Damage and injuries to the neck. Gunshot wounds to the neck

Neck injuries are rare in peaceful conditions. More often they have a chipped or cut character; not great in length. Open neck injuries most often include wounds inflicted by a sharp or piercing weapon, such as bayonet wounds, knife wounds, and gunshot wounds in peacetime or war. These wounds may be superficial, but can affect all anatomical elements of the neck.

Cut wounds to the neck

Among cut wounds of the neck, a special group consists of wounds made for the purpose of suicide. The wounds are often inflicted with a razor and are usually the same in direction - they go from the left and from above to the right and down, for left-handers - from the right and from above. These wounds vary in depth, often penetrating between the larynx and hyoid bone, usually without affecting the main vessels of the neck.

Gunshot wounds to the neck

When diagnosing neck wounds, the most alarming symptom is bleeding. Such combined wounds are explained by the fact that on the neck in small spaces in different topographic layers lies a large number of vessels. Especially many arteries and veins are concentrated in the supraclavicular fossa, where several blood trunks may be injured. It should be noted, however, that the wounded with such injuries remain on the battlefield. The topography of the injury makes it possible to assume which vessels and organs of the neck may be injured in this area.

To clarify the diagnosis, in addition to examining, palpating and determining the functions of the neck organs, mirror and direct tests are used. Helper Methods- fluoroscopy and radiography can significantly clarify the diagnosis.

Isolated neck wounds in war were less common than combined wounds of the neck and chest, neck and face. In the latter combined lesions, wounds to the pharynx were detected in 4.8%, and wounds to the esophagus - in 0.7% of all neck wounds. Only with stab wounds and gunshot wounds are sometimes isolated wounds of the cervical part of the esophagus, both in peacetime and in wartime. Along with the esophagus, the trachea, large vessels of the neck, nerve trunks, thyroid, spine with spinal cord.

Injuries of the larynx and trachea

With significant wounds of the neck, these do not present any difficulties for diagnosis, because these holes usually gape. With minor wounds, escaping air, emphysema of the subcutaneous tissue, and difficulty breathing are important for diagnosis.

Treatment. Tracheal wounds should be sutured under appropriate conditions. In case of injury, it is advised to apply sutures in such a way that they cover the hyoid bone and pass through the thyroid cartilage; the best suture material in these cases it is a nylon thread. If the larynx or trachea is completely cut, then both sections are connected with sutures or along their entire circumference, or the middle part of the wound is left open to allow the insertion of a tracheostomy tube. If the wound is located in an inconvenient location for tracheostomy, the latter is applied in the usual place. For preventive purposes, tracheostomy should be used more widely, providing the patient with free breathing.

Special attention with these wounds, attention should be paid to stopping the bleeding, since the flow of blood can lead to suffocation. If a large amount of blood has poured into the trachea and the patient cannot cough it up, it is necessary to suck out the blood using an elastic catheter or tube. In cases of difficulty breathing after tracheostomy, the larynx is tamponed above the tube or a special tampon tube is inserted to prevent further blood flow into the lungs.

Incised wounds of the cervical esophagus

Incised wounds of the cervical part of the esophagus are observed in suicides, who simultaneously injure other important organs in the neck along with the esophagus. With this type of wound, the mucous membrane of the esophagus is often not affected and protrudes outward through the cut muscle layers.

Treatment. In case of combined injuries, urgent measures are taken against life-threatening moments associated with simultaneous damage blood vessels, windpipe. As for the esophagus, the main danger is the penetration of infection through the wounded wall. Therefore, after an injury to the esophagus, a patient is prohibited from swallowing for 2-3 days. At this time, subcutaneous or intrarectal drip administration of saline or 5% glucose solution is prescribed. Nutrient enemas may also be used. The position of the wounded person on the bed should be with the lower limbs strongly elevated to protect against the possibility of numbness.

The neck wound is widened, a temporary dense tamponade of the esophageal wound is performed, all adjacent affected organs are treated - the blood vessels are ligated, and the airways are restored. After this, the peri-esophageal space opens wide. On the esophagus, especially with fresh cut wounds, stitches are applied. For heavily contaminated wounds, the hole in the esophagus is sewn into the wound. A soft tampon is applied to the peri-esophageal tissue, as in the case of a cervical one. For complete unloading of the esophagus and nutrition of the patient, gastrostomy is recommended. Restore, if possible, the muscles and fascia of the neck.

Injuries to the cervical spine

Combined injuries of the spine in the neck, according to a specialized hospital, during the war of Ukraine against the Russian occupiers were determined to be 3.7%. According to neurosurgeons, the frequency of such injuries was 1.75% of all spinal injuries.

In case of combined injuries of the spine in its upper part, slight tangential injuries to the bodies of the 1st and 2nd vertebrae without pronounced neurological disorders were observed. In the first days after injury, mild meningeal-radicular syndromes were observed.

Severe injuries of the spine are accompanied by damage to the membranes, roots, and sometimes the spinal cord. In most cases, such wounded died on the battlefield or in the most advanced stages of evacuation from shock, respiratory failure or life-threatening bleeding.

In survivors of combined wounds, the most common injuries were posterior sections the spinal column, often with opening of the spinal canal. Less commonly, the anterior and lateral parts of the spine were affected, i.e., the vertebral bodies, transverse processes, and even less frequently the articular processes. With such injuries, the spinal canal is rarely opened and the spinal cord is not directly injured, but only bruised and concussed (see Diseases of the spinal cord).

Neurologically, with these injuries, the most early dates radicular phenomena can be detected in the form of mild hypoesthesia within the damaged segments.

Diagnosis. Limiting the mobility of the neck and studying the course of the wound canal allows one to suspect a spinal injury. Sometimes early diagnosis is helped by the appearance of Horner’s symptom due to damage to the cervical part of the borderline sympathetic trunk, as well as finger examination posterior wall of the pharynx (infiltration of prevertebral tissues).

With axial loading of the spine, pain is detected. Clarifies the diagnosis X-ray examination. If the two upper cervical vertebrae are damaged, a frontal photograph is taken with a special tube through the open mouth.

After spinal injuries in late dates In more than 50%, gunshot osteomyelitis occurs. The frequency of osteomyelitis in the cervical spine is associated with the high mobility of this part of the spine, the peculiar location of the wound channel, the wide opening of which is prevented by the proximity of the neurovascular bundle, the vital organs of the neck. Infection of the vertebrae with osteomyelitis often occurs due to communication between the wound canal and the oral cavity.

Treatment of wounds based on the experience of wars remains largely conservative and comes down to immobilization of the neck and head with a removable plaster collar, cardboard collar or soft Shants collar, the prescription of antiseptics, and physical therapy - UHF, quartz.

All these measures are designed to prevent purulent complications. If osteomyelitis occurs and after removal of the sequestra, the orthopedic collar cannot be removed for up to 18 months.

For a surgical approach to the cervical vertebrae using method 3. I. Geimanovich, the most convenient way is obtained by making an incision along the posterior edge of the sternocleidomastoid muscle. To expose the lower cervical vertebrae, it is more convenient to walk along the anterior edge of this muscle, then highlight the anterior surface of the scalene muscles; When approaching the vertebrae, it is necessary to take into account the topography of the brachial plexus.

To access the upper 3-4 cervical vertebrae, I. M. Rosenfeld used transoral dissection of the posterior wall of the pharynx.

K. L. Khilov, considering transoral sequestrotomy insufficient, developed access to the arch of the first cervical and the bodies of the second and third cervical vertebrae.

The outcomes of combined wounds of the cervical spine during the Great Patriotic War were satisfactory, while those wounded with similar lesions in the war of 1914 rarely survived.

Combined injuries of the spine, pharynx and esophagus

Such wounds have a very high mortality rate. For such injuries it may be recommended next method: a probe inserted through the nose and passed below the esophageal defect provides feeding to the patient, protects the neck wound from leaking and serves together with the prosthesis around which the mobilized esophagus is formed. At the same time, measures are taken to eliminate the osteomyelitic focus to stop progression bone process And further development infections in the tissue of the neck, drained from the wide side cut. This method of treatment should be recommended for combined lesions of the spine, complicated by infection from the wounded esophagus and pharynx. Gastrostomy is not necessary, as was previously insisted on “with the expectation of producing plastic surgery in the future.” It is more advisable to introduce a probe on which the esophagus should form and which should protect the neck and, in particular, the wounded spine from infection.

Nerve damage from neck injuries

Damage to the cervical spine is often accompanied by injury to the spinal cord and its roots.

Blunt subcutaneous injuries to the brachial plexus in the neck in peacetime are the result of street and work injury. During war, the brachial plexus is stretched during transport, when struck by blunt weapons, sticks, or falling logs. More often in the neck, the brachial plexus is affected as a result of its overstretching.

Among the injuries to individual nerves in the neck, the most important are the damage to the vagus nerve and its recurrent branch, the nerve of the thoracoabdominal septum, the sympatheticus, the hypoglossal and the accessory.

