Gunshot wounds upper limb

What are Gunshot wounds of the upper limb -

Exceptional Variety gunshot wounds of the upper extremities determined, on the one hand, by the characteristics of the wounding projectile, on the other, by the structural features of the bone. The difficulty of diagnosing the true nature of the injury, the severity of soft tissue injuries accompanying fractures, and the overall severe reaction of the body to any gunshot injury are characteristic of gunshot wounds. Exists big number classifications of gunshot fractures.

Wound healing and consolidation of gunshot fractures of the upper extremity occur more favorably than those of the lower extremities. A common purulent, anaerobic infection, osteomyelitis is less common. The conditions for this are wide incisions, care in performing the procedure for excision of non-viable tissue, and, if necessary, timely secondary necrectomy, which should not be postponed if indicated. In the case of open wound and granulating surfaces, an early secondary or late secondary suture cannot always be used, so in such situations one should definitely keep in mind the use of free skin grafting, and if necessary, use a skin stem according to Filatov.

Pathogenesis (what happens?) during gunshot wounds of the upper extremities:

Shoulder fractures

Gunshot wounds with fracture humerus make up about 4/3 of all shoulder wounds. In addition to the deformation or malposition of the limb, pathological mobility at the fracture site, dysfunction of the limb, pain in the fracture zone, the results of measuring the length of the limb, one should also take into account such a sign as the presence of fat droplets in the wound discharge.

For gunshot wounds of the shoulder area, especially in upper third shoulder, combined injuries are not so rare, when the same wounding projectile: a bullet, a fragment - first causes a fracture of the humerus, and then penetrates into pleural cavity, causing injury to the lung, blood vessels, and other anatomical structures. In some cases, along with a fracture of the humerus, the scapula may be injured, and bone fragments seriously injure the muscles above and subscapular region. Since the direction of soft tissue injury does not always correspond to the true direction of the wound canal, a thorough physical and radiological examination of the patient, including radiography, is especially important chest in two projections, and, if necessary, in more projections.

The question of the need for thoracotomy for such wounds should be decided on the basis of firmly established principles of military field surgery: thoracotomy is indicated only for ongoing intrapleural unstoppable bleeding, large hemothorax, and for valvular pneumothorax that cannot be eliminated by conservative measures.

Forearm injuries

2/3 of those wounded in the forearm are admitted to the hospital without signs of suppuration. Provided that surgical treatment is carefully performed and bone fragments are stablely fixed, the results of treatment of this category of wounded can be considered quite satisfactory. Transosseous osteosynthesis devices should be considered the method of choice for immobilizing fragments. For gunshot wounds of the forearm, it is often necessary to resort to free skin grafting to close skin defects.

Features of gunshot wounds of the forearm Nerve damage is common, requiring subsequent neurolysis and nerve suturing.

Wounds to the hand

Diversity gunshot injuries The brush is quite large. It is not uncommon to be injured by shrapnel when the main localization of the injury is in another area. Extensive damage to bone, muscle and tendon structures occurs when the left hand is wounded at close range.

Treatment of gunshot wounds of the upper extremities:

Shoulder fractures

Most often, during surgical treatment of a gunshot fracture of the shoulder, the wound is dissected, bone fragments and foreign bodies are removed, and then soft tissue is excised. Thus, when the shoulder is wounded, relatively simple surgical procedures, which is explained by the relatively small volume of muscles, the absence of dense fascial layers, less contamination of the wound, and a relatively high percentage of through wounds.

In severe, comminuted fractures of the upper third of the humerus, it may be necessary to completely remove the proximal end of the humerus. In this case, complete healing of the wounds is achieved and subsequently they resort to endoprosthesis replacement of the proximal end of the humerus. Since in such fractures it is not always possible to fix the fragments using an external fixation device, one has to resort to an abduction splint or thoracobrachial bandage. Immersion metal osteosynthesis for gunshot fractures of the bones of the forearm, and not only them, can be used only in extremely favorable situations: with the general good condition of the wounded, carefully performed surgical treatment, a sufficient number of well-supplied muscles, the possibility of closing the wound without tension, good drainage, observation of the patient by the operating surgeon.

Gunshot fractures of the humeral shaft, as a rule, end-to-end. Surgical treatment of such fractures is carried out according to general rules, carefully protecting the radial nerve from additional trauma. With a gunshot fracture of the shoulder optimal methods fixations are the Ilizarov apparatus, as well as a plaster thoracobrachial bandage.

For through and through fractures of the shoulder and large exit openings, you can limit yourself to surgical treatment of only the exit opening. In this case, sufficient access is provided, conditions for excision of non-viable tissue, comparison of bone fragments and subsequent drainage.

A significant number of gunshot fractures of the humerus can be reduced after surgical treatment using an abduction splint fixed to the body with plaster rings. The same rings are used to secure the shoulder and forearm on the splint.

