CASE TECHNOLOGY
for Education on "Combat damage pelvis and pelvic organs" of the object
field surgery
Shodiev A.I.
CASE
solve the problem, what is the tactic of a general practice
with combat injuries of the pelvis and pelvic organs in combat
Teaching abstract
The subject: TOLC
The theme "Combat damage pelvis and pelvic organs"
Study level: Student
Course: 4th year medical, preventive health.
The purpose of this case study: To familiarize students with the basic principles
triage, medical evacuation stages, types of medical assistance to the victims.
Giving students a volume medical procedures that are part of each type of medical
care, the principles of medical care to the wounded at some point or another
medical evacuation.
Expected learning outcomes: the results of the work with a case students learn
how to:
Assessment and analysis of the situation with injuries of the limbs.
selecting the right algorithm for the diagnosis of action
make informed decisions in wounds of extremities
provide first medical aid to the wounded on the battlefield, which in turn will
prevent the development of wound infection
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medical care at the stages of medical evacuation
For the successful resolution of the case study student should know
• define limb injuries;
• define the concept of a wound;
• Basic principles of triage to the wounded limb at a particular stage of medical
evacuation;
• problem of medical evacuations from combat wounds of the extremities;
• the types of care for the wounded;
• The volume of the main activities provided wounded every form of medical care.
This case reflects the real situation in primary care
Sources of information case:
1. Yumashev GS "Traumatology and Orthopaedics" Moscow, "Medicine" in 1990.
- 575s.
2. Musalatov HA "Traumatology and Orthopaedics", Moscow, "Medicine" in 1995.
-c.
3. V. Maslov "Practical lessons in military surgery" Saratov in 1988 with 220
4. "Notes on military surgery" V.N.Byalin, L.N.Bisenkov,
P.G.Bryusov etc. M. 2000. - 415s.
5. WWW.ejbjs.org
WWW.jbjs org.uk
WWW.traumatic.ru
WWW.trauma.bd.ru
Characteristics of case study according to typological features.
This case is classified as a desk, scene. It is short, structured. This casequestion task.
For didactic purposes Case Training, stimulating thinking in the real world in
a hovercraft and GWP.
Case can be used in the disciplines: War-surgery, emergency condition
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Introduction
"Combat damage pelvis and pelvic organs"
Classification
1. Open neognestrelnye gunshot injuries:
- Non-penetrating wounds without damaging the internal organs;
- Penetrating injury with damage of parenchymal organs, hollow organs, hollow
and solid organ, retroperitoneal organs, spine;
- Thoraco-abdominal injuries.
2. Closed injuries of the abdomen:
- Bruising of the abdominal wall;
- Closed hollow organ damage;
- Closed solid organ injury;
- Closed damage hollow and solid organ;
- Closed kidney damage.
In modern warfare, we should expect a significant severe wounds and closed
injuries of the abdomen. Increase the number of closed injuries, combine-• whined.
multiple and combined injuries. Especially difficult will flow "ball" injury multiplicity; most diverse localization of ports (often on the back), one-time heavy
damage to various organs due to sudden changes of direction the ball, more
extensive ruptures organs, increasing the number of thoraco-abdominal injuries.
Difficulties to diagnose injuries represent swept elements - low profile inlets as yes
the abdominal wall and the abdominal organs.
DIAGNOSIS closed injuries BELLY
Damage to the hollow organs - pain at rest and try n-.. tspai.chi, dry tongue, rapid
pulse, wooden belly, lack of motility, lack of hepatic dullness, with X-rays - gas
below the diaphragm or in the sides of at lateroposition
Solid organ damage - symptoms of blood loss, symptoms of fluid accumulation in
the abdominal cavity.
Closed injuries of the kidneys - hematuria, blurred contours podvzyushno-psoas
hematoma on radiographs because necessarily performed intravenous urography to
avoid wicking contrast in perirenal fat (then shown lumbotomy).
Closed injuries of the pancreas - retroperitoneal hematoma, pain encircles the
upper part of the stomach, increased diastase.
Closed injuries of the retroperitoneal part of a duodenum-pain in the upper
abdomen and in the lumbar region, the emerging signs of retroperitoneal phlegmon
may be signs of high intestinal obstruction.
DIAGNOSIS OF OPEN ABDOMINAL INJURY
Absolute signs of penetrating wounds 1. loss of bowel or omentum;
2. discharge from the wound feces, bile, urine;
3. symptoms of peritonitis.
