Answers to problems in medicine surgery – Part 1

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Dressing and Bandage

A woman with a 10-year-old boy turned to you due to the fact that the child is worried about the pain in the right elbow joint. A bandage was applied to a boy 6 hours ago in an outpatient clinic on an infected abrasion of the elbow joint after its treatment. On examination, slight cyanosis of the right forearm and hand, swelling of the saphenous veins, even when raising the arm up, is determined. What happened? How can I help my child?

The bandage was applied to the child tightly, as a result of which there was a violation of blood circulation. The bandage needs to be loosened or changed. The bandage on the elbow joint is fixed with a tortoise (converging or diverging) bandage.

 

A 40-year-old man came to the appointment with an itchy left forearm. Three days ago I received a thermal burn of the I-II degree. An aseptic bandage was applied to the forearm. On examination, it was found that the bandage on the dorsum of the middle third of the forearm was wet with yellowish-gray discharge, dry. How to remove the bandage correctly?

It is necessary to remove the bandage either by cutting it away from the damaged area or from the opposite side of the burn wound. The bandage must be unwound, collecting it with a veil and shifting from one hand to another, at a close distance from the wound. A dried-on dressing is easier to remove after moistening it with a 3% hydrogen peroxide solution.

 

A 34-year-old man was admitted to the emergency room with a cut wound on the palmar surface of the middle third of the right forearm. According to the victim, an unknown person stabbed him 1.5 hours ago in the street. The wound toilet was made, primary sutures were applied. The nurse secured the dressing on the wound with a bandage, tying the ends of the bandage in a knot over the wound. After that, she injected the patient subcutaneously with 0.5 ml of tetanus toxoid and 300 IU of tetanus toxoid. What is the mistake of the bandage technique?

When fixing the dressing, neither the ends of the incised bandage nor the knot itself, should overlap with each other on the wound surface.

 

A 68-year-old patient has a trophic ulcer 1.5×2 cm in size on the inner surface of the lower third of the right leg with a necrotic bottom, skin hyperemia, and soreness around. The ulcer was treated with an antiseptic solution, drained, covered with a napkin with Iruksol ointment. What kind of reinforcing bandage will you use?

In this case, a circular (circular) bandage on the lower third of the lower leg is convenient for bandaging.

 

The patient, due to varicose expansion of the saphenous veins in the stage of subcompensation, underwent venectomy of the great saphenous vein on the right thigh and lower leg. The wounds were sutured, treated with 1% iodonate solution, and covered with napkins. What kind of bandage should be applied to the lower limb to secure the dressing?

At the beginning of the bandaging, a creeping (serpentine) bandage is used to hold the dressing over a considerable length of the limb. After this, an ascending spiral dressing should be applied. Due to the conical shape of the lower leg for bandaging, it is convenient to use a spiral bandage with bends in the bandage. In such cases, the Tedenian bandage of the lower limb can also be used, the essence of which consists in a combination of several bandages: an eight-shaped bandage of the foot, a turtle bandage of the heel region, a spiral bandage with bends on the shin, a tortoise bandage on the knee joint, a spiral bandage with bends on the thigh, ascending spica bandage in the area of ​​the hip joint and pelvis.

 

Patient K., 20 years old, underwent emergency laminectomy due to injury of the cervical spine and injury to the spinal cord in order to decompress it. The wound on the back of the neck was sutured and closed with gauze napkins. What kind of bandage will you put on to secure the dressing.              

A cruciform bandage should be applied to secure the dressing to the back of the neck. Before bandaging, in order to prevent squeezing of the neck, it is advisable to overlay its front surface with a layer of cotton wool. To prevent the bandage from straying upwards, it is advisable to supplement it with the moves of a bandage such as a cruciform back bandage.

 

You are an emergency doctor. You have been called to a patient with a penetrating chest wound on the right. The victim’s condition is grave. He instinctively covers the wound with his hand, leaning to the right. When examining the wound, air is sucked through it at the time of inhalation, and when exhaling, air leaves it with noise. Your actions?

It is necessary to urgently apply an occlusive dressing to the chest at the time of exhalation. To do this, the skin around the wound is smeared with 5% alcohol solution of iodine, the wound is closed with a sterile gauze napkin, and strips of adhesive plaster are tiled on top, which go far beyond the edges of the napkin. If you have an individual dressing package, you can use it. In this case, the wound is closed with a cotton-gauze pad, the skin around the pad is lubricated with petroleum jelly for better sealing, a rubberized package is applied to it with an internal (sterile) surface and secured with a spiral bandage on the chest. For more reliable prevention of displacement of the dressing, it is advisable to bandage the corresponding arm to the affected side of the chest. The patient is injected with anesthetic,

 

Patient S., 28 years old, performed an autopsy of purulent ulnar bursitis. The bag is washed with an antiseptic solution, drained with a turunda soaked in a hypertonic sodium chloride solution, covered with a gauze napkin. How will you secure the dressing?

You can apply a turtle bandage to the elbow joint in a bent position, or secure the dressing with a tubular elastic bandage.

