Classification of gunshot wounds. The nature of the defeat from pneumatic weapons of biological and non-biological objects What is the name of the wound from a pneumatic gun

By studying gun wounds Since 1990, we have been dealing with peacetime (PMT) since 1990. This is due to the fact that until 1990, no more than two wounded patients with PMT were admitted per year, which is why they did not represent a problematic interest. After 1992, the number of such wounded increased sharply, which required a focus on the features of the diagnosis and treatment of such victims.

Gunshot wounds. Gunshot wounds are wounds inflicted from any firearms or device (pistol, gun, gun, mine, improvised firing device, etc.), the projectile from which (regardless of its type: bullet, gas, shot, "chop", fragments primary or secondary, etc.) is ejected by means of an explosion explosive(gunpowder, plastic, dynamite, etc.).

Weapon wounds. Weapon wounds mean wounds inflicted from any non-firearm weapon or device (bow, crossbow, wind (pneumatic) gun or pistol, speargun, production device (dowel), etc.), the projectile from which, regardless of its type (bullet, arrow, metal rod, etc.), is released by means of any throwing device that is not associated with an explosion (spring, bowstring, compressed air).

We explain the sharp increase in the number of such victims with the criminalization of Russia, when disputes between individual groups of "business" began to be resolved not on the legal, but on the criminal field, and the stratification of society into the very poor, the poor and the very rich gave rise to flourishing banditry. The acquisition of firearms (including service weapons) is not difficult.

In peacetime, in the first two hours after being wounded, 78.8% of the wounded enter the neurosurgical hospital, and after 7 hours from the moment of injury, they do not arrive at all, or such admissions are single and amount to tenths or hundredths of a percent.

This leads to two fundamental provisions:

in neurosurgical hospitals, in peacetime and wartime, the structure of the wounded (in terms of type and severity of PUR) is different;

Specialized medical care in peacetime is provided faster than during war.

The rapid, within the first hours, delivery of the wounded to the neurosurgical department leads to the fact that the wounded, who die on the battlefield in wartime, end up in a specialized hospital. These are usually victims in a coma with radial, diametrical (completed or incomplete) wounds, as well as injuries of the posterior cranial fossa. These injuries (especially the posterior cranial fossa) are classified as very severe. In addition to unusually severe gunshot craniocerebral wounds inflicted from service weapons, there are other features of gunshot wounds in peacetime.

The features of gunshot wounds in peacetime include wounds from a gas pistol. Shots are usually fired either at close range or from a short distance (1-2 meters). In this case, especially if the injury is inflicted in the area of ​​the scales of the temporal bone, it can be penetrating and accompanied by damage to the brain not only by charge particles (wad-type pads) or bone fragments, but also by the charge itself (gas). The degree of damage to the brain by the charge depends on the composition of the gas (tear, nerve, etc.). Such an injury may be accompanied by the development of specific encephalitis, and a purulent infection that has joined can significantly aggravate the condition of the wounded.

Also specific are the OCMR, applied from a smooth-bore: long-barreled - hunting rifles or short-barreled - converted to a gas pistol shot charge, or a foreign-made shotgun. The charge of such a pistol most often contains shot number 9 - "snipe".

Wounds inflicted from a short distance (up to 2 meters) can be penetrating and be accompanied by damage to the dura mater and brain substance, both by the charge itself and by bone fragments. A shot charge usually does not penetrate deep into the brain; it is located compactly in the cortical regions of the brain, although individual pellets can also penetrate deep enough into the white matter.

The severity of gunshot wounds inflicted by hunting long-barreled non-rifled weapons depends on the caliber of the gun, drilling of its barrel (cylinder, choke, pay) and charge (shot, bullet). Shot of various calibers is used here, most often No. 3 and larger, up to buckshot. Such a charge, released from a short distance, when it hits the human body, behaves like an explosive bullet, causing a deep, lacerated wound with massive damage to the brain substance.

Other wounds are also possible, inflicted from self-propelled guns, usually made by handicrafts and teenagers. Such a device is a metal smoothbore tube, tightly sealed on one side (breech) and having a hole for the fuse. The powder charge can be either gunpowder (most often hunting or extracted from live ammunition), as well as a home-made explosive (a mixture of saltpeter, crushed coal, sulfur, potassium permanganate powder and other ingredients in an arbitrary proportion). The weapon is extremely unstable, dangerous to use, often explodes in the hands of the shooter. The imperfection of such a weapon leads to the fact that almost equally often both the charge (“chop”, shot, steel balls) and the breech (the last in the head of the shooter) fly out of it.

When fired at close range, a gunshot wound is complicated by thermal and chemical burns, especially if potassium permanganate is included in the explosive mixture. Such burns can lead to toxic encephalitis, which is difficult to treat.

Penetrating wounds to the skull can occur when fired from "harmless" non-firearms. Such injuries are quite common when fired at close range from a pneumatic (“wind”) weapon, especially if it is loaded with steel balls or lead bullets, and the weapon is automatic and several charges hit the head at once (especially in the scales of the temporal bone).

No less serious craniocerebral wounds can be wounds inflicted by an arrow fired from a bow. An arrow fired from a crossbow can pierce through the chest of an adult elk. Getting into the human skull, it can cause a diagonal (radial) penetrating wound of the skull.

There are two main tasks in the diagnosis of PTSD:

assessment of the general condition of the wounded and the identification of life-threatening disorders and

definition of the very nature of the PTSD.

Under all circumstances (the ability to quickly after injury) the provision of specialized medical care is of paramount importance.

The main principle of the surgical treatment of gunshot wounds of the skull and brain is their early, radical debridement by primary surgical treatment with the removal of all foreign bodies, liquid blood and blood clots, cerebral detritus and necrotic brain tissue with active drainage of the wound, free dural plasty and wound suturing. tight (around the drain).

During the surgical primary treatment of a gun wound, it must be remembered that the most infected foreign bodies brain (during the first half of the year), are bone fragments, particles of a headdress, and not the bullet itself. Therefore, the actions of the surgeon should be aimed at removing all foreign bodies. Chasing the "bullet" is not an end in itself of the operation, although its removal (along with other foreign bodies) is desirable. In addition, we should not forget that the wound channel is not a smooth-walled tube. Due to the fact that when passing through the brain, a temporarily pulsating cavity appears, cracking of the brain occurs at a distance from the main wound channel. As a result, from the main wound channel, along its entire length, many microcracks extend into the depths, into the substance of the brain. These cracks are infected as well as the main wound channel.

It should also be borne in mind that foreign bodies (bone fragments, hair, parts of a headgear, etc.) at the inlet penetrate deep into the skull and brain, and at the exit, on the contrary, into soft tissues, into the integument of the skull. The bulk of foreign bodies (except for a bullet) is concentrated in the cranial cavity at the inlet at a depth of up to 5-7 cm. The pursuit of individual pellets located in the depths of the brain, in its nuclei or ventricles, is far from always appropriate. It should be borne in mind that in this case, the surgical intervention itself can cause more trauma than the gunshot wound itself. At the same time, the more radically the primary surgical treatment of a gunshot wound was performed, the less chances of purulent complications (meningitis, meningoencephalitis, brain abscess, purulent ventriculitis) - one of the main causes of mortality in PMT.

17137 0

In peacetime, craniocerebral weapon wounds (CMOR) are much more diverse than during military operations, both in terms of the characteristics of the craniocerebral lesion and in the weapons used - both firearms, specific in design (smooth-bore or rifled hunting rifle, short-barreled, "self-propelled gun" , gas weapons in the form of revolvers or pistols) and charge (shot, "cut", lead casting, hunting bullet - round or type "Zhakan"), and non-firearms (bow, crossbow, pneumatic weapon in the form of a pistol or gun, guns for spearfishing, and other devices intended for use in peaceful purposes- dowel). A feature of peacetime CHMOR is the fact that even when a single charge (for example, shotgun) hits the head, damage can be multiple and differ from each other both in extent and depth of damage.

The variety of FMOR is determined not only by inconstant factors (ballistic properties of a projectile fired from a wounding weapon - its kinetic energy, translational, rotational, oscillatory, speed), but also from more constant factors - the resistance of the environment surrounding the flying projectile (or projectiles), soft tissues head, skull, brain, their viscosity. The latter determines the degree of friction force of the projectile, and hence the magnitude of the destruction of the brain mass adjacent to the projectile, the size of the temporarily pulsating cavity (VPP), the formation of brain detritus and its movement and foreign particles deep into the wound, the infection being drawn deep into the wound and its spread beyond the wound channel into the wound. in particular and through WFP. Therefore, for example, with a shot wound or with a wound from an automatic pneumatic weapon, the variability of each individual wound stroke matters.

The classification of wartime gunshot wounds is described in this manual. For wounds in peacetime, the classification of combat defeats requires some clarification. The modern classification of peacetime weapon wounds (Fig. 22-1) is given in only one monograph.

The basic principles for classifying FMOR in peacetime are the same as for gunshot wounds during military operations (through and blind, penetrating (with damage to the dura mater) or non-penetrating, tangential, diametrical, segmental, sheer and diagonal). Wounds can be accompanied only by damage to the soft tissues of the head, or both soft tissues, and the skull, and the brain itself.

According to the type of weapon and the characteristics of the injuries inflicted by them, peacetime CHMORs are divided into: gunshot wounds, wounds from pneumatic weapons, spring-crossbow-beam wounds.

GUNSHOT WOUNDS

To understand the pathological processes that develop after gunshot wounds in peacetime, the meaning of surgical intervention and its scope, it is necessary to be familiar with the medical and ballistic characteristics of gunshot wounds in peacetime.

Peacetime gunshot wounds inflicted from hunting smooth-bore guns, with their features, resemble (more than gunshot wounds from service weapons) wounds inflicted at one time from muskets, squeakers, arquebuses. Wounds from such weapons are accompanied by damage to the skull and brain, not only at the point of contact with the projectile, but also at a distance from the inlet in the form of cracking of the bones of the skull and brain tissue.

The damaging effect of a firearm depends on its ballistic performance transfer and transformation of energy, anatomical structure and topographic relationship of body tissues.

Rice. 22-1. Classification of gunshot wounds in peacetime.

Hunting wounds
Shotgun wounds

When firing at close range or from a small (1-2 meters) distance from a long-barreled smoothbore hunting weapon on the scalp around the wound and in the wound itself there are traces of powders and burns, "lead". The inlet is from 1 to 5 cm in diameter, rounded. The edges of the wound are uneven, crushed, torn.

When fired from a short distance, other things being equal, the defeat depends on the mass of the charge and the size (number) of the shot - the larger the charge (gun caliber), the greater and heavier the damage it inflicts. A 12-gauge wound is worse than a 20-gauge. (The caliber of a hunting rifle is determined by the number of ball bullets that can be cast from a pound of lead for the diameter of a given barrel. Therefore, 12 gauge is larger than 16, and 16 is larger than 20).

The shot charge has its own characteristics of destruction. Released from the barrel, the shot charge appears as a mass of individual pellets flying compactly. Each such pellet has its own mass, its own kinetic energy, its own range of distance from the target, its own angle of contact with the head, determined both by the position of the individual pellet and by the sphere of the skull at the place of its contact with it. Therefore, individual pellets can ricochet along the outer surface of the skull, others - along the inner one, some penetrate into the cranial cavity, others do not. When shot at close range or from a short distance, the vast majority of pellets (fired from a gun) penetrate the cranial cavity. The total effect of such a shot is very close to the effect of an explosive bullet. The wounds are usually very severe (even if the charge was from the smallest fraction No. 9 - “snipe”). With an increase in the weight of the pellets in the charge, and even more so when using buckshot, the severity of the wound also increases sharply.