The essential features of penetrating wounds:
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dry tongue, rapid pulse, delayed stool and gas, lack of peristalsis, muscular
defense, positive signs of peritoneal irritation, loss of hepatic dullness, shortening
of percussion sound in the sloping ground.
SPECIAL DIAGNOSTIC TECHNIQUES
- Comparison of the input and output of wounds in Exit Wounds;
- Finger study rectum (blood indicates penetrating injuries to the colon);
- Determination of the loss of blood;
- X-ray;
- Celiocentesis;
- Diagnostic laparotomy (minilaparotomy in critically ill patients with multiple
injuries, when you need to reliably exclude bleeding in the stomach or damage to
the hollow organs of the abdomen);
- The dynamic observation
TREATMENT FOR stages of medical evacuation of wounded from battle damage
BELLY
Battlefield, BMP:
- Bandages large immobilization (fallen bodies do not reduce a);
- Analgesics;
- Quick takeaway.
First medical aid (WFP):
For the wounded of the first group - the state average weight: fixing bandages,
antibiotics and tetanus toxoid, with clear evidence of penetrating wound morphine, the primary evacuation HMO.
The second group - wounded in serious condition to prepare for evacuation should
be performed: procaine blockade (perirenal, vagosympathetic inside pelvic), pour
intravenously polyglukin, enter the heart, analgesics.
Skilled surgical care (HMO)
The faster operated wounded with penetrating wound to the abdomen, the greater
the chances of a favorable outcome.
Triage:
The first group - the wounded with symptoms continuing abdominal bleeding,
wounded with obvious signs of damage to the hollow organs - immediate surgery.
Vtooaya group - with no clear signs of internal bleeding, but in the "shock II-III
degree. Patients requiring dynamic monitoring - operation indications in 1-2 hours.
The third group - inoperable wounded - after antishock therapy pressure does not
rise - conservative treatment in the hospital ward.
The fourth group - may be towed:
bruising of the abdominal wall, in the GLR, kidney-bruising .v Urological
Hospital, non-penetrating wounds without damaging the organs of the abdomen in general. Surgical Hospital.
Laparotomy in HMO C features):
- Under general anesthesia;
- Only midline laparotomy;
- The search for the source of bleeding and stop bleeding;
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- Full audit of the abdominal cavity (opening bruising under visceral peritoneum,
the revision of the stomach wall Okay, finding pairs of wounds on hollow organs);
- Stitching wounds colon, stomach, small bowel resection with anastomosis "side
to side> resection of the colon leading to excretion and removing bowel into the
wound of the abdominal wall (shotgun), suturing wounds of the rectum with
imposing unnatural anus:
- Laundering and drying of the abdomen;
- The introduction of novocaine into the root of the small intestine (may be
mikroirrigator);
- Drainage of the subphrenic space left after the removal of the spleen, right, after
mending the wounds of the liver (the drainage in this case is derived from
posterior-axillary line), lateral drainage channels and pelvis through an incision in
the iliac region after operations on hollow organs:
- Laparotomic suturing wounds;
- Stretching the anus (under anesthesia);
- Suturing the stomach into the sheets. Evacuation contraindicated 7-12 days.
Postoperative complications
In 2/3 of all the operated.
Mortality from the experience of the Great Patriotic War - | 50% after laparotomy 10%.
Complications early - shock, intestinal paresis, peritonitis.
Complications later - festering wounds eventeratsiya (10%), pneumonia (25%),
fistulas, adhesive disease, ventral herniaSpecialized surgery:
(Hospitals for the wounded in the chest, abdomen, pelvis) shameful operations and
treatment of peritonitis, abscesses limited opening of the abdominal cavity, and
closure treatment of intestinal fistula, recovery operations on the gastro-intestinal
tract.
COMBAT Open pelvic injuries (gunshot),
- Soft tissue injuries.;.
- Wounds of soft tissue and bone;
- Wounds of soft tissue and bone for internal injuries - injuries intraperitoneal
bladder and rectum damage extraperitoneal bladder and rectum.
Closed fractures: edge,
pelvic ring fractures without broken, broken in violation of the integrity of the
pelvic ring (the front half rings, half rings back, vertical, diagonal). Breaks the
pubic joint, breaks the sacroiliac joint.
