Lead Wad Cutter

Gunshot wounds. Wound ballistics. Modern firearms wound and wound disease. Principles of treatment of gunshot wounds.

General questions theme

Shells used by people since time immemorial, in the era of the invention of spears, slings, bows and crossbows. This man himself became a victim of his experiments. The first mention of a firearm related to the XIV century – it was “fire tubes” that were used for metal and stone throwing projectiles by means of ignition of gunpowder. Rifled barrels appeared in the XV century, but their use is banned as “obscene” and dangerous perfection.

In 1840 there was a weapon that was charged with breech, this rifle Shasspo and Dreize. Even after 10 years of seclusion, copper sleeve and smokeless powder allowed increasing power of the projectile and its speed, to reduce the weight of weapons. Rifled barrels, providing rotation of the ball and stabilize it in flight, demanded its hard shell coating. Skip to multiply models (1861), a more effective piroksylinovoho powder (1880), the invention of a machine gun “Maxim” (1883), the use of bullet pointed oval shape instead of (1900) – these are the main stages in the evolution of small arms previous century. In XVIII century English surgeon Henter wrote: “The art of hitting a man makes great strides larger than his art to heal.”

Problem gunshot wound is one of the pressing in military surgery.

Despite the considerable experience of large and small wars, military conflicts beginning is always accompanied by the typical errors in the provision of surgical care, particularly in engineering wound. This is due to insufficient knowledge of most surgeons, including characteristics of gunshot wounds, wound ballistics theory, the structure of gunshot wounds, and individual approach to their general and local treatment. All this leads to unfavorable results of treatment of patients.

Figure. 1 Bullet wounds of the chest.

 

According to international humanitarian law, which followed the army most civilized countries, with the defeat of manpower should be used only tools that derive from the ranks of soldiers, deprived of their capabilities, but do not cause them unnecessary suffering and is not intended to necessarily take their lives. It should be noted that the formation of international humanitarian law put St. Petersburg Declaration of 1868, which is the first international agreement on non-use against people explosive bullets and other weapons, causing them additional suffering extends beyond the action of solving the main task of military confrontation and withdrawn from the army the maximum number of enemy fighters.

However, despite all accepted international agreements, the severity of combat gunshot injuries in recent years has increased. This is due to the general scientific and technical progress, changes in conditions and methods of warfare in modern warfare. War became more dynamic, spread on water and airspace. There is a challenge: to create a lightweight ammunition for firearms, which enables it to move large distances at the lowest cost, while not losing its damaging effect. Thus was established automatic firearms using small-caliber bullets 5,56 and 5,45 mm. These balls have a high initial velocity

Fig.2. Mechanism of Mine injuries.

Figure. 3 Mine injuries. The gap between the lower leg at the upper and middle thirds.

 

These circumstances create substantial difficulties in developing a unified classification of modern gunshot wounds.

Classification of gunshot wounds:

I. The nature of the charges that hurt: ball, fragmentation (fragments of irregular shape; standard fragmentation elements swept, ball, etc..).

II. The nature of injury: blind, cross-cutting, shear, rebound.

Figure. 4 Types of injuries: a – tangible; b – through; in – blind; g – rebound.

 

III. With respect to body cavities: penetrating, nonpenetrating .

IV. For quantitative characteristics: single, plural.

V. Localization: insulated (head, neck, chest, abdomen, pelvis, spine, extremities); combination (2 anatomical areas or more).

VI. For burdensome consequences involving:

– Massive bleeding (including damage to major blood vessels);

– Acute regional ischemia of tissues;

– Damage to vital organs, anatomic structures;

– Damage to bones and joints;

– Traumatic shock.

Figure. 5 Fire much comminuted fracture of the femur (5.56 mm ball socket M 193).

 

VII. During the clinical course of wound healing: complicated, uncomplicated.

In addition, there are combined and combined injuries.

Combinations considered injury caused to one type of weapon, but with damage to two or more different anatomical areas of the body.

Combined lesions caused by the influence of several damaging factors: gunshot wound, thermal, mechanical, radiation, chemical.

The unusual course of wounds firearms, frequent development of septic complications and high mortality forced doctors to study wound ballistics and morphological changes in the tissues.

The specified version of the classification of modern gunshot wounds allows for a differentiated approach to their diagnosis and treatment during medical evacuation. In severe gunshot wounds of various parts of the body, this classification should include additional classification features based on the needs of specialized treatment.

Gunshot wounds. Wound ballistics. Modern firearms wound and wound disease. Principles of treatment of gunshot wounds.

General questions theme

Shells used by people since time immemorial, in the era of the invention of spears, slings, bows and crossbows. This man himself became a victim of his experiments. The first mention of a firearm related to the XIV century – it was “fire tubes” that were used for metal and stone throwing projectiles by means of ignition of gunpowder. Rifled barrels appeared in the XV century, but their use is banned as “obscene” and dangerous perfection.

In 1840 there was a weapon that was charged with breech, this rifle Shasspo and Dreize. Even after 10 years of seclusion, copper sleeve and smokeless powder allowed increasing power of the projectile and its speed, to reduce the weight of weapons. Rifled barrels, providing rotation of the ball and stabilize it in flight, demanded its hard shell coating. Skip to multiply models (1861), a more effective piroksylinovoho powder (1880), the invention of a machine gun “Maxim” (1883), the use of bullet pointed oval shape instead of (1900) – these are the main stages in the evolution of small arms previous century. In XVIII century English surgeon Henter wrote: “The art of hitting a man makes great strides larger than his art to heal.”

Problem gunshot wound is one of the pressing in military surgery.

Despite the considerable experience of large and small wars, military conflicts beginning is always accompanied by the typical errors in the provision of surgical care, particularly in engineering wound. This is due to insufficient knowledge of most surgeons, including characteristics of gunshot wounds, wound ballistics theory, the structure of gunshot wounds, and individual approach to their general and local treatment. All this leads to unfavorable results of treatment of patients.

Figure. 1 Bullet wounds of the chest.

 

According to international humanitarian law, which followed the army most civilized countries, with the defeat of manpower should be used only tools that derive from the ranks of soldiers, deprived of their capabilities, but do not cause them unnecessary suffering and is not intended to necessarily take their lives. It should be noted that the formation of international humanitarian law put St. Petersburg Declaration of 1868, which is the first international agreement on non-use against people explosive bullets and other weapons, causing them additional suffering extends beyond the action of solving the main task of military confrontation and withdrawn from the army the maximum number of enemy fighters.

However, despite all accepted international agreements, the severity of combat gunshot injuries in recent years has increased. This is due to the general scientific and technical progress, changes in conditions and methods of warfare in modern warfare. War became more dynamic, spread on water and airspace. There is a challenge: to create a lightweight ammunition for firearms, which enables it to move large distances at the lowest cost, while not losing its damaging effect. Thus was established automatic firearms using small-caliber bullets 5,56 and 5,45 mm. These balls have a high initial velocity

Fig.2. Mechanism of Mine injuries.

Figure. 3 Mine injuries. The gap between the lower leg at the upper and middle thirds.

 

These circumstances create substantial difficulties in developing a unified classification of modern gunshot wounds.

Classification of gunshot wounds:

I. The nature of the charges that hurt: ball, fragmentation (fragments of irregular shape; standard fragmentation elements swept, ball, etc..).

II. The nature of injury: blind, cross-cutting, shear, rebound.

Figure. 4 Types of injuries: a – tangible; b – through; in – blind; g – rebound.

 

III. With respect to body cavities: penetrating, nonpenetrating .

IV. For quantitative characteristics: single, plural.

V. Localization: insulated (head, neck, chest, abdomen, pelvis, spine, extremities); combination (2 anatomical areas or more).

VI. For burdensome consequences involving:

– Massive bleeding (including damage to major blood vessels);

– Acute regional ischemia of tissues;

– Damage to vital organs, anatomic structures;

– Damage to bones and joints;

– Traumatic shock.

Figure. 5 Fire much comminuted fracture of the femur (5.56 mm ball socket M 193).

 

VII. During the clinical course of wound healing: complicated, uncomplicated.

In addition, there are combined and combined injuries.

Combinations considered injury caused to one type of weapon, but with damage to two or more different anatomical areas of the body.

Combined lesions caused by the influence of several damaging factors: gunshot wound, thermal, mechanical, radiation, chemical.

The unusual course of wounds firearms, frequent development of septic complications and high mortality forced doctors to study wound ballistics and morphological changes in the tissues.

The specified version of the classification of modern gunshot wounds allows for a differentiated approach to their diagnosis and treatment during medical evacuation. In severe gunshot wounds of various parts of the body, this classification should include additional classification features based on the needs of specialized treatment.

General characteristics of modern balls

 

Bullet – the projectile  small arms. They are divided into ordinary and special (armor-piercing, incendiary, tracer, explosive).

Types of Balls:

– Spherical (lead);

– AP (balls with steel core or lead antimony, tungsten carbide, depleted uranium). There are simple armor, armor-piercing incendiary, armor-piercing incendiary tracer;

– Inflammatory (containing phosphorus, termites, etc..)

