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Chest injury clinical manifestations. Symptoms of sternum injury

Injury chest in children it accounts for about 3% of all injuries. Injuries to the chest are divided into closed and open, with and without damage to the chest skeleton and internal organs chest cavity. Traumatic injuries to the chest wall and internal organs may include:

  • subcutaneous emphysema,
  • hemothorax,
  • pneumothorax,
  • pneumomediastinum,

if they occur, severe complications may develop in the form of pleuropulmonary shock and compression syndrome of the superior vena cava.

Subcutaneous emphysema, i.e., the accumulation of air in the subcutaneous fatty tissue, is often observed with a penetrating wound and air entering through the wound, as well as with injury to the lung, bronchus, and trachea. The presence of air in the subcutaneous fatty tissue is determined by palpation, accompanied by a sensation of crunching (crepitus). Subcutaneous emphysema is often combined with pneumomediastinum, in which air accumulates in the mediastinum, which can lead to compression of internal organs. Increasing, i.e. spreading to the chest, neck, face and even to abdominal wall and lower back, subcutaneous emphysema indicates the continued flow of air through the bronchi in the presence of a defect in the visceral pleura or through a wound with broken skin.

Hemothorax- presence of blood in the pleural cavity - develops when the intercostal and other vessels of the chest wall are injured, as well as when damaged pulmonary vessels and other organs of the chest cavity. Hemothorax can also be observed with thoracoabdominal wounds

The accumulation of blood is accompanied by a clinical picture of internal bleeding and is determined by shortening the percussion sound and weakening of breathing during auscultation in the lower pulmonary fields during vertical position sick. Significant hemothorax is accompanied by dizziness, pallor of the skin, bluish coloration of the lips, decreased blood pressure, frequent weak pulse, shortness of breath, thirst. These symptoms include chest pain, restless behavior child, weakness. The mediastinal organs are displaced to healthy side. X-ray examination clarifies the diagnosis.

Pneumothorax- the presence of air or gas in the pleural cavity - more common with penetrating wounds of the chest.

There are open, closed and valve pneumothorax. Free entry of air into pleural cavity and its free exit with a sufficiently wide or straight wound channel cause an open pneumothorax. In this case, there is a greater or lesser decline (collapse) of the lung. When you inhale, you can hear the sound of air being sucked through the wound. When you cough, foamy blood comes out through the wound. If at the time of injury air enters the pleural cavity, and subsequently does not leave or enter it, a closed pneumothorax occurs.

Its symptoms are not so pronounced. With the oblique direction of the wound channel, air enters the pleural cavity when inhaling, but when exhaling, the channel closes and with each subsequent inhalation in the pleural cavity, the amount of air that cannot find an outlet increases. This is how a valve pneumothorax is formed. It can occur when the lung is damaged if, when inhaling, air passes into the pleural cavity, and when exhaling, the edges of the lung tissue collapse and cover the lumen of the bronchus. In this case we're talking about about internal valve pneumothorax.

In these conditions, air progressively accumulates in the pleural cavity (tension pneumothorax), causing compression of the lung and displacement of the mediastinal organs. Signs of tension pneumothorax are progressive cardiac and pulmonary disorders, sometimes increasing subcutaneous emphysema. On percussion, tympanitis is detected instead of a pulmonary sound, and on auscultation, weakening of breathing is detected. The heart is displaced to the opposite side.

Fractured ribs It is rare in children due to the elasticity of the rib frame and good shock absorption in case of chest injury.

Clinic and diagnostics

For isolated rib fractures characteristic symptom is a local pain that sharply intensifies when coughing, deep breath, sneezing. Local swelling, bruising and, rarely, crepitus are detected. The child spares the site of injury, takes a forced position and reluctantly performs movements. Usually there is no significant displacement, but at the time of injury the sharp edge of a broken rib can disrupt the integrity of the parietal pleura or damage lung tissue. In such cases, the formation of subcutaneous emphysema and pneumothorax is possible. Injury to the intercostal vessels may be accompanied by bleeding into the soft tissue and into the pleural cavity (hemothorax).

On examination, mild cyanotic skin, shortness of breath, shallow breathing for fear of increased pain when taking a deep breath. During palpation along the broken rib, increased pain is noted. Compression of the chest in the sagittal and frontal planes during the examination also causes pain to the child, so palpation should not be used when negative reaction sick. X-ray and fluoroscopy clarify the diagnosis. Paradoxical breathing can be observed with a “fenestrated” rib fracture.

Treatment

For rib fractures, treatment consists of novocaine intercostal blockade, as well as alcohol novocaine anesthesia of the fracture area. In case of severe symptoms of pleuropulmonary shock, it is advisable to carry out a vagosympathetic blockade according to A.V. Vishnevsky. If hemopneumothorax is present, a pleural puncture is performed. Bandages are not applied, since tight bandaging of the chest limits lung excursion, which negatively affects recovery period(possible complications in the form of pneumonia, pleurisy). In uncomplicated cases, recovery occurs within 2-3 weeks.

Chest compression- severe type of damage observed during earthquakes and landslides. Compression when the glottis is closed leads to a strong increase in intrathoracic pressure, which is transmitted to the branches of the superior vena cava, which does not have valves. As a result, a reverse flow of blood occurs, which leads to increased pressure and rupture of small veins of the head, neck and upper half of the chest. A picture characteristic of traumatic asphyxia develops: in specified places, as well as on the conjunctiva, mucous membrane of the oral and nasal cavity and the eardrum, characteristic small-point hemorrhages appear, which slowly resolve within 2-3 weeks.

Traumatic asphyxia is often accompanied by symptoms of shock, and therefore, when providing assistance to an injured child, anti-shock measures should be carried out. With direct and strong impact on the chest, more severe damage to internal organs can occur. With significant ruptures of lung tissue and damage to blood vessels, severe intrapleural bleeding can occur, which leads to death. Damage to the bronchi accompanied by tension pneumothorax is dangerous.