If for some reason an external fixation device is not used for gunshot wounds of the shoulder or forearm, a thoracobrachial bandage can be used with the arm in abduction. The bandage is relatively easily tolerated by patients, simplifies subsequent management and does not cause stiffness in the shoulder joint when the arm is fixed for 2-3 weeks. This bandage is convenient to apply at the end of the operation under anesthesia. In the interval from the 5th to the 8th day, if necessary, a “window” is cut out in the wound projection in the thoracobrachial bandage and the necessary therapeutic measures are carried out, for example, applying delayed sutures or free skin grafting.

It is advisable to divide shortening of upper limb segments into functionally compensated (up to 4 cm), conditionally compensated (4-6 cm) and uncompensated (more than 6 cm).

Forearm injuries

A technique has been developed for inserting the needles on the bones of the forearm, as well as a special conductor that allows the needles to be inserted at the desired angle.

Using conservative and surgical methods treatment, it is possible to restore the anatomical integrity of the bones in almost 90% of the wounded. Approximately 10% of the wounded remain with persistent defects, false joints; characterized by a high percentage (more than 20) of contractures.

Wounds to the hand

The main condition for a successful operation for a gunshot fracture of the hand is to perform it in specialized hospital using special instruments, an operating microscope, etc.

It should be considered proven that intervention on the hand should be definitive, in other words: the operation should be carried out by a specialist who knows the methods of intervention on the hand. Consequently, such victims should be left in a specialized institution, and operated on at other stages only with the aim of stopping bleeding, prophylactic administration of antibiotics, applying a bandage and transport immobilization.

Trauma to the hand is of particular importance from the point of view of the importance of the organ and the characteristics of the anatomical structure. It should be considered quite justified in most cases to divide the treatment of hand wounds into two stages - primary surgical treatment and final reconstructive interventions in specialized medical institutions. American surgeons in Vietnam, with fairly good equipment and trained personnel, used a two-stage technique when wounding the hand.

When determining the timing and type of surgical intervention, one should proceed primarily from the nature of the injury and its severity, the time that has passed since the injury or injury, and evacuation transport capabilities. It is also necessary to take into account the patient's age, his general state, profession.

Gunshot wounds of the hand, as a rule, are accompanied by bone fractures, and with wounds of the fingers, tendons and very often joints are almost certainly affected, with the formation of extra-articular or intra-articular fractures.

An injury to the hand itself can rarely be the cause state of shock wounded, in such cases you should always look for one or more other injuries. A delay in performing surgical treatment of the hand is quite justified if there is a good primary medical dressing and reliable immobilization, although purulent infection is a frequent companion to wounds of the hand, especially when the bones of the wrist are damaged.

First aid for a hand injury consists of applying a sterile bandage, sometimes a pressure bandage. For widespread injuries of the hand, immobilization with a scarf or using standard means is indicated. The wounded hand must be fixed in a functionally advantageous position, for which a thick ball of cotton wool is placed in the wounded person’s palm and the fingers are placed on it, the entire hand is bandaged to a ladder or mesh splint modeled on the palmar surface.

Rendering surgical care wounded in the hand should be limited at the stage of qualified surgical care only to stopping bleeding and immobilization, since without x-ray You cannot begin complex surgical treatment of a hand wound.

When surgically treating large wounds of the hand, general anesthesia is preferable; conduction or intraosseous anesthesia can be used.

The surgeon must perform operations on the hand with the help of an assistant. The necessary conditions- a well-lit surgical field, sufficient time and good surgical instruments and suture material.

Careful preparation surgical field very important: nails should be cut short, hair should be shaved, the entire brush should be washed thoroughly warm water with soap.

If the ulnar or radial arteries are injured, one of them can be ligated, but in no case both, as this will cause necrosis.

The skin on the hand can be excised only if it is undoubtedly non-viable; in other cases, even heavily contaminated skin should be preserved.

During surgical treatment, it is necessary to carefully examine the deep formations of the hand and determine the degree of damage to all structures. At severe injuries hand, a transverse incision of the transverse carpal ligament is advisable.

Amputation of fingers is indicated in case of obvious necrosis. This especially applies to the first finger. Sometimes it is necessary to save at least part of the skin from the amputated finger to close the skin defect on the remaining one.

When amputating fingers, a flap is cut out, carefully ligating the blood vessels and sawing the phalanx with a thin file. After intersection, the tendons should be sutured to the periosteum.

The ends of the destroyed nerves usually extend far to the sides. They should not be sought during initial surgical debridement; however, if possible, the ends of the nerves should be brought closer to relatively healthy tissue and the nerves should be secured with nonabsorbable suture material.

In most cases, it is better to delay wound closure primary seam. The use of thin Kirschner wires is indicated for fixation of fractures and dislocations of the phalanges of the fingers. In case of intra-articular fractures of the interphalangeal or metacarpophalangeal joints, in cases where the articular ends of the bones are completely crushed, one should resort to very economical removal of these areas. We must not forget about the mandatory immobilization of the hand after any intervention on it.

The bandage should cover the entire wound, but not squeeze it. Healthy fingers should be visible. The hand is fixed in a functionally advantageous position.