– Tracer;

– Explosive (for use on manpower prohibited by international conventions);

– Shell (with tsilnometalichnoyu shell partial shell, bullet shell which destroyed);

– Shell expansive (balls that unfold. Divided into those deformable and destructible napivruynuyutsya balls) (for use on manpower prohibited by international conventions);

– Shell with a flat head part;

– Combined (combine the properties of expansive and armor-piercing bullets);

– Balls that are easily broken (balloon filled with grains typically more than 30 pcs, closed with a plastic cap. Rekoshetiv Do not give in the body creates a conical flow fraction, which destroys tissue);

– High-speed high-stopping action and soulful low resolution;

– Fleshed ball (with stilopodobnym shell);

– SOST bullet (with a cavity);

– Bullets for pneumatic weapon;

– Bullets for hunting weapons .

 

Types of modern bullets for small arms

FMJ – standard bullet shell

   1 – shell (steel, tombac, brass)

2 – lead

The most common type of ammunition that adopted by the armies of the world (according to international conventions)

 

 

 

 

JSP – compared to the shell

 

  1 – shell (steel, tombac, brass)

2 – lead

 Compared to the shell has more stopping action (The photo shows the bullet is deformed when hitting the target), less ability to rebound and less penetration

Hydrashock – compared to the shell with expansive fossa and steel core

1 – shell (steel, tombac, brass)

2 – lead

3 – expansive fossa

4 – steel core

The combination of expansive and armor-piercing bullets

 AP – AP bullet

 

  1 – shell (steel, tombac, brass)

2 – lead

3 – tipped armor-piercing core

Balls instantaneous (discontinuous)

Incendiary balls ACTION

Tracer bullets

GLASER SAFETY SLUG – balls of “controlled ballistics” “

  1 – nose balls (metal)

2 – bullet shell (metal)

3 – Fractions

Bullet for shooting people in vulnerable circumstances where it is necessary to completely eliminate ricochet and punch through (for example, in the cabin). When it enters the goal, the ball is destroyed, and will make “target” conical flow generated small fraction (30 – 200 Drobin or more), which leads to devastating effect.

 

This delivers significant stopping performance in combination.

 

Light high-speed bullet without the core. Due to the special form if it enters the body distributes the shock wave to the side, not in front, and rapidly inhibited, translate significant energy to the tissues.

Lead Wad Cutter

  Bullet primarily for target shooting. When injected into the target leaving a neat round hole. Used for sport shooting, or ammunition for self-defense.

 

Lead Semi Wad Cutter

 

Lead RoundNose

  Very simple and cheap ball. Used in “small-caliber” (5.6 mm) ammunition.

 

     Bullets for pneumatic weapon

  Fractions

SOST bullet

A bullet with a cavity. When you hit the target easily destroyed

Damaging effect ranyachoho projectile flight speed is determined by weight, a cross-section, the degree of stability when released into tissue susceptibility to deformation and fragmentation, the magnitude of the kinetic energy that is transferred bullet tissues. The severity of tissue injury is determined by the magnitude of the kinetic energy that is transferred to the tissues. The higher it is, the more damage.

Depending on this isolated high-speed bullet (700 m / sec), spheres with an average speed (400-700 m / sec), spheres with low speed (up to 400 m / sec).

Traumatic agent world:

1 Effects of shock-wave processes at the first contact with the fabric. (more than 1000 kPask). It is dispositional deployment tissues.

2 Action traumatic shell.

3. The side impact energy of formation of pulsating (temporary) cavity.

4 Action wake – turbulent flux fabrics that are absorbed into the wound channel.

Features gunshot wound:

1 complex configuration of the wound channel.

2 The presence of zones of primary and secondary necrosis.

3 Uneven  separations a necrotic tissue along the wound

4 The frequent presence of foreign bodies wound channel.

5 Significant microbial contamination of the wound, which in the absence of antibiotic prophylaxis is the development fester for 6 hours.

6 The rapid development of traumatic edema tissue that impairs their perfusion and trophism.

7 Favorable conditions for anaerobic infections.

 

Mine-explosive  – arising from the action of an explosive ordnance action (exchange), by direct contact. There are three types – the explosion when the advance, the explosion in the distance, the explosion in his hands. Characterized by the development of tissue  or separation limb oskolchatymy multiple injuries, thermal burns and significant contamination of wounds.

 

Explosive  – resulting from the action of excessive yew air blast. The result is a concussion and contusion of the brain, ear barotrauma, comotio-contuziones lesions and ruptures internal organs. Trauma can be combined with multiple fragmentation wounds.

 

Wound ballistics and morphological changes in the tissues in gunshot wounds.

 

Wound ballistics – the branch of science that deals with the definition of impressive efficiency traumatic bullet shells by studying their movements in biological tissues and substances of target-simulators. The term “wound ballistics” refers Callender and French (1935). IP Davydovskii understands her physical phenomenon that occurs in the tissues at the time of passing through them ranyachoho shell. In “The guidelines NATO military emergency surgery” (1975) wound ballistics is defined as the study of motion within the body ranyachyh shells and their traumatic properties. The purpose of the study of wound ballistics – developing a common methodology for the impressive features of modern firearms, protective properties of individual body armor and mechanisms of formation of gunshot wounds, and the creation of a unified diagnostic and treatment algorithm military firearms injuries.

To explain the heavy flow of gunshot wounds created different theories.

Theory poisoning wounds dust. Assumed that with gunshot wounds with ranyachym projectile entered the wound dust particles, which “poison” the tissue in the area of ​​the wound channel. The doctrine of the gunshot wound, as stated in the book of Braunschweig (1497), permeated with the conviction that all gunshot wounds “poisoned” gunpowder, and according to this author recommended peculiar treatments: “If someone shot a gun, and gunpowder wound poisoned , take the rope hair and push it through the hole prostrilenyy and stretches her back and forth in every way, and then you will reach the exit wound with gunpowder; then the wound will fester. “Fear of contamination of wounds dust forcing surgeons to combat this pollution, which burned the wound with a hot iron or boiling oil poured them.

The fallacy of this theory has been proven by the French surgeon A. Paré in the XVI century, formulated the demand that “to the surgeon immediately expanded the wound area unless it allows its distribution.” He proved that the characteristics of a gunshot wound depends not poisoned dust, and crushing of tissues.

The theory explains the peculiarities of care gunshot wound that the bullet passing through the tissue as a result of conversion of mechanical energy into heat heats up and causes burn tissues. Subsequently, many authors experiments have shown that the temperature of the balls passing through tissue increases very slightly and can cause burn tissue surrounding the wound channel.

Theory of hydraulic action. Ancestor it was Bush, but in its completed form it is formulated Kocher, Reger and Bruns. According to this theory the penetration ranyachoho shell fabric in them as there are conditions in a hydraulic press, where the rolling piston creates a fluid pressure, and this pressure is transferred to the cylinder wall by the law of Pascal, in all directions with equal force. Hydraulic effect of the proponents of this theory to explain the very great  of internal organs in the abdominal wounds. In convincing experiments EV Pavlov, VA Thiele showed failure of this theory and showed that tissue  as we move projectile becomes increasingly large, while the laws of hydraulic theory it is spread evenly.

Currently, there are generally accepted theory of forward and side impact, based on the defined end of XIX century theory Impact Thiele and hydrodynamic theory Sherninha Kohler and formation mechanism of gunshot wounds. The action is carried out on a direct shot at the tissue site where ranyachyy shell directly in contact with them. Power side impact effect on tissues outside the wound channel. Using modern equipment registration (photo pulsed, high-speed filming, strain gauges, etc.), managed to decipher the mechanism of forward and side impact. It was found that around a bullet shaped air flow in a wedge. The direction of this flow parallel and radial trajectory of a bullet. Compressed air is ahead of the balls – the main shock wave – one of the factors that damage tissue. This is followed by the very ball that primarily provides mechanical damage and depending on the energy which it possesses, causing various injuries. The bullet that has a large amount of energy in lesions of skin breakdown provides an action that creates a hole, devoid of skin. New to the presence of gunshot wound of the skin defect noticed NI Pirogov In his book “On a trip to the Caucasus,” which was published in 1849

Any damage to the ball with erratic flight path is its kuvyrkannya in tissues. This raises two key features. First, the ball movement is not straightforward, and secondly, there is a massive tissue damage. Direct action causes the projectile breaks, splitting, crushing tissue. The degree of tissue  depends on their structure and velocity, caliber and shape of the projectile.

The flow of air is the radial trajectory of a bullet, creates a temporary pulsating cavity, which may not exceed the diameter of the projectile in 30-50 times. Reached its maximum size, is its “collapse.” The lifetime of the temporary pulsating cavity greatly exceeds the time of the balls in the tissues. Differences of positive and negative pressure in it up to 50 atm. This contributes to widespread tissue damage, infiltration of germs and foreign bodies at a considerable distance from the wound channel with pulsating cavity formation associated to present the main characteristics of gunshot wounds, especially the severity of damage to organs and tissues far beyond the wound channel. This is because temporary pulsating cavity occurs mainly due to the strength side impact energy of a bullet aimed at the side of the wound channel.