In the wound, in addition to pellets, there are other components of the charge: powders, felt or cardboard wads (or parts thereof).

The hydrodynamic force of the shot charge is significant. It is made up of the total (compact) mass of the entire charge and the mass of each individual pellet. When shot at close range, the brain and skull are torn at a considerable distance, the damage is very large and the wounded, as a rule, die at the scene.

When shot at close range, the severity of the wound is determined not only by the quality of the charge, but also by the angle of its contact with the skull. However, even with tangential wounds, a significant part of the charge enters the skull, destroying both the skull and the brain. Part of the pellets slides over the sphere of the skull under the soft tissues, between them and the bone, partly remaining in the soft tissues, partly flying out (a through wound of the soft tissues of the head). The main charge, even with a perpendicular contact with the head, usually causes a blind wound, which is why there is usually no exit hole.

The wound was clogged throughout its depth with foreign bodies: shot, powder, hair, parts of a headgear and fragments of skull bones. In addition to the main wound channel, where the main part of the shot charge is located, at different distances from it, there may be additional wound passages from individual pellets that have separated from the main mass.

With an increase in the distance from the target, depending on the weight of the projectile and the drilling of the gun barrels (“CHOK”, “PAY” or “CYLINDER”), the quality of the damage to the skull and brain also changes. The entire charge and each pellet separately, as

flight, lose their kinetic energy. The lethal force of the projectile is lost, the number of pellets penetrating the skull decreases, the number of pellets ricocheting or sliding over the bones of the skull, between them and soft tissues increases. Among the pellets penetrating the cranial cavity, their number increases with internal ricocheting.

So, when shot from a close (7-15 meters) distance, the wound also resembles a wound from an explosive bullet (Fig. 22-2). However, there will be no powder in it, there will be no traces of a burn, or they will be observed rarely and unsharply expressed. Due to internal ricocheting, wound passages inside the skull and brain will not be straight, but curved, zigzag. The more the distance to the target lengthens, the fewer pellets will be inside it, the greater part of the pellets that penetrated into the cranial cavity will ricochet inside it. Internal ricocheting at the point of impact of the pellet on the inner vitreous plate can lead to its fracture. At the same time, the spongy part of the bone and its outer vitreous plate remain intact.

Rice. 22-2. Blind penetrating shot wound at close range. CT. Axial cut.

Fractures of the internal vitreous plate are characterized by its fragments - thin, sharp bones that can injure the venous or arterial vessels of the dura mater (dura mater) or the brain. In this case, intracranial hematomas can form - epi- or subdural with all the ensuing consequences. Considering that the pellet that broke the internal vitreous plate inside the skull ricocheted, the resulting hematoma will not necessarily be in the area where the pellet responsible for this is located. Therefore, one should not be guided by the location of the hematoma by the position of the pellet inside the skull. Internal ricocheting also makes it difficult to determine the course of the wound channel of the ricocheted pellet. This, in turn, is reflected in the surgical tactics.

When fired from a long distance (20 meters or more), the shot charge usually “crumbles”, it does not go heap, its kinetic energy (lethal force) decreases sharply. Therefore, when it hits the head, only a small part of the pellets gets inside the skull, or the shot does not get inside the skull at all, and everything remains in the soft tissues of the head (Fig. 22-3).

Rice. 22-3. Shotgun wound from a distance. The shot is mainly in the soft tissues of the head. Radiographs in direct (A) and lateral (B) projections. It is impossible to determine (according to radiographs) whether the shot has penetrated into the cranial cavity, and if it has penetrated, then which part of it is impossible.

According to radiographs made in 2 standard (direct and lateral) projections, as well as in additional lateral projections with a large amount of shot in the soft tissues of the head, it is not possible to determine what part of the shot penetrates into the cranial cavity and whether it penetrates at all. The pellets that hit the head are prone to ricocheting and spreading under the soft tissues of the head. Therefore, the point inlet of the projectile itself (pellet) may not be, and it may sometimes be at a considerable distance from the inlet, under the soft tissues of the head, without penetrating into the cranial cavity.

When penetrating into the cranial cavity, due to the low kinetic energy, such pellets are also prone to internal ricocheting. In this case, fractures of the internal vitreous plate are possible. The destructive power of such a pellet is small, and the damage to the brain from it is not as great as from a pellet that has fallen into the cranial cavity from a shot from a short distance.

There are no traces of burns in the wound, there are no inclusions of powders. However, there may be traces of lead.

The overall mortality rate for shot craniocerebral wounds is 77.3%. The shot that got into the brain is not limited to mechanical damage to the brain. Lead has a toxic effect on the brain tissue, leading to the development of specific encephalitis.

Shotgun wounds from short-barreled weapons. Usually these are factory-made pistols or revolvers or gas pistols converted to a shot load. The damage is usually not as devastating as from a hunting rifle. This is explained by the fact that a shot of small weight and diameter is usually used as a charge (“bekasinnik” - shot No. 9). In addition, there are much fewer shots in such a charge than in a shotgun charge. The cartridge itself is relatively small (compared to a rifle cartridge), therefore both the mass of the shot and the amount of gunpowder in it (even in revolvers of caliber 9 or 12) are incomparably smaller than in a gun. Hence the lower kinetic energy of both the entire charge as a whole and each of its individual pellets, the lower “killing power” of the charge (compared to a rifle). Drilling the barrel according to the “cylinder” type leads to a large scree of the charge already at close range, which also reduces the lethal force of the entire charge as a whole.

Shots are usually made from a short distance or almost point-blank range. The wound appears either as a rounded lesion with crushed soft tissues in the center, or as a more or less extensive lesion area with multiple wound passages. Such a wound usually bears traces of a burn. There are inclusions of powders, secondary foreign bodies (particles of a headdress, hair, etc.), leaded edges of wounds.

Most of the projectile (or even the entire projectile) does not penetrate the cranial cavity. There is external ricocheting under the soft tissues of the head. Separate grains fall into the cranial cavity (Fig. 22-4).

Rice. 22-4. Craniograms in the anterior-posterior (A) and lateral (B) projections when injured from a short-barreled shotgun (a gas pistol converted into a shot charge) from a distance of 1 meter. Non-penetrating wound. Shot (No. 9) is located in the soft tissues of the head.

When penetrating into the cranial cavity, the shot is prone to internal ricocheting, as a result of which the formation of intracranial hematomas is possible. Brain lesions are small, usually superficial.

Thus, wounds from short-barreled shotguns bear the features of a shot shot from a long distance when using hunting rifles (non-penetrating wound, or penetration of a small amount of pellets into the skull), and features of a shot from a short distance or point-blank range (burn marks, interspersed with powder).

Bullet wounds

Bullet wounds from smoothbore hunting weapons can be inflicted by two types of bullets: either explosive (such as "Zhakan"), or non-explosive, more often ball. These are bullets of a fairly large caliber (12, 16, less often 20).

Explosive bullet wounds are very severe. An explosive bullet hit from close and medium distances is accompanied by massive destruction of body tissues and therefore such wounded rarely go to the hospital. They usually die at the scene. Wounds are characterized by all signs of a gunshot wound. On the soft tissues of the head there are traces of burns, “leading”, the inclusion of powders when shot at point-blank range and at close range. A craniocerebral wound is characterized by massive crushing of the brain, its several lobes and multiple cracking of the skull both at the inlet and at a distance from it. The wound may be penetrating.

When shot from a long distance, the damage is not so great and such wounded can go to the hospital. However, even here the damage is significant. Usually several (2 or more) lobes of the brain are affected. Cracking of the skull both in the region of the inlet and at a distance from it. Tangential wounds, as a rule, penetrating, are accompanied by multi-comminuted fractures of the skull and its cracking both at the point of contact of the skull with the bullet, and at a distance from it. Brain damage is also extensive, usually spreading over several lobes and localized both at the site of injury and away from it. The explosive action of the bullet contributes to the occurrence of foci of bruising, gray and red softening of the brain by the mechanism of cavitation. It is also possible intracranial bleeding at a distance from the site of injury with the formation of an intracranial hematoma (intracranial, epidural or subdural). The wound is usually blind (unless it is tangential). Due to the fact that an explosive bullet breaks into fragments upon contact with an obstacle, there may be several wound channels. Each of them may contain part of a bullet, which may give the false impression that this wound is explosive or shrapnel. Secondary foreign bodies may also be present in the wound.

When wounded by a spherical (non-explosive) bullet, the damage is less significant than when wounded by an explosive one. A ball bullet is unstable in flight, and hunting gunpowder has less explosive (pushing) force than combat. A bullet fired from a hunting rifle makes oscillatory and rotational movements, in flight it loses kinetic energy relatively quickly, which is why its lethal force quickly decreases. With shots from close and medium distance, craniocerebral wounds can be not only blind, but also penetrating. The inlet is usually smaller than the outlet. It is characterized by signs of a gunshot wound. The edges of the wound are crushed, indented. Soft tissue wound smaller than bone, bone

less than the dura mater, the dura mater is less than the brain. The brain wound appears as a funnel-shaped expansion at its beginning, and after 3-5 cm it narrows somewhat. The appearance of the wound resembles a funnel. Bone fragments and secondary foreign bodies are drawn into the skull - into the brain, located mainly at a distance of about 5 cm from the inlet in the above-described "funnel", which is of practical importance in the surgical treatment of the wound. The wound channel itself can be deep, extending both to the homolateral and contralateral hemispheres. In case of a blind wound, there is a bullet at the bottom of the wound channel.

When fired from a long distance, penetrating into the cranial cavity, the kinetic energy of the bullet may not be enough to destroy the bones of the skull or only soft tissues on the opposite side. The so-called "incomplete" penetrating wound is formed. With the loss of a significant part of the kinetic energy, the bullet can make an internal ricochet from the opposite wall of the skull. The wound channel then takes the form of a broken line. Therefore, it is impossible to judge the course of the wound channel from conventional x-rays (comparing the location of the bullet with the inlet). At the point of impact of the bullet on the inner vitreous plate, the latter may break. Its sharp fragments can injure the vessels of the dura mater or the cerebral cortex, which can be a source of intracranial hematomas.

With a through wound, there is no bullet in the cranial cavity. The outlet is larger than the inlet. Foreign bodies (bone fragments) are usually located outside the brain, at the exit from the skull, in the soft tissues of the head. The area (extensiveness) of head tissue damage in the area of ​​the outlet is opposite to the inlet: damage to the DM is less than that of the bones, damage to the bones is less than that of the soft tissues.

Bullet wounds from rifled hunting weapons are inflicted from a small-caliber rifle (type TOZ) or from a hunting carbine, or from a smooth-bore hunting rifle with a special barrel rifled insert. Such wounds are as close as possible to wounds from small arms service weapons. However, they also have significant differences from them, which is explained by the caliber of the cartridge, the properties of the gunpowder used and the mass of the bullet. The explosive power of hunting gunpowder is much less than combat. Hence the speed of a bullet fired from a small-caliber rifle or a hunting rifle, its kinetic energy, lethal force is less than the speed of a bullet fired from a standard small arms.