Diagnosis of closed fractures of the pelvis:
- Palpation of the pelvic ring;
- Palpation of the pelvis through the rectum in women - through the vagina;
- A symptom of "sticky heel> fracture front half rings.
In fractures of the pelvis always do finger study rectal and urine output (if he can
not help).
Signs of intraperitoneal bladder injury: can not urinate during catheterization or no
urine can be a lot at once, cystography.
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Primakov extraperitoneal bladder injuries: can not urinate, urinary catheterization
in small, it bloody, and over time can be uroplania crotch, thighs, scrotum,
cystography.
Signs of damage perineum urethra: can not urinate, blood in the external opening
of the urethra, a catheter (rezinovyy!) does not pass into the bladder, the bladder
may be full, cystography!
Symptoms of rectal injury in closed fracture of the pelvic bones, blood vials in the
rectum, recent signs of pelvic cellulitis.
Diagnosis of open pelvic injuries:
- Examination of the wound, to determine the direction of the wound channel
- Palpation - diagnosis of fracture;
- Finger study rectum (fractures, pelvic inflammation of the peritoneum - the pain);
- Diagnosis vnebryushnnnyh direct bowel injury, degeneration of feces and gas
from the wound, palpation of bone fragments and blood in the rectum;
- Diagnosis of intraperitoneal rectal injury:
signs of peritonitis;
- Diagnosis of intraperitoneal bladder injuries;
lack of urine catheterization or her very much, signs accumulation of fluid in the
abdominal cavity;
- Diagnosis of bladder lesions vnebryushichnyh:
outflow of urine sludge wound. absence of urination, blood in the catheter.
Cystography.
Staged treatment of the wounded from the battle damage PELVIS
Stage of first aid (self-help, mutual aid, aid medical orderly, paramedic BMP):
- Bandage on the wound;
- Transportation of the shield with the roller under your knees;
- Analgesics of syringe-tube. stage of the first medical aid (WFP):
- Correction of dressings;
- Puncture of the bladder;
- Stop the bleeding (tamponade wound suturing the skin over it!)
- Treatment of severe shock;
- The introduction of antibiotics;
- The introduction of tetanus toxoid;
- Transportation of the shield with the roller under your knees. Step qualified
surgical assistance: Sort:
- Wounded with ongoing bleeding;
- The victim in a state of shock;
- Wounded on intra-and extraperitoneal rectal injury and bladder, but no signs of
shock,
- Wounded with closed and open pelvic injuries. with internal organs intact
perineum is damaged, the bony part of the urethra and genitalia;
- Bruises and superficial-v. soft tissue wounds;
- Moribund.
Surgery for gunshot wounds of the pelvis - pchssechenie wound excision of
nonviable tissue, removal of foreign bodies and bone fragments
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svobodnolezhashih, stop bleeding (n possible ligation of the internal iliac artery),
drainage of the wound.
If the damage of the rectum - certainly imposed unnatural anus.
Intraperitoneal bladder injury-laparotomy. suturing wounds bladder DIL hub catgut
suture, the imposition suprapubic fistula, draining the bladder through the urethra
with a rubber catheter.
Intraperitoneal rectal injuries - laparoscopic ¬ tomy, revision of the abdominal
cavity, suturing wounds of the rectum, imposing unnatural anus, abdominal
drainage, suturing wounds of the abdominal wall.
When vnebryushnnnyh injuries bladder - extraperitoneal exposure of the bladder,
suturing wounds front or side wall (if possible), drain fat okolopuzyrnoy on
Buyal'skiy, imposing nadlobko ¬ Vågå fistula with the introduction of a catheter
into the bladder type Peltzer.
With injuries perineal urethra - the imposition of suprapubic fistula drainage
okolopuzyrnoy fiber on Buyal'skiy, the introduction of a rubber bladder catheter.
Primary suture and plastic urethral gunshot wounds are not shown.
Stage specialized surgical care:
- Clarification of the nature of injury (X-ray, urography, urethra-cystography,
cystoscopy);
- Treatment of ascending infection of the urinary tract;
- Opening and drainage streaks, phlegmon, abscess, the treatment of osteomyelitis
of the pelvis;
- Plastic urethral scar its structure;
- Closure of the suprapubic fistula, unnatural anus;
- Treatment confusions pelvis special techniques (skeletal traction, reposition
hammock, etc.)