 

Figure. 6 Pulse radiographs. Formation of pulsating cavity in the gelatin block. Rotating the ball without its .

 

Figure. 7 Pulse radiographs. Formation of pulsating cavity in the gelatin block. The  of the world.

 

Dimensions temporary pulsating cavity substantially exceed the caliber of charge, hurt, and the duration of its existence 500 times the charge time of the injury through the object. Width tissue damage around the circumference of the wound channel is directly dependent on the size of the temporary cavity and the duration of its existence. In turn temporary pulsating cavity parameters depend on the ballistic characteristics of the charge that hurts (flight speed, kinetic energy to injury, the proportion of energy that is absorbed by the tissues during the passage of the charge distribution of energy in the tissues along the carriage charge and sides of the wound channel). The greater the kinetic energy of the ball, the more pronounced ripple temporary cavity and its longer existence. It is these factors explains the large tissue damage along the wound channel and the formation of interstitial hematoma, damage to blood vessels, nerves and even bone away from the wound channel.

Size and scale of the temporary cavity tissue damage also depend on the anatomical and physiological features of tissues and organs through which is bullet or splinter. For example, the passage of charge through the brain, which has a soft texture in the formation of temporary pulsating cavity is its shift away from the wound channel. This prevents bone vault and base of the skull, which causes bleeding in the brain and its ventricles at a considerable distance from the wound channel. Thus, the severity of injury to the skull and brain depends not only on the direct charge damage brain tissue, but the total deformation of the brain in the formation of temporary pulsating cavity.

With the passage of charge through the lungs there is a small temporary cavity, and hence small compared with other organs and tissues damage. This is easily the lung tissue and the presence in it of a large number of elastic fibers.

With the passage of charge through the hollow organs of the abdomen, which are filled with liquid or gas content, pulsation temporary cavity leads to significant gaps in the walls toward the periphery of the wound channel. Such injuries occur as a result of energy transfer charge through the walls of their contents. This

 

explains the small size of the zone of necrosis (up to 0.2-0.3 cm) in the area of the walls of large gaps that must be considered in the surgical treatment of gunshot wounds of the abdomen.

If the damage parenchymal organs charging energy is transmitted directly to the fabric. Here the path of the temporary pulsating cavity no intermediary in the form of liquid or gas, so there is  of these bodies with cracks difference in different directions. The extent of damage of parenchymal organs depends on the ballistic properties of charges that hurt.

At high flight speed projectiles may have strong shock waves. These waves do not cause severe mechanical damage and affect intracellular processes that lead to the  of cellular structures. Under the influence of shock waves is changing coagulation, coagulation protein.

The bullet that has a large amount of energy hitting a hollow body with a liquid content or krovonapovnenyy parenchymal organs, cause hydrodynamic effect, and hitting bone, destroy it, showing dividing effect. The bullet that has until contact with the body of low energy, can provide a wedge effect, which manifests itself apart tissue or slaughter, the consequences of which may be limited hemorrhage, hematoma or superficial wound crammed.

Properties globe, affecting the nature of the injury is its weight, gauge, shape and design features. These characteristics are interrelated balls. Therefore, to regard the impressive properties of balls in respect of certain structural types. The greatest stability in flight and in lesions have a biological purpose ball with greater mass, length and caliber. Tupokintsevi ball quickly transfer energy to the tissues and lead to the so-called stopping effect. Acute elongated bullet shell fabrics often give only 1/10 its kinetic energy. The most significant damage occurring during the formation of a supersonic flow in tissues with energy transfer. Acute balls form a stream at a rate of interaction with a target of about 1300 m / s, with a rounded bullet warhead – at 800 m / s.

Soft balls have a high plasticity and in contact with soft biological tissues spend some energy on its own deformation, thereby increasing the impact and power stroke. This fact served as one of the reasons that the Hague Declaration (1899) banned the use of man to destroy balls that flatten in the body.

The displacement of the center of gravity orbs to its tail significantly reduces the stability of motion in the air and along the wound channel. In such circumstances, contact with the surface peaked balls poshkodzhuvanoyi body leads to occurrence of supersonic shock flow in tissues at an angle of 90 ° meeting at the speed of 130 m / s and at an angle of 45 ° – 600 m / s. It is often the  of the ball and its internal ricochet. It should be noted that the medium-caliber bullets lose stability only at a distance of 1800-2000 m, while the small-caliber bullets are unstable at the initial portion of the trajectory. High balls in simulators biological tissues substantially lose stability, turning the longitudinal axis 90 ° or more with respect to the direction of a ballistic trajectory. This gives rise to temporary cavity whose size is ten times the caliber of the projectile. Energy and high-speed small-caliber bullets are generally lower energy bullets of 7.62 mm at all distances shot, but the amount of energy delivered to them above.

Small-caliber bullet has a large impressive performance as the object is able to give a large proportion of the kinetic energy compared with medium-caliber bullet. This type of bullets suggests a new, qualitatively different set of structural and ballistic properties providing integrative impressive performance: high initial velocity, low stability in flight and in the tissues, small mass, shifted to the tail center of gravity, soft core.

Soviet bullet ammunition to 5,45x39mm. Ball ammunition used in an AK-74, which belongs to a new generation of small-caliber weapons. It has a solid metal shell of steel with a copper coating. Inside is a large steel core. A characteristic feature is the free space length of about 5 mm in the main part. Its purpose – to shift the center of gravity toward the bottom of, forcing the ball to change the position in the initial stage of the way in human tissues. In addition, the moment of impact within the existing lead bullet moves forward into space. Move the lead is not symmetrical, and it is one of the reasons abrupt change ball trajectory as it passes through tissue. However, this behavior is not too balls increases its lethality. Although ball changes position after 7 cm after penetration into the body, there is a significant gap in the final section (Fig. 1).

Home of balls is about 60% of its original weight. The back part is divided into many fragments that fly to the side and penetrates tissue to a depth of 7 cm. When injected into soft tissue appears the same effect of the cavity, as in the defeat of the Yugoslav production bullet for AK-47.

Fig.1 The destructive effect bullet AK-74 (Murahovskyy VI, Fedoseev SL, 1992)

 

In addition, there is a significant gap tissue. This is because initially they punched fragments, and then exposed to temporary cavity. Therefore, the diameter of the hole in the hollow organs, such as intestine, can reach 7 cm.

American bullet ammunition to 5,56 x45 mm M193 (Fig. 2). This ball of solid metal shell is held in tissues distance of about 12 cm warhead forward. Then she unfolds at 90 °, and flattened broken up in the area of ​​the ring grooves designed to connect balls of the sleeve.

Balls NATO ammunition 5,56 x45 mm M855 and SS109. American M855 bullet has a slightly higher weight and length than M193 ball. In Europe known the same ammunition SS109. Although the balls are not identical, their behavior in tissues is virtually identical. BM Company, the developer of ammunition SS109, argues that the high speed of rotation reduces the severity of injury bullet. However, this is not true. Practice shows that the nature of injury in fact the same as the M193 bullet (Fig. 3).

Figure. 2 The destructive effect of the American M193 ammunition (Murahovskyy VI, Fedoseev SL, 1992)

Figure. 3 The destructive effect of the American M855 ammunition (SS109) (Murahovskyy VI, Fedoseev SL, 1992)

 

 

The leading aspect that determines the ability of damaging projectile body is the number of transmitted energy. It depends on the mass of the projectile and its speed and, according to Newton’s law, expressed by the formula:

  

where Ek – kinetic energy of the projectile, transferred the body; m – mass of the projectile; U1-speed projectile at the moment of contact with the body; υ2 – Projectile speed when coming out of the body; g – gravitational acceleration.

Thus, the mechanism of gunshot wounds play a key role following elements.

• Main shock wave (ballistic) wave severely compacted air is formed in front of the ball.

• Sam ranyachyy shell.

• Temporary throbbing cavity (energy side impact).

• Secondary Ranchi shells (bone fragments that fly at speeds up to 70 m / s).

• Impact wake.

Power is determined by the characteristics of a direct shot projectile and secondary shells: speed, weight, size, area of ​​impact collision resistance in flight. Power of a side impact is affected by the main shock and temporary pulsating cavity.

Interaction of firing a projectile part of the body gives rise to a qualitatively new dynamic performance: the absorbed energy shock waves, contact time, the shape and length of wound trajectory, temporary pulsating cavity stability or instability of the motion of a projectile, formation of secondary shells of biological nature, the position of the projectile at impact, power from shock and others.

To describe the harmful effect of firing a projectile being used the term “lesion area”.

The scope of  – a temporary pathological entity, created high-firing a projectile at a facility that includes a temporary pulsating cavity zone primary zone of necrosis and molecular shock. The outer limit of the sphere of  – an imaginary line separating healthy tissue from tissue damaged by gunshot ranyachym shell.

In biological tissues at the time of the shot volume pulsating temporary cavity is 3.2 volume of a sphere damage, and after the shot size radius of primary necrosis approximately equal to the radius of the molecular size of concussions, and the amount they will give the radius of the sphere of .

Dimensions primary areas of necrosis determined by the nature of inhibition in tissues shell dependent moment of inertia, which leads to a change in the size and nature of its procession-nutatsiynyh fluctuations, which manifests itself in a sudden change in the trajectory of the projectile.