The vagus nerve is relatively often injured when removed malignant tumors on the neck, especially when removed lymph nodes affected by metastatic tumors. The nerve can also get into the ligature when ligating the carotid artery, and more often the jugular vein (see Tumors of the neck).

The recurrent branch of the vagus nerve is often affected when the inferior thyroid artery is ligated or when a goiter is removed.

If an injury to the vagus nerve in the neck occurs below the origin of the superior laryngeal nerve, then the injury will respond to the functions of the corresponding recurrent nerve. A number of laryngeal muscles will be paralyzed, including the glottis dilators, and the corresponding vocal fold will become motionless (cadaveric position). In this case, the voice becomes rough, hoarse, or the patient completely loses his voice.

Flow. With unilateral transection of the vagus nerve and its resection, there are usually no dangerous phenomena from the lungs, heart, digestive tract and the whole body.

When the vagus nerve is captured in a ligature, severe symptoms of vagal irritation, respiratory arrest, and disruption of the heart occur. These phenomena are caused by both reflex excitation of the arresting centers of the heart and breathing in medulla oblongata, and by excitation of centrifugal cardiac branches. If the ligature from the nerve is not removed, death may occur.

With bilateral damage to the vagus nerves and the recurrent branch, death occurs within 2 days from paralysis of the glottis dilators and disruption of the heart and lungs. Oncoming pneumonia is associated with the ingestion of infected saliva, expansion of the lungs and an increase in the frequency of respiratory movements; the pulse is sharply increased.

Treatment. If symptoms characteristic of vagal irritation are observed, an attempt should be made to remove the ligature. If this is not possible, it is necessary to separate and separate the vagus nerve from the vessels ligated with it and separately cross the nerve above the ligature. This can save the patient. In rare cases, resection of the ligated nerve may be performed.

Hypoglossal nerve exposed to injuries due to injuries to the submandibular region, mainly in suicides. As a result of injury to this nerve, partial paralysis of the tongue occurs; when protruding, the latter deviates to the side. With bilateral wounds, complete paralysis of the tongue is observed.

Treatment should consist of suturing the hypoglossal nerve. G. A. Richter successfully restored the integrity of the wounded sharp knife. The literature describes 6 cases of injury to this nerve (3 stabbed and 3 gunshot); In none of these cases was a suture used. There was a case where incomplete transection of the hypoglossal nerve was observed due to a stab wound with a knife. There was a spontaneous improvement.

Unilateral injuries to the phrenic nerve often go unnoticed, since the innervation of the diaphragm is partially replaced by branches of the intercostal nerves. A. S. Lurie points out that during neck operations for a brachial plexus injury, he was diagnosed with a break in the phrenic nerve 3 times. He also notes that in one patient, due to collateral innervation (lower intercostal), the movements of the diaphragm on the side of the injury were not disturbed radiologically.

Thus, it should be said that the therapeutic use of frenicotomy does not always result in permanent paralysis of the diaphragm.

In animal experiments, bilateral transection of the phrenic nerves in the neck causes death from respiratory paralysis. Irritation of the phrenic nerve is characterized by a continuous cough with wheezing due to irregular contractions of the diaphragm.

Injuries to the sympathetic nerve are observed more often with gunshot injuries, localized either at the top of the neck, behind the angle of the jaw, or at the bottom, a few centimeters above the collarbone.

The most constant sign of injury to the sympathetic nerve is a narrowing of the pupil and palpebral fissure (Horner's syndrome), as well as a number of trophic and vasomotor disorders: redness of the corresponding half of the face, conjunctivitis, lacrimation, myopia.

Sometimes exophthalmos is observed - with an isolated wound of the nerve with a piercing weapon above its upper node.

When the sympathetic nerve in the neck is irritated, the pupil dilates, the heartbeat accelerates, and the same phenomena occur as with paralysis of the vagus nerve.

Paralysis of the accessory nerve can occur when it is crossed either before entering the sternocleidomastoid muscle or after it exits into the lateral triangle of the neck. Complete paralysis of these muscles does not occur due to collateral innervation from the cervical plexus.

If the accessory nerve is paralyzed, paralytic torticollis may occur, and if the nerve is irritated, spastic torticollis may occur.

Damage to the thoracic duct due to neck injury

Damage to the thoracic duct in the neck is relatively rare and occurs with stab, knife, or gunshot wounds. Much more often, damage to the thoracic duct occurs during operations of enucleation of tuberculous lymph nodes, during extirpation cancer metastases, at oncological operations, operations for aneurysms. However, descriptions of injuries to the thoracic duct on the right are provided.

The diagnosis of injury to the thoracic duct during surgery is facilitated if, 2-4 hours before a major surgical intervention on the neck, the patient is given food with easily digestible fats - milk, cream, bread and butter. If an accidental injury to the thoracic duct occurs, it is immediately noticed during surgery by the release of a whitish, milk-like fluid. Sometimes the damage is determined only a few days after the operation when the dressings are changed by the presence of lymph leakage - lymphorrhea. Sometimes, the morning after the operation, a bandage is found heavily soaked with light liquid - this makes one suspect a wound to the thoracic duct.

Flow. The consequences of lymphorrhea are not very dangerous, especially if one of the branches of the ducts flowing into the vein is injured. Sometimes the loss of fluid from the wounded duct can be quite massive. G. A. Richter reports on a patient in whom, after removal of cancerous lymph nodes in the supraclavicular region, lymphorrhea was discovered only during the first dressing; lymphorrhea continued for 2 weeks, despite tight tamponade. In such cases, large losses of lymph lead to cachexia and threaten life.

Treatment. If a wound to the thoracic duct is discovered during surgery, then ligation of both the central and peripheral ends of the cervical part of the duct is performed. This ligature is satisfactorily tolerated by patients due to the existence of several confluences of the duct into subclavian vein and other communications between the thoracic duct and the venous network.

WITH good results Sometimes suturing of the duct is used for lateral wounds. N.I. Makhov, using atraumatic needles, sutured the duct with nylon threads, placing a piece of muscle on them.

IN Lately There are reports of successful suturing of the end of the duct into an adjacent vein.

Surgeons describe sewing a duct into the vertebral vein this way. It is easily accessible in a triangle bounded by the sympathetic nerve medially, the thyrocervical trunk and the inferior thyroid artery laterally, subclavian artery at the bottom. The risk of air embolism when transplanting into the vertebral vein is much less than into the subclavian vein. The vertebral vein is ligated as proximally as possible, and the assistant presses it with a tuff distally. A 2-3 mm incision is made on the anterior surface of the vein in the space between the tuffer and the ligature.

The thoracic duct is pulled with two very thin vascular sutures to a transverse incision on the anterior surface of the vein.

When applying a suture, an incision is made on the duct from the outside inward, and on the vein - from the intimal side with an incision on its surface. The duct seems to be slightly drawn into the vein by the sutures. The suture area is covered with a section of the prevertebral fascia with 1-2 sutures. A small tampon is inserted into the corner of the wound.

The physiological suction of lymph by the central end of the ligated vein saves from lymphorrhea to a greater extent than the sealing of the suture of the anastomosed vessels.

If it is impossible to perform one of the mentioned recovery operations produce a dense tamponade, which also manages to achieve cessation of lymphorrhea by restoring the main lymph flow through one of the collateral ducts. However, the possibility of septic complications in these cases is greater.

Enhanced nutrition is necessary for patients with neck wounds due to their loss of a significant amount of lymph containing a large amount of nutrients.

The article was prepared and edited by: surgeon

CHAPTER 11 INFECTIOUS COMPLICATIONS OF COMBAT SURGICAL INJURIES

CHAPTER 20 COMBAT CHEST INJURY. THORACOABDOMINAL WOUNDS

CHAPTER 19 COMBAT INJURY OF THE NECK

Combat injuries to the neck include gunshot injuries(bullet, shrapnel wounds, MVR, blast injuries), non-gunshot injuries(open and closed mechanical injuries, non-gunshot wounds) and their various combinations.

For many centuries, the incidence of combat wounds to the neck remained unchanged and amounted to only 1-2%. These statistics were greatly influenced by the high rate of death of those wounded in the neck on the battlefield, which in the pathological profile reached 11-13%. Due to the improvement of means personal protection military personnel (helmets and body armor) and their rapid aeromedical evacuation, the proportion of neck wounds in armed conflicts in recent years was 3-4%.

For the first time in the world, the most complete experience in the treatment of combat wounds of the neck has been summarized N.I. Pirogov during Crimean War(1853-1856). During the Second World War, domestic ENT specialists ( IN AND. Voyachek, K.L. Khilov, V.F. Undrits, G.G. Kulikovsky) a system and principles of staged treatment of those wounded in the neck were developed. However, due to a restrained attitude towards early surgical interventions, the mortality rate for neck wounds at the advanced stages of medical evacuation exceeded 54% and almost 80% of the wounded developed severe complications.

