MINISTRY OF HELTHCARE OF THE REPUBLIC OF UZBEKISTAN
TASKENT MEDICAL ACADEMY
APPROVED
Vice-rector for studying process
Senior Prof.
Teshaev O.R.
«_________» __________2011y
Lecture
For students of VII course of treatment faculty
By theme
chest foundering syndrome AT NONSPECIFIC purulent DISEASES of LUNGS
And PLEURAS, the TRAUMA of the THORAX
Written on basis of tutorial
Tashkent 2011
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APPROVED
On conference in department of surgical diseases for general practitioners
Head of department___________________senior prof Teshaev O.R.
Text of lecture accepted by CMC for GP of Tashkent Medical Academy
Report №___________from____________2011 y
Moderator senior professor Rustamova M.T.
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The Purpose of lecture: to learn students to find out этиопатогенез, diagnostics,
дифф.диагностику, to scheduling of inspection, tactics of introduction and treatment ННЗЛ and pleuras. To train students to be close{attentive} to patients, to protect interests of patients, to know questions
of medical ethics and деонтологии. To bring up at будующих ВОП feeling of the responsibility.
Questions subjects to analysis:
1.1 Motivation - a substantiation of a theme
1.2 Brief анатомо-physiological data, methods of inspection of patients (radiological бронхография,
бронхоскопия, АПГ, the BUG, etc.
1.3 Concept of an abscess, a gangrene, бронхоэктазы, эмпиема pleuras, classification ВНИИП, этиопатогенеза, clinic-симптоматология, stages of current, diagnostics and дифф. Diagnostics, treatment.
Complications ННЗЛ and pleuras of the indication to operation and preoperative
preparation. Kinds of operations.
1.4 Эмпиема pleuras.
The text of lectures.
Last decade ННЗЛ on value in desease, physical inability and death rates of the population, in many
countries were put forward on 3 place after ССЗ and malignant tumours. The number of these patients annually increases for 5 %. Then a significant part of these diseases, especially chronic are irreversible.
According to academician Struchkova В.И. НЗЛ make 5-7 % of all diseases of bodies of breath,
and эмпиема pleuras of 9-11 %.
Летальность at ННЗЛ on the average 7-12 %.
At 26-40 % complicated by a bleeding.
At СДЛ hospital летальность - 20 %.
At a gangrene of a lung hospital летальность - 50 %.
Greater{Big} frequency of diseases and greater{big} летальность causes a urgency of disease.
About п р е д е л е н and е
The abscess of a lung is the limited гонйно-destructive process, accompanied formation{education} of single or plural purulent cavities in a pulmonary fabric.
The gangrene of a lung is the process widespread purulently-некротический in the pulmonary fabric, not having precise borders.
Brief анатомо-physiological data.
Lungs - the pair body, has the form of the truncated cone. Between lungs is средостение. Each lung
is concluded in the separate pleural bag formed висцеральной (covering a lung) and париетальной
laying from within a chest cavity by leaves of a pleura. From top to bottom from a root these two
leaves of a pleura incorporating, form a pulmonary sheaf.
Париетальная the pleura consists from реберно-грудинной, диафрагмальной and медиастинальных parts, forms a dome of a pleura, выстоящий on 3-4 sm above ключицей: between leaves
of a pleura sine (реберно-диафрагмальный intershare) are formed.
The Right lung slanting and horizontal бороздой shares on 3 shares (top, average, bottom), and
the left lung slanting бороздой on 2 shares (top, bottom).
In 1958 the congress of anatomists has accepted segmentary classification of lungs distinguish 10 segments in right (3-top, forward, back in the top share, 2-латеральный medial in an average share, in the bottom share) and 8 segments in the left lung (in the top share since top and back
are united and 4 segments in the bottom share).
Purulent diseases of lung and pleuras
Classification of purulent diseases of lung and pleuras.
I. On pathogenesis
1. Bronchogenic (including aspirational and obturational)
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2. Hematogenic (including embolic)
3. Posttraumatic
II. On character of pathological process
1. An acute purulent abscess
2. An acute gangrenouse abscess (the limited gangrene)
3. A gangrene of the lung (the widespread gangrene)
4. A chronic abscess
III. On weight
a)
easy
b)
average
c)
heavy
IV. On character of current
1. Not complicated
2. Complicated (empyema of pleuras, pulmonary bleeding, a sepsis, a pneumonia opposite lung
etc.)
ABSCESS OF LUNG
There is a lot of classifications of pulmonary abscesses. We adhere to classification in view
of separate attributes.
1. On pathogenesis
a.
postpneumonic
b.
aspirational
c.
hematogenic-embolic
d.
traumatic
2. On localization
a.
an segment, a lobe, lung
b.
peripheral, central
c.
single, plural, bilateral
3. On weight of current
a.
easy
b.
middle
c.
heavy.
4. On clinical current
a.
blocked, draining
b.
acute, chronic.
5. On complications
a.
bleeding
b.
pyopneumothorax
c.
sepsis
The abscess of lung (a suppuration, apostema, an abscess) is a nonspecific purulent disintegration of the part of pulmonary tissue, accompanying with formation of the cavity filled with pus
and limited from environmental tissue by a pyogenic capsule. More often activators of an abscess is
pyogenic cocci, anaerobic microorganisms nonclosrtidium type and others. The combination of
those or others anaerobic and aerobic microorganisms is quite often found out. More often the pyogenic infection gets in pulmonary parenchime through aerogenous ways and much less often - hematogenic. Direct infection of pulmonary tissue is possible at penetrating damages. As casuality, distribution of purulent process is marked in lung from the neighboring organs and tissue, and also
lymphogenic.
It is necessary to note, that hit of pathogenic microflora in pulmonary tissue not always results in occurrence of an abscess lung. The situation accompanying with infringements of drainage
function of a part of lung is necessary for this purpose. More often it arises at aspiration or mycroaspiration of slime, a saliva, gastric contents, alien bodies. Aspiration, as a rule, is marked at infringements of consciousness owing to intoxication, epileptic attack, head traumas, and also during
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a narcosis. Aspiration at times happens at dysphagias of various origin. After aspiration develops
atelectasis of the part of lung, and then in it arises infectious-necrotic process. Indirect confirmation
of the aspiration mechanism of occurrence of pulmonary abscesses is more often defeat of back
segments (2,6,10) of the right lung. Infringements of drainage function lung are available at chronic
nonspecific diseases of the lung: chronic bronchitis, enphysema of lung, a bronchial asthma etc.
Therefore, at the certain situations, these diseases promote occurrence of pulmonary abscesses. To
an abscess of lung the influenza and a diabetes contribute. Thus, owing to acute obstruction of the
draining bronchial tube there is an inflammatory process (pneumonia), and then disintegration of a
part of pulmonary tissue. At a sepsis are marked metastatic abscesses in lung. Heavy bruises, hematomas and damages of the pulmonary tissue also in the certain situations may become complicated
by occurrence of abscesses. Hence, the reasons of pulmonary abscesses are diverse. Nevertheless, at
their occurrence interaction of three factors is marked: acute inflammatory process in pulmonary
parenchima, infringement of bronchial passability and blood supply of a site lung with the subsequent development of necrosis. Each of these factors in the certain situations may have crucial importance.