II. Methodical instructions student
Problem: The determination of the cause of poisoning and
development of measures to address the toxic effects.
Instructions for independent work in the analysis and
solution of practical situations.
Stages
Recommendations and advice
1. Familiarization
 first check with case
with case
 Reading, Do not try to analyze the situation
2.
Acquaintance again, read the information, select the paragraphs that seemed
with
a
given important to you.
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situation
Try to describe the situation. Determine that it is important
and what is secondary.
Problem:
Selecting tactics wounded prevention and treatment of
wound infections in phases honey. evacuation..
3. Identification,
formulation and
justification of the
key issues and subproblems
4. Diagnostic
In the analysis of the situation, answer the following
analysis of the
questions::
situation
 basic principles of triage,
 stages of medical evacuation, the types of care for
victims
 The volume of medical procedures that are part of
each type of care;
principles of medical care to the wounded at some stage of
medical evacuation
5. Selection and
List all the possible ways to solve this problem in a given
justification of the situation
methods and
means of
addressing
6. Development
Put diagnosis, determine how to solve the problem in a GWP
and resolution of
and AEP
the problem
situation
Instructions for group work to analyze and solve practical situation.
Stages
Recommendations and advice
Reconciliation of the situation Discuss and agree on different views of
and the problem.
members on the situation, the problem of the
subproblems.
Analysis and evaluation of the Discuss and evaluate the proposed options and
proposed methods and means of ways to address the problem. Select the
solving problems, the choice of priority, in your opinion, the idea of solving
priority the idea to solve the the problem.
problem.
Develop mutually acceptable Develop a mutually acceptable solution to the
solution to the problem and problem
and
the
detailed
design
detailed design implementation.
implementation.
1. Clearly and accurately describe the cause of
the poisoning;
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Prepare a presentation
2. Justify prescribing have chosen to treat
poisoning.
Make the results in the form of an oral
presentation on behalf of the group. Discuss
and decide the question of who will represent
the results of the group work: the leader of the
whole group, or with the division between the
participants (co-reports), depending on the
tasks to be solved by them in the course of
analyzing and solving problems.
Prepare illustrative materials in the form of
posters, slides or multimedia.

In the preparation of reports, especially
mark the rough outline of what you say, do
not go into the details!
Table assessment of individual work with case
Participants
evaluation criteria and indicators
Detailed
Анализ
Selecting
development
текущей Justification
ways and
of measures
ситуаци problem
means of
to implement
и
max max 0,5
addressing
the decision
1,0
max 0,5
max 0,5
Overall
Score
(Max 2,5)
*
1.
2.
№
* 2.0 - 2.5 points - "excellent", 1.5 - 2.0 points - the "good"
1.0 - 1.5 points - "satisfactory"
less than 1.0 points - "unsatisfactory"
The evaluation system options group decision problem.
1. Each group is given two evaluation points. It can give them all at once to one
embodiment of the decision or split into two (1:1 0,5:1,5, etc.), not including the
assessment of their own solutions.
2. All the scores for each alternative solutions are added. The winner is the solution
with the highest number of points. In disputed cases, you can take a vote.
9
Table evaluate options group decision problem, the score
Group
Alternative solutions to the problem
1
2
3
№
1.
2.
№
Sum
Score presentation of the proposed solution
Group Complete
ness and
clarity of
presentati
on (1 –
20)
visibility
of
representa
tion of the
universe
of
presentati
on (1 –
20)
mass
susceptib
ility and
activity
of
members
of
the
group (1
– 20)
Originalit
y
proposed
decision
(1 – 20)
the
admissibility
of
the
legislative
(1 – 20)
standard
s
(1 - 20)
total
score
(max
100)
1.
2.
№
III. OPTION ACTION CASEY
Teachers - KEYSOLOGOM
1. Symptoms listed above indicate that the victim through a clear bullet
wound in the left forearm.
2. The tactics of a general practitioner:
A quick assessment of the state of the wounded to determine the severity of
infection.
B.Zavedite hemodynamic monitoring list (time, pressure, pulse, respiratory
rate, temperature, blood loss are approximate)
B. Application of tourniquet and aseptic dressings, antibiotics
3. Tactics of the doctor at the stage of qualified and specialized honey.
assistance:
Surgical treatment, depending on the length and type of wound infection.