In local wars and armed conflicts of the second half of the 20th century. The treatment and diagnostic tactics for those wounded in the neck acquired an active character, aimed at quickly and completely eliminating all possible vascular and organ damage (the tactics of mandatory diagnostic revision of internal structures). When this tactic was used during the Vietnam War, the mortality rate for deep neck wounds dropped to 15%. At the present stage, in the treatment of combat wounds of the neck, early specialized care is of great importance, in the provision of which the mortality rate among those wounded in the neck does not exceed 2-6% ( Yu.K. Yanov, G.I. Burenkov, I.M. Samokhvalov, A.A. Zavrazhnov).

19.1. TERMINOLOGY AND CLASSIFICATION OF NECK INJURIES

According to general principles classifications of combat surgical trauma vary isolated, multiple and combined injuries (wounds) of the neck. Isolated called a neck injury (wound) in which there is one damage. Multiple lesions within the cervical region are called multiple injury (wound). Simultaneous damage to the neck and other anatomical areas of the body (head, chest, abdomen, pelvis, thoracic and lumbar spine, limbs) is called combined injury (wound). In cases where a combined neck injury is caused by one RS (most often a combined injury of the head and neck, neck and chest), for a clear idea of the course of the wound channel, it is advisable to highlight cervicocerebral(cervicofacial, cervicocranial) and cervicothoracic injuries.

Gunshot and non-gunshot wounds there are necks superficial extending no deeper than the subcutaneous muscle (m. platis-ma), and deep, spreading deeper than it. Deep wounds, even in the absence of damage to the vessels and organs of the neck, can have severe course and end with the development of severe IO.

Within the cervical area may be damaged soft fabrics and internal structures. TO internal structures of the neck include main and secondary vessels (carotid arteries and their branches, vertebral artery, internal and external jugular veins, subclavian vessels and their branches), hollow organs (larynx, trachea, pharynx, esophagus), parenchymal organs (thyroid gland, salivary glands), cervical spine and spinal cord, peripheral nerves (vagus and phrenic nerves, sympathetic trunk, roots of the cervical and brachial plexuses), hyoid bone, thoracic lymphatic duct. For the morphological and nosological characteristics of injuries to the internal structures of the neck, private classifications are used (Chapters 15, 18, 19, 23).

Based on the nature of the wound channel, neck injuries are divided into blind, through (segmental, diametrical, transcervical- passing through the sagittal plane of the neck ) and tangents (tangential)(Fig. 19.1).

It is also necessary to take into account the localization of the wound channel relative to those proposed by N.I. Pirogov three neck zones(Fig. 19.2).

Rice. 19.1. Classification of neck wounds according to the nature of the wound channel:

1 - blind superficial; 2 - blind deep; 3 - tangent; 4 - through

segmental; 5 - through diametrical; 6 - through transcervical

Rice. 19.2. Neck areas

Zone I , often referred to as the superior aperture of the chest, is located below the cricoid cartilage to lower limit neck. Zone II located in the middle part of the neck and extends from the cricoid cartilage to the line connecting the angles of the lower jaw. Zone III located above the angles of the lower jaw to upper limit neck. The need for such a division is due to the following provisions, which have a significant impact on the choice of surgical tactics: firstly, a significant difference between the zonal localization of wounds and the frequency of damage to the internal structures of the neck; secondly, the fundamental difference in methods for diagnosing the extent of damage and operational access to the vessels and organs of the neck in these areas.

More than 1/4 of all neck wounds are accompanied by the development life-threatening consequences (continuing external and oropharyngeal bleeding, asphyxia, acute cerebral circulation, air embolism, ascending edema of the brain stem), which can be fatal in the first minutes after injury.

All of the given sections of the classification of gunshot and non-gunshot wounds of the neck (Table 19.1) serve not only for the correct diagnosis, but are also decisive in the choice of rational treatment and diagnostic tactics (especially the sections that describe the nature of the wound, the location and nature of the wound canal).

Mechanical injuries necks occur due to a direct impact on the neck area (impact with a blunt object), during sharp hyperextension and rotation of the neck (exposure to a shock wave, a fall from a height, an explosion in armored vehicles) or strangulation (during hand-to-hand combat). Depending on the condition of the skin, mechanical injuries to the neck can be closed(with the integrity of the skin) and open(with the formation of gaping wounds). Most often, mechanical neck injuries are accompanied by damage to the cervical spine and spinal cord (75-85%). Closed injuries of the larynx and trachea are less common (10-15%), which in half of the cases are accompanied by the development of dislocation and stenotic asphyxia. Contusions of the main arteries of the neck may occur (3-5%), leading to their thrombosis with subsequent acute cerebrovascular accident, as well as traction injuries peripheral nerves(roots of the cervical and brachial plexuses) - 2-3%. IN isolated cases With closed neck injuries, ruptures of the pharynx and esophagus occur.

Table 19.1. Classification of gunshot and non-gunshot wounds of the neck

Examples of diagnoses of wounds and neck injuries:

1. Bullet tangential superficial wound of the soft tissues of the first zone of the neck on the left.

2. Shrapnel blind deep wound of soft tissues of zone II of the neck on the right.

3. Bullet through segmental wound of zones I and II of the neck on the left with damage to the common carotid artery and internal jugular vein. Continued external bleeding. Acute massive blood loss. Traumatic shock of the second degree.

4. Shrapnel multiple superficial and deep wounds of zones II and III of the neck with a penetrating wound of the hypopharynx. Continued oropharyngeal bleeding. Aspiration asphyxia. Acute blood loss. Traumatic shock of the first degree. ODN II-III degree.

5. Closed neck injury with damage to the larynx. Dislocation and stenotic asphyxia. ARF II degree.

19.2. CLINICAL AND GENERAL PRINCIPLES OF DIAGNOSIS OF NECK INJURIES

The clinical picture of wounds and mechanical trauma to the neck depends on the presence or absence of damage internal structures.

Damage only soft tissues of the neck observed in 60-75% of cases of combat neck trauma. As a rule, they are represented by blind superficial and deep shrapnel wounds (Fig. 19.3 color and illustration), tangential and segmental bullet wounds, superficial wounds and bruises due to mechanical trauma. Soft tissue injuries are characterized by satisfactory general state wounded. Local changes manifested by swelling, muscle tension and pain in the wound area or at the site of impact. In some cases, mild external bleeding is observed from neck wounds or a relaxed hematoma is formed along the wound canal. It should be remembered that with superficial gunshot wounds (usually tangential bullet wounds), due to the energy of a side impact, damage to the internal structures of the neck can occur, which initially do not have any clinical manifestations and are diagnosed against the background of the development of severe complications (acute cerebrovascular accident due to injury and thrombosis of the common or internal carotid arteries, tetraparesis with contusion and ascending edema of the cervical segments of the spinal cord, stenotic asphyxia with contusion and swelling of the subglottic space of the larynx).

Clinical picture damage to the internal structures of the neck determined by which vessels and organs are damaged, or a combination of these damages. Most often (in 70-80% of cases), internal structures are damaged when the second zone of the neck is injured, especially with a through diametrical (in 60-70% of cases) and through transcervical (in 90-95% of cases) course of the wound canal. In 1/3 of the wounded, damage to two or more internal structures of the neck occurs.

For damage great vessels of the neck characterized by intense external bleeding, a neck wound in the projection of the vascular bundle, a tense interstitial hematoma and general clinical signs of blood loss (hemorrhagic shock). Vascular injuries in cervicothoracic wounds in 15-18% of cases are accompanied by the formation of a mediastinal hematoma or total hemorrhage. When auscultating hematomas in the neck, vascular sounds can be heard, which indicate the formation of an arteriovenous anastomosis or false aneurysm. Quite specific signs of damage to the common and internal carotid arteries are contralateral hemiparesis, aphasia and Claude Bernard-Horner syndrome. When the subclavian arteries are injured, there is an absence or weakening of the pulse in the radial arteries.

Main physical symptoms of injury hollow organs (larynx, trachea, pharynx and esophagus) are dysphagia, dysphonia, dyspnea, release of air (saliva, drunk liquid) through a neck wound, widespread or limited subcutaneous emphysema of the neck area and asphyxia. Every second wounded person with such injuries also experiences oropharyngeal bleeding, hemoptysis or spitting of blood. At a later date (on the 2-3rd day), penetrating injuries to the hollow organs of the neck are manifested by symptoms of severe wound infection (cellulitis of the neck and mediastinitis).

In case of injury cervical spine and spinal cord tetraplegia (Brown-Séquard syndrome) and discharge from the wound are most often observed cerebrospinal fluid. Damage neck nerves can be suspected by the presence of partial motor and sensory disorders on the part of upper limbs(brachial plexus), paresis of the facial muscles (facial nerve) and vocal cords(vagus or recurrent nerve).

Injuries thyroid gland characterized by intense external bleeding or the formation of a tense hematoma, salivary (submandibular and parotid) glands- bleeding

and accumulation of saliva in the wound. In case of damage, lymphorrhea from the wound or the formation of chylothorax (with cervicothoracic wounds) is observed, which appear on the 2-3rd day.

