration of vitamins, etc. With combined combat injuries of the abdomen, the terms of hospitalization should be extended.

The prognosis for gunshot wounds of the abdomen is unfavorable.

Article content: classList.toggle()">expand

Any injury to the abdomen is always considered dangerous, since internal organs may be affected, and it is impossible to determine this at first glance, as well as assess the severity of the injury.

Therefore, the first aid to the victim is always the same, regardless of the type of injury (gunshot, knife, etc.). But providing assistance in the presence of a foreign body or protruding organs has some differences from the general algorithm.

Brief instructions for assistance

A particularly important point in case of injury to the abdomen, which must be taken into account when providing first aid, is that it is strictly forbidden for the victim to give food and drink, even if he asks for it. It is only allowed to wet clean water his lips and, if necessary, you can rinse your mouth without swallowing water.

Oral medications, including painkillers, should also not be given. As for painkillers, they cannot be given to a person on their own when the abdomen is wounded.

First aid for a wound in the abdomen is as follows:

First aid for penetrating wounds of the abdomen

If a person has a wound in the abdomen, it is important to immediately assess the situation. If an ambulance can arrive at the scene within half an hour, then the first thing to do is call the doctors and then proceed to provide first aid.

If the ambulance can reach the victim for a long time, measures should be taken immediately. first aid, and then deliver the person to the nearest clinic on their own.

If a person is unconscious, this does not interfere with first aid, especially in the case of an open penetrating wound to the abdomen or any other part of the body. You should not try to bring him to his senses, you just need to lay him on a flat surface, bend your knees, put a roller of clothes under them and tilt the person’s head back, turning it to the side to ensure free passage of air.

No need to feel the wound on the stomach, and even more so try to find out its depth. by dipping a finger or hand into it. In case of a gunshot wound, the victim should be examined and determined possible presence bullet exit hole. If it is available, it must also be processed, as well as the input, and a bandage should be applied. If there are several wounds in the abdomen, then everything will be treated, starting with the largest and most dangerous injuries.

It is important to stop if it is profuse, for which it is necessary to correctly determine its type, after which the wounds should be treated and cleaned of dirt and blood.

For cleaning, you need to use a clean cloth, gauze, bandages soaked in hydrogen peroxide, any solution of an antiseptic or potassium permanganate (furatsilina). In the absence of such drugs, you can use any alcoholic beverage.

Cleaning of the wound is carried out in the direction away from the edges of the damage around the entire perimeter. The cloth should be soaked in the solution abundantly. In some cases, one treatment may not be enough for a complete cleaning. In this case, you will need another piece of cloth or bandage soaked in an antiseptic solution.

Do not pour antiseptic preparations into the wound, as well as water and other liquids. Contaminants should be removed only from the surface of the skin surrounding the wound and its edges.

If possible, the skin around the wound should be treated with brilliant green or iodine to prevent secondary infection. After that, you need to apply a bandage and deliver the victim to the clinic. During transport, an ice pack or other source of cold may be applied over the dressing.

Algorithm of actions in case of injury in the presence of a foreign body

First aid in this case is carried out according to the general algorithm, but it is important to take into account special points, as well as pay attention to a number of rules, non-observance of which can lead to the death of the victim.

In case of a gunshot wound, if a bullet remains in the wound, in no case should you try to remove it yourself, as this can lead to the onset of serious bleeding, life threatening person.

The ban on extraction also applies to any other object in the wound, primarily to the one that was injured. Thus, in no case should a knife be removed as part of first aid in case of a knife wound in the stomach or abdominal cavity. The traumatic object closes the damaged vessels, pinching them and holding back the bleeding. They can only be removed in the hospital, in the operating room, where doctors can provide assistance in any situation.

Assistance in the presence of organs falling out of the wound

The general algorithm for providing first aid in this case is also relevant, but has some special points that must be observed. First of all, if internal organs are visible when injured in the abdomen, it is necessary to evaluate general situation, such as how quickly an ambulance can get to the scene.

If a team of doctors can reach the victim within half an hour, then the first thing to do is call an ambulance, and then begin first aid measures. If doctors need more time, they should immediately begin to provide assistance, and then deliver the person to the clinic in their own or passing transport.

If a person with a wounded abdomen is unconscious, it is necessary to tilt his head back and turn slightly to the side so that air can freely enter the lungs.

If the internal organs have fallen out of the wound on the abdomen, in no case should you push them back and try to push them back into the abdominal cavity. If there are several organs that have fallen out (or the intestines have fallen out), it is necessary to move them as close as possible to each other so that the area occupied by them is minimal. After that, as carefully and very carefully as possible, all organs should be placed in a piece of clean tissue or a clean bag, the edges of which must be glued with a plaster or ordinary tape to the skin of the victim around the wound.

It is very important to isolate the prolapsed organs from any impact. environment and protect them from possible damage.