Clinical picture. Most frequently pulmonary abscesses meet at middle-aged men. First of all
it is caused by that among them more often there are the persons abusing alcoholic drinks and
smokers, suffering a chronic bronchitis. Besides adverse production factors matter also: the dust
content and a gassed condition of workplaces, an adverse temperature mode etc. In a clinical picture
of an abscess of lung are allocated two periods: the period of formation of an abscess before break
of pus through a bronchial tree and the period after break (evacuation) an abscess in the draining
bronchial tube. For the first period is typically acute beginning with rise of a body temperature up to
high figures, a chill and down-pour then. There may be pains in a thorax on the side of defeat,
dyspnoea and cough, as a rule, without sputum. Infringements of the common condition as a headache, indispositions and weakness are marked also. The clinic purulent - resorptive fevers is totally
marked. At x-ray in this period in lung there is a site of inflammatory infiltration, a located more often in 2, 6 in 2, 6 or 10 segment right lung. On the average, the given clinic proceeds within 7-10
days. As a rule, the pneumonia at this time is diagnosed. In the second period when an abscess
evacuates through a bronchial tree, the clinical picture becomes typical. Sometimes a plenty purulent sputum at once is discharge (a full mouth), is frequent with a putrefactive smell. In other cases
discharge of sputum occurs gradually. At once after discharge of purulent sputum, the condition of
the patient is considerably improved. The phenomena of an intoxication are acutely reduced. The xray picture becomes typical for an abscess lung: there is a site of an enlightenment with horizontal
level of a liquid, and the zone infiltration gets the orbed form. If the cavity of the well drained abscess gradually the temperature is reduced also the common condition is normalized. The cavity of
an abscess eventually decreases, and in 6-8 weeks it completely may disappear and on its place is
formed scar from the connective tissue. In some situations it is formed thin-walled roundish formation without contents - pseudocyst, that also is recovery. At 80% of patients the acute abscess is
finished by recovery.
In some cases, when it is marked bad draining of the abscess, process may be delayed and
accept chronic current. It may be at the big sizes of an abscess and is especial, when it is located in
the bottom parts lung and is inadequate drained. Clinically the constant disharge of purulent sputum
is marked and the phenomena of an intoxication keep. At x-ray in these situations the cavity of an
abscess does not decrease, and its wall thickened. If in this stage it is not possible to unblock an abscess it becomes chronic.
Still allocate the gangrenous abscess. As a rule, it is a huge abscess in which cavity there is a
site become lifeless pulmonary tissue (sequestration).
Sometimes the acute abscess of lung may break in a pleural cavity that results in development of pyopneumothorax.
In diagnostics of pulmonary abscesses it is used roentgenography and tomography of lung.
Also it is applied computer tomography and ultrasonic research.
Conservative treatment of an acute abscess of lung includes three obligatory components:
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optimum draining a purulent cavity and its sanitation, antibacterial therapy, general improving
health therapy treatment and the actions directed on restoration of broken homeostasis. First of all,
it is necessary to sanify a cavity of an abscess adequately. In case of bad evacuations an abscess, its
puncture through a chest wall will be carried out. During a puncture evacuate contents of a cavity of
an abscess and then enter antiseptic and antibacterial preparations. In case of insufficient sanitation
with the help of a puncture, it will be carried out transparietal draining of an abscess. Last procedure
is better for carrying out under the ultrasonic control with convex detector. Sometimes it is carried
out bronchoscopy with cateterization of cavities of an abscess. Suppression of pathogenic microflora is made by introduction of antibiotics, antiseptic tanks and sulfapreparations. Sometimes these
preparations are entered in pulmonary and bronchial arteries, and also endolymphatic. Thus as
much as possible allowable dozes are used in view of sensitivity of microflora. The pharmacotherapy is directed also on stimulation secretolysis and expectorations, struggle with bronchospasm and
an edema of a mucous membrane of a bronchial tube, normalization and improvement of exchange
processes, replacement of immunologic defects etc.
Hence, acute abscesses, as a rule, are treated conservatively. At occurrence pyopneumothorax it will be carried out draining a pleural cavity. In the extremely rare cases when current of an
acute abscess may become complicated by the profuse bleeding, indications to emergency operation
may arise. For basically in these situations if not it is possible to stop pulmonary bleeding conservative means, it is carried out bronchoscopic tamponade of the draining bronchial tube. At the sequestration in an abscess is possible performance of pneumotomy (abscessotomy) with removal of the
sequestration. Now similar manipulations are carried out with the help of thoracoscopic interventions. The basic indication to operation is the chronic abscess. The choice of a method of operation
depends on volume of defeat pulmonary tissue. It is carried out segmentectomy, lobectomy and in
the extremely rare cases bylobectomy.
PLEURAL EMPYEMA
Empyema - a congestion of pus in a natural (anatomic) cavity, whether it be pleural or any
other cavity. Hence, the congestion of pus in a pleural cavity carries the name of pleural empyema.
There is also other term - a purulent pleurisy.
The purulent pleurisy is the inflammation of pleural lists accompanying exudating in a pleural cavity of the purulent exudate. Hence, terms "a purulent pleurisy" and "empyema pleuras" are
synonyms. Though at times and till now doctors of various specialities confuse these conditions.
Pleural empyema in 90% of cases is complication of purulent diseases lung. First of all it
arises at an abscess and a gangrene lung, acute pneumonias and sometimes at bronchoectasy. At
other patients (10%) empyema it happens by consequence of a trauma and outlung processes. To
outpulmonary diseases resulting in development of pleural empyema, concern: a pancreatitis,
paranephrities and subdiaphragmatic abscesses. Pleural empyemain in these cases refers to as sympathetic (concomitant). In these situations in purulent process it is involved diaphragm and there is
the concomitant inflammation of the pleural leaf, covering диафрагму in a chest cavity.
Classification of the pleural empyema.
1. On clinical current: the purulent-resorptive fever and the purulent-resorptive exhaustion.
2. By the form: empyema without destruction of the pulmonary tissue; with destruction of
the pulmonary tissue.
3. On pathogenesis: meta-and parapneumonic, posttraumatic, metastatic and sympathetic.
4. On extent: limited, widespread, total. 5. A degree of lung compression: 1,2,3.
6. Acute and chronic.
For the characteristic of intensity of purulent process both in lung, and in a pleura, in classification the common typical syndromes determining response of an organism are entered. In due
time I.V.Davydovsky has noted, that the organism answers to any purulent inflammatory process by
the common typical syndrome - purulent-resorptive fever. Further, at significant intensity and duration of process, the purulent-resorptive fever may pass in qualitatively other and very dangerous
condition - the purulent-resorptive exhaustion. For this reason in clinical current pleural empyema
are allocated purulent-resorptive fever and the purulent-resorptive exhaustion. According to the giv-
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en classification, to limited concerns empyema in cases of involving in purulent process only one
wall of a pleural cavity. At defeat of two or more walls of a pleural cavity empyema it is designated
widespread.
Total refers to an empyema at which all pleural cavity from diaphragm up to a dome is
amazed. To I degrees are referred those cases, when lung compressed within the limits of anatomic
borders of a raincoat, that is to one third. II degree means, that lung compressed within the limits of
a trunk, that is on two third. At III degree lung compressed within the limits of a nucleus (full lung
fall). Introduction in classification of empyema with destruction and without destruction pulmonary
tissue is made to show, what exactly destruction of the pulmonary tissue aggravates current of suppurative process and renders dominant influence on a condition of the internal environment of an
organism.
It is separately allocated empyema necessitatis (perforans) at which pus acts through intercostal intervals in soft tissue of a chest wall. Clinically the phlegmon of a chest wall is defined.
As a rule, the purulent inflammation of pleura begins from fibrinous pleurisy and arises in
two ways: first, owing to direct transition of exudative inflammations with lung on pleura and, second, at break in a pleural cavity of a subpleural lung abscess. The second way of development pleural empyema more often takes place. Pneumonias may divide on two groups: exudative type with
insignificant defeat of bronchial tubes and necrotic or absceding type. Thus necrotic sites, single
and plural, are frequently located subpleural and consequently, as a rule, are complicated a fibrinous-purulent pleurisy. At absceding pneumonias with plural abscesses of polysegmentary localization and their subpleural arrangement, break of an abscess in a cavity of a pleura is possible with
development of empyema.