Surgical treatment of a gunshot wound to the hand is not indicated for through wounds of the hand and fingers with pinpoint entry and exit holes, for tangential wounds of the fingers and hand, provided that the wound has smooth edges, as well as for superficial finely splintered wounds.

IN postoperative period Physical therapy is especially recommended for wounded people with injuries to the hand and fingers.

Which doctors should you contact if you have gunshot wounds of the upper limb:

Traumatologist
Surgeon

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Other diseases from the group Trauma, poisoning and some other consequences of external causes:

Arrhythmias and heart block in cardiotropic poisonings

Depressed skull fractures

Intra- and periarticular fractures of the femur and tibia

Congenital muscular torticollis

Congenital malformations of the skeleton. Dysplasia

Lunate dislocation

Dislocation of the lunate and proximal half of the scaphoid (de Quervain's fracture dislocation)

Tooth luxation

Dislocation of the scaphoid

Dislocations of the upper limb

Dislocations and subluxations of the radial head

Dislocations of the hand

Dislocations of the foot bones

Shoulder dislocations

Vertebral dislocations

Forearm dislocations

Metacarpal dislocations

Foot dislocations at the Chopart joint

Dislocations of the phalanges of the toes

Diaphyseal fractures of the leg bones

Old dislocations and subluxations of the forearm

Isolated fracture of the ulnar shaft

Deviated nasal septum

Tick paralysis

Combined damage

Bone forms of torticollis

Posture disorders

Knee instability

Gunshot fractures in combination with soft tissue defects of the limb

Gunshot injuries to bones and joints

Gunshot injuries to the pelvis

Gunshot wounds of the lower limb

Gunshot wounds to joints

Gunshot wounds

Burns from contact with Portuguese man-of-war and jellyfish

Complicated fractures of the thoracic and lumbar spine

Open injuries to the diaphysis of the leg

Open injuries to the bones of the hand and fingers

Open injuries of the elbow joint

Open foot injuries

Frostbite

Wolfsbane poisoning

Aniline poisoning

Antihistamine poisoning

Antimuscarinic drug poisoning

Acetaminophen poisoning

Acetone poisoning

Poisoning with benzene, toluene

Toadstool poisoning

Poisoning with poisonous wech (hemlock)

Halogenated hydrocarbon poisoning

Glycol poisoning

Mushroom poisoning

Dichloroethane poisoning

Smoke poisoning

Iron poisoning

Isopropyl alcohol poisoning

Insecticide poisoning

Iodine poisoning

Cadmium poisoning

Acid poisoning

Cocaine poisoning

Poisoning with belladonna, henbane, datura, cross, mandrake

Magnesium poisoning

Methanol poisoning

Methyl alcohol poisoning

Arsenic poisoning

Indian hemp drug poisoning

Poisoning with hellebore tincture

Nicotine poisoning

Carbon monoxide poisoning

Paraquat poisoning

Poisoning by smoke vapors from concentrated acids and alkalis

Poisoning by oil distillation products

Poisoning with anti-depressant drugs

Salicylate poisoning

Lead poisoning

Hydrogen sulfide poisoning

Carbon disulfide poisoning

Poisoning with sleeping pills (barbiturates)

Poisoning with fluoride salts

Poisoning by central nervous system stimulants

Strychnine poisoning

Tobacco smoke poisoning

Thallium poisoning

Tranquilizer poisoning

Acetic acid poisoning

Phenol poisoning

Phenothiazine poisoning

Phosphorus poisoning

Poisoning with chlorine-containing insecticides

Cyanide poisoning

Ethylene glycol poisoning

Ethylene glycol ether poisoning

Poisoning with calcium ion antagonists

Barbiturate poisoning

Poisoning with beta-blockers

Poisoning with methemoglobin formers

Poisoning with opiates and narcotic analgesics

Poisoning with quinidine drugs

Pathological fractures

Maxillary fracture

Fracture of the distal radius

Tooth fracture

Fracture of the nasal bones

Scaphoid fracture

Fracture of the radius in the lower third and dislocation in the distal radial-ulnar joint (Galeazzi injury)

Fracture of the lower jaw

Fracture of the base of the skull

Proximal femur fracture

Calvarial fracture

Jaw fracture

Fracture of the jaw in the area of the alveolar process

Skull fracture

Fracture-dislocations in the Lisfranc joint

Fractures and dislocations of the talus

Fractures and dislocations of the cervical vertebrae

Fractures of the II-V metacarpal bones

Fractures of the femur in the area of the knee joint

Femur fractures

Fractures in the trochanteric region

Fractures of the coronoid process of the ulna

Acetabular fractures

Fractures of the head and neck of the radius

Sternum fractures

Femoral shaft fractures

Humeral shaft fractures

Fractures of the diaphysis of both bones of the forearm

Fractures of the distal humerus

Clavicle fractures

Bone fractures

Fractures of the shin bones

Hindfoot fractures

Fractures of the bones of the hand

Fractures of the bones of the forefoot

Fractures of the forearm bones

Midfoot fractures

Fractures of the bones of the foot and fingers

Pelvic fractures

Bone fractures in children

Fractures of the olecranon process of the ulna

Scapula fractures

Fractures of the humeral condyle

Patella fractures

Fractures of the base of the first metacarpal bone

Humerus fractures

Metatarsal fractures

Spinal fractures

Fractures of the proximal end of the tibia

While on duty, a security guard at a private enterprise was attacked and received a gunshot wound to the right shoulder.