 

Patient S., 36 years old, was injured during a road accident. There is a profusely bleeding cut wound in the right temporal region and an extensive chopped-lacerated wound along the outer surface of the right shoulder joint. There are no signs of a shoulder fracture. What bandages should be applied to the patient when providing first aid?

In the presence of a bleeding wound in the temporal region, it is more rational to apply a so-called nodular bandage. The dressing on the wound in the area of ​​the shoulder joint can be securely fixed with a spike-shaped dressing. In addition, the right upper limb in this case must be suspended with a gusset.

 

You are an accidental witness to an accident: a child scalded his right hand with boiling water, screaming in pain. Blisters appeared on the dorsum of the fingers and hand. The home medicine cabinet contains a furacilin solution (1: 5000) and a sterile bandage in the package. For first aid purposes, what kind of bandage should be applied to the victim?

With a piece of bandage moistened with a solution of furacilin, it is necessary to cover the burned hand by pressing the folds of the bandage between the divorced fingers to prevent adhesion of the burned areas and maceration of the skin. After that, a returning bandage is applied to the hand (“mitten”). In such a case, when the necessary dressing material is not at hand, you can apply a scarf from a diagonally folded scarf.

 

A 52-year-old worker of a state farm with a bruised and chopped wound in the right parietal region was taken to a rural local hospital, which the victim himself covers with a folded handkerchief. How much medical care should be provided to the patient?

It is necessary to widely cut the hair around the wound, treat the skin with iodine solution, rinse the wound with an antiseptic solution, cover it with a sterile napkin and apply a fixing bandage (Hippocrates cap, cap or bridle). In addition, in order to prevent tetanus, it is necessary to inject tetanus toxoid subcutaneously and, according to indications, tetanus toxoid. The patient should be transported to the surgical hospital.

 

As a local pediatrician, after examining the child at home, you recommended to apply a warming compress to his right ear. The mother of the child, referring to her inability to perform this procedure, asked you to help. How to apply a warming compress to the ear and with which bandage to strengthen it?

A warming compress on the ear area is prepared as follows. The bandage is folded in 6-8 layers, a hole for the auricle is cut out in the center of the resulting napkin. The napkin is moistened with water mixed with alcohol (1: 1) or oil (camphor, etc.), wrung out and placed on the skin around the auricle. The napkin is covered with plastic wrap (thin oilcloth or wax paper) so that the film overlaps it by 2-3 cm. Outside, a layer of cotton wool 2-3 cm thick is applied, which overlaps everything below. It is convenient to secure the compress on the ear area with a Neapolitan bandage.

 

An 11-year-old boy turned to a doctor in a rural outpatient clinic, who about an hour ago, while playing hockey, received a blow with a club in the left eye area. First aid was immediately provided in the form of applying snow to this eye. Moderate hyperemia of the eyeball, corneal erosion are visually determined. On palpation, the eye is painful. Diagnosed with blunt trauma to the left eye. How much first aid should a child receive?

It is necessary to drip a 5% solution of novocaine into the eye, inject vicasol intramuscularly, give analgin, askorutin to the inside, cover the left eye with a sterile napkin, apply a light monocular bandage and urgently send the child to see an ophthalmologist.

 

A 47-year-old man fell off a bicycle. Complains of pain in the right forearm. Swelling, deformation, soreness and crepitus in the projection of the middle third of the right clavicle are visually noted. Pulse on the right radial artery is satisfactory. What will you diagnose and what kind of immobilizing bandage will you apply?

The victim has a traumatic fracture of the right clavicle. The right upper limb must be immobilized with a Dezo or Velpo bandage.

 

After reduction of the traumatic dislocation of the right shoulder in the victim, it is necessary to immobilize the right upper limb for an average of 1-1.5 weeks. What kind of immobilizing bandage will you apply?

After the dislocation of the shoulder has been repositioned, an immobilizing bandage from Desot or Velpo is shown.

 

 

BLEEDING

A 70-year-old patient suffering from varicose veins of both lower extremities suddenly developed bleeding from a ruptured node along the inner surface of the lower third of the right leg. Dark blood pours out from the wound in a rather sluggish stream. How much first aid should be provided to the patient?

To temporarily stop bleeding, a pressure circular or spiral bandage should be applied to the right shin, giving the limb an elevated position, and the patient should be transported to a surgical hospital.

 

A 17-year-old boy, during a bus ride, extended his right hand through the window. A lorry was approaching, its side hitting its outstretched hand. There was a traumatic amputation of the right upper limb, at the level of the middle third of the shoulder (the limb hangs on a flap of skin). Scarlet blood gushes from the damaged arteries. How to stop bleeding?

It is necessary to urgently make a finger pressure along the brachial or axillary artery, and then apply a standard (Esmarch) or an impromptu hemostatic tourniquet (twist tourniquet). The wound must be covered with a sterile bandage, the limb must be immobilized, and painkillers must be administered. The patient needs emergency transportation to the surgical department.