Clinical picture. At pleural empyema occur pains in a thorax on the side of defeat, the dyspnea is amplifies. Cough may be dry and with purulent sputum. Are marked the raised body temperature and chills. At percussion marked distinct dull sound, is more often behind on the scapular line.
Thus, there are clinic purulent-resorptive fevers and attributes of a collecting liquid in a pleural cavity. Nevertheless, the clinical picture is various. It depends on many reasons.
The typical answer of an organism to any form of a suppuration including pleural cavity is
the purulent-resorptive fever. In its basis three factors lay: suppuration, resorption (absorbing of
products of disintegration of tissue and products of ability to live of microorganisms) and the factor
of loss. Last factor is caused by losses, which are born with an organism at a purulent inflammation.
Clearly, that the degree of purulent-resorptive fevers, no less than intoxications, may be various beginning from easy and finishing the hardest. As it is marked above, frequently by the beginning
empyema happens the absceding pneumonia, therefore in some days after its crisis, again there is
rigor, a pain in a side, dyspnoea and high temperature. After 3-5 days comes to light dull sound at
percussion sound, weakens vocal fremitus and breath in the field of the struck site. In other cases
the clinical picture of development pleural empyema proceeds latently. It would seem, safely transferred inflammation of lung does not bring expected recovery and, on the contrary, the dyspnea, fever, pains in a side gradually amplify. Probably parallel development of a pneumonia and purulent
exudate in a cavity of a pleura. At break of a subpleural abscess in a pleural cavity distinguish three
clinical forms: acute, soft and erased.
At the acute form it is observed condition as a shock. Suddenly at percussion there is a box
sound above a place former dulling. Attributes of the increasing pneumothorax with total collapsing
of the lung are not excluded. The acute form of break of an abscess in a free pleural cavity meets
seldom.
At the soft form, as a rule, an abscess evacuate in closed incapsulated space. This form is
shown by a moderate pain and change of percussion and auscultative attributes. At the erased form
which meets most frequently, the moment of the beginning of penetration of pus in a pleura is difficultly perceptible.
The raised body temperature is one of the major attributes of empyema of pleura. Temperature reactions may proceed on remitting type, as wrong waves with the tendency to morning downturn. However, the temperature, as a rule, is not reduced up to normal or even subnormal figures.
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Pains in a breast more often are caused by involving in process parietal pleuras. In the same time a
pain may be caused by destruction of lung tissues. Frequently pains amplify at breath, therefore patients avoid deep breath. Trying to spare the struck half of breast, patient quite often borrow the
compelled position. Thus they are bent aside pathological process. It should be taken into account at
diagnostics. Complaints to headaches are quite often marked. Early there are functional changes on
the part of cardiovascular system, a liver and kidneys. Infringements of clotting systems of blood
are possible.
Restriction of respiratory excursions of a chest is marked on the side of defeat. At widespread and total pleural empyema smoothing intercostal intervals is quite often observed. Thus
scapula on the side of defeat rises up slightly and lags behind at breath in comparison with another
scapula. At palpation sometimes is marked resistence of soft tissues of chest wall. A characteristic
attribute of a congestion of a liquid in a pleural cavity is easing vocal fremitus and dullness of percussion sound. At auscultation is marked sharp easing vesicular or bronchial breath. Variegrated
moister rattles are listened at empyema, accompanying by destruction of lung tissues more often.
One of the important methods of diagnostics of the pleural empyema is the x-ray inspection.
Thus it is established, whether there is a liquid in a pleural cavity. A classical x-ray attribute pleural
empyema slanting line of Damuaso. There may be a total and subtotal congestion of a liquid with
displacement of mediastinum in the healthy side. In some cases it is defined limited (incapsulated) a
liquid. Sometimes x-ray research will be carried out in lateroposition (on one side). Also are applied
computer tomography and USI. At chronic pleural empyema it is applied bronchography which estimates a condition of a bronchial tree and a degree of compressing of lung tissues. With the purpose of specification of the sizes and a configuration of a cavity of chronic empyema it is sometimes used pleurography. At external fistulas it will be carried out fistulography. The big value at
last years is given to thoracoscopy, which will be carried out also with the medical purpose.
Treatment begins with a puncture of a cavity empyema. During a puncture contents with the
subsequent bacteriological and cytologic research leave. The pleural cavity is sanified with the help
of antibacterial and antiseptic preparations. However the puncture way more often possible to sanify
only local forms. Therefore, as a rule, it will be carried out draining a pleural cavity that is better for
combining with thoracoscopy. After sanitation of a pleural cavity the drainage tube joins system active aspiration. At absence of aspiration systems it is used water-jet suction-machine. At impossibility of using water-jet suction-machine it is carried out draining on Bulau. For this purpose on the
external end of a drainage tube the finger from a rubber glove on which the section is made becomes attached. Then this tube falls in bank with an antiseptic liquid. During an exhalation the liquid on a drainage follows from a pleural cavity in bank, and during a breath, due to fall of a rubber
finger, the liquid from banks with antiseptic solutions in a pleural cavity does not come back. All
patient will carry out intensive antibacterial treatment in view of sensitivity of microflora. Correction of volemic infringements is carried out by introduction of albuminous preparations, electrolytes
etc. Calorage is provided with introduction of the concentrated solutions of glucose and fatty emulsion. Necessarily corrected the acid-basic condition. The therapy directed on restoration of a functional condition of cardiovascular system, a liver, kidneys, CNS etc. will be carried out At destructions of the lung tissues, in necessary cases, bronchoscopic sanitation will be carried out. The duly
qualified treatment allows to achieve recovery at the most part of patients with acute empyema of
pleura. Nevertheless, at lines of patients develops chronic empyema.
At chronic empyema pleuras operative treatment is shown. On the form empyema and presence of changes from the party of lung tissues are carried out various operative interventions. The
most widespread operation is pleurectomy and decortication of lung. At pleurectomy the bag empyema leaves. The purpose of decortication, offered Delorm in 1894, consists in clearing of lung from
cicatricial layer, covering visceral pleura. As a rule, both operations (pleurectomy and decortication) are united. Sometimes pleurectomy is combined with removal of a site struck lung tissues. In
such cases of operation refer to as: pleurosegmentectomy, pleurolobectomy, pleurobilobectomy or
pleuropulmonectomy. One of the most hardest operative interventions is pleuropulmonectomy. It is
caused by that patients except for chronic pleural empyema have also a total defeat lung. Last years
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pleuropulmonectomy is carried out seldom. Earlier at pleural empyema it was widely applied thoracoplastic. Now thoracoplastic it will be carried ou basically at empyema a residual pleural cavity,
after various operations on lung. In connection with a wide circulation lung surgeries complication
as empyema a residual pleural cavity after removal of a part or all of lung has appeared. By the
most often reason of a similar sort empyema happens an inconsistency of stump of resected bronchial tube. At chronic empyema residual pleural cavity after pulmonectomy are carried out various
operations: transthoracal pleurectomy and suturing of stump of the main bronchial tube, transsternal
transpericardial occlusion of stump of the main bronchial tube and various kinds of thoracoplastic.
Concluding this section, it is necessary to note, that adequate treatment of acute empyema
with application in necessary cases thoracoscopic interventions frequently results pleuras in recovery.
GANGRENE OF LUNG
The gangrene of lung is purulent-putrefactive necrosis of lobe or all of lung, with absence of
a zone of demarcation from the healthy lung tissues, having the tendency to the further distribution
and shown by the heaviest common condition of the patient. As a rule, the gangrene is formed owing to putrid disintegration of the massive, become lifeless sites of lung tissues (a lobe, two lobes or
all lung). Etiopathogen moments of a gangrene in many respects are similar to those at an abscess of
lung. However, at development of a gangrene they are expressed in an extreme degree. It is frequently marked aspiration on a background of alcoholic intoxication. The big value has the common condition of the patient with reduction of resistence (immunity), and also heavy accompanying
diseases (a diabetes etc.). The significant role is played with previous chronic nonspecific diseases
of lung. More often at a gangrene of lung the microflora in various combinations anaerobic is
sowed with aerobic.