Objectively: on the front surface of the middle of the right shoulder there is a moderately bleeding wound, irregularly rounded, on back surface– somewhat similar wound large sizes with jagged edges. From the anamnesis it turned out that the victim was shot at a distance of about 30 m with a pistol. A paramedic was on duty at the health center of a neighboring enterprise, and the victim turned to him.

Sample answer:

The victim has a through gunshot (bullet) wound to the right shoulder.

The conclusion is based on anamnesis (the victim was attacked) and an objective examination of the right shoulder (the presence of a through wound with entry and exit holes characteristic of a gunshot wound; bleeding from the wound).

2. Algorithm for providing emergency first aid:

A) visual inspection wounds, assess the condition in order to identify hemodynamic disorders ( early diagnosis traumatic shock);

b) dressing the wound and applying an aseptic pressure bandage, objective examination: forced position of the limb, deformation, local pain, crepitus and pathological mobility at the site of injury;

c) hang your hand on a scarf;

d) immediately inform the duty department of the Ministry of Internal Affairs by phone. 02 about what happened;

e) call an ambulance team,

g) observe the patient until the ambulance arrives.

Application of a pressure bandage using PPI is carried out according to the algorithm.

Sample answer to ticket No. 26

TASK 1

The boy is 8 months old. Complaints about the child's lethargy, loss of appetite, unstable stool. A child from the 5th pregnancy, which proceeded favorably, 2 term births (weight - 3700 g, length - 50 cm). The neonatal period is without any peculiarities. Breastfeeding up to 2 months, from 3 months. introduced semolina without the advice of a doctor, unadapted mixtures were used. The child did not take vitamin D and rarely received juices. There were not walks every day. The weight gain was uneven. I suffered from acute respiratory infections 2 times. Material and living conditions are satisfactory.

Objectively: the general condition is satisfactory, but the child is lethargic, pale, and sweating. Sits with support on his hands, his back is round. Muscle tone is diffusely reduced. The head is square in shape, with prominent frontal and occipital protuberances. Large fontanel 2.5x3.0 cm, pliable edges. The back of the head is flattened and bald. No teeth. The chest is compressed from the sides, the lower edges are unfolded, there are small “rosary beads” on the ribs, and pronounced “bracelets” on the arms. There is kyphosis in lumbar region spine, which disappears when the child is positioned on his stomach. Palpation, percussion and auscultation did not reveal any changes in the respiratory and cardiac organs. The liver protrudes 2 cm from under the edge of the costal arch. The spleen is not enlarged. The stool is unstable, urination is not impaired.

Sample answer:

1. U child rickets II degree, stage of height. Iron deficiency anemia, mild. The conclusion is based on the anamnesis: breast-feeding only up to 2 months, early introduction of complementary foods, lack of vegetables and fruit juices in the diet, did not receive vitamin D for preventive purposes.

Objective examination: sweating, pallor skin, decreased muscle tone, severe deformation of the bones of the skull, chest, spine, and limbs.

Laboratory research: in the blood there is a slight decrease in hemoglobin, a decrease in phosphorus and calcium in the blood serum.

2. Additional symptom This form of the disease is craniotabes softening of individual areas occipital bone, which is determined by palpation. At the level of attachment of the diaphragm, a retraction occurs, a “Harrison’s groove,” and the timing and order of teeth eruption are disrupted.

3. B in this case the child does not need urgent hospitalization in a hospital, and if the material and living conditions are satisfactory, treatment can be carried out at home.

4. In a hospital setting, radiography is necessary to confirm the diagnosis. distal sections forearm bones and determine the level of the enzyme alkaline phosphatase in the blood serum, which plays an important role in the processes of bone calcification. First of all, you need to assign proper nutrition with daily inclusion in the diet of vegetable puree, cow's milk, kefir, grated apple, yolk, cottage cheese, low-fat meat broth, meatballs, liver. Within 30-45 days the child should receive specific treatment rickets with vitamin D in the form of calciferol 1600 IU per day. Considering the presence of anemia in the child, iron supplements (aloe syrup with iron) should be prescribed. ascorbic acid, vitamin B 1. Massage required, daily physiotherapy, pine baths, walks in the fresh air.

5. Technique for measuring height in children of different ages according to the algorithm for performing manipulations.

Gunshot wounds remain one of the most common traumatic injuries on our planet.

In recent months, we have seen on television screens a lot of people who received gunshot wounds in peacetime on the territory of Ukraine. Therefore, we understand that no one is immune from this. In order not to be confused in a difficult moment, when trouble has happened to you or people nearby, you need to know certain rules providing assistance.

In this material, we deliberately avoid real photos of gunshot wounds; our goal is to tell you what to do, and not to shock readers with photographs that, if desired, can be found on their own.