Therefore, FMOR caused by shots from such weapons are less traumatic than injuries caused by standard-issue small arms. However, when fired at close range or at close range, there may be both diametrical and penetrating wounds. More typical are blind wounds, not penetrating deep into the cranial cavity. Often there is ricocheting both inside the skull and outside. In the latter case, the gunshot wound appears to be sliding. It can only spread to soft tissues and have an elongated shape, it can be accompanied by a fracture of the bones of the skull, as soon as its outer or inner plate, or a complete fracture with depression of bone fragments deep into the skull with or without damage to the dura mater. Cranial fissures are usually located in the area of ​​the inlet and have a linear shape. Cracking of the skull, especially at a distance from the wound channel, as a rule, is not observed.

Due to the smaller than live cartridge, the kinetic energy of a bullet fired from a hunting rifle or small-caliber hunting rifle, brain damage at a distance from the wound channel (secondary brain damage) is also less significant. The wound channel itself, as well as the wound channel from a live bullet, contains brain detritus, liquid blood and its clots, foreign bodies and fragments of the shell of the bullet. Capillary ruptures in the brain tissue depart from the main wound channel, due to the effect of a temporarily pulsating cavity. In case of a blind wound, a projectile is located at the bottom of the wound channel. With a through wounding projectile in the cranial cavity, there is no. In case of an incomplete penetrating wound, the wounding projectile is located in the soft tissues of the head in the region of the exit hole in the skull.

The geometry of the wound channel is the same as when firing from small arms combat weapons: inlet in soft tissues it is less than in the bone, in the bone it is less than in the DM, in the DM it is less than in the brain. In the area of ​​the outlet, these values ​​are in reverse order.

Foreign bodies (bone fragments, headgear particles) in the area of ​​the inlet are located in the depth of the craniocerebral wound, mainly at a distance of about 5 cm from its beginning, although they can penetrate deeper. In the area of ​​the outlet, foreign bodies are mainly located in the soft tissues of the head.

Self-propelled wounds

A self-propelled gun is a handicraft weapon. It is a metal (most often made of iron) tube, reinforced in a wooden box. Both the diameter, and the length, and the strength of the tube are very different and depend on the manufacturer's imagination. Most often, samopals are made by teenagers, which is why wounds from samopals are most common in children.

The fragility of the entire device often leads to the fact that when fired, the self-propelled gun explodes in the hands of the shooter and injures the shooter himself.

The breech of the self-propelled gun is usually filled with lead. Often, for “strength”, a screw is screwed through the breech in a vertical direction. Such a design predisposes, especially when using real, even hunting gunpowder, the release of not only a projectile from a self-propelled gun, but also its breech, with the wound of the shooter himself. The fact that not all shots from self-propelled guns end in self-injuries is explained by the fact that teenagers usually use homemade gunpowder (a mixture of sulfur and crushed coal with various additives in the form of potassium permanganate, etc.), which has a much lower explosive force than combat. Self-propelled wounds are often combined (the head and hands of the shooter, much less often the chest or stomach), occur during the explosion of such a device in the hands of the shooter. A head wound is often caused by the lead casting of the weapon's breech. The charge is either shot, or lead balls, or "cut" (pieces of chopped wire), or other metal formations.

The size and indefinite shape of the lead casting of the breech of the self-propelled gun also determines the configuration of the wound - it is torn, large in area and has all the signs of a gunshot wound. The wound may be only soft tissue, non-penetrating with bone damage, or penetrating with significant brain damage. A projectile (or projectiles) that hit the head can ricochet both from the outer surface of the skull and inside it. The wound is usually contaminated with hair, headgear, skull bones, and projectile particles.

When shot at point-blank range when charging a self-propelled gun with small shot or chopping, in terms of the extent and depth of the lesion, the wound resembles a wound from a shotgun. When a lead casting hits, the wound is usually blind with a massive lesion of the brain substance. Penetrating wounds are rare, and if they occur, they are most often tangential or tangential. In case of self-injury with a lead casting, the frontal bone on the right and the frontal lobe of the brain are usually affected. In this case, brain damage can be both massive and relatively small. Once in the cavity of the skull, the lead casting in it can migrate both in the substance of the brain, and through its ventricular system, and through the intershell spaces. We observed an injured teenager who was wounded by casting the breech of a self-propelled gun into the right frontal lobe of the brain. In a local hospital, the patient was given a craniogram, according to which the location of the projectile was established. The wound was sutured, and the patient was transported to the Institute. N.V. Sklifosovsky by car (path - 25 km). Upon admission, before the operation, craniography was performed, on which the lead casting was determined in the region of the left ventricular triangle. The patient was operated on. Produced primary surgical treatment of the wound. Projectile (lead casting) removed. The postoperative course was complicated by meningitis. The wounded man was discharged in a satisfactory condition.

WOUNDS FROM GAS GUNS

Gas weapons are mainly represented by pistols or revolvers of various calibers. Injuries from pistols of 6 mm caliber and smaller are usually minor and victims are not hospitalized. The most common are pistols or revolvers of 9 and 12 mm (for example, the domestic revolver of the ICEBERG type), less often of a larger caliber. With an increase in the caliber of a weapon, not only its destructive power increases, but also its weight and dimensions, which makes such a revolver uncomfortable to carry.

Trunk gas weapons not cut. Its breech has a vertical bridge that divides the barrel in half and makes the weapon unsuitable for use with a shot cartridge.

The cartridges have a blank charge (a loud shot imitates a shot from a service weapon) or gas. Gas charges are also different - these are either tear gases-lacrimates such as chloroacetophenone, bromobenzyl cyanide, chloropicrin, or sneezing (adamsite, diphenylchlorarsine, etc.), or mixtures thereof. Abroad produce cartridges with nerve gas. These cartridges are prohibited for use in Russia. In addition, special cartridges for dogs are produced - antidog.

Usually wounds from gas weapons are not penetrating. But when fired at point-blank range, especially in the area of ​​the temporal bone scales, there may be cracks and depressed fractures of the skull with damage to the dura mater and the brain itself (penetrating wounds of the skull.

According to our data, wounds from gas weapons occur in approximately 16-17% of victims; damage to the bones of the skull occurs in 6-7%.

With penetrating wounds, not only bone fragments can be introduced into the cranial cavity, but also elements of the gas cartridge - various gaskets that separate the powder charge and the gas projectile and hold the gas charge, and the gas itself. When shot in the mouth, a multiple fracture of the bones of the base of the skull can occur with profuse bleeding and liquorrhea from the nose or ears, or into the oral cavity from the resulting cracks in the bones of the base of the skull.

When fired from a short distance (0.5-1.5 m), a skull fracture usually does not occur. The soft tissue wound shows signs of a gunshot wound (burn, inclusion of gunpowder particles). There is no lead. A wound with uneven, crushed edges, rounded in size from 0.5 to 3 cm. The burn of the skin can also extend significantly beyond the wound. In the first hours, the smell of gas emanates from the wound. There may be foreign bodies in the wound. Depending on the angle of contact of the gas jet with the skull, there may be detachment of soft tissues from its bones.

Due to the impact of a gas jet on the skull bone, intracranial vessels (meninges and brain) can burst at the site of impact, followed by the formation of intracranial hematomas (epidural, subdural or intracerebral) or foci of brain contusions or hemoangiopathic ischemia (due to the phenomenon of cavitation), or subarachnoid hemorrhage ( Fig. 22-5). Injuries from gas weapons can be accompanied by a concussion.

Wounds from gas weapons are combined. In this case, the body is affected by the forces of impact (ejected projectile of gas), the explosion of gunpowder (thermal burn), the effect of gas on tissue (chemical burn and toxic effect). These burns can be superficial or extend to the entire depth of the tissue, and with penetrating wounds, to the brain. Chemical burns most often go away after 10-15 minutes. In some cases, skin necrosis may also develop. Both, according to our observations, affect wound healing. The ingress of gas into the cranial cavity can cause toxic encephalitis.

Rice. 22-5. Craniocerebral injury from a gas pistol shot. CT. Subarachnoid hemorrhage in the region of the right Sylvian fissure. Soft tissue hematoma in the right temporo-parietal region.

Wounds from gas weapons can lead to motor, sensory or mental disorders. Sometimes there may be a fatal outcome due to toxic pulmonary edema.

ROCKET GUN WOUNDS

Usually done from a short distance. Light or noise rocket launchers are used. The lesion has all the features of a gunshot (burn, interspersed with particles of gunpowder), but there is no lead on the edges of the wound. The lesion extends over a large area of ​​the head. A wound with ragged edges, a deep skin burn, accompanied by soft tissue necrosis. Wounds are often penetrating with extensive cracks and comminuted fractures of the skull with the presence of foreign particles (fragments of the rocket itself, parts of the headgear, etc.). Burns occur not only thermal, but also chemical, especially if there is phosphorus in the rocket projectile. Therefore, the defeat is combined. Treatment of such wounds is especially difficult and lengthy.

INJURIES FROM EXPLOSIVE DEVICES

Unlike mine blast wounds due to live mines, handicraft mine-explosive devices do not have a shirt (metal sheath). In the event of an explosion, such a device produces a minimum number of fragments. This explains the small number of foreign bodies penetrating the skull with this kind of damage. Usually these are either secondary projectiles (stones, pieces of wood or other fragments of objects located in the explosion zone, or small particles of wire or other materials used in the assembly of a plastic explosive device).

Let's take an example. Wounded V., aged 38, was injured in January 1998 when a plastic device exploded on the windowsill of an office. Didn't lose consciousness. He was taken by gravity to one of the Moscow hospitals, where within 5-10 minutes he lost consciousness up to a coma. A collapse developed. Severe left-sided exophthalmos, left-sided hemiparesis, noisy breathing, hypertonicity of the muscles of the extremities. Convulsive syndrome. Pulse 52 beats per minute. BP 180/100 mmHg Art. Multiple puncture wounds on the head and torso. intubation. IVL. Produced resection trepanation of the skull 3x3 cm (!). A 50 ml subdural hematoma was removed. Transferred to the Research Institute of Sp. N.V. Sklifosovsky. Sopor. Left-sided hemiparesis. Survey craniograms show small foreign bodies of metallic density. On CT - multiple small foreign bodies, areas of cerebral ischemia and hemorrhage. Despite intensive therapy, the condition of the wounded continued to deteriorate, the stupor passed into a coma. Repeated CT showed an increase in cerebral ischemia foci, an increase in the hemorrhagic component in them, the presence of foreign bodies, and residual subdural hematoma. Reoperation - radical treatment of the wound of the skull and brain, removal of subdural hematoma 50 ml. Encephalitis developed in the postoperative course. The victim died 3 weeks after the injury. Diagnosis: Explosive penetrating injury to the skull. Multiple intracranial foreign bodies. Multiple foci of red and gray softening of the brain. Subdural hematoma in the right parietotemporal region 50 ppm. Meningoencephalitis. Edema of the brain. Multiple non-penetrating wounds of the trunk and limbs. Barotrauma of the lungs.

This observation confirms the thesis that the wounded with PMCI should be operated only in specialized neurosurgical departments, and the operation should only be performed by experienced neurosurgeons. Defect of the primary operation: a very small burr hole, through which it was impossible to make a thorough revision and sanitation of the wound of the skull and brain. Foreign bodies were left in the area of ​​the burr hole, resulting in the development of encephalitis. The severity, extent and depth of damage to the skull and brain depend on the strength of the explosive device, the distance from the wounded, on whether the defeat occurred indoors or outdoors.