Clinic. As a rule, the gangrene of lung begins sharply, with significant rise of a body temperature, a dyspnea, be sick in a chest on the side of defeat, weakness and sharp deterioration of the
common condition. Right at the beginning cough may be dry, and then occurs putrefactive fetid
sputum. The condition of the patient the heaviest becomes very fast. At cough it is increased discharge purulent sputum which has dirty - grey, greenish or (from an impurity of blood) chocolate
color. Sometimes cough out small slices lifeless lung tissues. Even being on significant distance
from the patient, it is possible to feel an intolerable fetidity coughed out sputum and exhaled air. It
is quite often marked hemoptysis, and at times and fatal pulmonary bleedings. Frequently current of
a gangrene of lung is complicated by development of empyema pleuras. In connection with sharp
intoxication, the septic shock with polyorgan insufficiency develops. Quite often at patients euphoria or confusion of consciousness is marked. Integuments of pale-grayish color with expressed acrocyanosis. At percussion zones of dullness above lung are quickly increased. On a background of
dullness there may be the sites of a high sound significative of formation of cavities of disintegration. In the beginning at auscultation breath weakened, and then becomes bronchial. Then dry and
damp variegrated rattles are listened. At x-ray comes to light diffuse blackout of the struck parts of
lung (a lobe, two lobes or lung) with plural cavities of disintegration the various size. Quite often
comes to light empyema pleuras. The forecast at a gangrene of lung frequently adverse. Especially
it concerns cases when all lung is struck and there is an inflammatory process in other lung (contralateral pneumonia). At a gangrene of one lobe of lung the forecast is more often more favorable.
Treatment of patients by gangrene of lung should be started with intensive therapy in reanimation department. This treatment should be considered as preoperative preparation. Sanitation of
purulent cavities and tracheobronchial tree will be carried out, antibacterial and desintoxication
therapy (including methods of extracorporal detoxication), is provided maintenance of gas metabolism, intimate activity and power balance, corrected volemic and immune infringements, and also
other frustration of metabolism. The main thing in treatment is stabilization of process in probably
short terms. If it does not manage to be carried out, operative intervention, despite of the heaviest
condition is necessary. The kind of operative intervention depends on volume of defeat lung tissues.
The lobe-, bilob-, or pulmonectomy is carried out.
AND CYST OF MEDIASTINUM
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Lecture for the students of medical faculty
First mention of operation on mediastinum belongs to Galen. He has distinguished abscess
behind sternum, formed after a trauma at the young man, has made trepanation of sternum and drain
abscess of mediastinum. I.I.Nasilov (1888) for the first time has offered access to posterior mediastinum. It is considered, that it was the beginning of esophagus surgery. V.I.Razumovsky (1899) has
offered cervical mediastinotomy - convenient and simple access to upper and posterior mediastinum. The academy has brought in the contribution to surgery of mediastinum. Its former rector Anatoly Yakovlevitch Ivanov has written the monography about abscesses and phlegmons of mediastinum. He has offered a sign of mediastinitis, carrying his surname: a pain at displacement of vascular bunch of a neck upstairs.
Mediastinum - (septum mediastinale, mediastans - placed in the middle) - area of a thoracic
cavity made between pleural bags. An anterior wall of it is sternum, posterior - the spine. The distinct upper border mediastinum has no, as cellular fatty tissue of mediastinum continued on cellular
fat of a neck. The lower border is diaphragm. Conditionally mediastinum is divided on anterior and
posterior. Border between them is the posterior wall of trachea. Anterior mediastinum is divided on
upper and lower. Lower mediastinum is included by pericardium and heart. In anterior mediastinum
placed thymus, upper cava vein an its inflows with azygos vein, ascending part and aortic arch,
pulmonary artery with their branches, pulmonary veins, thrachea and bronchus, lymph nodes. In
posterior mediastinum placed esophagus, thoracic duct, part of an arch and descending part of aorta,
azygos and hemiazygos veins, the boundary trunks of sympathic and vagus nerves, most part of recurrens nerves.
On localization of formation in mediastinum it is possible to assume the diagnosis. In an anterior part of mediastinum is from the top downward are marked more often: mediastinal goiter, it is
typical hustle away or narrowing of a trachea ("saber trachea"). In the bottom sites of the anteriorupper part of mediastinum tumours of thymus more often are located, a little bit lower are teratomes, dermoid and epidermoid cysts. A typical arrangement of cyst of a pericardium - right cardiodiaphragm corner.
Vascular tumours more often settle down in the field of formation of large vessels - in the
field of an aortic arch, bronchial cysts - in the field of a pulmonary root. Enterogenic cysts more often meet in posterior-lower parts of mediastinum. In posterior mediastinum - where pass nervous
trunks - most frequently meet neurogenic tumour. The malignant tumours, metastases of tumours,
lymphogranulomatosis, sarcoidosis of Beck more often meet in the field of a congestion of lymphatic nodes, on border of anterior-upper and anterior-lower parts of mediastinum. Have no typical
localization fibroms, fibromyoms, lypoms. Mediastinum settles down and contains organs which
are taking place in constant movement: heart is contracted and relaxs, lungs moved at breath. The
breaking of functioning of organs of a breast results to significant pathophysiologic shifts.
So, at unilateral intense pneumothorax mediastinum is displaced in the opposite party, that
conducts to an inflexion of vessels, distension of nerves and lymphatic ducts. Heart turns around of
the longitudinal axis, that strengthens an inflexion and compressing of such vessels, as cava veins.
Comes flotation of mediastinum.
To general clinical displays of illnesses of organs of mediastinum concern a fever (in particular at mediastinitis, lymphomas), change of a picture of blood (lymphoma), is possible muscle
weakness (at thymoma).
The local clinical displays of illnesses of organs of mediastinum can be divided into two
groups: 1) pain and weight for sternum; 2) connected with compressing of nerves, vessels and organs of mediastinum.
The first group of symptoms (pain and weight for sternum) meets at inflammatory processes
and quickly growing tumours. They also are defined at percussion or palpation of various parts of
sternum, neck, spine.
11
The second group of symptoms is connected with compressing of vessels, nerves and organs
of mediastinum.
Compressing of the veins breaks outflow of blood to heart and generate swelling of supraclavicular spaces and neck, face, expansion vein of these areas. These phenomena are united in upper cava vein syndrom.
Compressing or spreading of nervous trunks result to hoarseness (at a defeat of a recurrens
nerve). Therefore it is required preoperative investigation of the otorhinolaryngolog-expert.
The defeat of sympathic trunk and ganglions causes Horner sign - ptosis of the upper eyelid,
narrowing of a pupil (myosis) and recession of the eyeball (enophtalm) on the side of defeats.
Compressing of n. vagus can be accompanied by bradicardia and other cardial symptoms.
At the basic method of diagnostics of tumours and cysts of mediastinum serves roentgenoscopy and roentgenography of thoracic cavity, not less, than in two projections. Quite often for the
first time formations come to light casually, at fluorography of thoracic cavity. On roentgenography
in structure of formations more often meet calcification of walls, bone structure. At neurogenic tumours are possible bone defects as usuras in organs of spine, their arches, cross processes, in necks
of ribs.
Tomography allows to define depth of placing of tumors, its structure and interrelations with
environmental organs. Tomography in a combination with other methods of investigation is especially useful to revealing of cystous tumours, teratomes, having characteristic heterogeneity and
bone inclusion. On tomogrammes of a tumour and cysts of posterior mediastinum come to light on
depth 6-9 sm (at the account from surface of a spine), anterior mediastinum - 9-16 sm.