It is difficult to assess the extent of damage to the body caused by a gunshot wound, and in most cases it will be much more serious than it might seem at first glance.

In this case the best option All that remains for the victim is to get to the nearest medical facility as quickly as possible.

What is important when providing first aid:

Correctly determine the severity and nature of the damage

Take the right steps to save the life of the victim

Among gunshot wounds, bullet wounds predominate; shrapnel wounds are less common. With bullet wounds, the entrance hole is smaller than the exit hole.

When a bullet enters a person’s body, it causes certain damage to him, which in turn may differ from other traumatic injuries to the body.

The wounds are usually deep, and most often the bullet does not pass through the body and remains inside the body. Contamination of the wound may also occur due to foreign body entry into the body.

The severity of damage should be assessed based on the following factors:

Place of injury;

Type of injury;

The behavior of the victim

Injury to arms and legs

Before providing first aid measures for injured limbs, it is necessary to determine whether the victim is bleeding. If an artery is damaged when the shoulder or hip is damaged, then death can occur within two minutes from blood loss.

Arterial bleeding can be determined by the scarlet color of the blood and its flow in the form of a fountain. Venous blood is dark in color and flows less intensely. You can stop the bleeding using a tourniquet, pressure bandage, or wound packing.

You cannot apply a tourniquet for more than two hours, but usually this time is enough for qualified help to arrive or for the wounded person to be taken to the hospital. It should also be taken into account that in case of venous or arterial bleeding, the tourniquet is applied above the wound. A pressure bandage should be applied over the wound, directly to the site of bleeding. Wound tamponade is performed in rare cases. To use this method, you will need some narrow, long object and a sterile bandage, with which you need to stuff the wound as tightly as possible until the bleeding stops visible.

In case of a gunshot wound, the victim may develop pain or hemorrhagic shock due to heavy blood loss.

1. Stop the bleeding

2. It is necessary that the limbs are slightly raised; for this, the victim should be provided with an appropriate body position

3. Use blood replacement fluids to replace blood loss

4. Use painkillers and anti-shock medications, if available

5. Cover the victim

The next thing to do is to examine the victim for possible bone fractures. If any are found, you need to immobilize the limb, this will help minimize the possibility of damage to muscles, blood vessels, and ligaments. Wrap the fracture site with a sterile bandage to secure the limb and prevent contamination of the wound.

Head wound

A gunshot wound to the head does not cause immediate death in about 20% of cases. Due to the fact that in the front part of the head there is a large number of vessels, these injuries are usually accompanied by severe bleeding.

A concussion may also occur. Often such injuries are accompanied by a rash or loss of consciousness, but these moments are not necessarily caused by brain damage.

First of all, place the victim in a horizontal position and ensure a state of rest. In such cases, it is advisable not to touch the wound itself (if it is not facial) until the ambulance arrives; the only thing that can be done is to apply a sterile napkin to the wound site.

If there is a gunshot injury to the head, respiratory or cardiac arrest may occur, then you should resort to indirect massage heart, artificial respiration.

During severe bleeding or a wound to the face, you need to cover the wound with a sterile swab. Trying to take a patient to the hospital yourself is highly discouraged. If you nevertheless decide to transport yourself, then you need to take all available precautions to provide the wounded with maximum rest.

Spinal injury

With a gunshot wound to the spine, a brief loss of consciousness may occur. The victim is given a bandage to stop bleeding and carefully moved to a horizontal position. Just as in the case of a head wound, first aid is limited to stopping the bleeding and establishing a state of rest for the victim. To avoid worsening the wounded person’s condition, it is not recommended to take him to the hospital yourself.

Neck wound

Injuries to the neck may occur carotid artery, larynx, spine. If the larynx is affected by a gunshot wound, then you need to immobilize (lay down) the victim and stop the bleeding with a sterile bandage.

If the artery was damaged during the injury, then in this case it is worth immediately pressing it with your fingers and tamponade the wound with a sterile bandage. Since death with such a wound can occur within 30 seconds, the above procedure should be carried out as soon as possible. A tourniquet should be applied to the neck as shown in the photo to prevent the person from suffocating. It is also possible to transport the victim in a gentle manner.

Wound to the chest and stomach

There are three sections in the human body in which all the organs are located. These sections are the pleural cavity, abdominal cavity and pelvic organs. The first two sections are separated by the diaphragm, and the second two by the peritoneum. With gunshot wounds to the chest or abdomen, hemorrhage does not always occur outward, because blood can accumulate in these areas. This makes it extremely difficult to determine the severity of the injury.

If the organs of the pleural cavity are injured, such damage is fraught with the following complications:

1. Pneumothorax is a term meaning the entry of air into the pleural cavity through the opening of the wound.

2. Hemothorax is a condition in which blood accumulates in the pleural cavity due to injury

3. Pneumothorax occurs when both air and blood accumulate in the pleural cavity

To avoid air entering the pleural cavity, apply a gauze pad to the wound, which should be anointed with Vaseline or boric ointment; you can also use a piece of polyethylene or cover the wound site with your hand.