The continued flow of air into the pleural cavity leads to lung collapse, mediastinal shift; Emphysema of the mediastinum develops. The child's condition is deteriorating catastrophically and only active actions the surgeon can save the patient. If the bronchus is damaged, the measures include urgent surgical intervention and suturing of the defect. Bülau drainage or continuous aspiration is advisable for minor injuries to the lungs and bronchi.

Damage to the diaphragm in children they are more often observed with severe trauma to the abdominal organs and, especially, in combination with a fracture of the pelvic bones. An increase in intra-abdominal pressure at the time of injury leads to rupture of the diaphragm, usually the left dome.

Clinic and diagnostics

With minor damage to the diaphragm, pain on the side of the injury and difficulty breathing are noted. Shortness of breath, increasing cyanosis and pallor of the skin are observed. If internal organs move into the pleural cavity, the child’s condition worsens. Infringement of the intestinal loops, as well as the stomach in the opening of the diaphragm, causes tension in the mesentery and increased pain. Increasing swelling of the intestine and its mesentery leads to intestinal obstruction.

X-ray examination helps to diagnose diaphragmatic rupture based on the displacement of the mediastinum to the healthy side, the absence of clear contours of the diaphragm and the presence of loops small intestine in the pleural cavity. As the stomach moves into the chest cavity, a fluid level may be noted that simulates an abscess or pleurisy. During puncture, gastric or intestinal contents enter the syringe. In this regard, if a traumatic injury is suspected diaphragmatic hernia puncture of the pleural cavity is contraindicated due to the risk of infection.

Treatment

Surgical intervention involves bringing down the displaced organs to abdominal cavity and suturing the defect in the diaphragm.

Chest wounds

If the chest is injured and there is an open pneumothorax, the latter must be converted to a closed one by urgently applying an occlusive dressing (tightening the edges of the wound with strips of plaster and applying a tight aseptic dressing). the main objective bandages - stop the flow of air into the pleural cavity. Urgent surgery is indicated.

Bychkov V.A., Manzhos P.I., Bachu M. Rafik H., Gorodova A.V.

The chest is formed by the corresponding part of the spine, ribs attached to each of the vertebrae with their cartilaginous extensions, some of which are attached to the sternum in front. Humans have only 12 pairs of ribs.

Chest injuries:

  • injury;
  • shake;
  • compression;
  • fractures of bone parts (ribs, sternum, spine);
  • penetrating wounds.

Closed chest injury

Complicated rib fractures


Rib fractures are often complicated by pneumothorax.

This is a more severe injury in which bone fragments are displaced inward and damage the pleura and lungs. Symptoms of a complicated fracture:

  • the victim tries not to lie down; it is easier for him to sit;
  • pain at the site of injury;
  • , feeling of lack of air;
  • pale skin;
  • bluish lips;
  • shallow rapid breathing, increased heart rate;
  • streaks of blood in the sputum.

When you feel the site of injury, you can determine the characteristic sensation of “crunching snow.” This is a sign of a closed one - damage to the outer layer of the pleura, as a result of which air enters the pleural cavity at the time of injury, and the lung collapses. Often, with a closed pneumothorax, there is also an accumulation of blood in the pleural cavity - hemothorax.

Fenestrated fractures pose a danger to life. They occur, for example, when hitting the steering wheel during a traffic accident. In this case, each rib has two fractures, and as a result, a mobile area is formed, which shifts during breathing and constantly damages the lungs.

The victim cannot take a breath and begins to suffocate. The neck veins swell and hemoptysis appears. Very quickly, air begins to accumulate under the skin, which is accompanied by swelling and a feeling of crunchy snow when palpated. This condition (subcutaneous emphysema) spreads from the chest to the neck, face, abdomen and even the lower limbs.

The victim should be immediately released from the compression, given an anesthetic and transported to the hospital in a sitting position.

Penetrating chest injury

Such an injury is dangerous due to the development of open pneumothorax, when there is a constant supply (“suction”) of air from environment into the damaged pleural cavity. The accumulating gas puts more and more pressure on the lung, causing it to collapse.

In addition to the signs characteristic of a complicated rib fracture, with an open pneumothorax in the wound area, squelching, smacking sounds can be heard when breathing. During exhalation, foamy blood is released from it.

With an open pneumothorax, the main thing is to seal the wound and stop the flow of air into it. To do this, you can first, for example, quickly cover it with your palm. Then several small pieces of fabric (handkerchiefs, individual dressing bags) are applied to the wound. From above, all this is covered with airtight material.

As a material impermeable to air, you can use:

  • oilcloth;
  • plastic bag;
  • cotton wool soaked in Vaseline;
  • several layers of adhesive tape.

Reinforce the sealing material with a spiral bandage, wrapping the bandage around the chest. Transportation is carried out in a half-sitting position, slightly tilting the victim back, and a cushion, rolled up clothes, a blanket, etc. should be placed under his half-bent knees.

Chest injuries - quite common species injuries, in the practice of ambulance and emergency care, accounting for 5.7 to 10% of all injuries to the human body.
The chest is the receptacle for such important organs, like the heart and lungs, and plays a primary role in the act of breathing. Therefore, injuries to the chest may represent great danger for life.
All injuries to the chest are divided into open and closed, injuries with and without damage to bones, with and without damage to the pleura and internal organs.

Closed chest injuries are the main type of peacetime damage. The severity, depth, nature of the damage and, accordingly, its clinical manifestations(bruises, hematomas of the chest wall, skin detachment, etc.).
The severity of damage to internal organs cannot be judged by the degree of trauma to the chest wall. Thus, it is incorrect to assume that a simple rib fracture cannot be associated with serious lung damage.