Pneumothorax as a rule is imposed unilateral through puncture in V-VI intercostal space.
Enter no more than 500 ml of gas (air, oxygen, nitrous oxide). On X-ray pictures it is possible to
see, how pulmonary tissue departs to periphery from a tumour.
Pneumomediastinography is made by two methods. Widely used a method of Rivas, offered
in 1948 - introduction of gas in precoxygeal space. For this purpose it is required to enter a plenty more than 1500 ml. For this purpose to the patient in a rule on all fours the surgeon enters a finger
in a rectum, then through a needle in space between a rectum and coccyx the gas is entered under
the control of the entered finger. An attribute of the good distribution of gas suffices is tympanitis,
arising along a spine. Then the patient cautiously translates in a vertical rule. An attribute of the
termination of procedure and its qualitative realization - occurrence of crepitation in supraclavicular
area. To this time, in 3-6 hours, it is possible to make roentgenograms.
Retrosternal pneumomediastinography is offered Condorelli in 1935. It is made with the
help of the curved needle entered behind sternum. A direction of a needle - on an average line,
along a back wall of sternum. At first gas enter in amount 500-1000 ml in a position of the patient
on a spine, then patient
lie down on abdomen, the snapshots make in 1,5-2 hours. A technique
same, as used earlier retrosternal novocain blockade.
These methods are desirable for combining with tomography, as on it the contours of tumours are more relief.
Scanning allows to define an accumulation of radioactive Jodine in aberrant thyroid. Besides
are useful.
CT.
NMR.
Angiography.
Bronchoscopy is applied seldom, though with its help the realization of transtracheal pneumomediastinography, contrasting of mediastinum by contrast substances, transtracheal puncture of
lymphonodes is possible.
Thoracoscopy at tumours of mediastinum is applied rare, allows to diagnose celomic cysts
of pericardium, lypoms, thymoms, with its help is possible to make biopsy.
Mediastinoscopy is offered by Carlense in 1959. This method - theme of the dissertation of
Anatoly Nikolaevitch Matizin. Under narcosis through a cross section above jugular clipping of
sternum enters mediastinoscope - device such as rectoromanoscope in length 15 sm, along which
12
the crack is cut. Under the control of sight it will be carried out lengthways of trachea down to bifurcation of trachea. The method allows to investigate trachea, main bronchus, cellular fat and lymphonodes, tumour of anterior-upper mediastinum, possible biopsy and hystologic investigation.
Through this method the introduction of driver of rhytm of heart, angiopulmonography was
earlier made. The method is unsafe. The complications are possible: a bleeding, paresis of a nerve
recurrens, damage of esophag, mediastinitis. Therefore method should be applied only in specialized thoracal clinics.
The sequence of application of diagnostic measures is defined first of all by degree of their
danger: least dangerous at first are made - analyses of blood, echo and X-ray, then difficult and
danger tool - pneumography, angiography, mediastinoscopy. On the second place there is an possibility of application of these methods for specification of localization, benign or malign quality,
hystologic structure, operability. The experience of the doctor speaks about that the quantity of investigationes, is especial traumatic, should be limited, since as the majority of questions can be
solved during operation. It is not necessary to forget about urgent hystologic investigation.
Except for tumors of mediastinum it is necessary to remember about mediastinal form of a
cancer described metastatic defeat of lymphonodes of mediastinum and as a rule not subject surgical treatment.
Diagnostics of diseases of mediastinum is important in connection with that the methods of
treatment are specific: nobody deletes of limphonodes at sarcoidosis of Beck, where the treatment
by hormones will be carried out it is not necessary to delete lymphonodes at lymphogranulomatosis,
where the basic methods of treatment remain radio- and chemotherapy. At lymphosarcoma of mediastinum the preliminary radiotherapy can result if not in convalescence, to significant reduction of a
tumour, which then can be removed.
The question on indications to operation is solved individual. If at the patient of 70 years
who have transferred a heart attack of a myocardium, is present hamartoma of mediastinum, existing a lot of years hardly is necessary to offer operative treatment to him. The general condition of
the patient is taken into account: age, a condition cardiovascular and other systems; duration of a
disease. Contra-indications to operation in most cases are metastasises in the remote areas, compressing of upper cava vein, a
hardy paralysis of a nervus recurrens, dissemination on parietal pleura with occurrence of hemorrhagic pleurisy. As exception, operations are described at a syndrome upper cava veins at which are created anastomoses between impassable inflows upper cava
veins and the right auricle.
Operative accesses. Surgical access for removal neoplasms of mediastinum should differ
minimal traumaticity, open the free approach to a tumour and environmental tissues.
At small tumours of anterior mediastinum, protruding in a pleural cavity, preference is given
to anterior transpleural access. The patient lays in physiological position on a back, on an arrangement of neoplasm the section is made at level III-IV or IV-V intercostal spaces.
At tumours or cysts of posterior mediastinum use posterior-lateral access.
At tumours of anterior mediastinum, not protruding in pleural cavity, use transsternal access
at which it is possible extrapleural removal is expedient. Thus are used longitudinal, cross, T-or Lshaped sections with a partial or full section of a brest.
Among dangers and complication of operations on mediastinum are marked air embolism, a
bleeding, unnoticed bilateral pneumothorax.
Air embolism is distinguished on a characteristic sound of suction of air. More often air
through opened veins enter in the right half of heart, therefrom comes embolism of pulmonary arteries. For its preventive maintenance during operation in the field of large veins position of Trendelenburg is given to the patient.
The surgeon should be always ready to a bleeding and to have a reserve of blood and blood
substitutes. Especially this moment is important now.
For diagnostics and well-timed treatment of pneumothorax in many clinics after operation
always make X-ray of thorax on an operational table.
13
Infringement of breath after removal of intubation tubes may arise as a result of a trauma of
a nervus recurrens, more often after operations with left-hand transpleural access.
After an exposure of a tumour or cyst by palpation or visually define a degree of its mobility, expressiveness adhesions with the neighboring organs. Even benign tumors may be accrete with
adjoining organs (a spine, large vessels, tracheas, a esophagus, a pericardium, a pleura, lung). At
absence adhesions a tumour or cyst - that are divided easily, quite often with the help of a finger. At
existence of a vascular leg of a tumour it is necessary to allocate, tie up and remove together with a
tumour.
At intimate soldering of a tumour with main vessels or other important organs tactics of the
surgeon may be double. At benign process it is rational to leave a site of a tumour or its capsule on a
vessel than to receive terrible, sometimes a fatal bleeding. At a malignant tumour it is necessary to
resort to the expanded operation, which is removal of a tumour with a resection of the appropriate
body. In particular, at germination by a tumour lung, a pericardium, a pleura, recurrens nerve their
resection and removal together with a tumour the uniform block is justified. At removal with a tumour part of a vessel its plastic restoration is necessary. Windowed defects of a vessel close by sew
in auto- or allopatches. At a circular resection of a vessel restoration of integrity is made by anastomosis the end in the end or prosthetics.
At unextracted tumours necessarily a biopsy of a tissue for histologic investigation and specification of the further tactics.
Neoplasm of mediastinum share on: 1) true tumours; 2) cyst, filled with the liquid contents,
derivative their internal environment; 3) tumorous processes on appearance and localizations.
From true tumours the most often are derivative lymphoreticular tissues - malignant lymphoms (lymphogranulomatosis, lympho- and reticulosarcoma), sarcomas of various tissue genesis,
tumours of thymus, mixed teratodermoid cystous tumours, a cancer dystopic in a breast or aberrant
tissues of a thyroid gland.
Benign tumours. Develop from tissues anyone embrional tissue, among them prevail neurinoms and ganglioneuroms, less often fibromas and fibrolypoms. High quality teratoid and teratodermoid formation always causes doubts.