Clinical diagnosis of injuries to blood vessels and organs of the neck is not difficult when there are reliable signs damage to internal structures : ongoing external or oropharyngeal bleeding, increasing interstitial hematoma, vascular murmurs, release of air, saliva or cerebrospinal fluid from the wound, Brown-Séquard palsy. These signs occur in no more than 30% of the wounded and are an absolute indication for emergency and urgent surgical interventions. The rest of the wounded, even in the complete absence of any clinical manifestations of injuries to internal structures, require a complex of additional (radiological and endoscopic) research.

Among X-ray methods diagnostics is the simplest and most accessible X-ray of the neck in frontal and lateral projections. Radiographs may reveal foreign bodies, emphysema of the perivisceral spaces, fractures of the vertebrae, hyoid bone, and laryngeal (especially calcified) cartilages. Used to diagnose injuries to the pharynx and esophagus oral contrast fluoroscopy (radiography), but the severe and extremely serious condition of the majority of those wounded in the neck does not allow the use of this method. Angiography through a catheter inserted into the aortic arch using the Seldinger method, is the “gold standard” in diagnosing damage to the four main arteries of the neck and their main branches. If appropriate equipment is available, endovascular hemorrhage control is possible during angiography. vertebral artery and distal branches of the external carotid artery, difficult to access for open intervention. It has undeniable advantages in the study of neck vessels (speed, high resolution and information content, and most importantly - minimally invasiveness). spiral CT (SCT) with angiocontrast. The main symptoms of vascular injury on SC tomograms are extravasation of contrast, thrombosis of a separate section of the vessel or its compression by a paravasal hematoma, and the formation of an arteriovenous fistula (Fig. 19.4).

In case of injuries to the hollow organs of the neck, on SC tomograms one can see gas stratifying the periviscal tissues, swelling and thickening of their mucosa, deformation and narrowing of the air column.

Rice. 19.4. SCT with angiocontrast in a wounded person with marginal damage to the common carotid artery and internal jugular vein: 1 - displacement of the esophagus and larynx by interstitial hematoma; 2 - formation of a hematoma in the prevertebral space; 3 - arteriovenous fistula

More specific methods for diagnosing injuries to the hollow organs of the neck are endoscopic examinations. At direct pharyngolaryngoscopy(which can be performed with a laryngoscope or a simple spatula), an absolute sign of a penetrating injury to the pharynx or larynx is a visible wound to the mucous membrane, indirect signs are the accumulation of blood in the hypopharynx or increasing supraglottic edema. Similar symptoms of damage to the hollow organs of the neck are detected during fibrolaryngotracheo- And fibropharyngoesophagoscopy.

They are also used to study the condition of soft tissues, great vessels, and the spinal cord. nuclear MRI, Ultrasound scanning and Dopplerography. To diagnose the depth and direction of the wound channel of the neck, only in an operating room (due to the risk of resumption of bleeding) can a examination of the wound with a probe.

It should be noted that most of the above diagnostic methods can only be performed at the stage of providing agricultural products . This

This circumstance is one of the reasons for its use in those wounded in the neck. diagnostic operation - audits of internal structures. Modern experience the provision of surgical care in local wars and armed conflicts shows that a diagnostic revision is mandatory for all deep blind, through diametrical and transcervical wounds of the II zone of the neck, even if the results of instrumental examination are negative. For wounded patients with wounds localized in zones I and/or III of the neck without clinical symptoms of damage to vascular and organ formations, it is advisable to undergo X-ray and endoscopic diagnosis, and operate on them only after identifying instrumental signs of damage to internal structures. The rationality of this approach in the treatment of combat wounds of the neck is due to the following reasons: due to the relatively greater anatomical extent and low protection of the II zone of the neck, its wounds occur 2-2.5 times more often than injuries to other zones. At the same time, damage to the internal structures of the neck with wounds in zone II is observed 3-3.5 times more often than in zones I and III; Typical surgical access for revision and surgical intervention on the vessels and organs of zone II of the neck is low-traumatic, rarely accompanied by significant technical difficulties and does not take much time. Diagnostic examination of the internal structures of the neck is performed in compliance with all the rules of surgical intervention: in an equipped operating room, under general anesthesia (endotracheal intubation anesthesia), with the participation of full-fledged surgical (at least two-physician) and anesthesiological teams. It is usually performed from an approach along the inner edge of the sternocleidomastoid muscle on the side of the wound location (Fig. 19.5). In this case, the wounded person is placed on his back with a bolster under his shoulder blades, and his head is turned in the direction opposite to the side of the surgical intervention.

If a contralateral injury is suspected during the operation, then a similar approach can be performed on the opposite side.

Despite the large number negative results diagnostic revision of the internal structures of the neck (up to 57%), this surgical intervention allows in almost all cases to make a timely accurate diagnosis and avoid serious complications.

Rice. 19.5. Access for diagnostic inspection of internal structures in zone II of the neck

19.3 GENERAL PRINCIPLES OF TREATMENT OF NECK INJURIES

When providing assistance to those wounded in the neck, it is necessary to solve the following main tasks:

Eliminate life-threatening consequences of injury (trauma)

Necks; restore the anatomical integrity of damaged internal structures; prevent possible (infectious and non-infectious) complications and create optimal conditions for wound healing. Life-threatening consequences of the wound (asphyxia, ongoing external or oropharyngeal bleeding, etc.) are observed in every fourth person wounded in the neck. Their treatment is based on emergency manipulations and operations that are performed without

preoperative preparation, often without anesthesia and in parallel with resuscitation measures. Elimination of asphyxia and restoration of patency of the upper respiratory tract is carried out by the most accessible methods: tracheal intubation, typical tracheostomy, atypical tracheostomy (conicotomy, insertion of an endotracheal tube through a gaping wound of the larynx or trachea). Stopping external bleeding is initially done by temporary methods (by inserting a finger into the wound, tightly tamponade the wound with a gauze pad or a Foley catheter), and then typical accesses to the damaged vessels are performed with final hemostasis carried out by ligating them or performing a reconstructive operation (vascular suture, vascular plasty).

To access the vessels of zone II of the neck (carotid arteries, branches of the external carotid and subclavian arteries, internal jugular vein), a wide incision is used along the medial edge of the sternocleidomastoid muscle on the side of the injury (Fig. 19.5). Access to the vessels of the first zone of the neck (brachiocephalic trunk, subclavian vessels, proximal part of the left common carotid artery) is provided by combined, rather traumatic incisions with sawing of the clavicle, sternotomy or thoracosternotomy. Access to vessels located close to the base of the skull (in zone III of the neck) is achieved by dividing the sternocleidomastoid muscle in front of its attachment to the mastoid process and/or dislocating the temporomandibular joint and shifting the mandible anteriorly.

In patients wounded in the neck without life-threatening consequences of injury, surgical intervention on internal structures is performed only after preoperative preparation (tracheal intubation and mechanical ventilation, replenishment of the blood volume, insertion of a probe into the stomach, etc.). As a rule, access is used along the inner edge of the sternocleidomastoid muscle on the side of the injury, which allows for inspection of all the main vessels and organs of the neck. In case of combined injuries (traumas), the fundamental principle is the hierarchy of surgical interventions in accordance with the dominant injury.

To restore the integrity of damaged internal structures of the neck, the following types of surgical interventions are used.

Great vessels of the neck restored with a lateral or circular vascular suture. For incomplete marginal defects of the vascular wall, an autovenous patch is used, for complete extensive defects, autovenous plasty is used. For the prevention of ischemic

brain damage that can occur during the period of restoration of the carotid arteries (especially with an open circle of Willis), intraoperative temporary prosthetics are used. Restoration of the common and internal carotid arteries is contraindicated in cases where there is no retrograde blood flow through them (a sign of thrombosis of the distal bed of the internal carotid artery).

Without any functional consequences, unilateral or bilateral ligation of the external carotid arteries and their branches, unilateral ligation of the vertebral artery and internal jugular vein are possible. Ligation of the common or internal carotid arteries is accompanied by 40-60% mortality, and half of the surviving wounded develop a persistent neurological deficit.

In the absence of acute massive blood loss, extensive traumatic necrosis and signs of wound infection, wound pharynx and esophagus must be sutured with a double-row suture. It is advisable to cover the suture line with adjacent soft tissues (muscles, fascia). Restorative interventions necessarily end with the installation of tubular (preferably double-lumen) drainages and the insertion of a probe into the stomach through the nose or pyriform sinus of the pharynx. The primary suture of hollow organs is contraindicated in the development of neck phlegmon and media astinitis. In such cases, the following is performed: VChO of neck wounds from wide incisions using large-volume anti-inflammatory blockades; the area of the wound channel and the mediastinal tissue are drained with wide double-lumen tubes; gastrostomy or jejunostomy is performed to provide enteral nutrition; small wounds of hollow organs (up to 1 cm in length) are loosely packed with ointment turundas, and in cases of extensive wounds of the esophagus (wall defect, incomplete and complete intersection) - its proximal section is removed in the form of an end esophagostomy, and the distal section is sutured tightly.

