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For the first time, the morphology and mechanism of the appearance of the inlet and outlet openings was described in 1849 by N.I. Pirogov. He wrote: “The opening of the entrance differs from the exit in that the entrance always happens with the loss of the essence of the skin. The exit hole we never noticed was round. It is obviously formed through a single tear in the skin, without loss of its essence, or at least with a loss incomparably less than the opening of the entrance. “... The entrance bullet knocks out a round hole in it; exit - pulls it from the inside and tears it apart.
P.P. Zablotsky in 1852 stated that "the entry wound represents a general loss of matter, while the exit wound is a tissue rupture."
The loss of the essence of the skin - a tissue defect, which is the main sign of the entrance gunshot hole, was proved by M.I. Raysky and N.F. Zhivoderov (1935) by experimental shooting of skin pieces of the same size and weight, followed by their weighing after shooting. On the basis of the experiments carried out, a decrease in the weight of the skin pieces and the impossibility of reducing the opposite edges of the damage were established. Calling this sign "minus-tissue", they confirmed the conclusions of N.I. Pirogov and P.P. Zablotsky.
A tissue defect, depending on the distance of the shot, is formed by pre-bullet air, gases, a projectile, which allow, according to the characteristics of the wound and changes around it, to solve such problems. important questions, as the distance of the shot, the nature, shape and size of the projectile.
When describing gunshot wounds, it is necessary to indicate whether a fold of skin is formed during the reduction of the edges of the wound, which is the main sign of the entrance gunshot hole and indicates a penetrating effect. Although stabbing tools form holes, unlike firearms, they do not pierce, but stretch, tear and push apart all layers of tissues. Comparison of the edges of such wounds does not cause the appearance of skin folds, which makes it possible to establish the origin of the wounds.
The shape of the inlet is determined by the distance of the shot, the action of the pre-bullet air, gases, the size and shape of the projectile, the speed, the angle of entry of the bullet (Fig. 143), the ballistic properties of weapons and ammunition, the presence of underlying bones.
A bullet entry angle of about 180° or 90° forms a round or rounded wound, and about 70° or less brings it closer to an oval (Fig. 144). Due to the uneven contraction of tissues, and most importantly, muscles, the round shape becomes more or less oval.
The position that the oval shape of the wound always indicates a shot at an acute angle is erroneous. A confirmation of such a shot is a pronounced semi-lunar sedimentation of any part along the edge of the wound, especially if the sedimentation is accompanied by cracking of the epidermis and beveling of the walls on the opposite side.
Very rarely, the foramen ovale may resemble a rhombus (for example, with uneven damage and subsequent contraction of the tissues surrounding the hole).
The entry of the bullet with the side surface (flat) forms an elongated inlet, and the contours of the belt of precipitation can reflect the profile of the bullet.
When fired in a body area with a closely spaced bone, the pre-bullet air and gases spread along the bone, exfoliate the muscles, periosteum, sometimes causing skin tears at the entrance, sometimes partially break through into the wound channel, and can reach the exit hole.
The dimensions of the inlet hole depend on the elasticity of the skin, the degree of its tension in various areas of the body, the distance of the shot, the features anatomical structure the injured area of the body, the presence of underlying bones, natural skin folds, tissue compliance (chest, abdomen), and, as a rule, they are smaller than the caliber of the bullet, because the skin drawn in by the bullet, especially in areas with large array soft tissues, is reduced, and the size of the hole is reduced. In the projection of the bone, soft tissues are slightly pressed inward, the size of the inlet almost corresponds to the diameter of the bullet or may be slightly larger. The entrance holes in the natural folds of the skin may increase at the time of straightening these folds on the corpse. Shots at point-blank range and at close range (zones 1 and 2) leave large entrance holes, and from a long distance - smaller ones.
Sometimes radial ruptures depart from the edge of the hole, which there is no reason to consider as part of the hole, since they are formed from the action not of the bullet, but of the pre-bullet air, gases and, thus, do not carry information about the size of the bullet. Incorrect flight of a bullet in cases of shots from defective weapons and ricochets leaves holes of various shapes. A bullet fired from a sawn-off shot often fragments, inflicting several wounds, sometimes mistaken for shotguns. Special purpose bullets cause holes larger than the size of the bullet, which is explained by their design features.