In the case of an explosion accompanied by multiple secondary projectiles when the victim is close to the epicenter, the wounds can be extensive and penetrating. They have torn edges, are dirty, contain many foreign bodies. Skull fractures can be multiple or linear. Both primary and secondary projectiles can penetrate deep into the cranial cavity and cause significant mechanical and thermal damage. All this develops against the background of barotrauma with multiple organ failure.

INJURIES FROM PNEUMATIC WEAPONS

Pneumatic weapons include various devices, the throwing of a projectile from which is carried out by compressed air (gas). There are short-barreled (pistols or revolvers) and long-barreled (pneumatic - "wind") guns. Pneumatic weapons are compressor and balloon. Compressor devices have a chamber in which air is compressed using a special lever. In cylinder devices, compressed air is located in cylinders located under the barrel or in the handle of the weapon. Shot like cotton, quiet. Both shotguns and pistols can have rifled or non-rifled barrels.

Firing range up to 100 meters. Destructive power at a distance of up to 50 meters. Bullet caliber - from 3 to 5.6 mm. At this distance, depending on the degree of air compression in a given type of weapon, a fired bullet can pierce the bones of the skull. We observed a wounded man with a penetrating wound to the skull after being shot from a distance of about 10 meters. Similar observations are described in the literature.

Injuries from pneumatic weapon they have the features of both a gunshot (the presence of a bullet, leaded edges of the wound), and are different from it - there is no powder charge, therefore there is no burn, there are no gunpowder inclusions. More often than not, these are single wounds. However, when using "wind" machine guns, injuries can be multiple. On fig. 22-6 shows the types of pneumatic weapons and their projectiles.

Features of wounds from pneumatic weapons:

1. Usually the bullet is single, spherical, caliber 3-5.6 mm.

2. The wound of the skull is often non-penetrating (especially if the shot was fired from a smooth-bore weapon from a medium or long distance.)

3. The inlet is "pinpoint" (2-3 mm), usually does not bleed. Its edges are wrinkled. The wound does not gape. No burn and inclusion of powders. Possible "lead" edges of the wound.

4. The penetration of the bullet is shallow, there are no penetrating wounds. Often there are "sliding" wounds on the cranial vault. With penetrating wounds, internal ricocheting and fractures of the internal vitreous plate are possible. Due to the relatively small kinetic energy of the bullet and its mass, the hydrodynamic effect on the brain of a projectile fired from an air rifle is less than with gunshot wound. Hence, less damage to the brain than in a gunshot wound both in the wound channel itself, and near it and at a distance. How

with penetrating and non-penetrating wounds of the skull, fractures of only the internal vitreous plate are possible.

5. The wound channel is less contaminated with foreign bodies than with gunshot wounds.

6. With non-penetrating wounds, with "sliding" wounds without fractures of the bones of the skull, the formation of intracranial hematomas and contusion foci is possible both at the site of injury and at a distance from it.

Weapon craniocerebral wounds can also be caused by devices intended for economic purposes, for example, from a dowel gun. Such injuries are characterized by significant lesions of only soft tissues, or both the bones of the skull and brain. Soft tissue wounds are lacerated, usually of a large area, although they can (by area) be insignificant. It depends on which part of the dowel is injured ("head", sideways).

Rice. 22-6. Types of pneumatic weapons and their shells (diagram).

Bleeding is usually small. With the defeat of the main vessels of the neck (carotid arteries) or other large vessels of the head, it can be very significant. Having injured an artery, the dowel can cover its opening like a kind of plug, which should be borne in mind during the surgical treatment of such wounded. If the dowel hits the skull with a “head”, the inlet may be small, but the brain may be damaged to a considerable depth (Fig. 22-7).

Tangential and penetrating wounds of the skull are characterized by linear cracks extending radially from the point of contact of the dowel with the skull and multi-comminuted, often depressed, fractures. Bone fragments can penetrate the skull to a depth of 5 cm or more. Significant contamination with foreign bodies. The dowel may stick out of the wound, or may be covered with soft tissues. Brain damage is represented by a wound channel, gray and red softening of the medulla.

Rice. 22-7. Craniogram in direct projection. Penetrating dowel wound.

SPRING-CROSSBOW-BEAM WOUNDS

These include wounds inflicted by projectiles fired from a bow, crossbow or spring-loaded shooting devices (pistols or guns, including for spearfishing) or children's pistols, a projectile from which (an arrow with a sharp or rubber-sucking tip) when it hits the eye may result in serious injury. A modern bow (mostly sport bow) is made from a combination of wood, metal and plastic (composite bow), has a movable sight and up to 4 stabilizers. The string is made from synthetic threads. The total weight is about 1.5 kg. Designed for throwing arrows. Arrow length - from 60 to 120 cm, thickness - 0.5-1.2 cm. It is made of reed, wood, plastic and other materials. The bow has high accuracy with an arrow flight range of up to 350 meters. The combat head of the arrow - the tip - is made of metal or plastic. The shape of the tip is varied: two, three, or

multifaceted, with or without notches, fork-shaped, conical. The shot is silent. The main disadvantage is the cumbersome design.

The crossbow (crossbow) is an ancient throwing weapon. Consists of two main parts - a powerful bow and stock. The bed in modern crossbows is made of plastic, which significantly reduces the weight of the weapon. Arrows are short. Crossbows were used by the Germans during World War I as grenade launchers. Arrows equipped with explosive and incendiary projectiles can be used.

In connection with the development of crossbow sports, in the late 40s and early 50s, the design of crossbows improved significantly. The loading system has improved, folding crossbows, crossbows equipped with an optical sight have appeared, which significantly increased the rate of fire and accuracy of fire. Upgrading the string of the bow greatly increased the range. The energy capacity of the crossbow exceeds the muzzle energy of a 9x12 mm Parabellum bullet fired from a pistol or submachine gun. The firing range of a modern combat crossbow reaches 200 meters or more. An arrow fired from a crossbow can pierce through the chest not only a person, but also an elk. Given the noiselessness of the shot, it becomes clear that poachers are interested in this weapon.

When it hits a filament body armor, the arrow of the crossbow pushes the threads of the vest apart and is able to hit a person more reliably than a bullet from a firearm (pistol). Given the design of some crossbow arrowheads, which prevents it from being removed from the body without additional, significant tissue injury or creates massive damage to both soft tissues and the brain, a number of countries began to manufacture special combat crossbows, which suggests an increase in crossbow wounds in the near future. Figure 22-8 shows the types of crossbow-bow-spring weapons and the shells used in them.

The striking power of a bow and crossbow in terms of depth and massiveness depends not only on the design of the weapon, but also on the design and material from which the arrow is made. Arrows with a metal tip, other things being equal, have a greater penetrating power than those with plastic or wood. Arrows can inflict both penetrating and non-penetrating FM (Fig. 22-9).

Rice. 22-8. Types of crossbow-beam-spring weapons and the shells used in them (diagram).

The depth of penetration of bone fragments - from superficial, non-penetrating, to the depth of penetration of the arrowhead. The arrow or parts of it may stick out of the wound. The notched metal tip can have the effect of an explosive bullet when hit at close range. Parts of such a tip can be located both in the soft tissues of the head and in the substance of the brain at different distances from the inlet. Fragments of the plastic tip are more difficult to detect, because. many plastics are x-ray negative.

Wounds caused by guns with arrows for spearfishing are of particular complexity. These arrows have a complex tip configuration and are particularly difficult to remove from the wound, even with additional incisions.

Rice. 22-9. Diagonal penetrating wound from a crossbow arrow. The craniogram is presented from the neurosurgical department of the Moscow City Clinical Hospital No. 7 V.A. Nevzorov.

Wounds of the soft tissues of the skull are small and correspond in area to the diameter of the arrow. With tangential wounds, when an arrow slides along the cranial vault, lacerations of considerable length (up to 5-10 cm) can form. Wound edges - from cut to torn, depending on the configuration of the tip. Cut wounds may bleed.

Damage to the bones of the skull - from perforated with the introduction of bone fragments into its cavity when an arrow hits perpendicular to the surface of the skull, to depressed, comminuted fractures or linear cracks - depending on the distance

MEDICAL BALLISTIC CHARACTERISTICS

The striking force of a bullet (its kinetic energy) depends on the mass (less) and flight speed (more). A decrease in the kinetic energy of a projectile fired from a hunting weapon and its relatively low (compared to a live projectile) speed also determine its lower lethal force.

Small caliber bullets fired from hunting weapons compared to small caliber bullets military weapons, due to the lower kinetic energy, in flight it is easier to lose their original orientation. They are prone to tumbling to a greater extent than bullets from service weapons. The shell of such a bullet can burst, and the bullet itself can be deformed. Therefore, it does not necessarily hit the head with its “nose”. The hit can occur both sideways and “bottom”, conditions may arise that contribute to the bullet breaking on impact. Hence, the medical-ballistic characteristics of bullets of various calibers are of practical interest.

The given characteristics are calculated for the charge of military small arms. In hunting rifles, as mentioned above, the charge is weaker, which causes a lower kinetic energy of the bullet, and, consequently, its lower lethal force (the initial velocity of a spherical projectile is about 350-400 m / s). Therefore, wounds inflicted from rifled hunting weapons are less extensive than from combat ones.

Table 22-1

Ballistic characteristics of bullets of different calibers (20)

Table 22-2

The energy of the wounding projectile transferred to the tissues, depending on its caliber (20)

Index	Bullet caliber (mm)
Total Energy (J)
Transmitted energy (J)
The mass of excised tissues during surgical treatment (g)
Severe injuries (%) X

When it hits the skull with the “head”, the bullet changes its position to vertical (or approaching it), and when the bullet hits the side surface, a faster return of kinetic energy occurs. Both of these lead to an increase in the affected area. The greatest return of energy occurs when the bullet exits the skull. Therefore, it is here that the greatest damage to the skull and brain occurs. With small-caliber bullets, the wound channel becomes funnel-shaped. As already mentioned, the destruction is more pronounced at the outlet than at the inlet.

In smooth-bore hunting and pneumatic weapons, ball shells are used. The ball projectile of an air gun has an average mass of 1.3 g and initial speed about 350 m/sec. The round ball of a hunting rifle is much larger and corresponds to the caliber of the weapon. B "self-propelled guns" also often use a ball projectile. Its mass, diameter and initial speed are very variable and, in fact, not only individual for each individual samopal, but also for each individual shot (charge mass, quality and quantity of powder charge or powder surrogate, etc.). Common to all spherical projectiles is that when they hit the skull, they deform a little (except for spherical projectiles made of lead or tin in relation to self-propelled guns).

The configuration and structure of the skull (a rounded, enclosed space limited by bones), the specific structure of its contents (a viscous brain in combination with a liquid - blood and cerebrospinal fluid, intercellular fluid) create almost ideal conditions for the manifestation of the "explosive" action of a shot.

The first attempts to explain the explosive effect of a firearm on the skull and brain were based on the assumption that, when a projectile enters the cranial cavity, it creates air pressure in it, as in a closed space, which leads to rupture of the brain and cracking of the skull. It was also believed that the "incandescence" and "melting" of the projectile also contributes to the cracking of the skull and brain. However, the shell "heats up", and even more so "melts" by no means always, and the whole variety of lesions of both the brain and the skull cannot be explained by such a representation.

In 1901, the theory of "hydrostatic and hydraulic pressure" was proposed, according to which, according to Pascal's law, the pressure from a projectile (its mass and force) that hit the skull spreads evenly in the brain. It is this pressure that causes cracking of the skull at a distance from the inlet and the wound channel. This theory of hydraulic pressure was fairly common.