Cyst make about 20% from the common number of neoplasms of mediastinum. Allocate
true initial cyst of mediastinum, developing of celom (pericardium) or from an anterior gut (bronchial, enterocysts). The second group make cyst, arising of various organs and lymphatic formations
(thymus, lymphatic etc.). Meet also parasitic cyst (echinococcus) and cyst from boundary areas
(meningeal). Cyst are formed usually as congenital - dysembrionic. Therefore they surprise with the
singularity - both arrangements, and a histologic structure, this it enterogenic, pericardium, teratodermoid cyst, thymus etc. Acquired cyst - traumatic and parasitic (echinococcus) are extremely rare
and, as a rule, are observed at widespread (disseminated) echinococcus. To cysts, starting from
boundary areas, concerns intrathoracal meningocele. As it is understood protruding in mediastinum
arachnoidal environments of a spinal cord through an aperture for nervous root. Common for all
cysts of mediastinum is characteristic long, asymptomatic current and casual their detection at x-ray
investigation.
Further, in process of increase of their sizes, there is a semiology caused compressing of
heart, a trachea, bronchial tubes, a esophagus or large venous vessels. This semiology accrues slowly for a long time. There may be pains in heart, palpitation, arrhythmia. Are possible dyspnoea and
cough. At big cysts, located in back mediastinum and compressing of esophagus, it is marked dysphagia. In diagnostics help x-ray investigation, USI, computer tomography. There is a typical localization cysts of mediastinum. Pericardium cyst settle down, as a rule, in basal sites of anteriorbottom mediastinum, bronchial in anterior-upper mediastinum, and cyst from a nervous tissue - in
posterior mediastinum. Before application USI and computer tomography it was widely used
pneumomediastinography. Now pneumomediastinography it is applied seldom, in atypic cases, to
differential diagnostics. The modern equipment (USI, CT, NMR) has the big resolving possibility.
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Treatment cysts consists in their operative removal. Due to development endoscopic engineering, in particular, thoracoscopy, in the literature there are many communications about endoscopic removals cysts of mediastinum.
Teratoid formations of mediastinum (geteroplastic intrathoracic disembrioms) are divided
on epidermoid and dermoid cyst, teratoms.
Epidermoid cyst are formed in process embrional development at immersing in mediastinum
elements epidermis (hystoid - of one tissue).
Dermoid cyst are caused by rifting particles ectoderm and their immersing in mediastinum.
They contain not only elements epidermis, but also hair, sebaceous glands - some tissues, therefore
are included in organoid formations. They grow long, are sometimes opened in a bronchial tube and
then lose contents - hair and grease weights. Uncertain blunt pressing pains in a breast characteristic, there may be a dyspnoe and cough.
Teratoms contain derivative all three or two embryolists (ecto-, endo, mesoderma), are included with rudiments not only tissues (hystoid), but also organoids, sometimes and several organs organismoids. They more are dense, protruded in a pleural cavity more. Sometimes they contain affiliated cavities, cartilages, sites of calcification, a teeth.
Teratoid formations need to be differentiated from lymphadenitis, aneurism, malignant lymphoma. At mediastinal goiter the dyspnoe is more expressed, there may be phenomena thyrotoxicosis. Thymoma settles down closer to an average line, teratoma - sideways from an average line.
Cysts of a pericardium has characteristic localization.
Indications to operation at teratoid tumours put because of an possibility malignisation,
compressing of organs, a suppuration, break in a bronchial tube.
Bronchogenic cyst arise because of infringement process divisions of bronchial tubes, therefore settle down near to a trachea more often or bronchial tubes. But they may be in a wall of an
esophagus or in other parts of mediastinum. They represent as round formations filled viscous mucous contents reminding egg protein. The communication with a bronchial tube may result to infection. Inside cyst there may be a pus. Infection may result in death when the true diagnosis put only
on section. Are possible attributes of compressing organs of mediastinum (tracheas, veins). Malignisation is rare. On X-ray are characteristic round shadows with the precise contours, settling
down near to a root lung and tracheas. As against bronchogenic cysts dermoid cyst more often are
in an anterior part of mediastinum. It may mark displacement of an esophagus. At a suppuration
cyst its increase, occurrence of a level of a liquid with a gas bubble above it is possible.
Cyst of pericardium (celomic pericardium cyst) are connected to anomaly of development of
a pericardium. It is round formations filled with a transparent yellowish or colourless liquid (as
"spring water").
At a trauma contents may be hemorrhagic, at a suppuration - cream-like. The size cysts from 4-5 sm up to containing up to litre of contents (cysts from spring water). They may have the
communication with a pericardium. The clinic is expressed a little. The x-ray picture is rather characteristic. In overwhelming number they settle down in the right pleuropericardial corner. Contours
distinct, quite often pulse. The differential diagnosis first of all is necessary to carry out with aneurism of aorta and its branches. Operation will be carried out by anterior intercostal access.
Enterogenic cyst - esophageal, gastrogenic, enterogenic. Occur from an anterior gut, therefore and carry such name.
Cyst of esophagus settle down near to a esophagus, sometimes in its wall, intramural, and
the part of muscular fibres may enter into a wall cyst. The cavity of them is filled with jellylike
weight of azure-bluish colouring. The average size of 5-6 sm, are possible symptoms dysphagia,
vomiting, an eructation, cough, a dyspnoe.
For the natural reasons, gastrogenic or enterogenic cyst in mediastinum meet most less often
other.
Tumorous and tumor-like formations and granulomas have no pathogenetic communication
and are considered together casually. Exception makes only wrongly accepted for mediastinal for-
15
mation a pole low located neck-retrosternal goiter, hyperplasia of thymus with attributes of myastenia and without them.
Intrathoracic goiter.
Divide goiter: 1) diving when the goiter becomes retrosternal at swallowing; 2) retrosternal
which completely is behind a brest, but it may be probed by a finger entered for a brest during test
Valsalva in position of the patient on a couch with the platen, enclosed under a neck; 3) intrathoracic. It is necessary to distinguish intrathoracic goiter of the thyroid gland and an additional thyroid
gland.
Here necessarily x-ray investigation at which it is possible to see a deviation of a cervical
part of a trachea, displacement of a tumour at swallowing, calcification tumours, compressing and
deviation of the upper parts of a trachea. In x-ray pictures deviation of trachea by old radiologists
was designated as "sabre sabre trachea". Long compressing tracheas may result to it tracheomalacia
and development of a chronic bronchitis.
The constant or passing hoarseness dependent from compressing of a nervus recurrens is
possible. At big intrathoracic goiters syndrome Horner (ptosis, miosis, enoftalmas) may be marked.
Infringements of function diaphragmal nerve - high standing diaphragm, paradoxical breath, sometimes a hiccups and pains in the left or right half of the thorax, sometimes removed are less often
observed by introduction of atropine.
Compressing veins (the syndrome upper cava vein) develop at the big sizes retrosternal goiter. Be at complicate outflow from veins of a head, a neck, the upper finitenesses that results in persistent headaches, reddening and imbibition with blood scleras, often nasal bleedings more often.
Observe puffiness of the face and a neck, cyanosis. Expansion of veins of a breast - caput Medusae
is possible.
It is seldom observed compressing of an esophagus with development of dysphagia.
Symptoms of thyrotoxicosis are observed rather seldom, but at retrosternal toxic goiter
symptoms of infringement of intimate activity (change ECG, a pain in heart, arrhytmia) more often
are expressed. Here the help in diagnostics of an arrangement of goiter helps scanning.
In most cases the goiter is operated oversternal access with broaching it and gradual pulling
up in process of allocation. Seldom it is necessary to resort to sternotomy, even less often thoracotomy. Intrathoracic goiter is desirable to operate in the clinics specialized on thoracal surgery. The
best access in these cases considers full median sternotomy.