The most common injuries to the chest are rib fractures. Among all closed chest injuries they range from 40 to 80%.
In children and adolescents, injuries to the chest in the form of fractures are very rare, but with age, when the chest becomes more rigid, the frequency of these injuries increases. The rarity of rib fractures in children is explained by the elasticity and flexibility of their chest. However, this simultaneously increases the possibility of damage to visceral (internal) organs.
According to the mechanism of injury, rib fractures can be divided into direct, indirect and avulsion. In a direct fracture, the rib breaks where a traumatic force is directly applied, which also damages the soft tissues of the chest. When a fractured rib is pressed inward, an angular displacement of the fragments occurs. If an external force acts on a rib closer to the spine, then it causes a shear-type fracture: the central fragment remains in place, and the peripheral one - mobile and long - moves inwards. A double fracture of one rib occurs as a combined fracture (simultaneous exposure to direct and indirect impact). Multiple rib fractures are usually accompanied by significant displacement of the fragments, especially with double fractures. Avulsion fractures of the ribs (from IX and below) are characterized by a large displacement of the fragment torn from the rib.
When the ribs are fractured, their fragments can damage the pleura and lung, as well as intercostal vessels, which is accompanied by bleeding into the pleural cavity (pneumothorax). In addition, hemorrhages in the lungs (usually in the lower lobes) are possible, from small superficial to very extensive, occupying an entire lobe. Ruptures of lung tissue of various sizes with damage to blood vessels and bronchi are also possible.
A rib fracture always aggravates the already difficult general condition of the patient due to the development of hypoxia (lack of oxygen) and hypercapnia (excess carbon dioxide).

Symptoms. Pain at the site of injury, pain when the chest is compressed in the anteroposterior direction. Breathing movements short and superficial. The pain syndrome increases sharply when coughing. The patient feels better in a sitting position than in a lying position.

Treatment. First aid for victims with rib fractures and their further treatment are aimed at relieving (eliminating) pain, alleviating external respiration and prevention of pneumonia, which very often develops with multiple rib fractures in older people.
A fracture of one rib without other injuries to the chest organs is not classified as a serious injury and is usually treated on an outpatient basis.
Victims with fractures of 2 or more ribs may require hospital treatment. In such patients, for 1-2 weeks, and sometimes longer, pain is observed during respiratory excursions of the chest: pain can be reduced by recommending the patient to a semi-sitting position in bed, using tight bandaging of the chest or applying an adhesive bandage (at the moment of exhalation). You can wrap a wide towel or piece of linen around your chest. It must be remembered that the chest has the shape of a cone and therefore, without additional fixation, the bandages quickly move. It is best to secure the bandages at the top with small straps. We should strongly caution against applying pressure bandages to older people. reduces very well pain syndrome novocaine blockade at the fracture site with a 0.5% novocaine solution in an amount of 10-20 ml. In elderly people, instead of novocaine, it is better to administer a 1% solution of lidocaine as a less toxic drug (up to 20 ml). Sometimes you have to prescribe painkillers. Full recovery occurs in 4-6 weeks.
Other injuries to the chest are less common: bruises, concussions and compression. If you hit the chest with a blunt object, it can be bruised and concussed; Another injury is compression of the chest by blunt but hard objects. The mechanism of these injuries is different, but the clinical picture and pathogenesis are similar. They can be caused by a fall, the body being pressed by some hard object, collapses of loose and hard rocks, as well as strong air shock.

At concussions no anatomical changes are found in the tissues of the body, but an extremely severe picture of shock develops. Breathing movements are extremely uneven and painful. This condition can only be alleviated by inhaling oxygen under high blood pressure and ensuring complete peace.
Clinical picture concussion of the chest is characterized by the following symptoms: severe general condition, cyanosis, coldness of the extremities, barely perceptible uneven pulse, difficulty breathing, uneven, frequent, superficial with a fairly clear consciousness.

Chest contusions mild strength, characterized only by pain and a small hematoma (bleeding) at the site of the bruise; practically they do not require any treatment.
At severe bruises are coming extensive hemorrhages in tissue and cavity. Massive rupture of tissues and organs with fatal consequences can also occur. A contused lung can be ruptured in many places.

Chest compression bodies with blunt, but not hard objects resemble bruises in their clinical picture. With them, pinpoint hemorrhages (ecchymoses) are observed on the bluish skin of the chest, head and neck, but the latter are not extensive and often resemble a petechial rash. The same pinpoint ecchymoses appear on the conjunctivae of the eyes and on the skin ears and eardrum.
A rare injury is sternum fractures. Fractures of the sternum can be complete or incomplete, direct or indirect. A direct fracture of the sternum can occur as a result of a blow to the chest with a heavy object, in car accidents, especially when the driver’s chest hits the steering wheel, compression of the chest in the anteroposterior direction. An indirect fracture of the sternum is caused by excessive muscle traction in 2 opposite directions. Such fractures sometimes occur when the spine is hyperextended or, conversely, when it is sharply bent. Fractures of the sternum are most often localized at the border of the manubrium and the body and much less often on the body itself. Sometimes the body of the sternum shifts posteriorly, sometimes one fragment overlaps another. Lateral radiography plays a decisive role in the diagnosis of sternal fractures.
With fractures of the sternum, patients complain of pain that intensifies with deep inspiration and coughing. Palpation is always painful. Crepitation, deformation and hematoma are sometimes observed.
Treatment of isolated sternal fractures without displacement of fragments comes down to rest and the administration of analgesics. If the fragments are displaced, reposition is performed on a hard bed with the patient in the supine position with a rigid cushion placed (moderate flexion of the spine) with simultaneous traction in a Glisson loop for 2-3 weeks. In all cases, it is necessary to apply novocaine to the fracture site or a vagosympathetic blockade, and prescribe painkillers.

Open chest injuries in peacetime conditions they are rare, but their frequency increases sharply in wartime. There are gunshot and non-gunshot injuries to the chest, penetrating and non-penetrating, with and without bone damage (ribs, sternum, clavicle, scapula); based on the nature of the wound channel, blind, through and tangential injuries are distinguished.

At isolated chest wounds Without skeletal damage, the victims are in satisfactory condition. First aid consists of applying an aseptic or pressure (if there is bleeding) bandage.