The victim should be helped into a semi-sitting position. It is very difficult to stop bleeding, so it is worth calling as soon as possible ambulance or send the victim to the hospital (while ensuring complete rest).

If the injury affected organs abdominal cavity, then measures should be taken to prevent bleeding and infection. The victim should be placed in a half-sitting position. If necessary, apply antishock therapy.

To prevent infection from entering the body, you need to treat the edges of the wound with a disinfectant, and then apply a sterile bandage to it.

Injury to the pelvic organs

With a gunshot wound to the pelvic organs, the following complications can occur:

– nerve damage,

– bone fractures,

– ruptures of arteries and veins.

Severe bleeding is stopped by using a tight tamponade at the wound site. If a fracture of the pelvic bone occurs, it is necessary to create conditions for immobility for the damaged part of the body. It is also worth preventing infection from entering the body. In case of such injuries, transportation of the wounded person should be carried out in a gentle manner.

Useful tips

When providing first aid it is always necessary dressing. When it is not at hand, you have to use a handkerchief, parts of clothing; but if you find a place to store the gun, then maybe a sterile bag will fit in your pocket. A first aid kit is required in the car. At home, it is advisable to have a first aid kit no worse than a car one. The most necessary thing for blood loss - blood replacement solutions, sold in pharmacies without a prescription along with an intravenous injection machine.

Do not forget that some advice can be obtained over the phone when calling an ambulance. It is better if by the time you call an ambulance you have correctly determined the injury and condition of the victim. Remember that there are often cases when the victim could not be saved due to the fact that, based on the message from those who called the ambulance, the operator sent a doctor of a different profile to the scene of the incident.

In some cases, self-delivery of the victim to the hospital is preferable (faster). City hospitals are on duty on a rotating basis. The address of the duty hospital can be found by calling the ambulance phone. The dispatcher can warn the emergency room of the hospital where you intend to deliver the wounded person about the nature of the injury so that the medical staff can prepare to receive the victim.

A gunshot wound is one of the most traumatic injuries you can suffer. It is difficult to assess the severity of injuries caused by a gunshot wound, and first aid alone is usually not enough. For this reason, it is best to take the victim to the hospital as soon as possible. However, you can provide first aid until the medical team arrives.

Steps

Part 1

First aid

Make sure you are safe. If an accident occurs (for example, while hunting), make sure that no one's firearm is pointed at anyone, is not loaded, and is in a safe and secure location. If a person has become a victim of a crime, then make sure that the shooter no longer poses a threat, and that you and the victim are in a safe place. If personal protective equipment is available, wear it.

Do not move the victim. Do not move the victim unless necessary to ensure his safety or provide medical care. Moving the victim can aggravate the spinal injury. Elevating the wound site can help reduce bleeding, but should only be done if you are sure there is no injury to the spine.

Act quickly. When providing first aid to a victim, time is against you. Victims who are brought to a medical facility during the golden hour are much more likely to survive. Try to act quickly, but don't rush or panic.

Apply direct pressure to wound . Take a cloth, bandage or gauze in your hand and apply direct pressure to the wound. Do this for at least ten minutes. If the bleeding does not stop, check the location of the wound and, if necessary, approach it from the other side. Place new dressings over old ones; Do not remove bandages when they are wet.

Dress the wound. If the bleeding decreases, cover the wound with cloth or gauze. Wrap it around the wound to apply pressure. However, do not tighten so tightly that blood flow stops or the victim loses feeling in his limbs.

Encourage the victim. Tell the victim that they will be okay and that you are helping them. Encouragement is important. Ask the person to talk to you. Do not let the victim freeze.

Stay with the person. Calm and warm the victim. Wait for the authorities. If blood has clotted around the bullet wound, do not remove it as it acts as a plug, preventing blood from flowing out.

Check Airways. If a person can talk, their airways are likely clear. If the person is unconscious, make sure their airway is not blocked. If they are blocked, but there is no spinal injury, then tilt his head. Tilt your head back, lightly pressing on your forehead with one hand and holding your chin with the other.

Check your breathing. Can the victim breathe normally? Can you see his chest rise and fall? If the victim is not breathing, remove excess fluid from his mouth and begin artificial respiration immediately.

Check your circulation. Apply pressure to the bleeding wound and then check the victim's pulse at the wrist or throat. Can you feel his pulse? If not, start doing CPR. Check for any serious bleeding.

Check if the person can move. Stiffness may indicate damage to the spinal cord or neck. Check if the victim can move his arms and legs. If not, the spinal cord may be damaged. This injury may be indicated by open or obvious fractures, dislocations, or anything that looks abnormal or unnatural. If the victim cannot move, then under no circumstances should he be moved.

Check for open wounds. Always pay attention to open wounds. Carefully examine the victim, making sure that he has wounds that you did not immediately notice. Pay special attention to the armpits, buttocks, or other hard-to-reach areas. Do not undress the victim completely until emergency services arrive, otherwise the state of shock will only worsen.