The theory was more consistent with reality, according to which the distribution of the projectile force inside the skull does not occur evenly, but in accordance with hydrodynamic laws, "because all destruction has a clearly growing forward character, most of all in the direction of the bullet's flight and obliquely to the side." It was shown that damage to the skull and brain is a complex act and is determined by many reasons - the physical and biological characteristics of the affected tissues, the degree of their concussion, the impact force of the projectile, the deformation and tumbling of the bullet, which depends on the thickness, fragility and elasticity of the bones of the skull, as in each individual the victim, and in each damaged area. It was believed that for damage to the brain, it was important not that hydraulic pressure rises in it (from a hit projectile), but that, from the impact of a bullet, it shakes throughout its mass.

The resulting shock is transmitted in waves in the direction of the bullet's flight to the walls of the skull and increases the destruction that has begun in them. main reason the spread of damage was seen in the enormous impact force of the projectile and the large return of manpower (kinetic energy) to biological tissues. It was believed that the brain is involved in the destruction (cracking) of the skull by pressure on it from the inside. The main condition for the destruction of the skull is not the water content in the brain, but the ability of its mass to transmit a push in all directions. It was believed that for the destruction of the skull, the specific gravity (relative density in the modern sense) of the brain is decisive - the larger it is, the greater the destruction of the bones of the skull.

It was also believed that the action of a bullet is similar to that of a wedge. Therefore, for the destruction of the bones of the skull great importance has the amount of water contained in the brain.

To explain the impact of a projectile on the skull and brain in 1894, the theory of "hydrodynamic pressure" was put forward. According to this theory, the bullet can transfer its speed (kinetic energy) to the liquid. In this case, a “living force” appears in the liquid, which has an “explosive effect”. In the brain, as in gel, the bullet transfers its speed to the mass. This transmitted speed destroys the connections of individual parts of the brain, which is especially evident when shots are fired from a short distance. Due to the "onslaught" of the brain on the dura mater and the bones of the skull, they are destroyed. When fired from a long distance, the projectile loses some of its speed. In this case, the speed transferred to the brain is less than with shots from a short distance. This transmitted speed does not have enough energy to destroy the brain and skull, which is why cracking of the skull is not observed in this case, or it occurs rarely and in the form of elongated cracks.

In 1898, O. Tilmann found that when a shell hits the skull, the latter "swells" from the inside. Depending on this strength, the skull either bursts or collapses. The explosive action is not distributed evenly in all directions, but is directed cone-shaped, towards the outlet and only partially to the sides. In his opinion, the projectile acts primarily on the brain and only secondarily on the skull.

Common to all these theories is that during gunshot wounds, the brain is destroyed not only along the wound channel, due to the direct movement of the projectile through the brain, but also at a distance from it, throughout its mass, which causes serious condition wounded. The concussion covers the whole brain. The degree and radius of damage to the brain correspond to the manpower of the injuring projectile.

O. Tilmann believed that the wound channel consists of a zone of crushed tissue in the channel itself, and around it, going into the thickness of the brain, there are zones of softening of the layers of the brain closest to the wound channel and at a distance from it the concussion zone. In these zones, point hemorrhages are observed, prone to increase, and the smallest ruptures of the brain tissue. The degree and radius of damage to the brain are directly proportional to the manpower of the projectile (kinetic energy).

Interest in the effects of a projectile on the skull and brain resumed during the Second World War. In 1946, it was shown that the destructive effect of a projectile on the skull depends on its kinetic energy. However, kinetic energy is not the only factor that determines the degree of injury in a traumatic brain injury. It also depends on the shape of the projectile, the angle of its contact with the skull, and the resistance of soft tissues. The latter depends on the viscosity of the tissue. In this case, the boundary layer of tissue adheres to the projectile and moves with it. As the projectile moves, the tissue adhering to it breaks off, creates turbulence in the wound channel and fills the channel with its lumps. Here, the shape of the projectile is of great importance - fragments (when shot from a self-propelled gun various shapes lead castings) cause more drag than a bullet (or ball charge in hunting or airguns).

According to A.Yu. Sozon-Yaroshevich, when a projectile hits the head, a ballistic wave is created that has the shape of a parabola. It moves away from the bullet head in all directions at a distance of 4-5 of its lengths. The energy of the projectile is transmitted to the brain by this parabola, the same parabola also creates resistance. At the same time, brain particles adjacent to the wound channel acquire a certain speed, break off, move, settle in the wound channel, forming detritus in it. The bones are split under the influence of the cone of the moving mass of the brain, due to its impact on the inner surface of the skull.

After 1-3 days from the moment of injury, on CT at a distance from the wound channel, it is possible to identify foci of brain damage in the form of so-called foci of contusion I, II, or III of the type. In the future, these foci either decrease, regress, or vice versa, increase in volume both due to its dense part, and due to the perifocal zone of ischemia and edema. Then such a pathological focus can become “aggressive”, cause an increasing dislocation of the brain with compression of its trunk, which may require surgical intervention. All such pathological foci, late detected on CT scan, can undergo such a metamorphosis (including foci of the so-called brain contusion of the 1st type).

We explain the emergence and evolution of such late lesions in terms of cavitation theory adapted to medicine. When a projectile enters the cranial cavity, areas of high and low pressure appear in it. According to the theory of cavitation, a negative pressure acting even within the time of l / 7 sec "causes the formation of cavities in the tissues, which, as the pressure equalizes, collapse (cavitation). Such cavities appear most quickly in the flowing fluid, which is blood in the cranial cavity. They and appear first of all in fast-flowing blood.When the pressure is equalized, and even more so when it increases due to the release of kinetic energy by the projectile, these bubbles burst (“collapse”). When such a bubble “collapses”, a hydrodynamic impact force arises. evidenced by the fact that it can destroy the ship's steel propeller. Being released in the blood, this force acts on the wall of the vessel, damaging it and disrupting blood circulation in it. As a result, a focus of cerebral ischemia occurs in this area. With minor damage to the vessel and restoration of its function the focus of ischemia disappears. vessel, through it, erythrocytes penetrate into the focus of ischemia by diapedesis, forming the so-called "brain contusion II or III type." In fact, this is not a focus of brain contusion, but foci of post-traumatic hemangiopathic ischemia. In the future, this focus can either regress or grow.

The shock-wave mechanism causes the appearance of a temporarily pulsating cavity, and cavitation leads to the destruction of cellular and subcellular structures. At the same time, proteolytic enzymes are released from dying cells, which cause the development of necrosis at a distance from the wound channel. Thus, part of the necrosis of the medulla, located at a distance from the wound channel, are secondary and are caused by impaired hemodynamics and damage to the vascular wall with its nervous apparatus (foci of traumatic hemangiopathic ischemia of the brain).

Following the projectile moving through the brain, a pulsating cavity is formed. Its dimensions exceed the diameter, in particular, of a spherical charge (pellets, balls from pneumatic weapons, a ball bullet from a hunting rifle) by 2-3 times. The duration of the existence of the pulsating cavity exceeds the duration of the contact of the projectile with the brain tissue. Therefore, the wound channel is not a straight tube with smooth walls. In fact, during the formation and then subsidence of a temporarily pulsating cavity, adjacent areas of the brain crack at different depths with the formation of capillary gaps (Fig. 22-10) and damage to blood vessels. These lateral capillary passages, as well as the main wound channel, are filled with cerebral detritus, liquid blood and its clots. In addition, they may contain foreign bodies and, like the main channel, are infected.

Rice. 22-10. Capillary cracks caused by the formation of a pulsating cavity and diverging from the wound channel into the substance of the brain, x 100.

Destruction of the medulla occurs not only from the impact of the charge itself, but also from foreign bodies (parts of clothes, buttons, cockade, bone fragments).

The kinetic energy transmitted by the projectile to the brain, in addition to the cavitation effect, also causes "molecular concussion", which causes functional disorders at a distance from the wound channel. These functional disorders reduce tissue viability and can lead to late secondary necrosis.

In severe traumatic brain injury, including gunshot craniocerebral wounds, especially in explosive wounds (and improvised explosive devices in particular), there is a violation of lipid oxidation - ierexic lipid oxidation - LPO. This leads to the occurrence of multiple organ failure - PON. Against the background of depletion of the antioxidant system and insufficiency of the enzymatic link of protection against reactive oxygen species, there is an increase in the activity of leukocytes in the area immediately adjacent to the wound channel. These biochemical indicators make it possible to clarify the boundaries of the zone of secondary necrosis and judge the severity of the injury by the activity of the superoxide dismutase enzyme.

Based on the foregoing, it can be assumed that in practice the nature of damage to the skull depends on the distance of the shot, the angle of contact of the projectile with the skull, the kinetic energy of the projectile at the time of its contact with the skull, the centering of the bullet (projectile), its shape and structure of the shell, the structure of the skull at the site of injury his projectile.

COMPARATIVE STATISTICS OF GUNSHOOT WOUNDS WAR AND PEACETIME

The general characteristics of the peacetime CHMOR differ from the military one. Thus, in peacetime, there are significantly fewer combined FMIRs than in wartime.

Table 22-3

The frequency of combined and isolated injuries during military operations and in peacetime

Location of the event	Injury frequency
	non-penetrating,%	penetrating%
The Great Patriotic War
War in Chechnya
War in Afghanistan
Peaceful time

We explain the sharp decrease in combined NORs in peacetime (according to statistics) by the following reasons:

1. The statistics did not include those who died at the scene (their corpses ended up in various morgues of the city).

2. Combined injuries were also not taken into account, in which somatic injuries were the leading ones, and PMOR, in general, were non-penetrating, tangential. Of interest is the number of penetrating and non-penetrating FMORs in peacetime and wartime (see Table 22-4).

Table 22-4

The number of penetrating and non-penetrating FMORs in wartime and peacetime

Location of the event	CHMOR
	isolated,	combined,
The Great Patriotic War
War in Chechnya
War in Afghanistan
Peaceful time

The increase in penetrating wounds in peacetime is due to the fact that the wounded are quickly taken to the hospital. Therefore, the hospital statistics also include such (according to the severity of the injury) wounded who die on the battlefield in wartime. This also explains the appearance of the wounded in the posterior cranial fossa, who practically do not exist in hospitals in wartime (they also die on the battlefield without waiting for evacuation or in the first stages of evacuation - pre-hospital). For the same reason, in peacetime, the number of victims with diametrical wounds doubles (12.3%), while during hostilities their number ranges from 2 to 7%. Table 22-5 shows the timing of the arrival of the wounded in wartime and peacetime.

As can be seen from the table, 78.8% of the wounded in peacetime were hospitalized in the first 2 hours from the moment of injury, while during the war only from 8.4% (the war in Chechnya) to 15 were hospitalized during this period, 3% (war in Afghanistan), which increased the number of seriously wounded and the number of deaths among them. The increase in the number of wounded who arrived in wartime after a day or more (in peacetime, by this time, all the wounded were already hospitalized), increased the number of purulent complications (in particular, meningitis and meningoencephalitis) among them. This is explained by the fact that the primary surgical treatment of the wound and medical prophylaxis and therapy in peacetime were undertaken much earlier than in war.