Small wounds (up to 0.5 cm) larynx and trachea may not be sutured and treated by draining the damaged area. Extensive laryngotracheal wounds undergo economical primary surgical treatment with restoration of the anatomical structure of the damaged organ on T-shaped or linear stents. The issue of performing tracheostomy, laryngeal or tracheopexy is decided individually, depending on the extent of laryngotracheal damage, the condition of the surrounding tissues and prospects quick recovery independent breathing. If there are no conditions for early reconstruction of the larynx, tracheostomy is performed

level of 3-4 tracheal rings, and the operation ends with the formation of a laryngofissura by suturing the edges of the skin and walls of the larynx with tamponade of its cavity according to Mikulicz.

Wounds thyroid gland sutured with hemostatic sutures. The crushed areas are resected or a hemistrumectomy is performed. For gunshot wounds submandibular salivary gland, in order to avoid the formation of salivary fistulas, it is better to completely remove it.

Damage thoracic lymphatic duct on the neck are usually treated by bandaging it in the wound. Complications during dressing, as a rule, are not observed.

The basis for preventing complications and creating optimal conditions To heal wounds from battle wounds of the neck, surgery is required - PHO. In relation to neck injuries, PCO has a number of features arising from the pathomorphology of the injury and the anatomical structure of the cervical region. Firstly, it can be performed as an independent dissection operation - excision of non-viable tissue (with clinical and instrumental exclusion of all possible organ and vascular damage, i.e. when only soft tissues of the neck are injured). Secondly, include both surgical intervention on damaged vessels and organs of the neck , so diagnostic audit internal structures of the neck.

By doing PHO wounds s soft tissues of the neck, its stages are as follows:

Rational dissection of the wound canal openings for healing (formation of a thin skin scar);

Removal of superficially located and easily accessible foreign bodies;

Due to the presence of important anatomical formations (vessels, nerves) on limited area- careful and economical excision of non-viable tissue;

Optimal drainage of the wound channel.

Good blood supply to the cervical region, the absence of signs of wound infection and the possibility of subsequent treatment within the walls of one medical institution make it possible to complete the postsurgical treatment of neck wounds by applying a primary suture to the skin. In such wounded patients, drainage of all formed pockets is performed using tubular, preferably double-lumen, drainages. Subsequently, fractional (at least 2 times a day) or constant (like inflow)

ebb drainage) washing the wound cavity with an antiseptic solution for 2-5 days. If, after PSO of neck wounds, extensive tissue defects are formed, then the vessels and organs gaping in them are (if possible) covered with intact muscles, gauze napkins soaked in water-soluble ointment are inserted into the resulting cavities and pockets, and the skin over the napkins is brought together with rare sutures. Subsequently, the following can be performed: repeated PSO, application of primary delayed or secondary (early and late) sutures, incl. and skin grafting.

Surgical tactics in relation to foreign bodies in the neck is based on the “quaternary scheme” of V.I. Voyachek (1946). All foreign bodies of the neck are divided into easily accessible and difficult to access, and according to the reaction they cause - into those that cause any disorders and those that do not cause them. Depending on the combination of topography and pathomorphology of foreign bodies, four approaches to their removal are possible.

1. Easily accessible and causing disorders a - removal is mandatory during the primary surgical intervention.

2. Easily accessible and not causing disturbances - removal is indicated in favorable conditions or with the persistent desire of the wounded.

3. Difficult to reach and accompanied by disorders of the corresponding functions - removal is indicated, but with extreme caution, by a qualified specialist and in a specialized hospital.

4. Difficult to reach and not causing problems - surgery is either contraindicated or is performed when there is a threat of severe complications.

19.4. ASSISTANCE AT THE STAGES OF MEDICAL EVACUATION

First aid. Asphyxia is eliminated by cleaning the mouth and pharynx with a napkin, introducing an air duct (breathing tube TD-10) and placing the wounded in a fixed position “on the side” on the side of the wound. External bleeding is initially stopped by digital pressure on the vessel in the wound. Then a pressure bandage is applied with counter support across the arm (Fig. 19.6 color illustration). When wounded

The cervical spine is immobilized with a collar bandage with a large amount of cotton wool around the neck. An aseptic bandage is applied to the wounds. For the purpose of pain relief, an analgesic (Promedol 2% -1.0) is injected intramuscularly from a syringe tube.

First aid. Elimination of asphyxia is carried out using the same methods as when providing first aid. In cases of development of obstructive and valvular asphyxia, the paramedic performs a conicotomy or a tracheostomy cannula is inserted into their lumen through a gaping wound of the larynx or trachea. If necessary, mechanical ventilation is performed using a manual breathing apparatus and oxygen is inhaled. If external bleeding continues, a tight tamponade of the wound is performed, a pressure bandage is applied with counter support through the arm or a ladder splint (Fig. 19.7 color illustration). For the wounded with signs of severe blood loss, intravenous administration plasma-substituting solutions (400 ml of 0.9% sodium chloride solution or other crystalloid solutions).

First aid. In armed conflict First medical aid is considered as pre-evacuation preparation for aeromedical evacuation of seriously wounded people in the neck directly to the 1st echelon MVG for the provision of early specialized surgical care. In a large scale war After first medical aid is provided, all the wounded are evacuated to the medical hospital (omedo).

IN urgent measures first aid wounded with life-threatening consequences of a neck injury (asphyxia, ongoing external or oropharyngeal bleeding) are needed. They are in the conditions of a dressing room in urgently is performed: in case of breathing disorders - tracheal intubation (in case of stenotic asphyxia), atypical (Fig. 19.8 color illustration) or typical tracheostomy (in cases of development of obstructive or valvular asphyxia), sanitation of the tracheobronchial tree and giving a fixed position “on the side” on the side of the wound (with aspiration asphyxia); in case of external bleeding from the vessels of the neck, apply a pressure bandage with counter support through the arm or a ladder splint, or tight tamponade of the wound according to Beer (with suturing of the skin over the tampon). In case of oropharyngeal bleeding, after tracheostomy or tracheal intubation, a tight tamponade of the oropharyngeal cavity is performed;

For all deep neck wounds - transport immobilization neck with a Chance collar or Bashmanov splint (see Chapter 15) in order to prevent resumption of bleeding and/or aggravation of the severity of possible injuries to the cervical spine; during events traumatic shock- infusion of plasma-substituting solutions, use of glucocorticoid hormones and analgesics; in case of combined injuries with damage to other areas of the body - elimination of open or tension pneumothorax, stopping external bleeding of another location and transport immobilization for fractures of the pelvic bones or limbs. Wounded with signs of damage to the internal structures of the neck, but without life-threatening consequences of injury need priority evacuation to provide specialized surgical care for emergency indications. First aid measures for such wounded people are carried out in a triage tent and consist of correcting loose bandages, immobilizing the neck, administering analgesics, antibiotics and tetanus toxoid. With the development of shock and blood loss, without delaying the evacuation of the wounded, intravenous administration of plasma-substituting solutions is established.

The rest were wounded in the neck first medical aid is provided in order in the triage room with evacuation in the 2nd-3rd stage (stray bandages are corrected, analgesics, antibiotics and tetanus toxoid are administered).

Qualified medical care. In armed conflict with established aeromedical evacuation, the wounded from medical companies are sent directly to the 1st echelon MVG. When delivering those wounded in the neck to the Omedb (Omedo SpN), they perform pre-evacuation preparation in the scope of first medical aid. Qualified surgical care appears only according to vital indications and in volume the first stage of programmed multi-stage treatment tactics- “damage control” (see Chapter 10). Asphyxia is eliminated by tracheal intubation, performing a typical (Fig. 19.9 color illustration) or atypical tracheostomy. A temporary or permanent stop of bleeding is carried out by applying a vascular suture, ligating a vessel or tight tamponade of the damaged area, or temporary prosthetics of the carotid arteries (Fig. 19.10 color illustration). Further infection of the soft tissues of the neck with the contents of hollow organs

Penetrating neck wounds that violate the integrity of the subcutaneous muscle are considered. They make up about 5-10% of all injuries. Because the neck is a small anatomical region containing many vital structures, injuries to this area are an emergency requiring emergency care. The most common cause of death is bleeding.

Penetrating neck injury can lead to damage to the airways, upper digestive tract, blood vessels and nerves. Depending on the structures affected, all symptoms and signs of penetrating neck trauma can be divided into three main groups. Damage to the larynx and trachea is accompanied by respiratory failure, stridor, hemoptysis, hoarseness, tracheal displacement, subcutaneous emphysema, open pneumothorax.

Signs vascular damage are hematoma, ongoing bleeding, neurological disorders, absence of pulse, hypovolemic shock, murmur over the carotid arteries, nervous tremor, changes in consciousness. Nerve damage may be accompanied by the development of hemi- or quadriplegia, dysfunction cranial nerves, hoarseness, changes in perception. Signs of damage to the pharynx or esophagus are subcutaneous emphysema, dysphagia, odynophagia, hematemesis, hemoptysis, tachycardia, and fever. It should be noted that esophageal injuries often occur subclinically.