Part 3

Treating wounds on the arms or legs

Elevate the limb and apply direct pressure to the wound. Carefully examine the victim for signs of disability or any wounds that could cause spinal injury. If they are not, then raise the limb above the level of the heart to reduce blood flow. Apply direct pressure to stop bleeding as described above.

Apply indirect pressure. Besides direct pressure, indirect pressure can be applied to the injured limb to limit blood flow to the wound. This is done by applying pressure to the arteries, or pinch points as it is sometimes called. They will feel like particularly large and hard vessels to the touch. Putting pressure on them will limit internal bleeding, but you need to make sure you're putting pressure on the arteries leading to the wound.

Make a tourniquet. The decision to apply a tourniquet must be taken seriously, because it can lead to the loss of a limb. But at very heavy bleeding and if you have a bandage or cloth at hand, it is worth considering applying a tourniquet. Wrap the bandage tightly around the limb, between the wound and the heart, as close to the wound as possible. Wrap around the limb several times and tie a knot. Leave enough fabric to tie it to the stick. Twist the stick to restrict blood flow.

Part 4

Treatment of a "sucking" chest wound

Identify the "sucking" chest wound. If a bullet hits the chest, then there is a possibility of a “sucking” chest wound. Air enters through the wound but does not escape, destroying the lungs. Signs of a sucking chest wound include a sucking sound coming from the chest, coughing up blood, frothy blood from the wound, and difficulty breathing. When in doubt, treat the wound as if it were a sucking chest wound.

Find the wound and gain access to it. Find the location of the injury. Move clothing away from the wound. If there is a piece of tissue stuck to the wound, trim it around it. If the wound is through, then apply pressure to both sides.

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Wound healing and consolidation of gunshot fractures of the upper extremity occur more favorably than those of the lower extremities. A common purulent, anaerobic infection, osteomyelitis is less common. The conditions for this are wide incisions, care in performing the procedure for excision of non-viable tissue, and, if necessary, timely secondary necrectomy, which should not be postponed if indicated. In the event of open wound and granulating surfaces, early secondary or late secondary suture cannot always be used, therefore, in such situations, one should definitely keep in mind the use of free skin grafting, and if necessary, use a skin stem according to Filatov.

Shoulder fractures. Gunshot wounds with a fracture of the humerus account for about a third of all shoulder injuries. In addition to the deformation or malposition of the limb, pathological mobility at the fracture site, dysfunction of the limb, pain in the fracture zone, the results of measuring the length of the limb, one should also take into account such a sign as the presence of fat droplets in the wound discharge. Most often during surgical treatment of a firearm For a shoulder fracture, the wound is dissected, bone fragments and foreign bodies are removed, then soft tissue is excised.

Thus, when the shoulder is injured, relatively simple surgical procedures are performed, which is explained by the relatively small volume of muscles, the absence of dense fascial layers, less contamination of the wound, and a relatively high percentage of through wounds.

With gunshot wounds of the shoulder region, especially in the upper third of the shoulder, combined injuries are not so rare, when the same wounding projectile: a bullet, a fragment - first causes a fracture of the humerus, and then penetrates the pleural cavity, causing injury to the lung, blood vessels, other anatomical formations. In some cases, along with a fracture of the humerus, the scapula may be injured, and bone fragments seriously injure the muscles of the suprascapular and subscapular region. Since the direction of soft tissue injury does not always correspond to the true direction of the wound channel, a thorough physical and radiological examination of the patient is especially important, including chest x-ray in two projections, and, if necessary, in more projections.

The question of the need for thoracotomy for such wounds should be decided on the basis of firmly established principles of military field surgery: thoracotomy is indicated only for ongoing intrapleural unstoppable bleeding, large hemothorax and for valvular pneumothorax that cannot be eliminated by conservative measures.

The general good condition of the wounded person, carefully performed surgical treatment, a sufficient number of well-supplied muscles, the possibility of closing the wound without tension, good drainage, observation of the patient by the operating surgeon.

Gunshot fractures of the humeral diaphysis are usually through and through (Fig. 3.7). Surgical treatment of such fractures is carried out according to general rules, carefully protecting the radial nerve from additional trauma. For a gunshot fracture of the shoulder, the optimal methods of fixation are the Ilizarov apparatus, as well as a plaster thoracobrachial bandage.

With through fractures of the shoulder and large exit holes, you can limit yourself to surgical treatment of only the exit hole.

In this case, sufficient access is provided, conditions for excision of non-viable tissue, comparison of bone fragments and subsequent drainage. A significant number of gunshot fractures of the humerus can be reduced after surgical treatment using an abduction splint fixed to the body with plaster rings. The same rings are used to secure the shoulder and forearm on the splint. If for some reason an external fixation device is not used for gunshot wounds of the shoulder or forearm, a thoracobrachial bandage can be used with the arm in abduction. The bandage is relatively easily tolerated by patients, simplifies their subsequent management and, when the arm is fixed for 2-3 weeks, does not cause stiffness in the shoulder joint. This bandage is convenient to apply at the end of the operation under anesthesia. In the interval from the 5th to the 8th day, if necessary, a “window” is cut out in the wound projection in the thoracobrachial bandage and the necessary therapeutic measures are carried out, for example, applying delayed sutures or free skin grafting.