Among penetrating chest wounds wounds without open pneumothorax, with open pneumothorax and with valve pneumothorax are distinguished. All other things being equal, the severity of damage in penetrating wounds of the chest is largely associated with concomitant violations of the integrity of the chest skeleton, in which the scale of damage increases due to the action of bone fragments that penetrate into the lung tissue and contribute to the development of purulent infection.
With penetrating wounds of the chest, air penetration and bleeding into the pleura are observed (hemopneumothorax). The source of bleeding is damaged vessels of the chest wall or lung, or both.
Penetrating chest injuries are most often accompanied by a lung injury. This latter is characterized primarily by hemoptysis, subcutaneous emphysema and hemothorax. Each of these symptoms individually does not play a decisive role in the diagnosis. Diagnostic value has only a combination of several symptoms.
The most consistent symptom is hemoptysis. Subcutaneous emphysema often occurs as a result of forcing air into subcutaneous tissue from the pleural cavity, where it in turn enters through a wound or wounded bronchus. Extensive, rapidly spreading emphysema indicates the presence of valvular pneumothorax. In diagnosing these conditions important role belongs to X-ray examination.

Pneumothorax. Traumatic pneumothorax is called pathological condition chest, characterized by the accumulation of air in the pleural cavity. This air can enter the pleural cavity through a wound in the chest wall or damaged bronchus. The air pushes the pleura apart and the lung collapses.
Traumatic pneumothorax occurs in 55-80% of cases of all penetrating chest injuries. It can be open, closed or valved.

Closed pneumothorax They call this condition when the chest wound is closed by displaced tissues, and the air entering the pleural cavity is not communicated with the external environment. When hit small portions air into the pleural cavity, the latter quickly resolves. Moderate accumulation of air in the pleural cavity does not cause significant functional impairment.

Penetrating chest wounds with open pneumothorax characterized by the fact that air is sucked in through the wound when you inhale, and comes out of it when you exhale. This air causes collapse of the lung and displacement of the mediastinal organs to the healthy side.

A dangerous type of pneumothorax is valvular (increasing) pneumothorax, which is formed if the characteristics of the wound are such that it is possible for air to enter the pleural cavity and it is impossible for it to be exhaled back. The clinical picture of valvular pneumothorax is characterized by rapidly increasing respiratory distress. Choking, cyanosis, and tachycardia come first. During percussion, a box sound is detected.
The clinical picture of pneumothorax is generally characterized by shortness of breath, tachycardia, cyanosis of the skin and mucous membranes. These main phenomena may soon be joined by symptoms of advancing hemothorax.
With pneumothorax, the mediastinal organs shift to the healthy side with each inhalation and exhalation - mediastinal balloting. This complicates ventilation of the lung, blood flow to the displaced heart as a result of bending of the mediastinal vessels and causes significant irritation of the pleural receptors.
At the moment of inhalation during pneumothorax, outside air enters the healthy lung through the trachea, but at the same time, air from the collapsed lung is also partially sucked into it, which in this phase is even more compressed. When you exhale, the lung on the damaged side expands slightly, capturing some of the exhaust air from the healthy lung. This is how paradoxical breathing of the lung on the side of the injury occurs and the pendulum-like movement of air between both lungs. All this, together with increasing blood loss, gradually worsens the victim’s condition. Therefore, wounded people with open chest injuries, especially with valvular pneumothorax, need urgent medical care.

First aid for victims with chest injuries in the presence of pneumothorax consists of applying a bandage to the wound. The dressing must be sealing (occlusive). To do this, you can use the rubberized shell of a first aid bag, which the inner (sterile) side is applied directly to the wound, or the wound is sealed with an adhesive plaster. A massive pressure bandage is applied over them during the exhalation phase, immobilizing the chest.
In cases of severe pneumothorax, especially valvular pneumothorax, a pleural puncture is performed and the air trapped in the pleural cavity is sucked out until the pulled syringe piston does not independently return to its original position ( negative pressure in the pleural cavity). If this cannot be achieved, the victim is evacuated without removing the needle (the latter is fixed to the skin with threads and covered with a bandage).
Tension closed pneumothorax can cause the formation of subcutaneous emphysema due to mechanical action muscles that push air through the rupture of the parietal pleura. Traumatic emphysema can occur from compression of the chest of any etiology. However, it can spread over a considerable distance, reaching the scrotum and upper thighs. Mediastinal emphysema is observed with tension pneumothorax with rupture of the mediastinal pleura or due to rupture of the primary bronchi or trachea. Air passes into the mediastinum and emphysema spreads to top part chest, neck and face.

Hemothorax- accumulation of spilled free blood into the pleural cavity - can be observed when the lung, intercostal arteries or internal mammary artery are damaged. Open chest injuries are accompanied by hemothorax in up to 50%, closed ones - in up to 7.7% of cases.
The amount of blood spilled into the pleural cavity can be very different and range from a few milliliters accumulating in the sinuses to 1 liter or more. If little blood has been shed (up to 150 ml), then hemothorax often remains unrecognized. The amount of blood spilled into the pleural cavity is always related to the nature and location of the wound. With superficial damage to the lung, large hemothorax does not occur.
In some cases, hemothorax is combined with pneumothorax. This pathological condition is called hemopneumothorax.
The clinical picture of hemothorax is characterized by a combination of the following pathological conditions: intracavitary bleeding, atelectasis (shrinkage) of the lung, displacement of mediastinal organs, hemodynamic disturbances and shock.
I distinguish between a small hemothorax (the level of spilled blood reaches the middle of the shoulder blade) and a large one. With large hemothorax, the patient's condition is always extremely severe. The patient is in a forced sitting position, leaning his body on his hands, a suffering look, breathing is rapid and shallow, cyanosis is noted, the pulse is tense and rapid, consciousness is clear, i.e. there is a clinical picture of degree II or III. Subcutaneous emphysema is often pronounced. When the lung is damaged due to hemothorax, hemoptysis is observed. Required X-ray examination and diagnostic pleural puncture.
For small pneumothorax, and often for medium pneumothorax, it is necessary to conservative treatment. Blood spilled into the pleural cavity is absorbed. However, sometimes a medium hemothorax and almost always a large one require maximum removal of blood from the pleural cavity using pleural puncture on the 1st - 2nd day. For rib fractures and shock, vagosympathetic blockade is recommended. At the same time, antibiotics, humidified oxygen, artificial respiration, anti-shock measures, etc. should be used. In cases of increasing hemothorax, thoracotomy is recommended for the purpose of revision and stopping bleeding.