 

A patient with a stab-cut wound in the popliteal fossa was delivered to the surgical department. During the revision of the wound, damage to the popliteal artery was found, but you do not know the technique of vascular suture. What actions will you take?

The optimal tactics in this case should be a temporary bypass grafting of the vessel and the involvement of a vascular surgeon along the sanitary aviation line to perform a reconstructive operation.

 

A 48-year-old man was admitted to the emergency room with complaints of weakness, dizziness, moderate pain in the left hypochondrium. It is known from the anamnesis that 12 hours ago he fell down the stairs and hit with the left costal arch. On the eve of admission, he fainted. The patient lies in a forced position. Changing body position increases abdominal pain. The skin is pale. Pulse-120 beats per minute. Blood pressure-90 / 50mm Hg Breathing is shallow. Moderate tension of the muscles of the abdominal wall, dullness of percussion sound in the left hypochondrium and sloping places of the abdomen are noted on palpation. Hemoglobin of blood – 98gl. What is your presumptive diagnosis and tactics?

The patient should be suspected of shock, traumatic rupture of the spleen with intra-abdominal bleeding. Additionally, it is advisable to make a general X-ray of the abdominal cavity in the sitting position of the patient in the emergency room to exclude the presence of free gas in the abdominal cavity and an X-ray of the ribs. A patient on a gurney must be urgently taken to the surgical department for anti-shock measures and an emergency operation.

 

A young man was delivered to the emergency room with a closed chest injury on the right. The skin is pale. The pulse is 100 beats per minute. Blood pressure-110/65 mm Hg. There is pain, crepitus of bone fragments in the projection of the VIII, IX and X ribs on the right along the mid-axillary line. Percussion on the right in the lower sections is determined by a dull sound, breathing is not heard (in the patient’s sitting position). The radiograph, in addition to the fractures of the indicated ribs, additionally revealed an intense shadow with a horizontal level up to the border of the VII rib. What is your diagnosis and tactics?

The patient has a closed fracture of the VIII-X ribs on the right, complicated by hemothorax. The source of bleeding here may be damage to the intercostal vessels or the lung. A patient on a gurney should be taken to the surgical department, where he will be subjected to a diagnostic and treatment puncture of the pleural cavity, and hemostatic therapy with dynamic monitoring of the state of health is prescribed in the general complex of therapeutic measures.

 

A 30-year-old patient, suffering from gastric ulcer for 7 years, noted increasing weakness and dizziness throughout the day. This morning, after getting out of bed, he lost consciousness for a few seconds. After that, there was once vomiting in the form of “coffee grounds” and “tarry” stools. The skin is pale. The abdomen is soft, painless. You are a local doctor. What is your presumptive diagnosis. What urgent additional research needs to be performed to confirm your assumption. Where and in what way will you send the patient for treatment?

The patient most likely has stomach bleeding. He should be transported immediately by ambulance on a stretcher to the surgical department. If this does not delay the dispatch of the patient, it is necessary to measure blood pressure and, if possible, take blood from him to determine the number of erythrocytes, hemoglobin, hematocrit. The blood test result can be sent to the hospital by phone.

 

In a patient who underwent an operation for an inguinal hernia in the morning, in the evening the bandage on the wound began to bloody profusely. Applied topically for an hour, ice packs and sandbags had no effect. What is the complication in the early postoperative period of the patient. What is your next tactic?

A patient developed secondary bleeding in the early postoperative period. The patient should be taken to the operating room, revised the wound, ligate a bleeding vessel or additionally put 1-2 sutures on the wound for the purpose of hemostasis.

 

A young man came to you with complaints of pain in the right leg and its growing swelling after falling from a moped. The injury occurred about half an hour ago. When viewed on the front surface of the middle third of the leg, there is a swelling 10x6x5 cm. The skin above it is cyanotic. On palpation, pain and fluctuation are noted. The pulse in the dorsal artery of the right foot is preserved. What is your diagnosis? What kind of assistance will you provide to the victim?

The victim has a subcutaneous hematoma of the right leg. It is necessary to apply a pressure bandage on the lower leg, recommend topically ice packs, rest for the limb. Subsequently, the patient must be examined by a surgeon.

 

A patient was admitted to the emergency room of the hospital with complaints of pain in the left knee joint after an injury. Joint movements are limited, painful. The joint is spherical. The ballot of the patella is noted. No bone damage was found on the radiograph. What is your diagnosis and treatment?

The patient has hemarthrosis of the left knee joint. It is necessary to puncture the joint, apply a pressure bandage, immobilize the limb, and additionally recommend cold to the joint.

 

A patient with a closed abdominal trauma was admitted to the clinic. On admission, symptoms of intra-abdominal bleeding were expressed. As a result of an emergency operation (laparotomy), a rupture of the anterior surface of the right lobe of the liver with a size of 6x3x4 cm, hemoperitoneum, was established. How to permanently stop bleeding from a damaged liver? What to do with blood flowing into the abdominal cavity?