Sphere lesion size depends on the size of the temporary pulsating cavity. In a plastic substance-target simulator (ballistic clay, petrolatum) after firing residual cavity dimensions are the dimensions of internal pulsating band. Therefore, a comprehensive assessment of the severity of mechanical damage, call ranyachym shell or bullet, it is important to know the volume of the sphere lesion volume or temporary pulsating cavity, which not only determine the state of the victim at this time, but also to predict the course and outcome of injury.

We can assume that the damaging effect of firearms determined by the following factors:

• direct damage, ranyachym projectile (bullet);

• damage that occurs during braking projectile in the tissues.

Thus there are three stages in the formation of a gunshot wound that meet phases ranyachoho projectile motion (bullet) in the tissues.

The first phase begins to have effect at the time of the collision balls of the body surface. As a result, there is a sharp slowdown abrupt increase in pressure, reaching to 1h106 Pa.

Traumatic effect of punching phase depends mainly on the rate of rise and maximum overpressure generated by a bullet in which the tissues at a speed of 1450 m / s begin to spread waves of elastic deformation of the first order (WOOD I).

In stage II the formation of a gunshot wound has phase inhibition. It occurs after the passage of a bullet in the object distance of about 10-13 cm. Decreases its movement speed. As a result, the critical value increases the value procession-nutatsiynyh fluctuations, leading to a change in the trajectory of the projectile, sharp braking and the emergence of waves of elastic deformation of the second order (WOOD II).

After the departure of the object balls reached Stage III of forming a gunshot wound, according pulsation phase. It is what I WOOD and WOOD II come into active engagement with each other (interference, refraction and reflection) and cause the phenomenon of resonance in the tissues, which leads to the formation of waves of elastic deformation of the third order (WOOD III). WOOD III usually have the highest amplitude (up 3h106 Pa) and are forced, harmonic, mechanical, damped oscillations with a duration of 1.3 msec existence

The structure of gunshot wound

  According to morphological and functional changes, and most importantly, in the interests of medical tactics within the wound channel are three zones.

Primary wound channel (primary or permanent, cavity) resulting from splitting, crushing, separation and fragmentation of tissue along the axis of the flight of the projectile. Diameter and contour of the same channel throughout different, due to the behavior of the shell and anatomical characteristics of damaged tissues. Actually channel with gunshot wounds may not be as educated tissue defect wound filled with detritus, blood clots. Proceedings of the wound channel is largely complicated as it passes through the shell diverse tissue, differing in structure, density and elasticity. At the time of injury is the primary wound channel deviation (deviation from a straight line, which is a continuation of the trajectory of the projectile) that is characteristic of gunshot wounds. Secondary deviation to the mechanism of action of the projectile to do, it occurs after an injury, sometimes over a long period of time due to displacement of soft tissue and bone fragments, tissue hematoma compression or post-traumatic edema. Wound channel is filled with blood, foreign bodies, excluded scraps, broken, dead tissue – wound detritus. Number of damaged tissue increases towards the outlet.

Contusion zone (zone of direct trauma, primary necrosis) occurs at the area of ​​contact between the shell fabric. In this zone include tissue located in the vicinity of the wound channel and exposed necrosis at the time of injury or the next few hours afterwards as a result of physical effects on tissue ranyachoho shell. The depth of tissue necrosis in the walls of the primary wound channel is different in its different areas in different organs and tissues. Dimensions primary areas of necrosis depends on the ballistic characteristics of the projectile, structural and functional characteristics of tissues, including their ability to endure traumatic injury and hypoxic conditions. Best of all in the area of ​​concussion kept connective tissue stroma, which sometimes remains in the complete  of other surrounding tissue, which is particularly well seen in the walls of the wound channel in fat and muscle. The greater the energy imparted to fabrics ranyachym projectile, the larger the area of ​​contusion area and primary necrotic tissue.

Visually zone concussion is a relatively thin layer of tissue dark red soft consistency without capillary bleeding (if it is muscle, then there is no contraction of muscle fibers when cut or pinch). It is important to bear in mind that the configuration of the primary areas of necrosis may be different, which complicates the implementation of comprehensive primary surgical treatment of wounds.

Zone shake (shake molecular, secondary necrosis) – side impact zone, prylezhyt directly to tissues that have completely lost viability at the time of injury or in the next few hours afterwards. In the mechanism of formation of this zone central role played by the formation of temporary pulsating cavity wound channel and propagation of shock waves, especially wave pressure. In the area of ​​tissue exposed to shaking indirect impact of the projectile. Fabrics located near area contusion, concussion inner layer zone, exposed massive concussion, where they undergo a dramatic shift as a result of the formation of temporary pulsating cavity. In the tissues located at a greater distance from the axis arms channel, ie in the outer layer zone shake (the area of “molecular shake” by NI Pirogov), shake less pronounced.

The amount of tissue damage in the area of ​​concussion (zone kommotsiyi) varies widely and depends on tissue structure. Thus, in bodies that are characterized by a small compression ratio (brain, liver, spleen, bone), usually dominated by the effects of breaking or splitting apart. In tissues that contain large amounts of collagen and elastic fibers, damage less significant. It should be noted that the inner layer kommotsiyi area has a very low cell viability as the result of metabolic disorders predominantly at the molecular level. First changes in the outer layer zone kommotsiyi are mainly functional iature (disorders of blood circulation and nutrition of tissues of varying degrees of severity). Violation of microcirculation and associated phenomena edema, hemo-and lymphostasis contribute to the development of acidosis and hypoxia, which has adverse effects on the tissue in this area. There is a vicious circle: the swelling of the muscles in fascial cases, leads to their compression, further deterioration of blood flow and increase swelling. Thus, in the area kommotsiyi in the background enhance microcirculation disorders may progress dystrophic and necrobiotic processes that contribute to the development of secondary necrosis that occur in the area kommotsiyi at a considerable distance from the primary wound channel. At congenial wound healing, caused corresponding adequate local effect on the wound and the general treatment of the wounded, it may reverse the development of structural and functional changes in the external layer kommotsiyi zone, resulting in greatly reduced size of the secondary tissue necrosis.

Zone concussion is a concern to surgeons. It may be called the zone of unstable equilibrium. Under adverse conditions (increase edema, absence or delay of appropriate local and general measures in the treatment of the wounded), this area can significantly expand or fully undergo necrotic changes. Local and general treatment reduces this zone and thus helps to save the viability of damaged tissues, especially muscle.

Share tissues zone molecular concussion is defined as the degree of damage, and therapeutic management features. Under unfavorable course of wound healing, particularly in inadequate treatment, deep functional disorders can give rise to mikrovohnysch necrosis, which merge to form makrovohnyscha, and these in turn form a continuous zone of necrosis.

The state of tissue zones molecular concussion greatly influenced by the imbalance in the system of lipid peroxidation (LPO) and antioxidant system (AOS), microcirculation, hypoxia, nutritional disorders, and others.

Wound channel with cross wounds has input and output holes in the blind – only input. Military doctors need to know what kind of input and output holes do not give a complete picture of the amount of tissue damage. “The visible wound – just smoke from the fire” – wrote the French surgeon Depl. Hole size depends on the ballistic properties of charge. In high-speed small-caliber bullets wounds amount of damaged tissue increases to the outlet; in wounds swept elements and needle bullets even tissue damage observed on the input to the outlet, and in wounds steel ball fragments ribbed cubes, rubber and plastic beads, fragments of shells shells greatest damage observed in the area of ​​the inlet. This is due to the fact that the shape of the fragments contributes to a rapid loss of speed in the air, and in more dense environments, and therefore the area of ​​the outlet of the volume of tissue damage is usually minor.

Direction and length of the wound channel may vary and are determined during cross wounds by comparing the input and output openings. This caot predict, tissues and organs can be damaged in this injury. When blind wounds by simple inspection wounded set the length and direction of the wound channel difficult.

Wound channel even with bullet wounds cross 7.62 mm is rarely straightforward. This is because the ball at impact, for example against the bone, and can change the direction of the wound channel takes the form of an arc, horn etc.. These distortions are called primary deviation wound channel. Also damaged by direct impact skin, muscle, fascia and other tissues have different ability to reduce, and therefore the internal form of the wound channel is wavy, serrated. These distortions are called secondary deviation wound channel.

It should be tailored to suit the wound channel in wounds, accompanied by comminuted fractures in which the bone fragments of different sizes to obtain the energy of the charge, high speed fly to the sides of the wound channel, creating pockets of additional tissue damage.

The course of wound healing and wound healing are also associated with microbial contamination, which is inevitable and natural consequence of injury. However, the development of wound infection is not always accompanied by a gunshot wound. Wounds can heal without complications, despite the presence of microorganisms. This is because not all microorganisms trapped in the wound, it is found in terms of livelihood. There is a kind of selection. Thus, anaerobic poorly developed in the wide open wound, well aerated, some microorganisms can not develop in conditions of acidosis in the wound, some of them mechanically washed the wound with blood and wound secretion. In addition, microorganisms are subjected to phagocytosis and humoral immunological impact factors. At the same time there are a number of gunshot wound environment conducive to the development of wound infection. Thus, the wound can be closed cavity, which does not penetrate air promotes anaerobes. Necrotic tissue of the wound channel walls can serve as a good breeding ground for microorganisms. Note that the wound channel is surrounded by tissues with altered reactivity and reduced resistance to infection. Contribute to the development of wound infection and massive blood loss, protein and electrolyte imbalance, vitamin deficiency, immunodeficiency and other adverse factors.