Traumatic shock. For chest injuries without damage to the lungs and pleura, the clinical picture developing shock is typical, as with any traumatic shock. With penetrating wounds of the chest, the clinical picture of shock is somewhat different from the usual and is called pleuropulmonary shock.
The most important pathogenetic feature of pleuropulmonary shock is that with it there is not only transport hypoxemia associated with a decrease in the volume of circulating blood, as in other forms of shock, but also ventilation hypoxemia. The blood loss that often occurs against this background is especially poorly tolerated by patients and worsens their condition.
In chest wounded patients with open pneumothorax, respiratory and cardiovascular failure, phenomena of severe hypoxemia. Blood pressure drops, the pulse becomes thready, rapid and soft, breathing becomes rapid and shallow. sharp suffocation, cough, chest pain aggravate the patient's condition.
Shock therapy must be carried out along with other measures at the first stage of first aid. It includes administering drugs, dressing patients, intravenous drip administration of polyglucin solutions or other blood substitutes. In the hospital, such victims are placed either in an anti-shock ward or in intensive care unit and spend with them full complex measures to combat shock; if necessary, resort to surgical treatment.


Closed chest injuries In peacetime, chest injuries account for about 10% of all injuries. Among such injuries are usually considered: closed injuries without damage and with damage to internal organs; wounds that do or do not penetrate the chest cavity. Closed chest injuries include: bruises, concussions, compression, fractures of the ribs and sternum

Chest bruises are the result of a road traffic, household or sports injury. Clinical picture. The course and severity of the injury depend on its isolation or combination with other injuries. At the site of injury, pain and hemorrhage into the subcutaneous tissue and intercostal muscles are noted. The pain intensifies with palpation of the hemorrhage site, during inhalation and exhalation. Respiratory and circulatory disorders may be observed to varying degrees of severity. The diagnosis is made based on clinical and radiological examination of the patient. Treatment. When providing first aid in the first hours after an injury, it is recommended local application cold (ice pack, spraying the injury site with chlorethyl). Painkillers are prescribed internally (analgin, amidopyrine, paracetamol, etc.). In the future, heating pads and other physiotherapeutic methods of treatment are used locally to speed up blood resorption. The sensation of pain gradually decreases over the course of a week and then disappears.

Chest concussion is a kind of damage to the organs of the chest cavity when exposed to a shock wave. Due to rapid changes in atmospheric pressure, alveoli and lung tissue can rupture. Clinical picture. There is shallow breathing with interruptions, pallor (with a grayish tint) of the face, cyanosis of the lips, repeated vomiting, rare pulse, blackout. With severe concussions, death occurs quickly. The diagnosis is established on the basis of a clinical examination of the affected person, taking into account the impact of the shock wave. Treatment. First health care turns out using symptomatic means and taking into account the severity of the damage. The victim is evacuated to specialized therapeutic hospitals.

Chest compression occurs after compression between two hard objects. Such injuries occur in victims of landslides, earthquakes, trains, and agricultural work. In this case, ruptures of the lung tissue may occur, blood vessels and bronchi. At the moment of compression, the pressure in the veins of the neck and head increases, capillaries rupture. Clinical picture. Severe pain, shortness of breath appears, the pulse quickens, a bluish discoloration of the skin of the face and neck is noted with the presence of pinpoint hemorrhage on the skin of the head, neck, and upper chest. In severe cases, coughing produces serous sputum. With strong compression as a result of a sudden increase in chest compression, traumatic asphyxia may develop. The diagnosis is established on the basis of determining the mechanism of injury, clinical and radiological examination of the patient. Treatment. After removing the victim from under the rubble, he is provided with immediate first aid. Provide rest, and inject morphine or promedol to relieve pain. If respiratory failure increases, oxygen inhalation is performed and the victim is urgently evacuated to a specialized hospital.

Fractures of the ribs and sternum can be uncomplicated or complicated. They differ in that in uncomplicated fractures the pleura and lungs are not damaged, but in complicated fractures the pleura, lungs and intercostal vessels can be damaged. With uncomplicated rib fractures, the clinical picture is characterized by pronounced pain when inhaling and exhaling, when coughing and sneezing. There is a lag in the movements of the affected side of the chest when breathing. With multiple rib fractures, breathing becomes shallow and somewhat faster (20-22 per minute). The diagnosis is made on the basis of a clinical examination and then clarified by radiographic examination. Treatment. First aid for uncomplicated rib fractures should include giving the victim a comfortable position and ensuring rest. To reduce pain, painkillers are prescribed internally (analgin, amidopyrine, paracetamol, etc.). External chest immobilization is not required. The patient's ability to work is restored on average after 3-5 weeks.

Complicated rib fractures occur in severe traumatic injuries, in which fragments of the ribs can move inward and damage the intercostal vessels, pleura, and lung. Typically, the pressure in the pleural cavity is below atmospheric pressure, which promotes blood flow to the heart and expansion of the lung during breathing. Clinical picture. The patient takes a forced sitting position and seeks to reduce the excursion of the lung of the damaged half of the chest, complains of pain at the site of injury and lack of air. Breathing is shallow (22-24 per minute), pulse 100-110. Hemoptysis may be observed. Skin pale, mucous membranes are usually bluish. Subcutaneous emphysema can be detected - with careful palpation, a crunch of the skin. Subcutaneous emphysema indicates the formation of a closed pneumothorax. The diagnosis is established on the basis of clinical examination data and is clarified by X-ray examination.