Table 22-5

Terms (from the moment of injury) for the admission of the wounded to the neurosurgical hospital

Location of the event	Terms of arrival of the wounded (hours)
War in Chechnya
War in Afghanistan
Peaceful time

DIAGNOSTICS

Diagnosis of FMOR in peacetime has its own characteristics (compared to the military). This is due to the early (shortly after the injury) admission of the victims to the hospital, when their condition is usually severe due to both mechanical and mental trauma. They are often in a state of shock (especially with combined injuries), in a characteristic post-traumatic, "chaotic" state. Early post-accident hospitalization predetermines a large number of seriously injured people in critical condition. In peacetime, there is practically no simultaneous arrival of a large mass of wounded (20-50-100 or more). Usually from 1 to 3-5 people arrive at the same time. This allows you to focus all the attention of the staff on them and apply all the necessary resuscitation measures and diagnostic studies (CT, MRI, ultrasound, arterial hypertension, radiography, etc.). In wartime, first-line hospitals are deprived of such opportunities. In the conditions of a civil hospital, there are conditions for the wounded to be treated by the same doctor (preferably the neurosurgeon who operated on him), right up to his discharge from the hospital. In peacetime, it is necessary to abandon the term "injury incompatible with life" as detrimental not only to a specific wounded man, but also to medical science. Such a term, being often highly subjective, implies a rejection of active diagnostic and medical measures. This leads to the fact that people die, some of whom (albeit a small one) could survive. In addition, the refusal to actively treat such wounded leads to the refusal of the search for new, more progressive and reliable methods of treatment, to the progress of medicine. A striking example of this is the development of methods for the treatment of the same CMCI - from the complete refusal of surgical intervention in them and almost 100% mortality in the time of N.I. Pyro-

gov, to radical surgical treatment of a craniocerebral wound in the present and a decrease in mortality to 18-37%.

This concept of treatment of PMOR in peacetime does not imply a change in military field doctrine, when tens and even hundreds of wounded arrive at the same time, when there are not enough medical personnel, when the wounded are subject to further evacuation. Under these conditions, the term "injury incompatible with life" is legitimate, because. justifies saving the lives of many of the more lightly wounded, and not of a few among the seriously wounded.

Diagnosis of PMOR is based on the following provisions:

1. Primary diagnosis of PMCI should be quick, complete, based primarily on a clinical examination involving all the necessary modern instrumental and laboratory methods.

2. All diagnostic (clinical examination and instrumental methods) studies and resuscitation should be carried out in parallel with each other, not interfere, not compete with one another, but complement each other with one common goal - to cure the wounded.

3. The use of instrumental diagnostic methods should be based on the principle of delivering the device to the wounded, and not the wounded to the device (with the exception of non-mobile installations). The appointment of complex instrumental methods (for example, angiography) should be made only according to individual indications, which must be justified.

4. Diagnostic measures should be stopped immediately upon establishing a complete diagnosis sufficient for etiological, including surgical, treatment.

The main task of the diagnosis is to establish the severity of the general condition of the wounded and the number of injuries and their characteristics. The characteristic of FMOR means the establishment of the number of wounds and the description of the wound surfaces (stab, torn, cut, etc.), the presence of traces of burns and gunpowder, the lead edges of the wound, the presence of a gas smell. The degree of contamination of the wound with foreign bodies, the state of the skull, the presence and characteristics of fractures (cracks, depressed fractures), their number and location in relation to the wound (in its area or at a distance), the state of the internal vitreous plate are determined. Establish the quality of the injury - soft tissues, skull (through, blind, ricocheting, etc.), the presence of foreign bodies in the cranial cavity (bones, shells, etc.) and their localization in relation to the wound, skull bones and brain lobes, establish topography of the wound channel - its course (straight, zigzag), the state of the brain tissue both near the wound channel and at a distance from it (areas of ischemia, confluent and punctate hemorrhages, the presence of hematomas and their characteristics (type and localization, volume), presence and the severity of cerebral edema, its dislocation (transverse and / or axial), the state of the brain ventricles and their contents (hydrocephalus, the presence of blood or hemotamponade, deformities, etc.), determine the functional state of the brain (the presence or violation of bioelectrical activity), the degree of damage his trunk.

General medical and neurological examinations, as well as the principles of instrumental examinations are described in special chapters of the manual. We will focus only on some of their features in PMOR.

Clinical and neurological examinations are aimed at determining the general condition of the wounded and the number and quality of existing injuries. With FMOR, the head wound can be of different sizes - from a torn-scalped a few cm (up to 10 or more) to a point (for example, a bullet from an air gun), which is not always easy to detect. However, such a "point" wound can be penetrating, and even through. Primary examination can give more than any instrumental examination, including CT. It is especially important to examine in detail the entire patient with multiple wounds (for example, from a pneumatic machine gun) or with shot wounds. To do this, the head of the wounded must be shaved, otherwise there may be gross diagnostic errors, up to not recognizing the inlets.

In peacetime CHMOR, there are also casuistic wounds when the inlet is found

extremely difficult, and there is a bullet (projectile) in the cranial cavity. Bullet entry into the cranial cavity can occur when shot in the mouth. In some cases, there may be only an exit hole on the integument of the skull. We observed a patient whose bullet passed into the cranial cavity through the ear, leaving only traces on it in the form of singed hairs in the area of ​​the external auditory canal. The shell itself was in the cranial cavity. Similar descriptions are available in the literature. A bullet can also enter the cranial cavity through the nasal passage. A very important postulate is that the neurosurgeon is obliged to examine the entire patient, and not just the head, limiting himself to describing disorders of the nervous system. Also, the resuscitator is obliged to examine the entire victim. At the slightest suspicion of injury to somatic organs, it is necessary to involve related specialists (surgeon, traumatologist, etc.).

All the wounded are first of all performed craniograms of the skull in 2 mutually perpendicular projections. Using such images, one can determine whether a given wounded person has a penetrating or non-penetrating wound, what is the location of the projectile in relation to the bones of the skull, clarify the inlet and outlet, establish the presence and quality of foreign bodies and their location, establish the presence of cracks in the skull both in the area of ​​the inlet and and at a distance from it, the presence of fractures of the lamina vitrea.

In some cases, especially with shot wounds (see Fig. 22-3), it is impossible to determine whether a wounded person has a penetrating or non-penetrating wound according to craniograms. Helps clarify the diagnosis CT (see Figure 22-2). Craniograms help to determine the size and shape of the projectile and, thereby, determine the approximate type of weapon. According to the number and presence of projectiles (for example, pellets) penetrating the cranial cavity, according to craniograms, the range of the shot can also be assumed.

If nasal liquorrhea is suspected, if the condition of the wounded person allows, pictures of the anterior cranial fossa or its tomography can be taken, on which damage to the ethmoid bone can be detected (Fig. 22-11). With injuries to the temporal region and with ear liquorrhea, again, if the condition of the wounded person allows, to diagnose cracks in the pyramids, special images of the pyramid of the temporal bone according to Schüller and Mayer can be made.

X-ray computed tomography (CT) is a highly informative modern method for diagnosing PMOC. Foreign bodies in the cranial cavity on CT can cause artefacts and are often significant (see Fig. 22-2), which led some to consider such a study of little information. This is a deeply erroneous opinion. In fact, CT in most cases provides information that is not available for other instrumental methods, especially if the study is carried out in normal and "bone" modes.

Rice. 22-11. Tomogram of the anterior cranial fossa. Fracture of the ethmoid bone.

CT can give a clear idea of ​​the state of the wound channel and brain tissue in a particular wounded person (the course and shape of the wound channel, the presence of liquid blood and blood clots in it, its relationship to the brain ventricles, the presence of foreign bodies in it (bone fragments, injuring projectile and parts its membranes, secondary foreign bodies), determine the inlet and outlet, the presence of hemorrhages and contusion foci in the brain tissue near and at a distance from the wound channel, etc.).

With MOR, intracranial hematomas occur in 32.5% of the wounded. Among them, subdural hematomas - 28.7%, epidural - 7.1%, intracerebral - 57.1%, intraventricular - 7.1%. When characterizing a hematoma on CT, it is necessary to note not only the area of ​​its distribution, but also the greatest height of the hematoma and its volume, as well as the volume of the cerebral edema zone surrounding the hematoma and the total volume of the entire pathological focus - both dense and edematous (ischemic) parts. The presence of small, several ml hematomas in the immediate vicinity of the internal bone plate of the skull may be a trace of internal ricocheting of the projectile. They are formed as a result of damage to small vessels of the cerebral cortex or its membranes, either by a wounding projectile, or by sharp fragments of the lamina vitrea.

CT also allows you to determine the state of the brain itself - the presence and severity of its edema, the presence of contusion foci and foci of post-traumatic hemoangiopathic ischemia (according to the shock or the principle of cavitation), the displacement of the brain, both horizontal and axial, and the severity of this dislocation, which is very important for determining tactics of treatment and volume of surgical intervention. With diffuse, pronounced cerebral edema, the wound channel may not be determined at all, which should be taken into account by the clinician when making a diagnosis.

CT also gives a fairly detailed picture of the ventricular system of the brain - the presence of ventricular collapse (with massive liquorrhea) or vice versa hydrocephalus, the presence of blood in the ventricles or hemotamponade of one ventricle or the entire system, their deformation, the presence of blockade of the cerebrospinal fluid and its level.

It is known that fractures of the skull bones on CT are detected only in U5 cases identified on craniograms. According to our observations, when performing CT in the "bone" mode, the number of skull fractures detected on CT increases significantly and even exceeds the detection of skull fractures on craniograms. However, there is a variant in which cracks detected on craniograms are not detected on CT and vice versa. Therefore, when diagnosing skull fractures and bone fragments inside it, it is necessary to take into account the data of both craniography and CT.

The significance of CT examination in the diagnosis of PMCI (as well as in emergency neurosurgery in general) increases with the correct organization of this service (round-the-clock work, equipping the office with a ventilator, a set for intubation of the wounded, medicines for giving short-term anesthesia, and, if necessary, involving an anesthesiologist in the study). This makes it possible to conduct CT scans in the wounded who are in a state of motor arousal and not in contact with personnel, which occurs in more than 50% of the wounded.

Cerebral angiography is performed only according to strict indications - if a blood vessel is suspected to be injured (appearance of unilateral exophthalmos, noise when listening to the carotid arteries - suspicion of the formation of an arteriosinus anastomosis, traumatic aneurysm, rupture or compression of the vessel by a projectile or a secondary foreign body, topographic location of the injuring projectile in the projection of the main arteries), and in the absence of CT - to determine intracerebral hematomas.

Ultrasound examination with ECHO-11 or ECHO-12 devices is widely used and is used by almost all neurosurgeons. It allows you to judge the displacement of the median structures of the brain and thus indirectly about the presence of an intracranial space-occupying formation (hematoma), and indirectly about the expansion of the ventricles or the severity of cerebral edema.

Modern ultrasound devices allow scanning the brain to study the intracranial circulation (transcranial Dopplerography) and scanning the brain through a trepanation defect, which is very important in the postoperative period (diagnosis of postoperative hematomas, monitoring the development of cerebral edema, the formation of encephalitis and brain abscess) . Of particular interest is intraoperative brain scanning, which can localize a foreign body located in the brain tissue (Fig. 22-12), or intracerebral hematoma, or brain abscess, which greatly facilitates their search and removal. The use of ultrasound scanning increases the radicalness of the surgical intervention.

According to electrophysiological studies (EEG, EP), the functional state of the brain is judged both in the pre- and postoperative period.