After removal retrosternal goiter more frequently, than the bleeding, paresis of vocal chords
is usual, possible, Pneumonia, infringement of function parathyroid gland.
Intrathoracic goiter happens malignant.
Tumours of mediastinum
Tumours of mediastinum are divided on benign and malignant.
The first group make neurogenic tumours. To them concern: sympatogoniomas - tumours
from sympathetic nervous system, ganglioneuroms, pheochromocytomas - hormonal-active tumours
from chromaffin tissues, neurinoms, neurofibroms and neurogenic sarcomas. It is necessary to note,
that neurogenic tumours concern to number most frequently meeting neoplasms of mediastinum.
The following group of tumours concerns to mesenchymal neoplasms. These are fibromas
and fibrosarcomas, developing from of a fibrous connecting tissue. Chondromas, osteochondromas,
osteoblastoclastomas proceed from cartilage and a bone tissue. Chordomas grow from the rests of a
back string. Tumours from a fatty tissue - lypoms and lyposarcoms. From brown fat-formating embrion cells occur hybernomas. In the same group are referred mesenchymomas which develop from
several tissues mesenchimal nature. Vascular tumours: hemangioms, lymphangioms, angiosarcoms,
glomus - from glomus arterio-venous anastomosis, angioleyomyomas - from smooth muscles of arteries, hemangiopericitoms - from pericits. Muscular tumours: leyomyoms(is more often from
smooth muscles of a esophagus), rabdomyo and rabdomyosarcoms (from transvers-stripped muscular tissue).
The third group includes tumours of thymus: malignant and benign thymoma.
16
The fourth group includes tumours from reticular tissues: lympho-granulomatous, lymphosarcomas, reticulosarcoma.
The fifth group is made with tumours from displaced in mediastinum tissues. It mediastinal,
retrosternal and a "diving" goiter. It is described mediastinal seminoma.
To the sixth group are referred teratoid tumours: teratoms or as them still name, dermoids.
During these diseases allocate two periods - asymptomatic and clinical displays. Benign tumours, as a rule, long time develop as an asymptomatic. In clinical current of all tumours mediastinum allocate two basic syndromes: compression and neuroendocrine. The degree and a kind of a
compression depend on localization of a tumour (anterior or posterior mediastinum etc.) and its
size. Compression syndrome divided on 3 kinds: displacement and compressing organs of mediastinum (hearts, tracheas, bronchial tubes or a esophagus); compressing vessels (upper cava veins, humero-head trunk, an arch of an aorta, a chest lymphatic channel); neurogenic compressing (a vagus
nerve or its branches, recurrens nerve, a sympathetic trunk).
At compressions of hearts the tumour marks feeling of overflow, pressure behind a brest.
There are pains in the field of heart, palpitation, various infringements of a rhythm of heart and a
dyspnoe. The compression of a trachea or large bronchial tubes accompanies a dyspnoe, cough. At
involving in process of a esophagus it is marked dysphagia. Compressing upper cava veins (the
syndrome upper cava veins) is shown by a hypostasis and cyanosis of face, and also the upper half
of trunk. The compression of nervous formations is accompanied a various sort by pains, hypo- or
hyperestesia, vegetative infringements. Involving in process of a nervus recurrens is shown gets
hoarse - hoarseness.
The certain tumours of mediastinum have typical localization. Tumours from a nervous tissue, as a rule, located in back mediastinum. Lypoms are in the right cardiodiaphragmal corner more
often. Tumours thymus settle down in the upper parts of anterior mediastinum and quite often proceed with a syndrome myastenia (progressing muscular weakness). In average departments of anterior mediastinum there are teratoms, lympho-sarcomas of and lymphogranulomatous more often.
Sarcomas of mediastinum concern to the extremely malignant and fast-growing tumours which early sprout and squeeze organs of mediastinum. At sarcomas of the syndrome upper cava veins frequently develops. Basic for a clinical picture of tumours of anterior mediastinum is compressing
hearts and upper cava veins, and of posterior mediastinum - compressing a esophagus and nervous
formations. Diagnostics of tumours of mediastinum has the common principles.
Multiprojective x-ray inspection, Tomography is applied. Now computer tomography and
ultrasonic investigation solve all diagnostic problems. For morphological verification of a tumour
carry out transdermal puncture under control USI with convex gauge. In some cases it is applied
pneumomediastinography. Under indications (compressing bronchial tubes or a esophagus) it is
used bronchoscopy and esophagoscopy, and also thoracoscopy and mediastinoscopy. At a syndrome upper cava veins it is carried out angiography investigation (cavagraphy).
The tumour of mediastinum is the indication to operative treatment. Last years a number of
benign tumours of mediastinum removed by endoscopy. At operations are used various accesses
which depend on localization neoplasm. It is used thoracotomy: sternotomy, anterior, lateral or
back. It is applied partial, longitudinal, and also cross sternotomy. Operation consists in removal of
a tumour. Unfortunately, treatment of sarcomas of mediastinum remains a difficult problem. Therefore they are treated by the combined method: chemotherapy, an irradiation and operation. Treatment depends on the sizes and a stage neoplasm, and also involving in process of large vessels and
environmental organs. The approach to treatment lypoms of right cardio-diapragmal angle should
be strictly differentiated. At the established diagnosis lypoms and asymptomatic current probably
long supervision.
MALIGNANT INITIAL TUMOURS.
Neurogenic tumours occur from ganglions and trunks of sympathetic, vagus, intercostal
nerves, sheath of spinal cord. It is the most often tumour of mediastinum.
Ganglioneuroma - a tumour from a sympathetic nerve, roundish, along an axis of a body.
The sheaths is expressed well, "pedicle" is wide.
17
Neurinoma (neurilemmoma, schwannoma) occurs from scheats of a nerve. It also roundish
or oval, but may contain cavities.
Neurofibroma – Recklingausen`s tumour - proceeds from fibrous elements of nervous
trunks.
Extremely seldom there is neurogenic sarcoma and others.
All these tumours are accompanied by clinical displays, than cyst and other tumours more
often. Patients complain of pains in a breast and head, changes of sensitivity of a leather(skin) on
the party(side) of defeat, deterioration of sight and other complaints. Quite often there is syndrome
Horner, is observed compressing vessels and organs of mediastinum, deformations bones of thorax
are possible. There are possible expansions of an intercostal space, rib-spine joints or an intervertebral aperture. The impression about existence of vegetative reactions and frustration is created: vasomotoric, secretory, pylomotoric, trophic on the side of localization of a tumour. A way of definition of sweating is test of the Minor. For this purpose undertakes 15 g of crystal iodine, 100 g of
Oleum ricini, 900 g of wine spirit and this mixture becomes covered at the skin of the patient. After
drying it becomes covered by starch powder. After of the sweating the struck side is not painted,
and not struck side is represent as painted in dark blue color.
Symptoms compressinga spinal cord are possible. At tumours of wandering or nervus recurrenss there is a hoarseness of a voice, and recurrens nerve - a long hiccups.
Lypoms of mediastinum - are rather rare. An original kind lypoms of mediastinum is hybernoma. The name occurs from the animals running into hibernation, at which similar structure of a
fatty tissue. They may be surrounded with more dense capsule, is appreciable lobular. Lypoms may
be in several cavities and incorporate among themselves an isthmus - cervicothoracic, in both chest
cavities. May transformated in lyposarcoms.
Thymoma – neoplasms of goitrous gland. Goitrous gland may be named the lymphatic body
well advanced at children's age, then occurs involution. It finds behind a sternum and slightly enter
on a neck, consists of two lobes. Has cortical and brain layers. In cortical layer adenoid structure
with disseminated there lymphocytes, in brain a lot of cells – gassal bodies, which from 3-month's
age gradually died. Recognition of thymoma difficultly even at histologic investigation, as it cellsthymocites are similar with lymphocites and consequently them easily to mix up with lymphomas.