For final hemostasis, the site of liver damage should be sutured with U-shaped sutures, preferably with an omentum tightening to them.

Sutures are applied with a blunt needle with a double thread through the entire thickness of the liver.

The blood poured into the abdominal cavity is collected, filtered through 8 layers of gauze into vials with a stabilizing solution containing sodium citrate or heparin, and poured back to the patient.

 

 

TRANSFUSION OF BLOOD, BLOOD COMPONENTS AND BLOOD SUBSTITUTES.

A patient with a peptic ulcer was admitted to the surgical department, the duodenum, complicated by bleeding. BCC deficiency is 35. In order to replenish blood loss, emergency blood transfusion is indicated. What is the required minimum of laboratory tests (samples) that should be performed, without which blood transfusion is unacceptable?

To exclude possible post-transfusion complications caused by antigenic incompatibility of donor and recipient blood, before blood transfusion, it is necessary:

a) determine the blood group of the recipient and the donor;

b) determine the Rh-affiliation of the recipient and the donor;

c) conduct a test for the individual compatibility of the recipient’s and donor’s blood using the ABO system;

d) conduct a test for the individual compatibility of the recipient’s and donor’s blood according to the Rh system;

e) conduct a biological test.

 

Under the supervision of a physician in the treatment room, two nurses determine the blood group of four patients. To do this, they applied standard serums of two series on lacquered white earthenware plates under the appropriate designations. The test blood was thoroughly mixed with drops of standard sera. The plates were rocked, left alone for 1-2 minutes and then rocked again. Not earlier than 3 minutes after mixing drops of blood and serum, isotonic sodium chloride solution was added dropwise to the drops, where erythrocyte agglutination occurred. After 5 minutes from the beginning of the study, the doctor evaluated the results obtained and recorded them in the case histories. What the doctor did not pay attention to, thereby violating the requirements of the “Instructions for the determination of blood groups ABO”.

According to the “Instructions”, before determining the blood group, the surname and initials of the person whose blood group is being determined, or the number of the vial, if the blood is donated, are applied to the plates.

 

In order to quickly replenish blood loss, the patient was transfused with 1000 ml of one-group Rh-compatible donor blood, preserved with sodium citrate. By the end of blood transfusion, the patient developed anxiety, pallor of the skin, tachycardia, muscle cramps. What complication did the patient have? What is its prevention? What treatment measures are needed?

The patient should assume the occurrence of nitrate intoxication, which can occur with rapid and massive blood transfusion, preserved with sodium citrate. With a slow drip infusion of blood, this does not happen, since citrate in the body quickly breaks down and is excreted. Prevention of citrate intoxication is a DROP (!) Blood infusion and intravenous administration of a 10% solution of calcium chloride (gluconate), 5 ml for every 500 ml of citrated blood. Treatment is symptomatic.

 

Before blood transfusion, the attending physician began to conduct a biological test for compatibility. Blood taken from the refrigerator was kept at room temperature for 30-40 minutes. According to preliminary studies, it is compatible with the ABO system and the Rh factor. Intravenous stream, 15 ml with an interval of 3 minutes, 45 ml of donor blood was injected. With the introduction of the last portion, the patient developed nausea, chills, pain in the lower back, behind the breastbone, dizziness, pulse and breathing became more frequent, blood pressure decreased. What happened? Was the technique for setting up a biological sample followed? Your actions?

The biological test was carried out correctly, according to the “Instructions for the transfusion of blood and its components.”

The changes that have appeared in the patient’s condition indicate an individual biological incompatibility of the blood under study with the recipient’s blood. Blood transfusion should be stopped immediately by clamping the system. Then the transfusion system is disconnected from the needle in the vein, to which another system with saline is connected, calcium chloride or gluconate, adrenaline, and heart medications are injected. In no case should the needle be removed from the vein, so as not to lose the finished venous access in the future.

 

A patient with massive internal bleeding was taken to the operating room for urgent indications. Under intubation anesthesia, an operation was started, aimed at finally stopping the bleeding. In order to replenish blood loss during the operation, it became necessary for a blood transfusion. How to conduct a biological test for compatibility in a patient under anesthesia?

When conducting a biological test during a surgical operation, when the patient is under anesthesia, the change in pulse and blood pressure may depend not only on blood transfusion, but also on surgery, blood loss, administration of drugs and anesthesia. Therefore, after transfusion from each bottle of the first 100 ml of blood into a dry clean tube with a few drops of heparin, 5 ml of blood is taken from the patient’s vein and centrifuged. The presence of a pink coloration of the plasma (as well as a rapid pulse and a drop in blood pressure) indicates hemolysis and that incompatible blood has been transfused. If the plasma is of normal color, then the blood is considered compatible and the transfusion can be continued.

 

Patient K., 27 years old, was delivered with a knife wound to the abdomen 4 hours after the injury. Pulse is threadlike, 120 beats per minute. Blood pressure is 70/40 mm Hg. Art. An emergency laparotomy was performed. There is a lot of liquid blood and clots in the abdomen. As blood was aspirated, the source of bleeding was established: the vessels of the mesentery of the small intestine. Hemostasis was performed. No damage to hollow organs was found. What to do with collected blood?