Clinical signs of gunshot wound depends on the caliber and configuration charge that hurts from the through or blind, single or multiple, isolated or cumulative nature of injury, its location, damage to blood vessels, nerves and other important anatomical structures and internal organs, as well as the stage of wound process. Usually, the size and configuration of openings in the skin wound can determine what charge (bullet normal fragment or fragment of irregular shape) wound inflicted. When comparing the input and output apertures can provide damage various anatomical structures in the way of a charge that hurts. Pain in the wound, bleeding varied intensity and dysfunction of the affected areas are persistent clinical signs of gunshot wounds. Severity of common disorders depends on the severity and location of damage.

The general phylogenetically existing mechanisms of local processes in damaged tissues, healing is possible gunshot wound primary or secondary intention.

Healing by primary intention occurs when “spotted”, often cross gunshot wounds that are not accompanied by great  of tissue, swelling or bleeding. Such wounds usually do not require surgical treatment. Self-cleaning wounds thus is in the process of traumatic edema, which also contributes to closing the wound edges. Mortar, formed wound area speckled holes to fit the act as biological dressings and provides scarring with subsequent surface epithelialization of wounds.

Big gunshot wounds healing by secondary intention. This is due to the presence of necrotic tissue, in which self-cleaning wounds fester passes through. In this case, suppuration is not a mandatory feature of wound infection and replaced by the formation of granulation tissue, which means that the transition to the proliferative phase of inflammation. Healing the wounds of the boundary of epithelialization begins and ends with the formation of scar.

 

Pathogenesis of gunshot wound

 

Body in response to injury mobilizes general and local defenses aimed at healing the wounds that the essence of wound healing. Starting point pathogenesis gunshot wounds are the processes of membrane disease, which is characterized at the molecular level reactions involving reactive free radicals that are the initiators of physical and chemical process of transformation of kinetic energy tissue damage around the gunshot wound.

The basis of the morphological changes of the soft tissue gunshot wound lying dysfunction of cell membranes, disorders of basic metabolic processes of damaged tissue caused by activation of lipid peroxidation, the separation of oxidation and phosphorylation in mitochondria.

The first stage included the major pathogenetic factors characterized by  of cell membranes under enormous kinetic energy projectile ranyachoho, activation of lipid peroxidation, increased consumption of local tissue ischemia and deenergizing the emergence of the respiratory chain of mitochondria.

The second stage is characterized by inhibition of the major metabolic pathways, the lack of adenosine triphosphate (ATP) and the gradual development disorders cation balance cells. An important aspect of the pathogenesis of secondary necrosis with a gunshot wound is falling energy potential of cells due to violation of redox processes.

The third stage is to implement the lipid triad damage biomembranes, accompanied by an increase in excess Ca2 +, Na +, K + deficiency in cells and swelling of the latter. It was at this stage due to the violation of the membrane unit cell, probably a transition reversible ischemic damage in irreversible.

The fourth stage is the total  of cellular structures completed formation of necrosis.

Currently convincingly demonstrated that mechanical injury and ischemic tissue hypoxia zones molecular shake gunshot wound causing activation of lipid peroxidation, which in turn reduces the potential AOC. The intensity of LPO is determined from the date of injury and remoteness tissue from the wound channel. According to the literature, there are 6 main mechanisms for Sex: Shock – the damaging effect of projectile associated with the phenomenon of temporary pulsating cavity; posttraumatic ischemia; stress response; activation of phagocytes; activation of xanthine oxidase; appearance of increased amounts of catalytically reacti Activation of free radical oxidation leads to lipid peroxidation of the syndrome, including damage to the membrane lipids of cells and subcellular structures, breach of ATP synthesis, accumulation of perekysnoy denaturation lipids and proteins. Excess lipid peroxides gives physical and chemical structure of cell membranes, inhibits their enzymatic system inactivates cytoplasmic enzymes depolyaryzuye DNA splits ATP and amino acids, reduces the activity of thymol enzymes. It was established that the accumulation of lipid peroxidation products play an important role in the development of endogenous intoxication syndrome. All of the above pathological changes caused by an increase in the intensity of lipid peroxidation, occurring in the first hours after injury.

Wound healing – active protective and adaptive, biologically appropriate reactions, aimed to compensate the damage caused injury, and the elimination of the wound defect, ie wound healing.

Instead of the word “healing” is quite often used the term “regeneration” is translated as rebirth, rebuild tissue. However, a person significant in size and depth of the wound healing of defects filled with mostly not the tissue that has been destroyed and the newly established connective (scar) tissue. Only a few are able to truly regenerate tissue in the wound: the epithelium (not leather), bone tissue. Thus, the healing is not so much about regeneration (rebirth) or restitution (recovery) as a substitution – replacing one another tissue (scar tissue), which is a universal material in the body that can fill a defect, but not always fully take on the function of tissue destroyed when injured. SS Hirholav (1956) considers proper application with respect to the processes in the liquidation of the wound defect, the term “reparation”, which means compensation.

Unfortunately, the wound process not in all cases lead to wound healing. In a number of circumstances during wound healing may take adverse nature, resulting in serious complications can occur, leading to death of the wounded. This may depend on a number of reasons, or a combination thereof:

• the severity and prevalence of local damage;ve metals.

• permanent damage to vital organs;

• the general condition of the wounded as a result of blood loss, malnutrition, hypo-and avitaminosis, comorbidities, lesion penetrating radiation, bacterial toxic substances;

• from serious errors in medical tactics.

  Healing of any wound is due to inflammation. Feature inflammation as a biological process is in its protective and adaptive function that is vascular-mesenchymal reaction to injury for the elimination of the damaging agent and restore damaged tissue.

In any wound, and even more complicated by purulent infection, characterized by successive stages in the healing process. However, the precise boundaries transition from one stage to another missing, which causes differences faznosti researchers on the wound healing process.

MI Kuzin (1977) proposed a classification that identifies the following main phases of wound healing progress.

1 phase of inflammation, which is divided into two periods:

– Period of vascular changes;

– Period wound cleansing of necrotic tissue.

2 phase regeneration and the formation and maturation of granulation tissue.

3 phase reorganization of the scar and epithelialization.

The first two phases are mainly related to the formation of granulation tissue, the latter – with the maturation of scar tissue.

Division of wound healing at times rather arbitrary and sketchy, because really clear distinctions between the periods of time does not exist, and they seem to mutually penetrate each other. The process of progressive tissue necrosis may occur during the period of cleaning the wound necrosis. Thus in one area of the wound necrosis demarkuyetsya and resolves or rejected, otherwise progresses (next necrosis, often associated with infectious complications). Over a period of time can also be wound cleansing from necrosis and defect filling newly created living tissue (preliminary reparation). However, the classification of wound healing schematically correctly reflects the sequence of biological events that occur during healing.

Period of biological treatment of wounds of the dead substrate in various wounds proceeds differently, defining the basic qualitative features of the course of wound healing. Further developments of the wound depends on the interaction between body and microorganisms wounds.

Will develop wound microflora determines the way during the second period of wound healing wound is released from dead and foreign substrate. Depending on during wound healing may develop in three ways.

First, if the wound is sterile, the necrotic substrate can completely dissolve (rezorbuvatysya) assimilate into the wound. Secondly, if the bacteria in the wound with the conditions for the reproduction of the wound channel or in areas of necrosis, the latter may gradually melt, yielding sterile decay and vidtorhnutysya from the wound. Thirdly, if the interaction (wrestling) defenses and germs in the wound temporarily ends up as a “draw”, necrotic tissue and foreign bodies, including mikrobnozabrudneni may be encapsulated (remain in the body) after filling the wound defect living tissue .

In the first case resorbed necrosis, wound healing without suppuration – primarythe second case, the healing will take place after the compulsory secondary intention suppuration, during which will release the wounds of necrosis.

In the wound that heals through suppuration, wound microorganisms, highlighting enzymes such as protease, lipase, sucrose, contribute to the breakdown of necrotic substrate, eliminating him from the wound and thus it clean. Thus, if the wound heals with suppuration, it microflora plays a positive role and its presence in the wound does not mean any complications in the course of wound healing, that caot be identified with wound infection.

There is a third type of healing – by encapsulating necrosis. In this case, wound healing can occur without suppuration or partial suppuration, but this wound will be unstable, incomplete, since the depth of the wound is dead, usually infected substrate, which under certain conditions can cause suppuration, tearing away dead tissue and foreign bodies in the later stages and then have a final healing.