To simplify process decision making The neck can be divided into three anatomical zones. The most commonly injured zone II is located between the cricoid cartilage and the angle of the mandible.

Zone I located most caudally, between the cricoid cartilage and the jugular notch of the sternum, injuries to this area are especially life-threatening.

Zone III lies between the angle of the lower jaw and the base of the skull. It is important to consider how easy it is to implement surgical access within a particular area. The most accessible zone is II.

Zones I and III protected bone structures, so access to them is limited.

Patients with penetrating neck wounds can be divide into three groups: unstable, stable, asymptomatic. The examination and treatment algorithm should be based on the area of damage and the stability of the condition.

A) Mechanism of penetrating neck injury. The severity of the condition will primarily depend on the mechanism of injury and the strength of the traumatic factor. Gunshot wounds can be inflicted from weapons with low muzzle velocity and high muzzle velocity. Most civilian firearms have low muzzle velocity. Bullets fired from such weapons typically travel along natural tissue layers, dislodge vital structures, and generally cause relatively little damage.

Bullets fired from a weapon with high initial speed(for example, battle rifles), transfer their energy to surrounding tissues and cause significantly more serious damage. The bullet channel is usually straight, and the resulting cavity is much wider (the appearance of the entry and exit holes can be deceiving). Structures located at a distance of 5 cm from the wound may be damaged. Such neck wounds very often end fatal, and timely inspection of the wound can save lives. If the patient is in a stable condition, the decision to perform a wound revision is decided individually.

Knife wounds more predictable than gunshots. One of the key differences is the risk of damage to the subclavian vessels. In most cases, the bullet’s flight path is perpendicular to the neck, so the collarbone in this case somewhat protects the subclavian vessels from damage. Knife strikes, on the contrary, are often made from top to bottom, penetrating the collarbone. Because of this, the risk of damage to the subclavian vessels with knife wounds is much higher than with gunshot wounds.

b) Mandatory and selective neck revision. Examination and treatment of the patient is carried out depending on his clinical condition. First of all, the presence of an immediate threat to life is determined. First of all, you need to focus on signs of ongoing bleeding: increasing hematoma, hemodynamic instability, hypovolemic shock, hemothorax, hemomediastinum. In all these cases, an audit is carried out immediately.

If patient is in a stable condition, they help assess the extent of damage and make a decision on conducting an audit radiation methods diagnostics To further systematize the decision-making process for neck injuries, it is convenient to divide it into three anatomical zones, each of which has its own characteristics.

Damage first zone are especially dangerous because large blood vessels pass through here. Although the chest bones provide some protection for this area, they make surgical access much more difficult. The frequency of deaths due to damage to zone I reaches 12%. Therefore, before performing a revision, angiography is recommended to localize the damage.

IN zone III structures located above the angle of the lower jaw are localized. Of particular danger here are injuries to the cranial nerves and the upper parts of the carotid artery. Access in this zone, as well as in zone I, is severely limited due to the small distance between the angle of the mandible and the base of the skull. Therefore, if the patient is in a stable condition, there are no signs of bleeding, and the airway is intact, angiography is recommended. In the future, it is recommended to regularly examine the oral cavity, because hematoma formation can lead to airway obstruction.

Zone II, the most exposed area lying between the cricoid cartilage and the angle of the mandible, is the most commonly injured. There is still debate about whether mandatory revision should be carried out for all zone II wounds, or whether in some cases it is possible to resort to conservative tactics (regular examinations, including endoscopic examinations, angiography). An argument for conducting an audit is the fact that it can be quite difficult to detect injuries to the veins, pharynx or esophagus. But if the condition is stable, it is more reasonable to hospitalize the patient and monitor his condition over time, conducting regular, frequent examinations.

These patients may also need additional examination using radiation or endoscopic methods.

All patients with penetrating neck wounds, as with any injury, first of all it is necessary to conduct an examination according to the ABC algorithm: airway patency (airway), breathing (breathing), blood circulation (airway). To ensure airway patency, tracheal intubation, conicotomy or tracheotomy is performed. If the airway is injured, the safest method is tracheal intubation, but extreme caution should always be used as the airway can be further injured either due to poor visualization or simply by hyperextending the neck. For pneumothorax, drainage is performed pleural cavity. All patients have central veins catheterized.

For bleeding control or if the hematoma increases in size, the bleeding is first stopped with simple finger pressure. For patients with damage large vessels Inspection of the wound is performed urgently. All patients should be assessed for neurological and vascular disorders, because this may be useful to determine additional damage and the course of the wound channel, for example, existing damage to the carotid artery may be indicated by dysfunction of the hypoglossal nerve, hoarseness, Horner's syndrome.

V) Diagnosis of penetrating neck wounds. If the patient is in a stable condition, a careful history should be taken and a detailed examination should be performed. Particular attention should be paid to the entrance and exit openings of the wound, as well as to the neurological status. To exclude a fracture of the cervical spine, radiography is performed; X-ray of the chest organs makes it possible to exclude hemothorax, pneumothorax, pneumomediastinum, and in some cases it is also possible to diagnose damage to the subclavian vessels. To improve the accuracy of image interpretation, it is useful to mark the wounds with some radiopaque material.

There is still no consensus on what tactics to conduct the patient should be adhered to: mandatory or selective surgical revision of the wound. Since prospective studies have not demonstrated the superiority of one approach over another, many hospitals prefer to resort to selective revision tactics, which involves dividing into three groups: patients in an unstable condition (shock or symptoms of cerebrovascular accident), patients in a stable condition with existing symptoms, patients are in stable condition without any symptoms. Stable patients with injuries of zones I and III are sent for angiography, based on the results of which the issue of conducting a revision is decided.

For patients with zone II injuries and based on the existing symptoms, an audit is performed. In the absence of symptoms, angiography is either performed or observation is carried out for 48 hours.

Patients with penetrating wounds of zone II it is necessary to examine further so as not to miss hidden damage. The first step is to determine the condition of the respiratory tract. If the airway is obstructed, the patient should be stabilized, angiography, contrast examination of the gastrointestinal tract, flexible and rigid esophagoscopy should be performed; If a corresponding pathology is detected, a neck revision is performed. If the airways are free, attention is paid to the state of the respiratory, pulmonary, cardiovascular systems, and neurological status. The decision on the audit is made based on the results of the survey. In any case, all patients require regular examinations within 48 hours.

G) Damage to blood vessels in the neck. In case of injuries to the first anatomical zone of the neck, in most cases a consultation with a thoracic surgeon and a thoracotomy is required, although sometimes it is possible to obtain access through an incision in the neck.

IN zone II the common and internal carotid arteries are located. Revision is performed through an incision along the anterior edge of the sternocleidomastoid muscle. Extensive hematoma or damage to the proximal part of the artery will make its identification more difficult, since it will be more difficult to notice the pulsation of the vessel. In this case, for identification it is necessary to trace the branches of the external carotid artery in the proximal direction. If the branches of the external carotid artery are damaged, simple ligation is sufficient, because there is good collateral circulation. The veins of the neck can also be ligated without any risk, the only exception being damage to both internal jugular veins, in which case it is recommended to restore the patency of at least one vein.

At zone III damage Resection of the lower jaw may be required. Damage to several large vessels at once (external and internal carotid arteries, internal maxillary artery) is possible. If access to the skull base is difficult, consultation with an interventional radiologist may be required.

Several have been described methods for restoring vessel integrity: restoration of the integrity of the vascular wall, ligation of the vessel, graft in the form of a patch on the vessel, venous autograft, synthetic venous graft. In the presence of stenosis (according to radiation methods), it is recommended to perform an end-to-end anastomosis or use autografts. It is not recommended to ligate the internal carotid and common carotid arteries; the procedure is performed only in cases where restoration of patency is impossible. Without treatment, it is possible to develop long-term complications(formation of an aneurysm, rupture of a vessel, formation of an arteriovenous fistula).

d) Assessing the condition of the digestive tract. All patients with suspected esophageal injury should be carefully evaluated. Unnoticed ruptures of the mucosa can cause the development of media-astinitis, which is characterized by a high number of complications and high mortality. Some studies suggest that flexible esophagoscopy may help avoid general anesthesia required for rigid esophagoscopy; however, there are reports that when performing flexible esophagoscopy there is a risk of missing esophageal wall tears in areas with excess mucosal volume.

Important role Radiation methods play a role in the examination of patients with esophageal injuries. As contrast agent Gastrografin is used, since if barium enters the mediastinum, chemical mediastinitis may develop. In addition, the entry of barium beyond the esophagus can radiographically distort the normal layer-by-layer arrangement of tissues. If the study turns out to be uninformative, but clinically there is high risk esophageal perforation, barium X-ray is performed.