Collected blood must be reinfused. Before its implementation, it is necessary to find out whether massive microbial contamination of the collected blood has occurred due to damage to the organs of the urinary system or the gastrointestinal tract, and whether there is pronounced hemolysis. Latent hemolysis can be detected by Hempel’s test (after centrifugation of a portion of blood, the plasma should not be colored pink).

The blood that has poured into the wound and serous cavities and has been in them for no more than 12 hours is subject to reinfusion. The collected blood is filtered through 8 layers of gauze. Standard hemo-preservatives or heparin (10 mg in 50 ml of isotonic sodium chloride solution per 450 ml of blood) are used as a stabilizer. The collected blood before transfusion is diluted with isotonic sodium chloride solution in a 1: 1 ratio and 1000 IU of heparin is added per 1000 ml of blood. The transfusion is carried out through an infusion system with a filter.

 

A patient with chronic bleeding hemorrhoids, severe anemia was admitted to the department. Pulse-80 beats per minute. Blood pressure 120/70 mm Hg. Hemoglobin-60g / l. In order to replenish the deficiency of red cells in the postoperative period, the patient was transfused 360 ml of one-group Rh-compatible erythrocyte mass. How is the documentation for the blood transfusion performed?

Each case of blood transfusion is recorded in the medical history. First, the indications for blood transfusion, the date and time of its start are recorded, then the method – intravenous, intra-arterial, jet, etc., then the data indicated on the label of the vials (blood passport): group, batch number, date of preparation, surname and initials of the donor … After that, the results of determining the blood group of the donor and the recipient are entered, as well as testing for group and Rh compatibility, biological samples. At the end, the patient’s condition is indicated during and after transfusion. Moreover, after the transfusion, three times every hour, body temperature, pulse and pressure are noted. A day after the blood transfusion, it is necessary to do a general blood test (hemolysis!) And examine the urine for protein, since the appearance of protein in the urine is a sign of incompatible blood transfusion.

 

Patient I., 31 years old, blood group 0 (I), was in a regional hospital for incomplete late miscarriage (pregnancy 26-27 weeks), post-hemorrhagic anemia and septicemia. Produced by scraping the uterine cavity. Group B blood transfusion was started by mistake (111). After the injection of 100 ml of blood, lower back pain and chills appeared. The transfusion was stopped. After 15 minutes, the patient’s condition deteriorated sharply: weakness, sharp pallor of the skin, acrocyanosis, profuse sweat, tremendous chills appeared. Pulse-96 beats per minute, weak filling. Blood pressure is 75/40 mm Hg. What complication did the patient have? What treatment measures should be taken?

The patient has a clinical picture of II degree blood transfusion shock.

In an emergency it is necessary:

1) introduce cardiovascular, antispasmodic and antihistamines, corticosteroids, adjust the inhalation of humidified oxygen;

2) pour over rheopolyglyukin, hemodez, 5% sodium bicarbonate solution, 10-20% albumin solution, isotonic sodium chloride solution;

3) introduce furosemide, pour 10-20% mannitol solution;

4) to make a bilateral pararenal novocaine blockade according to A.V. Vishnevsky;

5) in the future, an exchange transfusion may be required.

 

A patient with profuse gastrointestinal bleeding was admitted to the surgical department. For a number of years she has been suffering from duodenal ulcer and stage III hypertension. Working pressure 190/100 mm Hg At the time of admission, the BCC deficit is more than 30%. Can a patient be given a blood transfusion?

Despite the existing contraindication (hypertension of the III degree), in this case, blood transfusion should be used for direct health reasons.

 

Patient S., 43 years old, had a curettage of the uterine cavity due to incomplete miscarriage. At the same time, in order to relieve anemia, 300 ml of blood of group B (111) was transfused intravenously, while her blood of group AB (IV) was determined. A day later, oliguria was found, the urine excreted had a brown color, contained 1.5% protein and single uniform elements. Blood urea – 27 mmol / l. Hemoglobin-56 g / l. The patient’s condition is serious, she is drowsy, adynamic, the skin is pale. Complains of nausea, vomiting. The patient gives off a urinary odor. Pulse-84 beats per minute. Blood pressure-140/85 mm Hg. Pasternatsky’s symptom is weakly positive on both sides. During the control recheck the patient was found to have blood group 0 (I). What complication did the patient develop? Your actions?

The patient developed acute renal failure syndrome after a blood transfusion. She should limit the intake of liquids, prescribe a salt-free diet with protein restriction, intravenously inject 10% glucose solution 400-600 ml with insulin (1 U of insulin per 4 g of glucose dry matter), sodium bicarbonate solution, anabolic hormones (methandrostenolone, testosterone propionate, etc. .), vitamins C, P, group B, nicotinic acid, calcium chloride. In case of nausea and vomiting, the stomach and intestines are washed. The patient should be urgently consulted by a specialist in hemodialysis.