Bacteriological examination is required. With PMOR, it is much more important than with an open craniocerebral injury. So, according to various statistics, the number of purulent complications after gunshot penetrating wounds of the skull during the war ranges from 36.5-5.6, 84.0% to 95%. Such a spread in the frequency of complications depends on at what stage of the evacuation of the wounded the material was processed. In the early stages of evacuation, there are fewer purulent complications (they do not have time to develop), in the later stages, more. In peacetime, there are fewer purulent complications than in wartime (from 15 to 41% - N.I. Arzhanov et al., 1995, G.G. Shaginyan et al., 1995, N.E. Polishchuk et al. ., 1995). This is explained by the fact that PST of a gunshot wound in peacetime is carried out at an earlier date than during the war.

Rice. 22-12. Ultrasound scanning of the brain during surgery. A bullet is determined (indicated by an arrow) in the region of the falx-tentorial angle.

A bacteriological study in case of MOR is absolutely necessary both for the immediate prevention of purulent complications and for their subsequent treatment (meningitis, encephalitis, brain abscess, wound suppuration, osteomyelitis).

Bacteriological culture is taken from the wound (soft tissues of the skull, brain) before and after its surgical treatment. Foreign bodies removed from the wound (bone fragments, secondary foreign bodies, injuring projectile) are sent for sowing. The cerebrospinal fluid obtained both at the first puncture and at subsequent punctures is sent for bacteriological examination, regardless of whether there is meningitis or encephalitis, or not. At the same time, they mean that the source of infection for primary meningitis or encephalitis is most often bone fragments and secondary foreign bodies. The source of infection for late meningitis or encephalitis is injuring foreign bodies (bullets, shell fragments).

PRINCIPLES AND TACTICS OF SURGICAL TREATMENT

They depend not so much on the development of the surgical technique itself, but on the progress of the sciences of asepsis and antisepsis, anesthesiology and resuscitation. So, in the pre-antiseptic period, during the Sevastopol campaign, when out of 7 trepanned N.I. Pirogov of the wounded died all 7, he was told that, theoretically, such wounded should be operated on, but practically they all die from suppuration of wounds. Then, when applying the Lister bandage, the tactics of superficial surgical treatment of the wound was established, followed by the application of an antiseptic bandage. During the Great Patriotic War, due to the lack of effective antiseptic drugs, the tactics of sparing surgical treatment of gunshot wounds of the skull were used.

At present, in the era of the development of antibiotics, modern anesthesiology and resuscitation, the era of microneurosurgery, the tactics of surgical treatment of PMOR, especially in peacetime, have changed dramatically. The main principle of the treatment of PMOR is their early, radical, completed primary surgical treatment, excluding re-surgical intervention. Remove all foreign bodies (especially bone fragments), liquid blood and blood clots, brain detritus and necrotic, non-viable brain tissue, followed by active drainage of the wound, washing drainage and suturing it tightly. Active flushing drainage, possibly in various modifications, is widely used by military neurosurgeons. At the same time, the removal of metal projectiles is desirable, but when the projectile is located in the region of the subcortical nuclei, in the deep parts of the brain, it is better to refrain from searching for them in order to avoid unjustified additional brain injury.

Neither modern methods intensive care, neither the latest generation antibiotics, nor their high doses can reduce the number of purulent complications if the wound is not surgically radically surgically treated. Hence: it is necessary to operate PMOR only where it is possible to perform a radical surgical intervention by a specialist neurosurgeon at the modern level. Back in 1940 and 1943. N.N. Burdenko wrote that operations carried out hastily, blindly, bring only harm. It should be added to this that neurosurgical operations performed by a general surgeon often do not reach the goal. So, among the wounded with external bleeding, operated on at the stage of qualified assistance, 91.7% died. The causes of death were: inability to stop bleeding - 33.3%, complications at the "brain" stage of the operation - 41.7%.

In the postoperative period, the wounded should be provided with modern resuscitation aid, constant supervision of one doctor for at least 2-3 weeks, and rehabilitation at the modern level. The operation should be performed under intubation anesthesia (with the exception of injuries of only the soft tissues of the head, which can be treated under local anesthesia) using microsurgical equipment (a loupe with a magnification of 2.5-4 times or an operating microscope), bipolar coagulation, modern aspirators (preferably ultrasonic ) and active wound-draining systems. Therefore, patients with PMCI should be hospitalized only in the neurosurgical departments of multidisciplinary hospitals, even if this increases the time from injury to surgery. In peacetime, this period can be extended by several hours, rarely a day. The probability of developing infectious complications is maximum for 3-5 days from the moment of injury.

Contraindications for surgery are:

1. Shock (before removing the early shock).

2. Atonic coma.

The technique of surgical treatment of gunshot wounds of the skull and brain is described in the section on gunshot craniocerebral combat injuries. It, with the exception of some features, is identical to the processing of peacetime CHMOR.

Before the operation of the primary surgical treatment of the wound, the ALL head of the wounded must be shaved. Head shaving is carried out in a dry way (without soap). At the same time, the number of suppurations is halved compared with the treatment of the head in a “wet” way - with soap.

Before starting the operation, it is necessary to take material from the wound for bacteriological culture (foreign bodies, smear). Then, regardless of the type of anesthesia under which the operation will be performed (narcosis or local anesthesia), the edges of the wound are infiltrated with a 0.5% solution of novocaine with an antibiotic (chloramphenicol, penicillin or another). The same is done after the end of the operation (after suturing the wound and establishing active, flushing drainage). Infiltration of the edges of the wound with a novocaine-antibacterial mixture is carried out from the side of intact skin. Needle injections through the gaping edge from the side of the wound are not allowed. These measures can reduce the number of infectious complications. Excision of the wound (its edges and bottom) should be economical, such that after the end of the operation, the skull bones would be completely covered by soft tissues, without leaving "patch" according to N.N. Burdenko.

Linear cracks of the skull do not trepan, unless there are special indications for this (intracranial pathological focus requiring surgical removal). Fractures pressed into the cranial cavity are subject to removal followed by primary, secondary or delayed plasty (according to indications).

Single pinholes in the bones of the skull (wounded by a pellet, a single ball projectile from a pneumatic weapon) are either not cracked or reamed with a cutter (depending on the degree of contamination).

The edges of the dura wound are excised sparingly. All foreign bodies (bone fragments, shot, secondary foreign bodies) are carefully removed.

If it is necessary to revise the subdural space and the brain, the DM is opened along the perimeter of the trepanapion hole, 0.5 cm away from the bone edge. at the same time, the operating field narrows by more than 1/3.

All primary and secondary foreign bodies lying in the brain wound along its surface and at a depth of up to 5-6 cm are removed (preferably by ultrasonic suction-destructor). Point, single wounds of the brain (for example, from a pellet or a spherical projectile of an air gun) are not treated in depth. The search for such a single, deeply located projectile leads to unjustified additional brain injury, which is why it is not removed.

The operation ends with the establishment of an active drainage system and re-infiltration of its edges with a novocaine-antibacterial mixture.

Prevention of purulent complications is carried out in all patients with PMCI. It is absolutely necessary to take the wound contents for bacteriological examination immediately upon admission of the wounded. Unfortunately, even the approximate data of bacteriological analysis come only after 2-3 days. Therefore, the prevention of purulent complications has to be started "blindly". Antibiotics (for emergency operations) are prescribed immediately upon admission of the patient, 1-4 hours before the operation (until the final diagnosis is established). Basically, antibiotics are administered intramuscularly, which reduces the risk of infection by 20%. Particularly effective are drugs with a long elimination period (ceftriaxone, cefuroxime) in combination with aminoglycosides. We, in addition, regardless of the type of anesthesia, before the start of the operation, infiltrate the edges of the wound with an antibiotic solution, preferably with a broad spectrum of action. After the end of the operation, the wound edges are infiltrated again.

Antibacterial therapy started on the operating table is continued in the postoperative period.

V.V. Lebedev, V. V. Krylov

Surface singing of textile fabrics was noted at shot distances up to 10 cm.

Powders were observed with shots up to 200 cm. At first, they were located near the edges of the entrance wound, and as the target moved away, they scattered over a larger area. Shot metals (mainly copper) were detected at distances up to 300 cm. At short distances, the metallization was continuous, at extreme distances - the appearance of individual points.

The polyethylene guide tip almost always collapsed immediately after leaving the bore, and its fragments had a local damaging, mostly superficial, mechanical effect. The intact tip was capable of causing deep damage to soft tissues at a distance of 2-3 cm. When using cartridges with wads, the latter caused the formation of shallow wounds that did not penetrate beyond the subcutaneous fat.

It should be emphasized that the experiments cited by A.P. Tsykunov were made with SMP brand ZM with cartridges only type B5. Quite naturally, the use of other SMP samples and cartridges of a different power will lead to the appearance of a different morphology of damage, a different effect of the shot products. Therefore, the data presented can be supplemented by published cases from expert practice.

As practice shows, many incidents are associated with the defeat of dowels, ricocheted from solid barriers. Although the interaction with the barrier reduces the kinetic energy of the dowel, the remaining energy is sufficient for penetrating and even penetrating wounds.

When investigating incidents during which damage was caused from the SMP, it is mandatory to conduct a forensic or engineering examination of the serviceability of the SMP and the degree of its compliance technical requirements and documentation. The data of these studies should take into account forensic doctors who solve the following tasks as their main tasks: establishing group signs characteristic of injuries caused by shots from the SMP, reconstructing the conditions for causing damage (direction and distance of the shot, properties of the used projectile-dowel, mutual position of the victim and the SMP in moment of damage, etc.).

The dowel removed from the body during a blind wound was preserved. Forensic research can not only prove the type, type and lot of the used cartridge, but also identify a specific instance of the used SMP.

DAMAGE FROM PNEUMATIC WEAPONS

As emphasized in Chap. 1. Pneumatic weapons, outwardly similar to firearms, are, in fact, not such, since it does not use the energy of powder gases, but the energy of compressed air, to eject a projectile. At the same time, the equipment of pneumatic weapons with small bullets capable of acquiring an initial velocity of 140 to 170 m / s when fired and, consequently, a certain destructive energy sufficient to receive even a fatal bullet wound, gives reason to consider the resulting damage in publications devoted to gunshot injury, primarily because they have to be differentiated from true gunshot wounds.

Air rifles are fired with lead, steel and ceramic bullets of 4.5 mm caliber. Lead bullets are divided into expansion and solid. Common in the design of expansion bullets is the presence of a cavity or recess in the body. When fired, a jet of air, penetrating into such a cavity, expands the body of the bullet and causes it to fit more tightly to the surface of the bore, which ensures the correct movement of the bullet along the rifling of the barrel and reduces air loss. Solid bullets with a monolithic body do not have recesses, belts and other design features. As a bullet, lead balls (usually shot No. 2 and No. 4), as well as bullets made in a home-made or artisanal way from lead or its alloys, can be used.

As follows from the experimental data, bullets fired from an air rifle with a low barrel wear have the highest penetrating power at a shot distance of up to 5 m, and from heavily worn bullets - up to 1 m. a pronounced rubdown belt, the holes have the shape of a truncated cone, with a wide base facing the outlet. In elastic objects, holes have a slit-like or irregularly round shape due to the formation of a tissue defect.