With persisting suspected esophageal perforation and lack of supporting data, the patient is transferred to a “nothing by mouth” diet, and careful monitoring is also necessary. If the mediastinum is widened on serial chest radiographs, fever, or tachycardia appears, repeat endoscopy or even exploration of the neck may be necessary.

Many surgeons see patients with emphysema of the soft tissues of the neck, hemoptysis and others threatening symptoms they prefer to perform direct laryngoscopy, bronchoscopy and rigid esophagoscopy. If perforation of the esophagus is detected, primary suturing with a double-row suture, wound cleansing, and adequate drainage are required. To further strengthen the esophageal wall, some surgeons also use a muscle graft. The priority, however, is always airway control.

e) Injuries to the larynx and trachea. Injuries to the trachea that do not compromise the airway or are not accompanied by complete break tracheal rings can be repaired with or without tracheotomy. More severe injuries require a tracheotomy, either through the defect itself or below it.

Damage laryngeal mucosa should be sutured within 24 hours of injury, this reduces the scarring process and promotes voice restoration. In case of displaced cartilage fractures and large tears in the mucous membrane of the folded and supraglottic sections, surgical comparison of the damaged tissues is required. CT and laryngoscopy help determine whether the patient is indicated for thyrotomy and open reduction of the fracture, or whether observation can be limited.

and) Blunt neck trauma. Blunt neck trauma can occur as a result of a criminal attack, sports, or a traffic accident. Possible damage to respiratory and digestive tracts and blood vessels. Because symptoms may develop long enough after the injury, careful monitoring is required to ensure they are not missed.

The carotid artery is the most important blood vessel that supplies oxygenated arterial blood to all tissues of the head and in particular to the brain. Since blood from the heart flows through the arteries, bleeding from this type of vessel is the strongest and most dangerous. If the carotid artery is injured, it is necessary to urgently take rescue measures, since no more than three minutes remain before death. A delay of just 1 second and the person can no longer be saved.

General information about the carotid artery

The paired vessel departs from the thoracic aorta and immediately branches into 2 separate arteries, rushing to opposite sides of the neck. Near the larynx, at the level of the Adam’s apple, each channel branches into 2 more - internal and external. It is to the outer one that fingers are applied to listen to a person’s pulse.

The internal artery runs deep in the neck, so injury to this branch is unlikely. This happens, but extremely rarely. Near temporal region the internal artery penetrates the skull, where it is divided into many branches, which are divided into many more branches, and those into many more... With the help of such a complex highway, all brain cells receive blood from the heart, and with it the elements necessary to carry out their functions and oxygen. Wound internal artery considered more dangerous than external.

The external branch is located in another area - in front of the neck. Therefore, she is more open to injury. However, this does not happen very often. The external artery branches into a whole network of capillaries that supply blood to the eyes and face. During unbearable heat or jogging, you can notice their presence in the form of a slight blush.

When ligatures are applied to the external artery, no consequences are observed when professional medical care is provided. But when performing the same operation on all other parts of the carotid artery, irreversible consequences are possible.

As for the common carotid artery, most often one of its branches is injured - the right or left. In this case, the blood supply to all tissues of the head, and most importantly the brain, is disrupted. One surviving artery is not able to deliver to them required quantity blood and oxygen, which can lead to softening, hemiplegia of the brain or death.

Most often, if one of the arteries is damaged, a person dies even before qualified assistance is provided. If the carotid artery is injured, it is necessary to act urgently! The only good news is that this kind of injury occurs quite rarely. After all, it is simply impossible to accidentally cut yourself, reaching the carotid arteries.

Signs of injury to the carotid artery

How to determine that the victim has a wound in the carotid artery? First, let's look at the differences arterial bleeding from venous.

Arterial blood moves through channels away from the heart, so bleeding from the arteries is rapid and pulsating. The blood has a bright scarlet color and flows out of the damaged tissues like a fountain. The streams splash out gradually - simultaneously with each heartbeat. Those. synchronously with the pulse. This is why a person loses a huge amount of blood in a very short period of time. And the carotid artery, in addition to everything, has an impressive size, which further accelerates the fatal process.

For venous bleeding other symptoms are characteristic - the blood flows out calmly, not in fountains, and has a dark tint.

Thus, damage to the carotid artery can be diagnosed by abundant splashes of bright scarlet blood, the frequency of which corresponds to the pulse. Help for arterial injuries is fundamentally different from measures taken for venous injuries.

All a person can do before the ambulance arrives is to prolong the victim’s life. And to do this you need to know how to stop the bleeding.

To stop arterial bleeding, several methods are used:

finger pressure;
application of a tourniquet;
tamponade;
dressing;
applying a pressure bandage.

The most effective for such anatomically complex area, like the neck - finger pressure and subsequent application of a tourniquet. This is what first aid should consist of. It is impossible to tie the artery with a pressure bandage, since the person may die from suffocation. In addition, the circular bandage will also squeeze a healthy vessel on the opposite side, which will inevitably lead to death.

The first thing that needs to be done when you find a person with a bleeding carotid artery is to digitally press the vessel against the bony prominence (on one side only!). The action is performed in the area of the neck where the pulse from the artery can be clearly felt. This is the area located between the larynx and the protruding neck muscle - the anterolateral muscle. Having placed the fingers in this area, they are lowered 2 cm and the hole is felt. By pressing on it, the pulse is measured. But this is the pulse. First aid actions should be quick, almost instantaneous.

It does not matter which of the carotid arteries is damaged - internal, external or common - finger pressure is carried out exactly in the described place. The common artery is located here, which means the blood will not continue to move upward in any case. Pressure with your fingers is applied towards the spine, you must try to press the vessel against it.

However, if the wound is located presumably below this zone, apply pressure below the wound. The fingers are placed in the cavity between the larynx and the large cervical muscle.

Immediately after pressing, bleeding from the carotid artery will stop. But not a single person is able to continue it for more than 5 minutes, because tense hands get tired and the force of pressure weakens. The slippery flowing blood also interferes with these actions. The gained time must be spent on organizing another method to prevent blood loss. And it’s better if a second rescuer does this.

Application of a tourniquet

To apply a tourniquet, you must have sufficient qualifications so as not to harm the victim. But given that he has little time, in some cases the skill of applying a tourniquet can be useful to an amateur.

Instead of a splint, use the victim’s hand located on the side opposite to the wound. Raise it up and bend it at the elbow. The forearm should be on the vault of the skull. Shoulder - along the ear.

The tourniquet is placed around the neck, capturing the limb used as a splint. This hand performs the function of protecting the intact artery from compression. After all, the brain receives nutrition only from it. You cannot place a tourniquet on bare skin. Place a thick gauze swab under it, be sure to be clean! If possible, I place it a few centimeters below the wound, since a completely cut artery (and this is possible) can slide lower and it will not be possible to stop the bleeding.

If the injury to the carotid artery may well be not the only injury, you cannot use the victim’s hand instead of a splint. For example, after a car accident. If a bone is broken in the arm, its fragments can damage other vessels. It's better to use a board.

Another known method of applying a tourniquet is the Mikulich method. But you should have a Kramer tire at hand, so this method can only be used in special conditions. During finger pressure, the wounded person is seated vertically, and a Kramer splint is installed on the side opposite to the injury. It should protrude in front of the trachea by about 2 cm. Place a roller under the tourniquet, stretch it with your hands and wrap the neck through the splint and roller. Tied on a splint.

After placing the tourniquet, you should write a note to the emergency physicians, noting the time the procedure was completed. The note can be placed under the bandage used for subsequent bandaging of the neck. This is necessary because the tourniquet cannot be used for a long time.

If you perform all the actions quickly and correctly, there will be a chance to save a life. But stopping the blood flow is only the first step on the path to salvation.

Health care

How to stop bleeding after removing a splint? Medical assistance, i.e. final stop bleeding is carried out using the following methods:

Application of a vascular suture.
Dressing.

Ligation is indicated in cases where the artery is wounded close to the bifurcation, and it is not possible to apply a vascular suture. For those who don't know, a bifurcation is a splitting of a major blood vessel. In the situation under consideration, this is a bifurcation of the carotid artery into internal and external.

According to statistics, in 25% of cases, ligation of the common carotid artery ends in death, which is why they resort to this method in the most extreme cases. Before dressing, the patient should be prepared and maximum intake should be ensured. arterial blood to the brain. For this purpose, the patient is placed on the operating table so that he lower limbs were raised and higher than the head.

During the operation, the victim's head is tilted back and turned in the direction opposite to the wound. The vessels are exposed in the area of the carotid triangle - by dissecting layer by layer of tissue from the upper corner of the thyroid cartilage and along the anterior edge of the cervical muscle - the sternocleidomastoid. The length of the incision is 8 cm. The hypoglossal nerve is shifted to the side (outward).

Ligation of the external carotid artery is more successful and does not entail consequences. This happens because the second external artery is located on the opposite side of the neck. True, it is much more difficult to damage it, since it is smaller in size.