 

 

INJURY OF SOFT TISSUES, HEAD, CHEST, ABDOMINAL.

A boy, 13 years old, hammering in a nail, missed and struck himself with a hammer on the index finger of his left hand. Immediately there was severe pain in the finger, reflex sparing restriction of mobility in it and blue skin on its back surface. What help will you provide to the child?

After making sure that there is no dislocation or fracture, the finger must be lubricated with vaseline oil and cooled with a stream of chloroethyl from a standard ampoule until frost appears on the skin. But since in a domestic environment, as a rule, this is impossible, you should immediately place your finger under a stream of cold tap water and hold until the skin is numb. If there is no cooling stream, then the bruised finger is immersed in cold water, covered with snow or ice. After cooling, the finger is dried, examined, and the possibility of movement in it is checked. The cooling is repeated until the pain subsides and the movement improves. After cooling, if there are no abrasions, the bandage is not applied. Subsequently, the child should be examined by a surgeon.

 

A teenager, 14 years old, fell from a gymnastic apparatus, hit his head. There was a short-term (several seconds) loss of consciousness. As soon as I came to my senses, there was a single vomiting. She cannot recall the circumstances of what happened. There is a swelling in the occiput, the inert integuments are intact, pale. The patient is lethargic. Pulse-84 beats per minute. Blood pressure is 115/75 mm Hg. There are no cranial signs and meningeal symptoms. What is your presumptive diagnosis? What kind of assistance will you provide to the victim at the scene of the accident?

 

The victim has a closed craniocerebral trauma, concussion. First of all, the child needs to create complete peace. Put a napkin soaked in cold water or plastic bags filled with water on your head. Then the patient on a stretcher must be urgently taken to the hospital. A child who has not received the necessary treatment often complains of headaches in the future, becomes nervous, and does not study well. Less commonly, epileptic seizures occur after a traumatic brain injury.

In addition, with a head injury in the near future after an injury, the possibility of a rupture of a blood vessel inside the skull and squeezing of the brain with poured blood cannot be ruled out. At the same time, the child, being at first in a satisfactory condition, loses consciousness some time after the injury, he has convulsions. In this case, only active treatment, including surgery, can save the child’s life.

Children with a concussion of the brain must be taken to a hospital!

 

A 20-year-old man was brought to the rural district hospital, located 35 km from the regional center, by passing transport from the scene of the road accident. Unconscious. Abrasions on the face, asymmetric folds. Akizokoria. Local swelling of soft tissues in the right parietotemporal region. Pulse-52 beats per minute. Blood pressure-100/70 mm Hg. Art. No signs of damage to the organs of the chest and abdomen have been established. You are the chief physician of a rural district hospital. What is your presumptive diagnosis? What will be your actions?

The victim has a severe closed craniocerebral injury, compression of the brain (possibly intracranial hematoma). The patient is not transportable. You should immediately contact the surgeon of the district hospital by phone to resolve the issue of the possibility of leaving the operating team and performing emergency surgery on the spot. Before the arrival of the team, it is necessary to carry out dehydration therapy (40% glucose solution, lasix intravenously), put cold on the head, keep the ventilator ready.

 

In the evening, a victim in a road accident was delivered to the emergency room of the district hospital. The condition is serious. Unconscious. Pulse 120 beats per minute. Blood pressure-110/70 mm Hg. Shallow breathing, 24 per minute. The pupils are wide, do not react to light. Bleeding is noted from the right ear canal. You are a doctor on duty, a therapist by profession. Your actions? What to do with bleeding from the ear canal.

The victim should be suspected of having a skull base fracture.

We need to urgently call a surgeon. Before his arrival, it is necessary to perform a general analysis of blood, urine (take a catheter!) And X-ray of the skull in two projections. Since the victim may stop breathing at any time, you need to be ready for resuscitation measures.

The right ear canal should not be tamponed, as this may contribute to the growth of intracranial hematoma and the progression of compression of the brain. It is permissible to drain the ear canal with gauze soaked in an antiseptic solution to prevent infection of the meninges.

 

You are an emergency doctor. You are urgently called to a 34-year-old patient who complains of “piercing” pain in the right side of the chest. The pains appeared suddenly about an hour ago during another attack of coughing. The patient lies on his right side. The skin is pale. Mild acrocyanosis. Shallow breathing, 28 per minute. The thaw temperature is 36.7 C. Blood pressure is 120/85 mm Hg. On the right above the lungs, breathing is not audible, the box sound is determined percussion. The abdomen is soft and painless. What is your presumptive diagnosis? What will you do with the patient?

The patient should assume a spontaneous (idiopathic) pneumothorax on the right. From urgent measures, he needs to administer painkillers and heart medications, establish oxygen inhalation and transport him to a hospital on a stretcher with a raised head end.