For wound healing by primary intention (or under crust), the following conditions:

• the lack of any significant defect of skin and gaping wound edges (in the gaping wound where the tissue facing the environment, primary healing is impossible);

• relatively little tissue damage deep wound and the lack there of large, particularly non-metallic, foreign bodies;

• sterility of the wound or its relatively small microbial contamination;

• satisfactory general condition of the wounded (no large blood loss, malnutrition, radiation illness, intoxication, severe comorbidities).

With a favorable combination of all these conditions (no first condition eliminates healing without suppuration, and the absence of any of these three reduces its probability) wound healing without suppuration and necrosis of the bulk resorbed and absorbed in the tissues. In that the most favorable form of healing, it takes 1 to 3 weeks and runs smoothly.

It should be emphasized that for wound healing without suppuration is not necessarily its complete sterility, absence of microbial contamination. Microbial contamination is typical for all wounds, even applied when performing aseptic operations.

Conditions for healing by secondary intention (through suppuration) directly opposite to those conditions that contribute to the primary tension:

• Large-sized defect or tissue necrosis;

• significant tissue damage in the circumference of the wound channel;

• significant microbial contamination and unfavorable composition of primary or secondary wound microflora;

• presence in the wound of large foreign bodies that are more severe microbial contamination;

• unfavorable condition of the body injured.

 

By combining these conditions, and sometimes in the presence of one of them there suppurating wounds and purulent necrotic substrate melting period in clean wounds that healing by secondary intention.

Features of wound healing is associated with factors such as localization wounds, bacterial contamination, the nature of surgical treatment, antibiotics and other drugs. This resulted in some success, but the frequency of suppuration of wounds with open lesions does not fall below 7.12%, as well as aseptic operations, the figure is no less than 1-2%.

 

Pathogenetic bases of modern treatment of gunshot wound

Treatment of gunshot wounds of various localization task is skilled and specialized surgical care. Generalized model on which to consider the principles of treatment of gunshot wounds is musculoskeletal wound inflicted by modern charges – speed small-caliber bullets and shrapnel explosive ammunition.

The main targets of therapeutic intervention with a gunshot wound is the primary zone of  (necrosis) and tissue necrosis secondary area around it, and wound microbial flora. From the first hours after injury, along with anesthesia and cessation of bleeding, it is necessary to create conditions for self-cleaning wounds and limit the spread of secondary morphologic alterations. Treatment begins with the imposition of primary dressings. The latter protects the wound from the adverse effects of the environment and the re microbial contamination, provides wound fluid flow with partial removal of small elements of primary contamination. For large gunshot wounds requires immobilization of the damaged segment, which prevents it from re-traumatization.

 

Gunshot wounds are different from other types of wounds combination of the following characteristics:

• tissue defect formation along the wound channel is always individual localization, length, width and direction;

• the presence of necrotic tissue area around the wound channel;

• the development of disorders of blood circulation and nutrition to the tissues bordering the wound area;

• wound contamination by microorganisms.

The main component of therapeutic effects of fire are wound debridement. Depending on the indications distinguish primary, secondary and repeated surgical debridement.

Primary surgical treatment (Pho) – this is the first surgery, performed on the wound to remove nonviable tissue, prevent complications and to create conditions for wound healing.

Repeated surgical treatment of gunshot wounds is performed when the first intervention for whatever reason, it was a moderate form. Then you may need re-intervention, which is usually carried out to onset of clinical signs of infectious complications, according to the same primary indication. Thus, repeated surgical treatment – this is the second in a row and following surgery, who performed at the disabled fore, the development of wound infection.

Secondary surgical treatment (VHO) is always performed by secondary indications, ie about complications (mainly infectious) ieed for the development of additional factors (active vegetative pathogenic microflora in the wound, etc.) that are not direct and indirect effects of fire injury. Even if surgical treatment, performed by secondary indications, was the first surgery of the account, it essentially remains a secondary surgical treatment.

Primary surgical treatment performed by primary indication, ie on the direct and immediate effects of fire injury. It aims to create conditions in the wound for biological protection against infection. The task of the surgeon during the Pho is the removal of the substrate, which is a breeding ground for pathogens and wound infection suppressed immune and regenerative activity of tissue around the wound. NI Pirogov (1846) defined the essence of Pho as the need to “transform the wound crammed into a cut.” Experience from previous wars and a large number of septic complications during World War II allowed the SS Yudin formulate the main goals of surgical treatment of gunshot wounds, “Aims of this operation lies in the fact that, together with foreign bodies removed from wounds all over completely and without reserve not only defeated and dead tissue, but also those elements that are under danger of necrosis and infection, being wounded or strained, crushed or anemizovani, and possibly infected penetrated through them shrapnel shell. Excision should be thorough and pervasive. Once it should remain everywhere smooth, flat, fresh, perfectly viable wound surface. “

As a result, Pho, believed OM Golden Eagle (1981), the walls of the wound should be alive, well vascularized. Desire surgeons perform Pho in the early stages may radically and simultaneously justified, but often impossible. According to some authors, the wound after treatment, becoming cut, will differ from the latter only by the presence of areas of molecular shock.

Experience medical support military action showed that fore gunshot wounds of soft tissues is necessary in 70-75% of cases, and 20-25% of the wounded do not need it. Do not be Pho minor superficial wounds through-ball soft tissue injury with point input and output holes with no signs of damage to the neurovascular bundle or great vessels, and bones, multiple small superficial wounds blind.

Pho depending on the terms that have passed since the injury to its implementation is divided into several types, although this division is conditional: early (performed within 24 hours after injury), deferred (in the period from 24 to 48 h) and late (after 48 h ).

Indications for PST wounds:

• general:

– Large scale  of tissue;

– Gunshot fractures of the extremities;

– Wounds of ongoing bleeding;

– Wounds heavily contaminated land, etc.

– Wounds contaminated with toxic and radioactive substances;

• Special:

– Wounds of the abdomen;

– Wounds of the skull;

– Wounds breasts, genitals, etc.

 

 

To perform a full PST gunshot wound necessary to achieve full anesthesia. Good conditions for surgery established in multicomponent anesthesia, but local anesthesia and remain important, especially in the mass inflow wounded. Local anesthesia provides autonomy of the surgeon, but high costs limit the time of its application, it is of little use in operations on the chest, abdomen, pelvis.

Before the operation, it is necessary to shave the hair around the wound, the skin clean (petrol ether) and aseptic process solutions (alcohol, iodine, pervomur, chlorhexidine, etc.). Surgical technique does not tolerate standard techniques as used in this case depends on the type of injury, the location of the wound, its size, length and projection of the wound channel.

  Under radical Pho understand not only the breadth of excision of damaged tissue as a full implementation of all tasks interventions that depend on the nature and timing of damage provedennyaPHO.

In summary the overall objectives of this operation are:

1 Incision wounds, turning it into a kind of yawning crater, with access to the deep cell damage and ensure the best conditions for biological self-purification processes.

2: Remove all dead and obviously nonviable tissue, which is the environment of formation and distribution of secondary necrosis of cells around the circumference of the wound channel due to enzymatic autocatalytic proteolysis.

3 Ensure thorough hemostasis with removal of large intramuscular, interstitial and subfastsialnyh hematomas.

4: Remove large foreign bodies and free bone fragments without food and are able to cause further injury to the tissues.

5 Creating optimal conditions for all branches wound drainage channel and interstitial “pockets”.

Contraindications to primary surgical treatment is traumatic shock (temporary and relative contraindications) and agonal state.

A decision on the need for surgical treatment of wounds taken after examination of the injured and removing the dressings further diagnosis of damage.

6 Reconstruction of damaged structures similar (seam nerve, blood vessels, tendons, blood vessels or tendons plastic, imposing external fixation devices with gunshot wounds of the extremities, various types of skin plasty.

Following all these requirements defines radicalism PST. During the operation, fully executed all elements of intervention must meet pathogenetic concepts of wound healing. However, this does not mean that radical surgical treatment is always final.

Under the current military surgical doctrine deaf primary suture after treatment gunshot wound not overlap. Imposing the initial stitches to the wound with a constant active drainage should be considered as an exception, permissible only if complete surgical treatment, the treatment of the wounded in a hospital under constant supervision of the surgeon that operated on. The exceptions are as wounds of face, head, external genitalia and wounds of the chest with an open pneumothorax, which is used to close the primary suture.

In the case of forced delay in mass Pho receive the wounded should be conducted measures to limit the spread of secondary necrosis and reduce the risk of infectious complications. These include, first of all, belongs to the proper organization of medical sorting out where the injured requiring surgical treatment in the first place: with prolonged bleeding imposed wiring, isolation and  of large limbs, signs of septic or anaerobic infections. All other wounded with indications for surgical treatment of primary surgical care is provided to a limited extent. The main event in this case is circular wound infiltration 0.25% novocaine solution and antibiotic solution (preferably broad-spectrum).

In addition, conducted Correcting infusion therapy. According to the testimony perform extensive subcutaneous fastsiotomiyu and drain the deepest “pocket” wound with additional autopsies.

Before surgery carefully study the nature of the wound in order to clarify the direction of the wound channel, the presence of bone damage, joints, large vessels and nerves. Depending on the intended scope of operation applied general or local anesthesia.

PST gunshot wound consists of 6 stages.