According to V.B. Zhivkovich (1961), when fired from a distance of 3-5 m, in most cases blind wounds of soft tissues are formed, less often bullets bounce, leaving abrasions on the skin, or penetrate into cavities, damaging flat bones, including bones adult skull. The entrance holes are round in shape, the tissue defect is up to 4 mm in diameter, around the hole there is a clear closed belt of sedimentation up to 1.5 mm wide, and along its peripheral edge there is an even, but not always complete, rubdown belt. A small area of ​​lead deposition detected using the method of color prints and the absence of other signs of a shot (soot, gunpowder), regardless of the distance of the shot, make it possible to distinguish damage from an air rifle from damage from small-caliber firearms [Movshovich A.A., 1972].

An X-ray examination in the area of ​​the inlet shows irregularly located rather large lead particles, and when examined under the rays of a mercury-quartz lamp using a Wood filter, a blue fluorescence of the oil ring appears on the skin around the inlet.

Exit holes, which were observed extremely rarely, as well as with ordinary gunshot injuries, slightly larger than the diameter of the bullet with uneven, ragged edges. GV Merezhko and Yu.A. Karnasevich (1991) carried out experimental work on the study of damage to biological objects and their non-biological imitators after being hit by shots from air rifles.

PNEUMATIC GUN

Pneumatic weapons include various devices, the throwing of a projectile from which is carried out by compressed air (gas). There are short-barreled (pistols or revolvers) and long-barreled (pneumatic - "wind") guns. Pneumatic weapons are compressor and balloon. Compressor devices have a chamber in which air is compressed using a special lever. In cylinder devices, compressed air is located in cylinders located under the barrel or in the handle of the weapon. Shot like cotton, quiet. Both shotguns and pistols can have rifled or non-rifled barrels.

Firing range up to 100 meters. Destructive power at a distance of up to 50 meters. Bullet caliber - from 3 to 5.6 mm. At this distance, depending on the degree of air compression in a given type of weapon, a fired bullet can pierce the bones of the skull. We observe-

whether a wounded man with a penetrating wound to the skull after being shot from a distance of about 10 meters. Similar observations are described in the literature.

Wounds from pneumatic weapons have the features of both firearms (the presence of a bullet, leaded edges of the wound), and are different from it - there is no powder charge, therefore there is no burn, no gunpowder inclusions. More often than not, these are single wounds. However, when using "wind" machine guns, injuries can be multiple. On fig. 22-6 shows the types of pneumatic weapons and their projectiles.

Features of wounds from pneumatic weapons:

Usually the bullet is single, spherical, caliber 3-5.6 mm.

The injury to the skull is often non-penetrating (especially if the shot was fired from a smooth-bore weapon from a medium or long distance.)

The entrance hole is "pinpoint" (2-3 mm), usually does not bleed. Its edges are wrinkled. The wound does not gape. No burn and no inclusion of powders. Possible "lead" edges of the wound.

The penetration of the bullet is shallow, there are no penetrating wounds. Often there are "sliding" wounds on the cranial vault. With penetrating wounds, internal ricocheting and fractures of the internal vitreous plate. Due to the relatively small kinetic energy of the bullet and its mass, the hydrodynamic effect on the brain of a projectile fired from an air rifle is less than with a gunshot wound. Hence, there is less damage to the brain than in a gunshot wound both in the wound channel itself, and near it and at a distance. Both with penetrating and non-penetrating wounds of the skull, fractures of only the internal vitreous plate are possible.

The wound channel is less contaminated with foreign bodies than with gunshot wounds.

With non-penetrating wounds, with “sliding” wounds without fractures of the skull bones, intracranial hematomas and contusion foci may form both at the wound site and at a distance from it.

Weapon craniocerebral wounds can also be caused by devices intended for economic purposes, for example, from a dowel gun. Such injuries are characterized by significant lesions of only soft tissues, or both the bones of the skull and brain. Soft tissue wounds are torn and bruised, usually of a large area, although they can (by area) be insignificant. It depends on

Features of craniocerebral weapon wounds in peacetime

Rice. 22-6. Types of pneumatic weapons and their shells (diagram).

of what part of the dowel is wounded (“head”, sideways). Bleeding is usually small. With the defeat of the main vessels of the neck (carotid arteries) or other large vessels of the head, it can be very significant. Having injured an artery, the dowel can cover its opening like a kind of plug, which should be borne in mind during the surgical treatment of such wounded. If the dowel hits the skull with a “head”, the inlet may be small, but the brain may be damaged to a considerable depth (Fig. 22-7).

Tangential and penetrating wounds of the skull are characterized by linear cracks, radially extending from the point of contact of the dowel with the skull, and multi-comminuted, often depressed, fractures. Bone fragments can penetrate the skull to a depth of 5 cm or more. Significant contamination with foreign bodies. The dowel may stick out of the wound, or may be covered with soft tissues. Brain damage is represented by a wound channel, gray and red softening of the medulla.

Clinical Guide to Traumatic Brain Injury

Rice. 22-7. Craniogram in direct projection. Penetrating dowel wound.

Publication in electronic media: 18.06.2013 under
Publication in print media: Topical issues of medical and forensic examination: state of the art and development prospects. Materials of scientific and practical. conf., dedicated 50th anniversary of MCO BSME Mosk. region, Moscow 2013

GBOU VPO FESMU of the Ministry of Health of Russia, Khabarovsk

At present, pneumatic weapons with high damaging properties have become widespread among the population. Modern legislation defines a pneumatic weapon as "a weapon designed to hit a target at a distance with a projectile that receives directed movement due to the energy of a compressed, liquefied or solidified gas" . Currently, pneumatic weapons are divided according to the principle of action, muzzle energy and caliber. In terms of muzzle energy and caliber, the following groups are of interest: over 7.5 to 25 J, k. 4.5; 5.0; 5.5; 6.35 mm - for sports and hunting, requires a license from the Ministry of Internal Affairs and registration; from 25 J and above, of any caliber - for sports and hunting, in Russia circulation is prohibited by law.

There are accidents in the careless handling of low-powered pneumatic weapons. However, forensic experts are more interested in modern long-barreled pneumatic weapons equipped with lead bullets with an initial velocity of over 140 m / s, with high damaging energy, up to causing a mortal wound. In such cases, the need for differential diagnosis from gunshot wounds is assumed.

In our country, for air rifles, the most common calibers are 4.5mm (.177), 5.5mm (.22), less often 6.35mm (.25) and even more exotic 7.62mm (.30), 9mm (.357), 11.45mm (.45), 12.7mm (.50). Bullets have a certain configuration.

For shooting from air rifles, "lead" are used (in the manufacture
0.8-1.5% antimony is added to increase the hardness and reduce the viscosity of lead) bullets of the appropriate caliber. The design of the rifling is designed for the subsonic speed of the bullet, so the increase in the energy of the bullet occurs due to an increase in the mass of the bullet and caliber. With an excessive increase in the initial speed of the bullet, it breaks off the rifling, the accuracy of shooting drops sharply.

Comparison of the speed of buckshot with the speed of a bullet (Table 1) from a pneumatic weapon with high kinetic energy (over 25 J) (with comparable projectile calibers) when fired from a hunting weapon establishes their practical identity. With a slight predominance of buckshot speed and projectile energy at the level of the muzzle (0 meters) when flying over a longer distance (up to 70 meters), the same indicators increase for pneumatic bullets of approximate sizes. Therefore, the damaging properties of such charges will be comparable to damage from firearms, incl. shot or shotgun charge.

Table 1 Comparison of the energy of one buckshot (caliber 5.25; 6.2) from firearms and pneumatic bullets (caliber 5.5; 6.35)

The passage of bullets from high kinetic energy airguns through a gelatin block has a significant direct and lateral impact on environment, which is especially pronounced in expansive projectiles with high stopping power.

It is noted that the initial speed of a bullet with a diameter of 4.5 mm when fired from rifles of the PCP system reaches 350 m/s. The study of damage from long-barreled pneumatic weapons (sporting and hunting pneumatic weapons) with a muzzle energy of more than 16 J (magnum class) is becoming increasingly important, which, after simple "artisanal modifications", acquires higher damaging properties with high kinetic energy (over 25 J). In this case, the energy and speed of the projectile reach the level of damage comparable to damage from a firearm.

According to our observations, using the S046 chronograph to measure the initial velocity of a bullet, the Diana 350 magnum air rifle, when fired with Baracuda k.4.5 mm bullets, weighing 0.69 g, demonstrates the initial velocity of the bullet V 0 = 280 m / s, bullet energy = 27.1 J. The EDgun Matador air rifle, when fired with JSB k.5.52 mm bullets weighing 1.17 g, demonstrates the initial bullet velocity V 0 = 295 m / s, bullet energy = 51 J.

The results of the experiment in case of damage to the barrier: After shots from a distance of 1.0 - 3.0 meters. The high striking properties of the bullet were noted when shot at a board, plywood, and timber. In a 20 mm board, when fired from a distance of 3.0 m, the damage is a through defect with rounded inlets, about 3x4 mm in diameter, with relatively even edges, and an intermittent wiping belt of about 1.0 mm. When shot through the fabric in the entrance area, a pronounced funnel-shaped depression. Exit holes - represent an irregularly shaped defect about 4x5 mm in size, wood chips up to 20x5 mm. Damage on 8 mm plywood has a similar appearance, with a more pronounced flake at the exit. Of interest is the damage on the bullet catcher (wooden beam 150 mm) when the bullet exits the soft tissues of the biomannequin (damage from 3.0 m) with low kinetic energy. There are crushing of wood fibers in areas of 6x4 mm, to a depth of 2-3 mm.

Fig.1. Inlet on synthetic fabric

Fig.2. Inlet on denim

The results of the experiment with tissue damage: After shots from a distance of 1.0 - 3.0 meters. In synthetic fabric, the inlet is about 3x2 mm in size with uneven edges, radial breaks (up to 5) are noted; with a "tissue defect" in the center (Fig. 1). On denim, the inlet is from 3.5x4 to 4x5 mm in size with uneven edges, radial tears (35), with a “fabric defect” in the center (Fig. 2).

The exit area of ​​the bullet, when the affected area is pressed tightly against the bullet catcher, on the undamaged tissue is a section of flattened threads with fixed hair from the corpse, on an area of ​​3.0x3.5 mm. With loose pressing, a breakthrough of the tissue at the exit is noted, sometimes with fixation of the bullet in the threads of the exit hole.

Fig.3. Bullet after passing through the soft tissues of the thigh

Fig.4. Bullet that pierced the frontal bone of a deer's head

The results of the experiment in studying the degree of deformation of bullets: After shots from a distance of 1.0 - 3.0 meters. The minimum deformation of the bullets was noted when passing through the array (14-16 cm) of soft tissues of the biomannequin (Fig. 3). Severe deformation with bullet fragmentation was detected during experimental shooting at biological objects with relatively thick flat bones (Fig. 4). On the bullets, particles of soft tissues and bone are detected. When non-biological objects were damaged, the maximum deformation was noted when shooting at 8 mm plywood, to a lesser extent - at 20 mm board.

conclusions

• Damage from pneumatic weapons with significant muzzle energy (from 25 J) poses a high threat when various areas of the human body are affected with the formation of through and penetrating wounds with damage to internal organs, damage to the flat bones of the human skeleton.
• By their nature, depth, striking properties, the above-described injuries differ from the low-powered pneumatic weapons previously studied.
• By macroscopic features, it is difficult to distinguish between lesions from pneumatic weapons with high damaging properties from firearms and requires detailed study.
• The minimum deformation of bullets is noted when passing through soft tissues, which makes it possible to determine the type of bullet and the nature of the weapon (pneumatic weapon).

Bibliography

1. Federal Law "On Weapons" dated December 13, 1996 No. 150-FZ