When the need for reconstructive types of operations
IV. Case Study Technology for practical training.
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Model of learning technologies
Subject
Hours – 2
Form of lesson
combat damage limbs
Number of students: 10 people
Exercise
increase
knowledge,
development of skills tactics wounded in
phases honey
Practical lesson plan
1. Introduction to the training session
2. Actualization of knowledge
3. Work with a case of mini - groups
4. Presentation of the results
5. Execution skills
6. Discussion, evaluation and
selection of the best option strategies
7. Conclusion. Evaluation of the
groups and students, the degree of
achievement of lesson
The purpose of the training session: expanded knowledge of the tactics of the
wounded on the steps honey. evacuation. Developing the ability to assess, analyze
the situation, the choice of tactics, diagnosis, emergency care, efficient transport of
wounded at the primary level.
Tasks the teacher:
Результаты учебной деятельности:
• consolidate and deepen the
• оценивают
и
анализируют
knowledge to assess and analyze the
ситуацию и общее состояние
situation and the general condition of
раненых
на
этапах
мед.
the wounded at the stages of honey.
эвакуации
evacuation
• выбирают алгоритм действий
• Develop the ability to select the
для постановки диагноза.
correct algorithm of actions for
• развивают
навык
diagnosis.
самостоятельного
принятия
• Develop skills to provide emergency
решения при ведении раненых
assistance
на этапах мед. эвакуации
• To develop the skills of independent
• вырабатывают
алгоритм
decision-making in the management of
действий оказаний экстренной
the wounded on the steps honey.
помощи при необходимости
evacuation of learning outcomes:
• assess and analyze the situation and
the general condition of the wounded
on the steps honey. evacuation
• Select action algorithm for diagnosis.
• develop skills of independent
decision-making in the management of
the wounded on the steps honey.
evacuation
• produce a sequence of actions for
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emergency assistance if required
Methods of teaching
case studies, discussion, practical method,
organizers
Learning Tools
Learning forms
Case, guidance
Individual Study mode, front, group work
Learning conditions
audience with technical equipment, work
in groups
Monitoring and Evaluation
Monitoring, blitz poll
vzaimootsenka, evaluation
presentation
Flow chart of lesson
and Д activity
Teachers
Explain the purpose of the preparatory stage
of case - the stage and its influence on the
development of professional knowledge.
Distributes materials case and introduces the
algorithm for analysis of the situation (see
Guidelines for students).
Gives the task independently analyze and
record the results in the "List of analysis of
the situation
1.1. Thread class is called, the plan, its
I stage.
goals, objectives and expected learning
Introduction
to the training outcomes.
1.2. Introduces the mode of operation for
session
employment and evaluation criteria (see the
(10-15
instructions for students)
minutes)
Stage
content
Phase II core
60 min
2.1. Justifies the statement of the problem
and the choice of the situation - relevance.
Conducting a poll in order to enhance
students' knowledge on the topic:
• Stages of medical evacuation
• The volume of medical care at the stages
of honey. evacuation
2.2. Divides students into groups.
Reminiscent of the content and objectives of
the case. Introduces (like) the rules of the
group and the rules of the debate.
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Students
Listen
Independently examine the
contents of an individual
case and fill the sheet of the
situation.
Listen
Are appropriate records
Are divided into groups
Discuss, conduct a joint
analysis of individual
problems, determine the
most important aspects of
the situation, the main
problems and their
solutions, process, results
of the decision
2.3. Gives the task, specify the correct
perception of the task:
• What nosologies to make a differential
diagnosis
• Diagnostic methods used in SVP and
GWP
• Further tactics GPs with injuries
2.4. Coordinates, advises, directs the
learning activities.
Evaluates the results of individual work:
Sheets of the situation.
2.5. Of the presentation on the results of the
work done to address the case study,
discussion.
Organizer of the discussion: ask questions,
remarks, recalled the theoretical material
2.6. Organizer - GP algorithm of actions in
a given situation
2.7. Tells own solution case study to answer
questions, discuss, ask clarifying questions.
III Summary of 3.1. Summarizes the results of training
studies,
activities, announces a joint evaluation of
analysis
and individual work.
evaluation 20 Analyzes and evaluates the group, notes the
min
positive and negative points.
3.2. Stresses the importance of case - the
stage and its impact on the future specialist
listen.
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Present options to address
issues 10-15 minutes after
the end of the presentation,
choose the best option
Develop a unified system,
the discussion
Can a self-assessment
Opine