 

First step – cut wounds performed with a scalpel through the input (output) hole wound channel as a linear incision of sufficient length. Layer rozsikayutsya skin, subcutaneous tissue and fascia. A very important step dissection of the fascia – fastsiotomiya. At the extremities fascia divide outside of the wound throughout the limb segment, complemented by a cross-section – Z-shaped fastsiotomiya for decompression muscle packs. Then cut through (defoliate) muscle fibers in the course, focusing on the direction of the wound channel.

The second phase – removal of foreign bodies: ranyachyh shells or elements of secondary fragments, blood clots, pieces of dead tissue, scraps of clothing, freely lying small bone fragments. The wound is cleaned with antiseptic solutions. Deep-seated foreign bodies requiring them to remove significant tissue damage, leaving the stage to specialized care. At the stage of surgical intervention is to be removed foreign bodies located in the heart of vital organs, to remove that require complex additional access.

The third stage – excision of nonviable tissue, ie excision of the primary zone of the zone of necrosis and secondary necrosis (areas of molecular concussion), where the tissue of questionable viability. Excision of tissue layers is carried out taking into account different tissue resistance to damage. The skin is quite resistant to injury because excised sparingly. Subcutaneous fat is unstable damage, easy to infection, so it is excised with distinct signs of vitality. Fascia is resistant to damage, so it sparingly excised those areas that lost contact with the underlying muscles Pig. Muscle tissue is that, where a devastating effect most pronounced shell.

Scissors must remove nonviable muscle: brown, dirty-gray color, which is not reduced and do not bleed.

Fourth stage – operation on damaged organs and tissues: the skull and the brain, spine and spinal cord, organs of the chest and abdomen, bone, organs of the pelvis, the great vessels, nerves, tendons, etc.

Fifth stage – obkalyvanie soft tissues adjacent to the wound with a solution of antibiotics and drainage of the wound – to create conditions for the outflow of the traumatic content. There are active and passive drainage. The easiest way – passive drainage through one or more thick PVC or silicone tubing. When wound drainage pipes carry two-channel flow-aspiration (flow-flushing) washing the wound.

Sixth stage – closing the wound. Primary suture after the wound is not imposed. The exception is the wound of the head, scrotum, genitals. Suturing the wound be open pneumothorax chest, abdominal wounds, large joints. Primary suture applied to postoperative wounds, used to access outside wound.

The elements of reconstructive surgery that can be performed in the course of Pho should include restoration of patency large main vessels, damage which can lead to limb necrosis (seam autovenous plastic, the use of vascular prostheses). This operation should be done early after injury (3-6 h). Contraindications to restore the integrity of the vessel is marked contracture of the muscles below the injury site artery. In some cases, may restore nerve roots, tendons.

The concept of radical Pho seems largely arbitrary. Even after the most careful surgical treatment performed in optimal time after injury, the wound will inevitably remain with reduced tissue viability. Carve these fabrics is impossible and hardly necessary. It may do more harm than good, because of the inevitable removal of parts functionally active structures: large vessels, nerve trunks. This radical intervention is not achieved, and the amount of dead tissue increases.

The concept of “early” and “one” are in conflict, because the process nekrodystrofichnyh changes occurring over time – from several hours to several days after the injury. Required simple and reliable criteria for assessing the viability of the tissues around the gunshot wound. This is particularly important in the early stages after injury. The basic method of determining the viability of tissues in gunshot wounds are now the subjective – assess color, consistency, contractility, bleeding muscle tissue. Only long experience can allow the surgeon to distinguish damaged tissues in irreparable damage. It is difficult to be sure that when Pho to completely remove non-viable tissue, which is subsequently formed new areas of necrosis in tissues of slaughtered. The desire to comply strictly with the provisions of fundamental military surgery that Pho should be as comprehensive and simultaneously led to the creation of the concept of two-stage surgical treatment. Its essence is to perform in the most early stages of Pho, and then (a few days) – repeated surgical treatment with removal of all nonviable tissue, regardless of their size and location. This concept led to serious complications, which in most cases have a negative impact on the functional state of organs and tissues, and therefore the concept was not accepted by practical surgeons.

Secondary surgical treatment is always performed by secondary indications, ie about complications (in most infectious), requiring for its development of additional factors like actively vegetating in the wound pathogenic organisms and, therefore, is not a direct and indirect result of gunshot injuries. Even if surgical treatment, performed by secondary indications, was the first in a row surgery, it essentially remains a secondary surgical treatment. After this operation the primary seams are imposed, resorted to imposing early or late secondary sutures.

Contraindications to the imposition of secondary joints:

  • absolute:

– Signs of acute inflammation in the wound;

  – Heavy general condition of the wounded;

  • relative:

– The remaining foreign bodies;

  – Osteomyelitis;

  – Eczema around the wound;

  – Inability approximation of the wound edges due to the high tension power;

  – Inability of excision scars due to proximity to major blood vessels and nerves;

  – Location wounds on bone protrusions;

  – Dystrophy expressed forms of beriberi.

  Both primary and secondary surgical treatment can be repeated. On repeated Pho can say when the first intervention for various reasons were deliberately non-radical. Then you may need re-intervention before onset of clinical signs of infectious complications, for the same primary reasons. Indications to perform secondary treatment for severe forms of local wound infection may occur repeatedly. Immobilization of the affected limb reduces tissue trauma and destination antimicrobials completes a set of practical measures. Since itself wound process aimed at healing the wounds and healing the wounded, all medical tactic should be based according to its phases. It is necessary to create conditions for their normal course and in any case does not interfere with the natural repair.

The main problem in the treatment of gunshot wounds can be expressed as.

  • Combating emerging acute life-threatening disorders (blood loss, shock, respiratory failure).

  • Prevention and treatment of infectious complications.

  • Provide wound healing defect in perhaps less time.

Primary and secondary suture

In VII enlarged plenum of the Academic Council HVSU Red Army in April 1943 adopted a single classification stitches proposed NN Burdenko.

• Primary seam that runs immediately after the initial debridement.

• Primary-deferred or delayed primary suture (5-6 days after surgery, the development of granulation in the wound) and in the absence of inflammation.

• Secondary early suture – 10-12 th day, the development of scar tissue.

• Secondary seam later – after 3 weeks; scar tissue before applying seam Pig.

Because the seams are imposed on firearms wound to reduce treatment time and improve functional results wounds, we should recognize that these tasks are best using deferred primary suture. In fact delayed primary suture retains almost all the advantages of primary suture and at the same time deprived of its shortcomings. This method is practically safe. If this application prevent the condition of the wound and wounded or operational-tactical situation, should be resorted to early secondary suture.

The method of choice at the end of surgical treatment of gunshot wounds in the present conditions and peace, and war remains the delayed primary suture.

Amount of aid during medical evacuation

  Providing medical care to the wounded in wartime carried out on the basis of phased evacuation for treatment purposes. Under this system, only the healing process, that is the whole complex of curative measures, which requires injured, divided into separate types of assistance. Each type of health care is characterized by specific objectives and a list of typical health care measures, qualified medical personnel, equipment and conditions necessary for the implementation of these measures.

First aid instructor provided health company, arrows, nurses, and in the manner of self-help and mutual aid. For this purpose, PPI and individual first aid kit. Cleaning instructor has military medical bag, which is designed to help 25-30 wounded. Widely used the means available, mainly for the purpose of transport immobilization.

In the scope of PHC includes the following measures:

– Temporary stop external bleeding (finger clamping vessels and overlay harness, twist, tyskalnoyi dressing, bending or pererazgibaniya limbs in the joint);

– Imposition of primary aseptic dressings that not only protects the wound from re microbial contamination, but also from repeated small injuries and drying, provides peace of mind;

– Introduction analgetic with pre-filled syringes, located in the medicine cabinet, individually;

– Transport immobilization materials at hand; in their absence prybyntovuyetsya injured upper limb to the body, the lower – to the undamaged lower extremity;

– Ingestion antibiotic tablets (0.2 g doxycycline hydrochloride with individual kits);

– Protection of repeated injuries and inclement weather, careful removal of the wounded from the battlefield.

First in first aid every wound should be covered with a bandage, called protective. The main value of this bandage is to protect the wound from contamination. “Primary dressing decides the fate of the wounded,” – said the head of the Military sanitary control of the Red Army, Colonel EI Smirnov. He thus zeroing in on a timely and efficient overlay bandages on the battlefield, which requires good teach each soldier first aid techniques.

 

An important element in the treatment of wounds, and often by saving the lives of wounded is stop the bleeding, which can be done in different ways (finger pressing vessels, forced flexion of the limb, imposing crushing bandage, tourniquet). You must be aware of the dangers and vymushenist overlay harness, limited time of his stay, the need to constantly monitor the correctness of its imposition.