Treatment. First aid for complicated rib fractures comes down to applying a circular pressure bandage on the chest using a bandage or improvised means (towel, sheet). Before applying the bandage, the patient is advised to exhale and hold his breath as he exhales. To relieve pain, the victim is administered painkillers (morphine, promedol) and is evacuated in a semi-sitting position to a specialized medical facility. A small amount of air in the pleural cavity with closed pneumothorax does not require special treatment. Usual conservative measures (rest, painkillers) lead to the resorption of air within a few days. In the presence of pleuropulmonary shock, antishock treatment is carried out.

Fractures of the sternum occur from a direct blow or pressure on the sternum in a perpendicular direction. The clinical picture is characterized by sharp pain, intensifying at the moment of inspiration, difficulty breathing, and the formation of a large subcutaneous hematoma. The diagnosis is established on the basis of the clinical picture, taking into account the nature of the traumatic force applied. Treatment. If a fracture of the sternum is suspected, the victim is placed on a rigid stretcher in a supine position and evacuated to a specialized medical facility. Before transportation, painkillers and cardiac medications are administered. A clavicle fracture can occur from a direct blow to the collarbone, which is relatively rare, but more often as a result of an indirect impact on the collarbone (a fall on an outstretched arm, a blow to shoulder joint, body compression). The collarbone accounts for 3% of all fractures. Most often, fractures are localized at the border between the outer and middle thirds.

Clinical picture. There is a pronounced downward drooping of the shoulder and the entire arm, shortening of the clavicle, deformation of the fracture site, displacement of fragments and pain on palpation of this place, limitation of active movements injured limb. In children with subperiosteal fractures, limb dysfunction may not be observed. Sometimes with closed clavicle fractures, the subclavian vessels and nerves are damaged. The diagnosis of injury is obvious based on clinical signs of injury. Treatment. First aid involves the following immobilization of the injured limb: 1) a tightly rolled gauze roll is placed in the axillary fossa; 2) the arm is bent at the elbow joint and tightly fixed with a bandage to the body; 3) the forearm is suspended on a scarf. You can also apply a Deso bandage. After the victim is evacuated to a medical facility, the diagnosis is clarified. If displacement of fragments is detected, reposition is performed under local anesthesia and apply a fixing bandage. Further treatment of such patients is usually carried out on an outpatient basis.

Open chest injuries Open chest injuries can be non-penetrating or penetrating. Non-penetrating wounds include those that do not violate the integrity of the parietal pleura, and penetrating wounds include those in which the integrity of the parietal pleura is disrupted and a connection between the pleural cavity and the wound is formed. Non-penetrating chest injuries occur without damage to the bones of the chest wall or with damage to them. They may be accompanied by contusion of the pleura and lung tissue with the development of hemorrhage in them. The clinical picture is characterized by pain in the area of ​​the chest wound and bleeding from the wound. General state The patient is satisfactory, his behavior is active. There is no symptom of air suction in the wound during deep inhalation, exhalation and coughing, which indicates non-penetrating wound. Diagnosis is based on the presence clinical symptoms. Treatment. First aid, as with other wounds, consists of applying an aseptic pressure bandage, administering painkillers and evacuating the victim to a medical facility. Treatment of such patients is carried out in thoracoabdominal or trauma hospitals according to general rules for the wounded.

Penetrating chest injuries are often accompanied by damage to the lung, and less often to the heart and esophagus. With a penetrating wound, the parietal pleura is damaged and a connection is formed between the pleural cavity and the outside air. Pneumothorax occurs, which can be closed, open or valvular. Closed pneumothorax is more common with complicated rib fractures. A broken rib can damage the lung, from which air freely enters the pleural cavity and compresses the lung. Typically, this develops pneumothorax, in which air and blood appear in the pleural cavity. Pure closed pneumothorax is rare. In this case, the source of bleeding can be the blood vessels of the damaged lung and intercostal vessels. Closed pneumothorax sometimes occurs with gunshot wounds, in which atmospheric air penetrates into the pleural cavity at the time of injury through a chest wound. After the edges of the chest wound close, the pneumothorax becomes closed, as the connection between the pleural cavity and the external environment disappears.

Clinical picture. The victim notes pain in the damaged half of the chest. It intensifies when breathing, and there is a feeling of lack of air. With pneumothorax, this is accompanied by weakness and dizziness. The patient takes a forced position (semi-sitting) and limits the movement of the chest. The skin takes on a bloodless appearance - it becomes pale, the lips become bluish, with normal temperature protrudes on the skin cold sweat. Breathing increases to 24 or more per minute, pulse - up to 100-120 beats per minute. In the area of ​​the wound, palpation of the chest reveals subcutaneous emphysema, and if the ribs are damaged, a crunching of bone fragments due to their displacement is detected. A more severe clinical picture develops with fractures of several ribs, when fragments are formed that move freely during breathing, irritate the pleura and lung and contribute to the development of pleuropulmonary shock. At the same time, breathing becomes more frequent (more than 24-26 per minute), shortness of breath develops, swelling jugular veins, the skin acquires a bluish tint, hemoptysis intensifies, subcutaneous emphysema rapidly increases, spreading to the neck, face, abdomen, and thigh. There is a danger of emphysema spreading to the mediastinum, which can cause cardiac arrest. The diagnosis is made based on examination data of the patient.

Treatment. First aid should include measures for pain relief, releasing the lung from compression, and oxygen inhalation. For pain relief, a subcutaneous injection of promedol or morphine (1 ml of 1% solution) is given. During transportation, the victim's body is placed in an elevated position. During transportation, it is advisable to inhale oxygen mixed with nitrous oxide, injections of agents that increase the tone of blood vessels (mesaton, norepinephrine, etc.). For further treatment the victim is evacuated to the thoracoabdominal specialized hospital. Therapeutic measures in the hospital depend on the type of pneumothorax; conservative treatment with symptomatic means is used only in cases where air occupies less than 25% of the volume of the pleural cavity. To speed up the expansion of the lung, aspiration of air from the pleural cavity is used. In case of closed pneumothorax of any etiology, air is removed using pleural puncture. In case of traumatic valve pneumothorax, drainage of the pleural cavity and active or passive aspiration of air from it are urgent and effective measures.