 

An ambulance was called by a police patrol. Arriving at the scene, you found a man lying on his back within the chest in the VI intercostal space on the left along the anterior axillary line a knife sticks out. The victim’s consciousness is darkened, contact is almost impossible. The pupils are narrow, the pulse is 120 beats per minute, it is determined only on large arteries. Blood pressure is 70/40 mm Hg. Art. Breathing left sharply weakened. What should you do with a knife sticking out of the wound? What kind of assistance will you provide to the victim?

The victim must be carefully laid on a stretcher and urgently transported to the hospital, notifying the surgeon on duty and the resuscitator by radio. In no case should you remove the knife from the wound yourself. The fact is that in the depths a large vessel or heart can be damaged, and while the knife sticks out in the wound, there is no bleeding or it is noted to a lesser extent. If a foreign body is removed from a wound in conditions where it is impossible to immediately provide assistance until the operation, the patient may die from bleeding at the scene. During transportation to the hospital, the victim should be given an intravenous drip of blood substitutes, and painkillers should be administered.

 

A 23-year-old man turned to a rural local hospital, who was stabbed in the stomach by a stranger about an hour ago at a wedding. Moderate condition. Pulse-92 beats per minute. Blood pressure-120/80 mm Hg. On the anterior abdominal wall to the left and below the navel there is a stab-cut wound up to 3.5 cm in length with an omentum falling out of it. The abdomen is soft, painless in all parts. Symptom Shchetkin-Blumberg questionable. Percussion hepatic dullness is preserved. As a local doctor, what kind of assistance will you provide to the victim? What to do with an omentum falling out of a wound?

The victim has a penetrating stab wound to the abdomen. It should be laid down, painkillers should be administered (in this case, the diagnosis is absolutely clear). The large omentum that has fallen into the wound should not be set into the abdominal cavity, as this will lead to additional infection of the abdominal cavity and the development of peritonitis. After lubricating the skin around the wound, an aseptic dressing is applied over the fallen omentum. The victim should be urgently transported to the district hospital.

 

A 35-year-old man was admitted to the emergency room of the hospital with complaints of abdominal pain. About 8 hours ago he was beaten by unknown persons. Moderate condition. Pulse-104 beats per minute. Blood pressure is 120 / 80mm. Hg The tongue is coated, dry. The anterior abdominal wall does not participate in the act of breathing, it is tense. The abdomen is painful, more in the lower parts. Hepatic dullness is preserved. Shchetkin-Blumberg’s symptom is positive. Single weak peristaltic noises are heard. Blood test: leukocytes – 16.4×109 l, stab neutrophils – 8%. Urinalysis was normal. On the survey radiograph of the abdomen in the sitting position of the patient, free gas under the domes of the diaphragm is not detected. Is it possible to exclude a rupture of a hollow organ in a victim? What should be the treatment tactics?

The victim has clinical manifestations of acute peritonitis, apparently due to rupture of a hollow organ. Preservation of hepatic dullness and the absence of radiological data on the presence of free gas in the abdominal cavity do not exclude damage to the hollow organ. The patient should be admitted to the surgical department without delay for emergency surgery.

 

A 43-year-old man with a diagnosis of acute traumatic peritonitis, intestinal rupture was delivered to the hospital emergency room by an ambulance. About 12 hours ago I received a kick in the lower abdomen. The abdomen is tense, Blumberg’s symptom is positive. He cannot urinate on his own, although he did not urinate for 6 hours before and after the injury. There is no free gas in the abdominal cavity on the plain radiograph. What should be assumed in the victim? What special research method can be used to verify the diagnosis?

The patient should assume intraperitoneal rupture of the bladder, acute diffuse urinary peritonitis.

An affordable and easily performed method for verifying the diagnosis can be retrograde cystography, in which leakage of contrast agent into the abdominal cavity is detected. In this case, catheterization of the bladder with a rubber catheter, when a very small amount of urine is excreted from the bladder, is also of diagnostic value.

 

An ambulance delivered a patient to the emergency room of the hospital with complaints of pain in the lumbar spine and right lumbar region. About 1 hour ago I fell from the scaffolding from the height of the third floor. The condition is serious. The skin is pale. Pulse-120 beats per minute. Arterial pressure-70/40 mm Hg. The abdomen is soft, painless. There is pain when pressing on the spinous process of the XII thoracic vertebra and on palpation in the right lumbar region, where swelling is determined. Urine analysis: 4-5 red blood cells in the field of view. What is your presumptive diagnosis? What special research methods can be used to verify the diagnosis?

The victim should assume a rupture (detachment) of the right kidney, compression fracture of the XII thoracic vertebra, shock of moderate severity. The patient needs to perform X-ray of the lumbar-thoracic spine in two projections, intravenous (excretory) pyelography and ultrasound examination of the kidneys. It must be remembered that hematuria is not observed when the renal pedicle is detached or the ureter is blocked by a blood clot.

 

Fractures, dislocations.