The nature of the edges of the inlet is affected by the shape, flight speed and angle of entry of the projectile into the body. The edges of the holes made by pointed bullets are more even. Rounded and blunt bullets hurt more, and the edges formed by them are uneven, finely serrated, and from shot shells they are scalloped. The walls of the wound channels are sloping, uneven. Along the edge of the inlet, there is a rim of settling and rubbing. On the clothes there are loose threads of the material around the fabric defect.
As a result of bruising and friction of the bullet around gunshot wound there is an area devoid of the epidermis, called precipitation belt. The rim (belt) of sedimentation was first noted by the Russian surgeon M.F. Krivoshapkin (1858), and in 1865 N.I. Pirogov. In the 70s, E. von Hoffmann explained the appearance of the parchment rim by the drying of the besieged area by a penetrating bullet. Its shape is determined by the angle of entry of the bullet into the body, and its dimensions are determined by the speed of kinetic energy and the contact surface of the bullet with the skin. The belt of sedimentation becomes noticeable on average 3.5 hours after the injury. The bullet, which has a high speed of movement, does not form a belt of deposition, which allows us to assume that a wound was caused from a modern long-barreled weapon. On the scalp, the belt of sedimentation is indistinguishable, that I.V. Slepyshkov (1933) explains the rupture and detachment of the edges of the wound.
Entering the skin, the bullet acts differently on different layers. The skin is more elastic than the epidermis, which is torn before it, is carried away by the bullet and is torn off in the circumference of the wound at a distance of 1-2 mm from its edges. As a result, a belt of sedimentation is formed (traumatic ring, contusion ring, rim of drying, erosive border, etc.). A bullet entering at a right angle causes a belt of deposition of the same width, and at a sharp angle it is wider on the side of the bullet's flight. In case of wounds with large rounded bullets, not only precipitation occurs, but often bruises occur in the immediate circumference of the wound, which is explained by the bending of the bullet, which has a large surface. Microscopic examination around the wounds revealed ecchymosis. Foreign authors they are called the ecchymotic excoriative ring. The size of the belt of deposition depends on the degree of compliance of the skin of the injured area, the nature of the underlying tissues, the speed, shape and angle of entry of the bullet into the body.
The outer diameter of the belt is approximately equal to the size of the bullet. In cases of wounds through clothing, the rim of the wound is wider due to the pressure of the clothing by the bullet to the body.
On the palms and plantar surfaces of the feet, which have a thick stratum corneum, precipitation does not form, but radial ruptures up to 0.3 cm long and detachment of the epidermis occur.
Wiping belt - a trace left by a bullet along the edges of the inlet, and in the initial section of the wound channel due to rubbing from the surface of the bullet the smallest particles of metals and compounds belonging to the primer, cartridge case, bullet, barrel bore metal, products of the initiating substance and explosive decomposition products of gunpowder.
A bullet sliding along the bore erases grease, rust, metal, soot remaining on its surface. Entering the body, it conically stretches the skin, tightly covering and erasing most of the listed overlays from its surface, leaving a gray or dark gray belt 0.05 to 0.2 cm wide along the edges of the inlet. belt of pollution(rubbing, metallization). It can be layered on the sediment belt or coincide with it. The bullet, passing through the clothing, leaves a rubdown belt on the front surface of the material, sometimes it may be absent.
When shot at the scalp, the ends of the hair hanging down into the lumen of the wound were crushed, divided into strands, like a panicle, individual hairs were crushed along the length. The hair is covered with a blackish coating and separate blackish clumps.
Sometimes a belt is located next to the belts of upsetting and wiping depressed, arising from the pressure of the barrel and adjacent parts of the weapon (ramrod) on the tissue in the circumference of the wound when fired at close range.