Open pneumothorax is a pathological condition in which the pleural cavity is constantly in communication with the outside air. Open pneumothorax is rare in peacetime, only when injured by large metal objects that have great lethal force. At the same time, at the moment of inhalation, the damaged lung collapses and the used air passes into the healthy lung. When you exhale, part of the air from a healthy lung passes into the damaged one. All this is accompanied by oscillatory movements of the mediastinum and causes the development of cardiopulmonary shock. Clinical picture. From local signs Open pneumothorax is noted by squelching sounds in the wound area during inhalation and exhalation, bleeding from the wound in the form of foamy blood, which increases with exhalation, and subcutaneous emphysema around the wound. From common symptoms there is a pronounced respiratory failure. Shortness of breath develops with increased respiration rate up to 26 or more per minute. Pulse 120-140 beats per minute, weak filling, blood pressure decreases. The skin is pale.

The diagnosis is made based on clinical examination data. Treatment First medical aid should include sealing the pleural cavity, pain relief and eliminating hypoxia of the body. Sealing of the pleural cavity is achieved by applying an occlusive dressing (Fig. 1) using an adhesive plaster, a rubberized shell of an individual dressing bag, a rubber medical glove or other material that does not allow air to pass through. The victim is given a semi-sitting position (Fig. 2), given oxygen inhalations, anesthetized by injecting a narcotic analgesic (morphine, promedol) and urgently evacuated for further treatment to a thoracoabdominal specialized hospital.

Valvular pneumothorax is the progressive accumulation of air in the pleural cavity as a result of the formation of a valve from damaged tissue lung, which closes the hole in the damaged bronchus or chest wall when exhaling. At the same time, with each inhalation, the pleural pressure inside increases, the damaged lung is compressed, and then shifts to the healthy side and the mediastinum, the work of the heart is disrupted, blood stagnation in the pulmonary circulation, hypoxia and cardiopulmonary shock develops (Fig. 3). Clinical picture The general condition of the patient is severe, progressive deterioration is observed with each subsequent breath. Inspiratory shortness of breath with increased respiration rate (over 26 per minute) is noted. Subcutaneous emphysema develops, spreading to the trunk, neck, face and limbs. The veins of the neck swell sharply. The pulse quickens to 120-140 beats. per minute , blood pressure drops. The skin is pale at first and then acquires a bluish tint. When you inhale, sounds of air entering the pleural cavity can be heard above the wound; when you exhale, there is no noise. The diagnosis is made based on the clinical picture and confirmed by X-ray examination.

Treatment First medical aid involves the application of a sealing occlusive bandage, oxygen inhalation, administration of narcotic and non-narcotic analgesics, and urgent evacuation to a thoracoabdominal specialized hospital. For transportation, the victim is placed on a stretcher with the head end elevated and provided with oxygen inhalations. After delivery to the hospital, the patient is immediately placed in the intensive care unit, where vagosympathetic blockade with novocaine is performed according to the Vishnevsky method, puncture and drainage of the pleural cavity according to Bulau. If you are confident in the diagnosis, it is advisable to perform a puncture of the pleural cavity on the side of the injury while still providing first aid. To do this, use a special needle with a valve, which does not allow air into the pleural cavity when inhaling. Forecast. If first medical aid is delayed, death from asphyxia occurs on average 20-30 minutes after the onset of the disease.

Damage to the heart Damage to the heart can be closed or open (wounds). Depending on the nature of the wound channel, non-penetrating and penetrating wounds are distinguished. Closed heart injuries occur as a result of closed injuries to the chest (bruises, compression, falls from a height, concussion by a shock wave). Minor damage in most cases is definitely not noticeable and often goes unnoticed.

Severe injuries without compromising the anatomical integrity of the heart are accompanied by severe symptoms. The most characteristic sign in this case is tachycardia (140-160 contractions per minute) with significant arterial hypotension, which is not corrected with medications. Patients are restless, they note severe pain behind the sternum with irradiation to left hand and shoulder blade, shortness of breath, general weakness. Upon examination, it is revealed that the heart sounds are muffled and the boundaries are expanded. Sometimes coronary artery thrombosis occurs and myocardial infarction develops with characteristic changes on the ECG. Myocardial ruptures with closed injuries cause hemorrhage into the pericardial sac and the development of cardiac tamponade with typical clinical manifestations. Diagnostics closed damage heart difficulty. The most important thing for establishing a diagnosis is an electrocardiographic examination. Accurate diagnosis It is rarely established during the patient's lifetime - most victims die from rapidly increasing heart failure.

Open heart injuries (wounds) in most cases are accompanied by injury to the pleura and lungs, less often to the diaphragm, liver, stomach, etc. The severity of the condition of the wounded does not always correspond to the nature of the injury. The fate of the patient often depends on the rate of blood accumulation in the pericardial sac and the total volume of blood loss. When blood spills into the pericardial sac, it partially coagulates, complicates the work of the heart, and cardiac tamponade occurs, from which victims often die before being admitted to the hospital. Clinical picture. In typical cases of injury, the patient's condition is serious. Blackout or loss of consciousness is often noted. The wounded are restless, experiencing a feeling of fear, lack of air, pain in the heart, and difficulty breathing. When examining the patient, pale skin, cold sweat, rapid small pulse, and decreased blood pressure are revealed.

In cases of cardiac tamponade, the skin becomes pale gray or bluish in color, breathing is rapid and shallow, and the neck veins swell. The pulse is low or not detected at all, blood pressure is lower critical level(70 mm Hg), the borders of the heart are expanded, sounds are weakened or cannot be heard. An X-ray examination reveals signs characteristic of cardiac tamponade - expansion of the boundaries, smoothness of the contours, absence or decrease in pulsation along the contours of the cardiac shadow. The diagnosis is made based on clinical examination and electrocardiography. Treatment of heart damage is determined by the nature of the anatomical changes and the severity of the heart disorder. For bruises and concussions, conservative treatment is carried out aimed at eliminating pain, restoring blood volume, hemodynamics and myocardial contractility.