A 26-year-old man, at work, was pushed by the side of a car to an overpass. Complains of pain in the pelvic region, inability to urinate. The victim’s condition is grave. The skin is pale. Pulse-116 beats per minute, weak filling. Blood pressure-90 / 55mm Hg. Art. The abdomen is soft, painful above the bosom. Dullness of percussion sound in sloping places is not noted. Symptom Shchetkin-Blumberg negative. The symptom of “stuck heel” on the right is positive. With a slight squeezing of the pelvis from the sides, the patient notes an increase in pain. You are an emergency doctor. What is your presumptive diagnosis? How much first aid will you provide to the victim?

The patient has clear signs of a fracture of the pelvic bones with damage to the bladder or urethra, anemia and shock.

With fractures of the pelvic bones, especially multiple ones, a large amount (1-2 liters or more) of blood flows into the retroperitoneal space. In addition, irritation of the nerve plexuses, nodes and nerve endings of the pelvic region, pain lead to the development of shock. The victim must be given an anesthetic (promedol, omnopon, or morphine). Gently lay it on a stretcher in the “frog” position: put rollers made of a rolled blanket, quilts, etc. under bent and parted knees. This position relaxes the pelvic muscles, reducing pain in the fracture area, and prevents further displacement of fragments. In an ambulance, it is necessary to establish an intravenous infusion of anti-shock blood substitutes (polyglucin, etc.). The patient is transported to a specialized (traumatological) medical institution.

 

A young woman fell out of it while washing the window. The fall occurred from the height of the second floor. Complains of pain in the upper lumbar spine, aggravated when trying to sit or turn on its side. Active movements in the joints of the lower extremities are preserved. Soreness is noted on palpation when pressing on the spinous process of the first lumbar vertebra. What is your preliminary diagnosis? How much first aid should be given to the patient?

Taking into account the patient’s complaints, anamnesis, objective data, one should assume a compression fracture of the first lumbar vertebra.

If possible, the victim should be administered anesthetic and arrange for delivery to a hospital, laying her on her back or stomach. If the patient lies face down, do not turn her onto her back, but carefully (there is a danger of secondary damage to the spinal cord!), Lifting her up and laying her on a soft stretcher with her hands under her head. The patient can be transported on a backboard or on a hard-surfaced stretcher in the supine position with a reclining roller under the lumbar spine in order to create hyperlordosis.

 

A patient came to you with complaints of pain in the right shoulder joint. Pain appeared 3 hours. back when he took off his coat and wanted to hang it on a hanger. A year ago he suffered a traumatic dislocation of his right shoulder. On examination, there is a forced position of the limb, stepwise deformity in the area of ​​the right shoulder joint. The head of the shoulder is palpable in the armpit. When trying to make passive movements in the joint, spring resistance is determined, accompanied by increased pain. What is your diagnosis? What help will you render to the patient?

The patient has a habitual dislocation of the right shoulder. It is necessary to immediately correct the dislocation, apply an immobilizing bandage on the limb for up to 3 weeks, recommend massage of the shoulder girdle on the right and electrical procedures (UHF, diathermy, etc.).

 

A 13-year-old boy, playing hockey, fell into the palm of his extended right hand. Disturbed by pain in the lower third of the forearm. On examination, there is swelling in the area of ​​the wrist joint and the distal third of the forearm, soreness, deformation, limitation of pronation-supination of the forearm and movements in the wrist joint. The pain intensifies in the projection of the lower third of the radius with axial load on the forearm. How much first aid should be provided to the victim? What additional diagnostic and therapeutic measures must be performed at the trauma center?

The victim should be suspected of having a fracture in the lower third of the radius of the right forearm. In terms of first aid, it is necessary to immobilize the right upper limb, for example, with a Kramer splint from the fingertips to the middle third of the shoulder with the limb bent at a right angle at the elbow joint.

At the trauma center, X-ray images of the lower third of the right forearm are performed (always in two projections!).

When confirming a fracture of the radial bone with a displacement, it is necessary to reposition the fragments and apply a dorsal plaster splint from the middle of the shoulder to the phalanges of the fingers with the forearm bent at a right angle on average between pronation and supination.

In the first two days, due to a possible increase in edema and a violation of the blood supply to the limb, it is necessary to observe the child in order to cut the bandage that fixes the splint longitudinally in time and push its edges apart.

 

A patient was delivered to the emergency room by an ambulance, who the day before, jumping out of the back of a truck, fell on his left arm bent at the elbow. The surgeon in the emergency ward removed the previously applied transport bus from the limb and examined the patient. The victim supports the injured limb with his healthy hand. Passive movements in the left shoulder joint are sharply limited, painful, and springy resistance is noted. There is a stepped retraction in the projection of the left shoulder joint. The head of the shoulder is palpable in the armpit. The pulse on the left radial artery is somewhat weakened. After intramuscular injection of 1 ml of 1% morphine solution, the surgeon injected 40 ml of 1% novocaine solution into the patient’s left shoulder joint and began to correct the alleged shoulder dislocation. What mistake was made by the surgeon?

Despite the “obvious” clinical symptoms of traumatic dislocation, the victim should definitely perform an X-ray of the left shoulder joint in order to exclude the simultaneous dislocation of the impacted shoulder fracture.

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