A shot from a lubricated weapon is accompanied by the release of particles of weapon grease from the barrel bore, which settle on the barrier. Most clearly traces of lubrication are expressed after the first shot. The amount of lubricant progressively decreases with the increase in the number of shots. The lubricant is located along the edge of the inlet in the form of separate splashes at a distance of up to 45 cm. Along with this, traces of lubricant can also be detected from the touch of the muzzle end of the weapon to the barrier. The presence of lubricant allows you to judge the inlet, the area of \u200b\u200blocation - about the distance, and the number - about the sequence of shots. Traces of grease when viewed in the UV light look like brightly glowing spots.
- this is a wound resulting from the action of projectiles (bullets, shrapnel, buckshot, fragments, shots) fired from a firearm. Distinctive features gunshot wounds are a severe reaction of the body, massive tissue damage, a significant duration of healing, a large number of infectious complications and deaths. Pathology is diagnosed on the basis of anamnesis, examination data and X-ray examination. Treatment includes anti-shock measures, replenishment of blood loss, PST with suturing or removal of damaged organs, dressings and antibiotic therapy.
ICD-10
W34X95
General information
A gunshot wound is a set of injuries resulting from the action of a projectile fired from a firearm. The nature and course differs from other types of wounds. It is accompanied by the formation of a large array of non-viable tissues and a severe general reaction of the body. There is a tendency to prolonged healing and frequent complications.
With gunshot wounds, all types of damage to organs and tissues can be observed: violation of the integrity of nerves, muscles and blood vessels, fractures of the bones of the trunk and limbs, damage to the chest, as well as damage to any hollow and / or parenchymal organs (larynx, liver, etc.). Wounds with damage to internal organs are great danger for life and often end in death. Orthopedic traumatologists, thoracic surgeons, vascular surgeons, abdominal surgeons, neurosurgeons and other specialists can deal with the treatment of gunshot wounds, depending on the damage to certain organs and tissues.
The reasons
A gunshot wound is the main type of injury during combat operations. AT Peaceful time is relatively rare and can be the result of criminal incidents or hunting accidents.
Pathogenesis
Gunshot wounds are characterized by certain features that distinguish them from other types of wounds. A zone of dead tissues (primary necrosis) is formed around the wound channel. The wound channel has an uneven direction and length. With penetrating wounds, an exit hole of considerable diameter occurs. Foreign particles are found in the wound, drawn in there due to high speed projectile. After some time, new areas of dead tissue (foci of secondary necrosis) form around the gunshot wound.
The destructive effect of the projectile is due to two components: a direct impact, that is, a direct impact on tissues and a side impact, that is, the action of a shock wave that instantly forms a zone high pressure throwing tissue to the side. Subsequently, the resulting cavity abruptly “collapses”, a wave with negative pressure arises, and the tissues are destroyed due to the huge difference between negative and positive pressure.
Taking into account the characteristics of the traumatic effect in any gunshot wound, three zones are distinguished: the wound channel or wound defect (the zone of direct impact of the projectile), the contusion area (primary necrosis is formed in this zone) and the concussion area (secondary necrosis is formed in this zone). A wound defect can be true or false. A true defect is formed when a piece of tissue is torn out (“minus” tissue), a false defect is formed when the disconnected tissues contract (for example, when damaged muscles contract).
Classification
Treatment of a gunshot wound
The first step is to stop the bleeding. In case of slight or moderate bleeding, the wound is closed with a pressure bandage, in case of heavy bleeding, a tourniquet is applied above the injury site. The victim is given painkillers, if possible, an intramuscular injection of analgesics is performed. The patient is placed in a horizontal position (with the exception of wounds in chest, in which, to facilitate breathing, the patient should be given a sitting or semi-sitting position), immobilization is carried out using special tires or improvised means.
If the delivery of the victim to the honey. the institution is difficult or delayed, anti-shock measures are carried out at the primary health care center and wound infection is prevented by administering antibiotics intramuscularly, washing the wound channel with antibiotic solutions, and also performing chipping of the wound area.