For cardiac injuries, urgent treatment is always indicated. surgery- suturing the wound. First aid involves applying an aseptic bandage to external wound, administration of painkillers, urgent evacuation of the victim to the surgical department of the hospital. The success of the operation depends on the timely delivery to the hospital and the speed of the operation, serious condition the patient cannot stop the surgeon's actions.

The chest not only contains vital organs and protects them from the harsh influences of the external environment, but is also an active organ, damage to which leads to disruption of the function of external respiration.

Chest injuries. Classification

If we classify chest injuries, it is necessary to distinguish between closed (blunt injuries) and open injuries (for example, wounds).

Closed chest injury

You can get a closed chest injury during road accidents, falling from a height, and also if you are injured with a blunt object, as is often described in a criminal situation. Closed chest trauma often occurs in the rubble of destroyed houses or underground communications of mines, less often in sports.

The severity of damage to internal organs is of decisive importance for clarifying the diagnosis, choosing treatment tactics and prognosis. Among the chest injuries closed type without violating the integrity of the internal organs, a distinction is made between chest injuries when bones are damaged (meaning the chest and ribs, because spinal fractures are an independent nosological category) and without bone damage.

Closed chest injuries without fractures of the ribs or sternum, as well as injuries to internal organs, are considered minor injuries that do not require special treatment. Sometimes there are still victims with large subcutaneous and intermuscular hemorrhages, which causes the patient’s serious condition even without fractures or injuries to the intrathoracic organs.

Closed chest injuries accompanied by rib fractures can cause catastrophic consequences, regardless of whether the internal organs:

  • firstly, multiple, and especially bilateral, rib fractures lead to a gross disruption of the pulmonary respiration mechanism, resulting in severe hypoxia;
  • secondly, with rib fractures (even in the case of a fracture of only one rib), rupture of the intercostal artery and parietal pleura may occur, followed by the development of massive hemothorax and accumulation of more than 1.5 liters of blood in the pleural cavity.

Blunt injuries to the chest, accompanied by damage to internal organs (lungs, heart, trachea, bronchi and great vessels) are considered severe, regardless of the condition of the bone frame of the chest.

According to the classification, there are closed chest injuries with damage to internal organs, accompanied or not accompanied by fractures of the ribs or sternum. Both may be complicated by pneumothorax and/or hemothorax. It may also be that there will be no hemorrhage and/or air will not accumulate in the pleural cavity. Pneumothorax can occur due to rupture of the trachea, lung, or even bronchus during a sharp increase in intrathoracic pressure immediately at the time of injury. And at the moment of fracture - due to damage lung tissue and visceral pleura with sharp ends of bone fragments.

Massive hemothorax with blunt trauma caused by bleeding from ruptures of the lung, main blood vessels and heart, intercostal vessels. Pneumothorax and hemothorax, regardless of the genesis and source of air and blood entering the pleural cavity, greatly complicate the condition of the victim, which worsens the prognosis.

Open chest injury

Required component open injury chest wall is a wound of the chest wall. Such a wound can be caused by bladed weapons and firearms, fragments of devices that have exploded, sharp and blunt objects, as well as hard objects. Chest injuries can occur in wartime, as well as in peacetime, in everyday life and in criminal situations, during mass injuries and accidents. If the chest wound does not penetrate deeper than the pectoral fascia and the parietal pleura remains intact, then the wound is non-penetrating. If the parietal pleura is damaged, the wound is regarded as penetrating. Penetrating and non-penetrating wounds can be blind or through. This grouping is especially important for characterizing spherical, fractional and shrapnel wounds, because when a blind wound occurs (as opposed to a through wound), the object that wounds remains inside the victim, and the surgeon must weigh all the indications and contraindications for its removal.

First aid for chest injury

Based large quantity With different types of chest injuries, it is quite difficult to immediately determine the nature and severity of the injuries, which causes problems when providing first aid for chest injuries. Because it is difficult to immediately tell exactly what has been damaged, you should pay close attention to the signs and symptoms of damage and act on the assumption of the worst.

  1. If a rib is broken, it is necessary to give the victim pain medication, since such injuries are very painful. After this, you need to apply a tight fixing circular bandage. In case of air penetration into the pleural cavity (pneumothorax), it is necessary to make a sealed bandage (apply a layer of polyethylene to the wound, and then bandage the damaged area). When transporting a casualty, the patient should sit and not lie down. If there are complex fractures, the patient is hospitalized.
  2. Compressions, concussions and bruises are less severe chest injuries, although they are no less painful. First, you need to eliminate the pain with painkillers, then quickly call an ambulance. If pneumothorax is observed, apply an insulating bandage, then urgently take the patient to the hospital. In this case, surgical intervention is necessary.

Transportation of victims with chest trauma should be carried out by specialists.

Consequences of chest injuries and complications of chest injuries

Chest injuries may be accompanied by damage to internal organs. At first glance, the possibility of injury to internal organs when a non-penetrating injury occurs may seem paradoxical. However, this happens if the object that wounds does not penetrate the pleural cavity, but at the time of injury causes a concussion of the chest, sharp increase intrathoracic pressure and rupture of internal organs, most often the lungs. This insidious option causes diagnostic errors, because the surgeon, having convinced himself of the non-penetrating nature of the wound, excludes damage to internal organs. The antipode of damage to internal organs with a non-penetrating wound is the so-called lucky through wound, when the internal organs remain unharmed.

The presence or absence of pneumothorax, hemothorax, emphysema and mediastinal hematoma, and pericardial tamponade is of decisive importance in assessing the severity of the condition, treatment tactics and prognosis. These complications occur during various injuries breasts They cause severe, sometimes catastrophic, breathing and circulatory disorders. The organization of first aid and the treatment program depend on understanding the essence of the pathophysiological disorders that occur during complications.