It is advisable to divide shortening of upper limb segments into functionally compensated (up to 4 cm), conditionally compensated (4-6 cm) and non-compensated (more than 6 cm). Forearm injuries. 2/3 of those wounded in the forearm are admitted to the hospital without signs of suppuration (Figure 3.8). Provided that surgical treatment is carefully performed and bone fragments are stablely fixed, the results of treatment of this category of wounded can be considered quite satisfactory. Transosseous osteosynthesis devices should be considered the method of choice for immobilizing fragments. For gunshot wounds of the forearm, it is often necessary to resort to free skin grafting to close skin defects.

A feature of gunshot wounds of the forearm is frequent nerve damage, requiring subsequent neurolysis and nerve suture.

A technique has been developed for inserting the needles on the bones of the forearm, as well as a special conductor that allows the needles to be inserted at the desired angle.

Using conservative and surgical treatment methods, it is possible to restore the anatomical integrity of the bones in almost 90% of the wounded. Approximately 10% of the wounded remain with persistent defects, false joints; characterized by a high percentage (more than 20) of contractures. Wounds to the hand. The variety of gunshot injuries to the hand is very large. It is not uncommon to be injured by shrapnel when the main localization of the injury is in another area. Extensive damage to bone, muscle and tendon structures occurs when the left hand is wounded at close range.

The main condition for a successful operation for a gunshot fracture of the hand is to perform it in a specialized hospital using special instruments, an operating microscope, etc.

A wound to the hand itself can rarely cause the wounded person to go into shock; in such cases, one or more other injuries should always be looked for. A delay in performing surgical treatment of the hand is quite justified if there is a good primary medical dressing and reliable immobilization, although purulent infection is a frequent accompaniment of wounds of the hand, especially when the bones of the wrist are damaged.

First aid for a hand injury consists of applying a sterile bandage, sometimes a pressure bandage. For widespread injuries of the hand, immobilization with a scarf or using standard means is indicated. The wounded hand must be fixed in a functionally advantageous position, for which a thick ball of cotton wool is placed in the wounded person’s palm and the fingers are placed on it, the entire hand is bandaged to a ladder or mesh splint modeled on the palmar surface.

Providing surgical care to wounded people in the hand should be limited at the stage of qualified surgical care to stopping bleeding and immobilization, since without an x-ray it is impossible to begin complex surgical treatment of a wound of the hand.

When surgically treating large wounds of the hand, general anesthesia is preferable; conduction or intraosseous anesthesia can be used.

The surgeon must perform operations on the hand with the help of an assistant. The necessary conditions are a well-lit surgical field, sufficient time and a good surgical instrument and suture material.

Careful preparation of the surgical field is very important: nails should be cut short, hair should be shaved, and the entire hand should be washed thoroughly with warm water and soap.

When performing interventions on the hand, good hemostasis is very important, which is controlled by periodically removing the tourniquet; The tourniquet should be on the arm for no more than 1 hour continuously. If the ulnar or radial arteries are injured, one of them can be ligated, but in no case both, as this will cause necrosis.

The skin on the hand can be excised only if it is undoubtedly non-viable; in other cases, even heavily contaminated skin should be preserved.

During surgical treatment, it is necessary to carefully examine the deep formations of the hand and determine the degree of damage to all structures. For severe hand injuries, a transverse incision of the transverse carpal ligament is advisable.

Necrotic muscles, blood clots, and foreign bodies are removed. It is advisable to preserve bone fragments that are not very dirty. Obviously non-viable tendons should be removed, but literally every millimeter of viable tissue must be fought for. Amputation of fingers is indicated in case of obvious necrosis. This especially applies to the first finger. Sometimes it is necessary to save at least part of the skin from the amputated finger to close the skin defect on the remaining one.

When amputating fingers, a flap is cut out, carefully ligating the blood vessels and sawing the phalanx with a thin file. After intersection, the tendons should be sutured to the periosteum. The ends of the destroyed nerves usually extend far to the sides. They should not be sought during initial surgical debridement; however, if possible, the ends of the nerves should be brought closer to relatively healthy tissue and the nerves should be secured with nonabsorbable suture material.

In most cases, it is better to close the wound with a delayed primary suture. The use of thin Kirschner wires is indicated for fixation of fractures and dislocations of the phalanges of the fingers. In case of intra-articular fractures of the interphalangeal or metacarpophalangeal joints, in cases where the articular ends of the bones are completely crushed, one should resort to very economical removal of these areas. We must not forget about the mandatory immobilization of the hand after any intervention on it.

The bandage should cover the entire wound, but not squeeze it. Healthy fingers should be visible. The hand is fixed in a functionally advantageous position. Surgical treatment of a gunshot wound to the hand is not indicated for through wounds of the hand and fingers with pinpoint entry and exit holes, for tangential wounds of the fingers and hand, provided that the wound has smooth edges, as well as for superficial finely splintered wounds. In the postoperative period, physical therapy is especially recommended for wounded people with injuries to the hand and fingers.