The volume and sequence of therapeutic measures in a specialized institution are determined taking into account the patient's condition. They replenish the bcc, carry out anti-shock measures, perform surgical treatment of wounds. During the surgical intervention, if possible, contaminated and non-viable tissues are excised, the wound is washed and drained. Damaged vessels are tied up, damaged organs are partially excised and sutured or completely removed, small fragments of bones are removed, large fragments are compared. Usually on initial stage for complex and unstable fractures, skeletal traction is applied.
At wound channel small diameter sutures are not applied to the gunshot wound, with a defect big size match the edges of the wound using rare single sutures. A contraindication to surgical intervention is an agonal state and traumatic shock. Surgical treatment is not subject to shallow tangential wounds, multiple shrapnel and small superficial "stuffed" gunshot wounds.
In the postoperative period, antibiotics are prescribed, hypovolemia is continued to be corrected, dressings are performed. Subsequently, it is possible to apply delayed primary sutures (after 5-6 days), early secondary sutures (after 10-12 days) and late secondary sutures (after 3 weeks). Since gunshot wounds, as a rule, heal through suppuration, in the long term, such injuries often require reconstructive interventions: skin plasty, tendon plasty, nerve restoration, intra- and extrafocal osteosynthesis, etc.
The main signs of an entrance gunshot wound (holes) with explosive and penetrating action of a bullet:
fabric defect or "minus-fabric", having great kinetic energy the bullet acts like a punch, knocking out the skin in the area of the entrance wound, when you try to bring its opposite edges together, they do not coincide with each other, but if you bring them closer due to skin tension, then folds are formed in the corners of the wound, the diameter of the defect is 1-2 mm. less than the diameter of the bullet;
sediment belt, which looks like a brownish-yellow annular abrasion 1-3 mm wide, is formed as a result of the fact that the surface layer of the skin (epidermis) is less elastic than the skin itself and is partially torn off when in contact with the side parts of the bullet; if the bullet enters at an angle, then the wiping belt will be wider from the side of the bullet entering the skin at an acute angle;
rubdown belt(contamination belt, metallization belt) is formed due to deposits on the surface of the bullet (soot, grease, metal particles, etc.), which are erased and superimposed on the sediment belt, the wiping belt of gray or gray-black color, 0.5-2 wide, 5 cm;
entrance wound shape(holes) round, if the bullet enters perpendicular to the surface of the body, if the bullet enters the side surface, then the shape of the entrance wound is oval;
edges of the entry wound(holes) uneven due to small tears of the skin, more often turned inward;
entrance wound dimensions, usually less output.
Features of the inlet on the bones (flat and tubular):
A distinctive feature of the entrance gunshot injury on the flat skull bone is a chip of the inner bone plate, forming the appearance of a truncated cone, the base of the cone is directed in the direction of the bullet's flight.
In the diaphysis of tubular bones, from the side of the entrance, a round hole with radial cracks is formed, which form large fragments on the lateral surface of the bone, resembling butterfly wings.
When wounded by a bullet having a small kinetic energy, a tissue defect in the area of the entrance wound ("minus-tissue") is not formed.
Exit gunshot wound (hole)
The main signs of the exit gunshot wound (holes):
exit wound shape varied (arc-shaped, round, oval, slit-like, etc.);
edges of the wound are uneven with small tears, often turned outward;
exit wound dimensions larger than the size of the entry wound, but may be equal to or even smaller than the entry wound;
lack of wiping belt.
The defect ("minus-tissue") can be in the area of the exit wound, provided that the bullet must have high kinetic energy and there must be a small layer of tissue during the passage of the bullet, for example, a shot from a large-caliber weapon into the palm.
A belt of sedimentation can form in the area of the exit wound, when in the area where the bullet exits the body, the skin is pressed against any solid object (wall, floor) or dense parts of clothing (belt, boot, etc.), skin sedimentation occurs as a result of pressing and impact o a solid object of a skin area protruded by a bullet at the moment the bullet exits the body.
On a flat bone in the area of the outlet, a chip of the outer bone plate.
A large bone defect is formed in the diaphysis of the tubular bone; multiple longitudinal cracks extend from its edges along the length of the bone.