A further element of first aid is to provide the damaged area as possible peace. This is particularly important when injured limbs, accompanied by damage to the bone, as the mobility of fragments broken bone causes intense pain and tissue damage deep gunshot wound. Calm injured limb is achieved by imposing all sorts of Immobilizing bandages. For this purpose, widely used means at hand, prybyntovuvannya upper limb to the trunk and lower limbs damaged – to the sound. In gunshot injuries of the pelvis and spine wounded laid on panel, board, bench, door, etc. Of great importance in providing first aid must provide removal or reduction of pain. For this purpose, use promedola solution with pre-filled syringes that individual is in the medicine cabinet. During WWII widely used morphine-alcohol mixture (5 ml of 1% solution of morphine in 500 ml of vodka) 50 ml per wounded. Cottage analgesic product should be preceded for normal immobilization.

In terms of prevention of infectious complications of gunshot wounds play a big role all first aid measures (primary protective bandage, stop bleeding, transport immobilization, relieve pain, taking tablets from medicine chest individual antibiotics).

First aid provided by a medical assistant battalion. It features a set of PF (field, medical assistant), designed to provide first aid to the wounded and burnt 80-100; set of B-1 (sterile dressing) for up to 100 wounded and burned; set of B-2 (tires), scheduled for 50 immobilization; oxygen inhaler CI-4, AC-10, TD-1, etc..

When submitting DD must address the shortcomings of the 1st MIT: check the feasibility of blending and correct improperly imposed earlier harnesses, aseptic dressings, tires.

Moreover, at this stage is performed:

– Re-introduction of anesthetics;

– The imposition of Personnel Vehicle Tires (set of B-2);

– The introduction of the testimony heart (caffeine 1.0) and respiratory analeptics (kordiamin 2.0);

– Antishock therapy;

– Intravenous fluid resuscitation (400 ml Ringer’s solution or 400 ml or 400 ml Sorbilactum rheosorbilact);

– Inhalation of oxygen;

– Savings evacuation.

  Medical assistant controls the correctness of applying bandages, harnesses and corrects them, imposing standard tires and upgrades of earlier transport immobilization, carries oxygen inhalation, if necessary, repeated administration analgesic drugs, as well as cardiovascular and respiratory analeptics (kordiamin 25% 2 ml caffeine benzoate 20% sodium 1 ml 5% ephedrine 1 mL).

Measures PLD for urgent indications performed in dressings include:

– Elimination of asphyxia exemption airway; insertion of the tongue; endotracheal intubation; tracheostomy; overlay occlusive dressings in open pneumothorax; puncture or drainage of the pleural cavity with intense pneumothorax; oxygen and squeezing;

– Temporary stop external bleeding: pressure bandage to the wound; longing tamponade wound overlapping seams fixing liquid on the skin; overlay clip on the damaged vessel; control and the imposition of tow;

– Protyshokovi events in severe shock: pain – analgesics, and intravenous drugs except morphine, avtoanalheziya vehicle “Trynhal”; infusion; Therapy – Ringer, rheosorbilact (10 ml / kg), sorbylakt (5 ml / kg); intravenous cardiac and respiratory equipment; inhalation of oxygen; deficiencies transport immobilization, contributing to the development of shock;

– Prevention of infectious complications intramuscular prophylactic dose of antibacterial drugs (ofloxacin, ciprofloxacin, leflotsyn), subcutaneous injection of 0.5 ml of tetanus toxoid.

Other emergency measures performed depending on the nature of the injury.

Fill primary medical record at all injured.

Measures PLD that can be deferred are:

– Infiltration of the wound edges antibiotic solution;

– Novocaine blockade in wounds of extremities without TSH phenomena;

– Deficiencies transport immobilization that do not threaten the development of TS.

Must strictly comply with all the rules of asepsis and antisepsis in the performance of first aid measures.

Given the severity of the injuries indications evacuated first to the stage of surgical intervention are:

– Internal bleeding that lasts;

– The presence of harnesses on the limbs;

– Head injury with respiratory failure;

– Penetrating wounds and closed abdominal trauma;

– Open and valve pneumothorax;

– Znekrovlyuvannya expressed shock and severe;

– Infected wounds radioactive and toxic substances.

The first medical aid aimed at addressing phenomena that directly threaten the life of the wounded at the moment, preventing severe complications, evacuation of wounded to the next stage of medical care. When providing first aid to WFP primarily draws attention to the wounded in a state of traumatic shock with continued bleeding and respiratory failure. They conducted a series of measures for the prevention and treatment of respiratory and cardiovascular disease, stops external bleeding. Controlled and corrected dressings, imposed harnesses and pressure bandage, means of transport immobilization administered analgesics, tetanus toxoid, antibiotics. Assistance to WFP completed filling in primary health card.

Of surgical intervention aims to perform surgeries and procedures aimed at preserving life wounded, prevent complications of wounds and fighting developed complications to create the conditions for recovery of damaged and lost functions of organs and systems, successful treatment and speedy recovery.

  Of surgical intervention. In the provision of QCD wounded distinguish 4 groups:

1 Wounded ieed of surgical intervention at this stage.

2 Wounded subject to evacuation.

3 wounded in term treatment up to 10 days.

4 Ahonuyuchi wounded.

Wounded first group, depending on the severity of the injury, carried out measures of surgical intervention: 1) for health reasons; 2) urgent measures in the first place; 3) urgent measures in the second stage.

For health reasons provided urgent surgical bleeding events Pho, Pho is made with a view to closure of open pneumothorax, secondary surgical treatment – with anaerobic infection.

In the narrow scope primarily held urgent and more urgent surgical measures: Pho with gunshot wounds of the extremities with significant soft tissue injuries or gunshot fractures of long bones, in wounds that are contaminated PR, PP or land, with significant open lesions m ’tissues; amputations in their  or ischemic gangrene; Pho at penetrating hollow wounds without signs of bleeding, asphyxia or significant peritonitis; secondary surgical treatment in wound infection.

With a minimum amount of assistance do:

• stop bleeding any location;

• surgery for anaerobic infections;

• surgery for injuries of the abdomen opened and valvular pneumothorax;

• Suppression of asphyxia;

• Comprehensive treatment of shock, severe anemia, traumatic toxicosis.

The reduced amount of aid to these activities add:

• surgery for injuries of large blood vessels, accompanied by limb ischemia; primary amputation with limb necrosis;

• Pho wounds in the combined chemical and radiation injuries;

• Pho wounds with significant tissue , under intense pollution of the Earth.

 

Fully executed urgent urgent measures first and more urgent surgical steps of the second stage (Pho on the testimony and repeated debridement).

After Pho wounded with operation-dressing department sent to the department temporary hospitalization. Depending on the location and extent of injury to surgery they performed a set of remedial measures, including the prevention of infectious complications. These are the same steps:

– Intramuscular doses of prophylactic antibiotics (ofloxacin, ciprofloxacin, leflotsyn);

– Parenteral administration of plasma substitutes, blood products, vitamins;

– Symptomatic treatment depending on the indications (inhalation of oxygen, anesthesia, cardiac and respiratory analeptic antihistamines and other drugs).

Specialized surgical care. SHD should wear exhaustive. It aims to achieve a successful treatment outcome with maximal recovery less labor and efficiency wounded. Specialized surgical care provided by medical specialists using special equipment in specialized hospitals or departments. There are the following types of specialized surgical care: neurosurgical, dental, ophthalmic, ENT, urology, ortopedotravmatolohichnu, wounded, gynecological, torakoabdomynalnu and burned.

Specialized surgical care provided in military field hospitals advanced surgical hospital and rear bases front. X-ray study required. In specialized hospitals (departments) exercise in full all shown therapeutic and diagnostic measures. Performing initial surgical debridement, if it has not been done before, treatment complications, wound closure by secondary sutures, etc. Prolonged treatment time and the lack of prospects for the resumption of combat capability wounded evacuated to the rear of the country. The main errors to provide surgical care are:

– A moderate form of PST gunshot wound leaving nonviable tissue, foreign bodies, debris charges that hurt, bone fragments, nerozsichenyh fascial cases, nezupynenoyi bleeding;

– Applying primary sutures after Pho in all cases without limit;

– Excision of damaged skin in multiple areas of superficial wounds in small fragments;

– An attempt to provide specialized medical care to skilled care stage, especially in wounds of the head and extremities;

– Lack of immobilization in the presence of large soft tissue injuries of the extremities;

– Unjustified expansion of indications for urgent surgery at the stage of quality medical care to the wounded in the head, chest, limbs;

 

– Surgical intervention wounded in a state of TSH without proper antishock infusion-transfusion therapy.

Such errors lead to an increase in the number of adverse effects of treatment of wounded.

 

The whole arsenal of surgical treatment methods in specialized hospitals reduced to primary, secondary and repeated surgical treatment of gunshot wounds all localizations performed by specialists surgeons narrow profile and those with appropriate material equipment.

Postoperative treatment includes the following methods of conservative treatment as antibacterial and infusion-transfusion therapy, stimulation of the reactivity and the process of healing. For indications are used modern methods of detoxification (lymphomas and hemosorbtion), UV-blood hiperoksybaroterapiya and symptom management, exercise and physical therapy.

Along with treatment and prognostic expert solved the issue. If within the prescribed period of treatment (60-90 days) convalescence come and wounded will return to the system, treatment is carried out in a specialized hospital to a successful conclusion. If treatment continues longer the deadline or damage obviously incompatible with the performance of military duties, he has evacuated the wounded to hospitals in the rear of the country.

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