Preparing the patient for surgery is the same as in the previous version. But the incision is made from the lower part of the jaw and runs along the front of the same muscle. The incision ends at the upper part of the thyroid cartilage. The muscle is moved to the side. The exposed vaginal wall of the neurovascular bundle of the medial cervical triangle dissected. Ligation of the artery is carried out in the interval between the lingual and thyroid arteries.

The internal branch of the carotid artery is damaged even less frequently, since it runs very deep and is well protected. Its dressing is done according to the same rules as external dressing. Possible consequences.

When you see a person with a wounded carotid artery, you need to act quickly and decisively. Only with timely assistance can the victim survive. Don't panic. As you know, fear is the main enemy of man!

Trauma to the face and neck causes damage to the skin, soft tissues, and bones. facial section skull, pharynx, larynx, thyroid gland, trachea, esophagus, blood vessels, nerves, eyeballs. Damage to the arterial blood vessels in the neck is very dangerous; this leads to severe bleeding and rapid death.

When the airways are destroyed or closed, such serious complications occur as acute disorder breathing and its cessation. The first aid provider must be able to correctly assess the condition of the victim, quickly and clearly carry out the necessary manipulations: stop the bleeding, restore breathing.

Depending on the nature and type of injury, facial injuries are divided into closed and open, with fractures of the facial bones of the skull and lower jaw and without damage to the bone skeleton.

Actions in case of facial injury

Wounds, bruises and abrasions of the face

With facial bruises, hemorrhages into soft tissues usually resolve quickly and therefore no special treatment is required. In these cases, it is enough to apply local cold (ice pack) and apply a moderate pressure bandage. Abrasions and superficial wounds of the face should be lubricated with an alcohol solution of iodine or a solution of brilliant green, covered with a sterile napkin from an individual dressing bag and bandaged.

For minor wounds and abrasions, the wound surface can be covered with BF-6 medical glue. In case of a large gaping and heavily bleeding wound of the face, it will be necessary to treat the skin around the wound with an alcohol solution of iodine, connect its edges with strips of adhesive tape, and possibly sutures.

Fracture of the nasal bones

The most common fractures of the facial skull are fractures of the nasal bones. These fractures are always accompanied by bleeding. If there is bleeding from the nose, the patient is placed with the head of the bed raised, ice or a towel moistened is placed on the bridge of his nose. cold water. If bleeding continues, insert strips of bandage or gauze moistened with a 3% solution of hydrogen peroxide into the nasal passages. It is necessary to force the patient to spit out the blood that gets into the mouth, since swallowing the blood and the accumulation of its clots in the stomach will cause him to vomit.

Jaw fracture

A special place among injuries of the facial part of the skull is occupied by jaw fractures and, above all, a fracture of the lower jaw, which is often (especially bilateral) accompanied by severe complications (recession of the tongue root, respiratory arrest) requiring emergency care.

The type and nature of the fracture of the lower jaw depend on the mechanism of injury (fall, impact, compression, location of application, direction and power of the traumatic force). The main symptoms: pain at the fracture site when palpating and during opening and closing the mouth, lack of even and complete contact of the teeth of the upper and lower jaws, disruption of the contour of the lower jaw and mobility.

Fractures of the lower jaw within the dentition are most often open, as a rupture of the oral mucosa occurs. In these cases, it is recommended to rinse your mouth with a weak solution of potassium permanganate (potassium permanganate). It is advisable that the patient, before arriving at medical institution did not eat (although with a fracture, most likely there will be no time to eat).

Fractures of the upper jaw are accompanied by bleeding from the nose and mouth, hemorrhage in the orbital area, mobility of bone fragments, and severe pain; often combined with concussion and contusion of the brain, fracture of the skull bones. Therefore, if the condition of a patient with a fracture of the upper jaw is moderate or severe, he should be given the same care as for a traumatic brain injury. The patient must be placed on his side, giving him a stable position (there is a danger of vomit getting into the respiratory tract!), open his mouth, stretch out his tongue and fix it by the tip with a pin to the skin of the chin, clean the oral cavity.

To prevent displacement of fragments of a broken jaw during transportation and to avoid increased bleeding, pain, and retraction of the root of the tongue, it is necessary to temporarily immobilize the lower jaw (press it tightly to the upper jaw using a soft bandage made from a bandage, scarf, or scarf).

Damage, eye injuries

Eye damage can be mild, moderate or severe. Minor injuries are not penetrating wounds of the eyelid, or a foreign body entering the eyelid. A rupture or partial tear of the eyelid, a bruise of the eyeball without visual impairment are considered injuries of moderate severity.

Severe injuries are considered perforation wound eyeball (fluid leaks from the wound) or its bruise with decreased vision, fracture of the bones of the orbit with retraction or protrusion of the eyeball.

First aid consists of quickly applying sterile dressing from an individual dressing bag, a clean handkerchief or a piece of linen. You should not rinse the injured eye. Only in case of chemical burns, the eye should be quickly rinsed with copious amounts of water.

Injuries, neck injuries

The mechanism of injury to the neck can be direct (a blow to the neck area with a hand, an object, during a fall, compression, sharp turn and bending) and indirect (a blow to the vault of the skull, when falling head down, a blow with the parietal region on the roof of a car).

Emergency measures for a neck injury depend on the type and severity of the injury. The injury can be closed or open, with or without damage to the cervical spine and spinal cord.

Since the pharynx, larynx, thyroid gland, trachea, esophagus, large arterial and venous vessels, and nerve trunks of the spine are located in the cervical region, the manifestations of these injuries are varied and present diagnostic difficulties, but the most important thing is that some injuries to the neck are extremely are life-threatening, and only correctly and quickly provided assistance can save the patient.

With closed injuries to the neck, its configuration changes and mobility is significantly reduced. The patient tries to keep his head in one position, tilting it towards the side of the injury. Careful palpation of the neck can reveal soft tissue tension, subcutaneous crunching, and mobility of bone or cartilage fragments.

With a closed injury to the carotid artery, an increasing pulsating subcutaneous protrusion forms on the anterior-inner surface of the lateral neck muscle.

Damage to the carotid artery and closed injury to the cervical spine, even without visible signs dysfunctions of the spinal cord (i.e. without paralysis, paresis of the limbs, breathing problems and urination) are life-threatening and require emergency assistance - immobilization of the head, neck and cervical spine.

This prevents dangerous displacement of the vertebrae, which can cause secondary damage to the spinal cord, spasm and tearing of the carotid artery, and therefore impairment cerebral blood flow, significant bleeding.

If you suspect a spinal fracture, you should not move the victim or change his position until the ambulance arrives.

Do not put the patient in a sitting or upright position, try to tilt or straighten the head, or pull the arms or legs.

An injured person must be transferred onto a stretcher or shield with extreme care, supporting all parts of the spine using extremely smooth synchronized movements. This requires at least three people experienced in first aid. Failure to comply with transportation rules can lead to spinal cord injury and irreversible consequences: paralysis or death of the victim.

For uncomplicated bruises, compression and sprains of the neck muscles, apply a high collar bandage to the cervical area using a towel, from the lower jaw to the shoulder girdle, and secure it with a bandage.

Damage to the larynx and trachea (airways) occurs during a blow to the front of the neck. Depending on the degree of displacement, broken laryngeal cartilage and tracheal rings often partially or completely close the airway. This can cause difficulty breathing and even suffocation.

You need to know that suffocation very quickly, in a matter of minutes, leads to death. Breathing becomes wheezing, quickens to 30-40 per minute, and its rhythm is disturbed; sputum, mucus, and vomit accumulate in the oral cavity. The skin of the face and neck becomes pale, with a bluish tint, and covered in cold sweat. The pulse is weakly filled, up to 110-120 beats per minute. If the breathing rhythm is disrupted, it stops.

Emergency care consists of restoring airway patency. To do this, you should open the patient’s mouth and, to prevent the jaws from closing, place a wooden stick (covered with a bandage) up to 3-4 cm thick between the upper and lower teeth on both sides; stretch out your tongue, grabbing it by the tip with your fingers wrapped in a napkin; clean the oral cavity and nasopharynx from vomit, mucus, saliva, blood clots, and foreign bodies. If breathing stops, you need to start artificial respiration"mouth to mouth" or "mouth to nose".

At open damage neck, life-threatening injuries to large vessels - the carotid arteries and jugular veins. Blood flows out from a wound in the carotid artery high pressure. You need to press this vessel with the first or two (index and middle) fingers to the spine below the wound. Then place a gauze roll under your fingers and bandage it tightly to your neck. In order not to squeeze the vessels and nerve trunks of the opposite side of the neck with a fixing bandage and not to compress the airways (larynx, trachea), a roll of towels, clothes, or better yet a support board (from the parietal-temporal region to the middle third of the shoulder) is placed on the undamaged side.
When the jugular vein (the largest vein in the neck, located along the inner edge of the sternocleidomastoid muscle) is injured, there is little bleeding, but there is another danger. Air is sucked into this vessel through the wound, resulting in air blockage of the heart cavities (embolism). A moderate pressure bandage should be immediately applied to the damaged vein.