A gunshot wound is a specific and rather severe injury that is the result of mutilation with the help of a factor such as a firearm. The wounded surface with such a type of damage as a gunshot wound has a number of differences from all other wounds according to all possible criteria.
Types of gunshot wounds
Gunshot wounds, depending on the injuring object, into two types:
- bullet;
- fragmentation.
In addition, depending on the damaged structure of the human body, there are:
Features of the course of gunshot wounds
Gunshot wounds have their own characteristics, which distinguish them from other types of wounds. Primary necrosis is formed around the wound itself, the wound channel itself has a direction with pronounced deviations and the course itself. Often the edges of the wound are torn and do not match.
With through types of gunshot wounds, as a rule, the inlet is much smaller than the outlet. The size depends on the type of firearm. In the wound, gunpowder residues or foreign elements that remain there are most often found. This is due to the high speed with which the bullet penetrates the human body. After some time, in the absence of adequate medical care, borders of secondary necrosis develop around the wound.
A gunshot wound can be complicated by conditions such as shock, various types of hypoxia, or severe bleeding. In addition to local manifestations gunshot wound, common symptoms also develop, referred to as "wound disease". As a rule, a wounded disease is accompanied by serious disorders. respiratory system, metabolic disorders, heart failure, endocrine system and central nervous system.
Local manifestations of a gunshot wound include fractures, hemorrhages, ruptures of internal organs, blood vessels, damage to nerve endings causing serious consequences.
Symptoms of gunshot wounds
A gunshot wound is divided into the main stages: the direct influence of the weapon - the formation of a wounded channel, a contusion zone and a concussion zone.
Wound channel - the resulting cavity with crushed, split or corroded edges due to damage firearms. The diameter of the contour of the wound channel is different throughout, this is due to the structure of the bullet and the anatomical features of the tissues.
A characteristic feature of gunshot wounds is the primary deviation of the wound channel. This is the so-called deviation from the straight line of the bullet fragment or the bullet itself. Secondary deviation occurs immediately after injury.
The contusion zone is an area of the damaged body that lends itself to primary necrosis. Surrounding tissues are exposed to concussion, which are injured in the first few hours. Just as with a wound channel, the amount of damage depends on the damaging element and on the structural features of the tissues, their structure and density.
The shock zone is the zone that is completely covered by the shock wave during application. gunshot wound, while the tissues exposed to this influence completely lose their viability.
Diagnostic measures
Diagnosis of a gunshot wound is based on the data of the collected anamnesis, laboratory and instrumental studies.
Anamnesis
When collecting an anamnesis, it is very important under what circumstances the damage was inflicted, the duration of the events occurring and the amount of prehospital care provided.
Objective research
At this stage of diagnosis, the level of severity of the inflicted injuries is assessed according to the general condition of the victim. At severe conditions diagnostics should be carried out in parallel with resuscitation.
Laboratory research
Before starting treatment with surgical intervention, the patient must undergo a series of standard laboratory tests.
Instrumental diagnostic methods
This diagnostic stage is necessary to identify the depth of the wound and the presence of other damaged elements. Most often, diagnostic methods such as radiography, computed tomography, magnetic resonance imaging and ultrasound scanning are used.
First aid for gunshot wounds
Gunshot wounds are the most common injuries, accompanied by serious injuries. Therefore, in order to avoid the development of complications for the patient, it is necessary to get to a specialized medical institution as soon as possible.
Important first aid steps:
- saving the life of the patient;
- determining the severity of the injury.
A bullet entering the human body causes deep damage, in addition, most often it does not pass through the body and therefore remains inside. If possible, it must be removed immediately, this is not always possible, it all depends on the place of its localization.
Performing successively all stages of medical care provides the possibility of a full recovery.
Stop bleeding
First you need to determine the presence of bleeding, its localization and nature. As a rule, gunshot wounds are accompanied by profuse blood loss. In cases where the limbs are damaged, a tight tourniquet is applied for 2 hours in the summer and 1.5 in the winter.
Anesthesia