If it is impossible to isolate the fallen organs in this way, the procedure is carried out a little differently. You should prepare several rollers from a clean cloth or bandages, cover the fallen organs with them and cover them on top with a piece of gauze or a clean cloth. After that, it is necessary to carefully and not tightly fasten the structure to the body of the victim at the site of the injury.

It is very important to take into account that the internal organs, when applying such a bandage, should not be squeezed even slightly, since this can lead to many complications.

After fixing the prolapsed organs in any of these ways, the victim should be given a normal sitting position, while his legs should be half-bent at the knees. Cold should be applied to the wound, but it is important that the ice pack be wrapped in a cloth or towel. After this, the victim must be wrapped in a blanket (this is mandatory). Transportation of a person with such a wound should be carried out in a sitting position.

During transportation to the clinic, it is important to constantly moisten the fallen organs with clean water, preventing them from drying out. If the organs are placed in a bag, then water can be poured inside from a conventional syringe. If they are in a fabric or under a special bandage, then it will be enough to periodically soak the dressing with water, preventing drying.

It is important to remember that the drying of the surface of the internal organs, caught in the air, will lead to their necrosis, due to which doctors will be forced to remove them. With necrosis, vital important organs death comes.

- 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 reasons are possible (falling on sharp object, gunshot wound). Closed injuries are usually caused by falls from heights, car accidents, industrial accidents, etc. The severity of injury from open and closed abdominal trauma can vary, but special problem present closed injuries. In this case, due to the absence of a wound and external bleeding, as well as due to the accompanying traumatic shock or serious condition the patient often has difficulties 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 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 left shoulder. 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 about sharp pains in 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 a state of shock, pain, muscle tension in the lumbar region and hypochondrium on the side of the damaged kidney, a drop in blood pressure, tachycardia.

Bladder rupture may be extraperitoneal or intraperitoneal. The reason becomes blunt trauma 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 calls for urination. 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 clinical manifestations and the severity of the patient's condition.

With the advent of modern, more accurate methods of research, 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.

An accessible and informative research method is ultrasound, which allows diagnosing intra-abdominal bleeding and detecting subcapsular damage to organs that can become a source of bleeding in the future.

If there is appropriate equipment for examining 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 injuries and minor bleeding.

If a bladder rupture is suspected, catheterization is indicated - confirmation of the diagnosis is a small amount of bloody urine released through the catheter. AT 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 diagnostic methods 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. At superficial wounds that do not penetrate into the abdominal cavity, the usual primary surgical treatment is performed with washing 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 an indication for emergency surgery. Under general anesthesia, a 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.

Penetrating wounds of the abdomen are accompanied by injury to hollow or parenchymal organs, eventration of organs (prolapse of organs to the outside), and rarely only damage to the parietal peritoneum.

Clinically observed symptoms of acute blood loss, traumatic shock, peritonitis. Runs very hard gunshot wounds. The presence of a wound, pain in the abdomen, sharp pain on palpation and tension in his muscles, sharply severe symptom Shchetkin-Blumberg, the absence of abdominal breathing and intestinal motility indicate a penetrating injury to the abdomen.

Peritonitis develops rapidly. The tongue becomes dry, the body temperature rises, vomiting appears, a pronounced leukocytosis in the blood. With a digital examination of the rectum, pain and overhanging of the peritoneum in the Douglas space are determined. Urination is delayed, diuresis is reduced.

First aid is to apply aseptic dressing, cold at the site of injury, the introduction of anti-shock drugs and hospitalization in surgery department for emergency surgery. In case of eventration of the internal organs, it is necessary to lay a bandage roller around the fallen organs and apply a wet bandage with saline solution on top.

In the treatment, a laparotomy is performed with a revision of the internal organs, their suturing and drainage of the abdominal cavity. Postoperative treatment carried out in the intensive care unit. The patient should be in a semi-sitting position. The first days in the stomach cavity there is a probe for permanent removal its contents. Within 5-7 days, it is necessary to take care of the drainages in the abdominal cavity.

Caring for a patient with abdominal trauma

In case of damage to the abdomen, the patient stays on strict bed rest. Before the operation, while monitoring the patient, he should not be given painkillers, drink or eat. Before the operation, an active infusion therapy, measurement of blood pressure and body temperature, pulse counting, research general analysis blood and urine.

During the postoperative period, the patient is placed in intensive care unit. After coming out of anesthesia, he is given a half-sitting position in bed. The drainages are being taken care of, the quantity and quality of the allocated water through the drainages, daily diuresis are taken into account. Peritoneal dialysis is performed, pulse rate is monitored, blood pressure and body temperature, bandage in the area of the postoperative wound.

Prevention of postoperative thromboembolism and pulmonary complications is carried out. A day later, the patient is allowed to turn in bed, engage in respiratory exercises. The first day the patient entered the probe into the stomach. At first, parenteral nutrition is carried out and on the 2nd day it is allowed to drink in fractional doses, it is possible to eat liquid food only from the 3rd-4th day with the resumption of intestinal motility.