In gland development of carcinomas, sarcomas, myxosarcomas is possible. The remote metastasises
are possible. There are possible cystoid thymoma. The combination of thymoma with a syndrome of
progressing muscular weakness - miasthenia gravis is extremely important. There is an opinion, that
myasthenia at thymomas meets less often, than thymoma at myastenia. The great experience of
treatment of thymoma had the clinic of chest surgery St.-Petersburg MAPO.
The diagnosis may be specified at mediastinoscopy.
Some, but not everything, malignant thymoma give in to beam therapy.
The best access for removal thymoma is median sternotomy.
MALIGNANT SECONDARY TUMOURS.
LYMPHOGRANULOMATOSIS.
Characteristic attributes OF lymphogranulomatosis are increase lymphoNODES of various
localization, including of mediastinum, a fever, a skin itch, changes of blood: leucocytosis, eosinophilia, accelerated ESR. Defeat only units of mediastinum causes special difficulties, sometimes it
be required puncture for what it is necessary mediastionoscopy. We know many supervision when
deleted a cancer of a thyroid gland, tumours of mediastinum. Operations were finished by fatal outcome, therefore we and know about it, but lymphogranulomatosis (except for it organ forms) basically is treated beam and chemotherapy.
It is especially effective beam and chemotherapy at a lympho-ssarcoma of mediastinum.
Damages of thorax
The organization.
Board for transportation, a rule of three cateters, x-ray, USI, CT equipment. Analyses of
blood and urine, frequently in dynamics.
Classification of traumas.
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Isolated - a trauma of one body within the limits of one anatomic area.
Plural - a trauma of several organs within the limits of one anatomic area.
Conjoined trauma - damage of several organs in different anatomic areas.
The combined trauma - the damages arising at influence on an organism etiologic different
injuring factors.
Damages of a breast
All traumas of a breast share on 2 big groups: open and closed.
Open damages of a breast - wounds of a breast
On side of damages: unilateral and bilateral.
By the form wounded weapon: punctured-cut and fire.
On character of wound channel: blind and through.
On character of a wound: penetrating and not penetrating. As criterion serves damage of parietal leaf of a pleura.
Penetrating wounds share on 2 groups: with damage of organs and without damage.
With separate group are allocated thoracoabdominal wounds at which damage of diaphragm
and wound channel passes through 2 cavities: pleural and abdomen.
Thoracoabdominal wounds share on the following groups
1. Without damage of organs of abdomen and chest cavities
2. With damage of organs of chest cavity
3. With damage of organs of abdomen and retroperitoneal spaces
4. With damage of organs of breast, abdomen and retroperitoneal spaces.
The closed trauma of a breast
1. Without damage of a bone skeleton of a thoracic cell: bruises, hematomas, breaks of muscles
2. With damage of a bone skeleton of a thoracic cell: fractures of ribs, clavicle and scapula
1. Without damage of internal organs.
2. With damage of internal organs: lung, heart and large vessels, a trachea and bronchial
tubes, a gullet and organs of posterior mediastinum.
Pathophysiology.
Conducting part in pathogenesis damages of a breast - infringements of breathe and blood
circulation.
The reasons of infringement of function of breathe are: a pain, infringement of a skeleton of
a thoracic cell, morphological changes in a pleural cavity, lung and tracheobronchial tree. Infringement of a skeleton of a thoracic cell and a pain at fractures of ribs reduce volume lung ventilation.
The congestion of a secret in a bronchial tree on a background of the reduced volume of ventilation
results in a pneumonia. At plural fractures of ribs with formation of fragments there is a paradoxical
breathe with flotation of a thoracic cell. Infringement lung ventilation cause: damage of lung tissues, hemothorax, pneumothorax. To athelectasis lung conducts obturation of tracheobronchial tree
by blood, slime and alien organs.
Principal causes of acute respiratory insufficiency.
1. Infringement of the biomechanics of breathe, owing to damage of a thoracic cell, damage
lung, compressing their blood, air which has got in a pleural cavity.
2. Corking of bronchial tubes by blood, slime, fibrin.
3. Bronchiolospasm.
4. Change of conditions of hemodynamics in a small circle of blood circulation.
5. The acute infringements of microcirculation conducting to an ischemia lung tissues
6. Reduction of formation surfactant with amplification of bent to athelectasis.
7. Shunting venous blood.
Infringements of system of blood circulation.
The reasons.
1. Infringement VCB, connected to an external and internal bleeding. As a source of a bleeding serve: intercostal and internal chest arteries, vessels of mediastinum, damages of lung, hearts.
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Reduction VCB conducts to hemorrhagic shock.
2. Compressing pliable departments of heart, caval and pulmonary veins blood, air.
3. A congestion of blood in a cavity of the pericardium, complicating work of heart.
4. Extrapericardial tamponade hearts.
5. A bruise of heart with its infringement retractive abilities.
DIAGNOSTICS
Main principles.
1. Speed and efficiency of statement of the diagnosis in conditions of limited time.
2. The simultaneous combination of diagnostic actions with medical, is especial at heavy patients.
3. Observance of the certain algorithm in diagnostics, on weight of a condition of the
wounded.
4. To reveal the basic infringement causing weight of a condition of the wounded and creating direct threat for his(its) life (a - airway, b - breatheing, c - circulation).
5. Coordination and interaction of all members of an on duty brigade at realization of diagnostic actions.
Methods of diagnostics.
1. Complaints and finding - out of circumstances.
2. Anamnesis of the wounded, palpations, percussion, auscultation.
3. X-ray methods of diagnostics.
а) rentgenoscopy and roentgenography of thoracic cell.
в) tomography.
г) roentgenocontrast methods of research.
4. Ultrasonic diagnostics. A computer tomography (conditions!)
5. ECG.
6. Laboratory diagnostics.
7. A pleural puncture.
8. SPW and audit of a wound.
9. Thoracoscopy.
10. Tracheobronchoscopy.
11. Special methods of research.
Algorithms of diagnostics at different kinds of damages of a breast.
For this purpose all woundeds it is divided on 4 groups
1. Woundeds in the heaviest condition (sometimes in a condition of clinical death) at the
damages conducting to dangering life infringements of vital functions (damage of heart, large vessels, bronchus, heavy conjoined trauma). Diagnostics includes: anamnesis and revealing of clinical
symptoms of damage. The task of the surgeon - as soon as possible to make operation and to execute a final stop of a bleeding.
2. Woundeds in a heavy condition, but without dangering of life infringements.
Diagnostics includes a minimum of inspection: anamnesis, roentgenography a thoracic cell,
ECG, a pleural puncture. The further inspection will be carried out after a final stop of a bleeding
and stabilization of a condition of the patient.
3. Woundeds in a condition of average weight, without infringements menacing for life and stable hemodynamics. All necessary volume of inspection (anamnesis, rentgenoscopy (-graphy) a thoracic cell, ECG, clinical and
biochemical analyses, a pleural puncture, thoracoscopy, consultation of adjacent experts) is made.
4. Woundeds in a satisfactory condition. All volume of inspection is made.
Symptoms of damage of a breast.
1. The general symptoms.
1. Attributes of a shock.
2. Symptoms of a bleeding.
3. Attributes of infringement of breathe and blood circulation.
2. Local symptoms.
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4.
5.
6.
7.
8.
9.
A pain.
Presence and character of a wound.
An external bleeding.
Attributes of fractures of bones of thoracic cell.
The data of percussion and auscultation.
Specific symptoms.
1. pneumothorax.
2. hemothorax.
3. subdermal emphysema.
4. emphysema mediastinum.
5. athelectasis of lung.
6. hemoptysis.
Pneumothorax. This congestion of air between parietal and visceral sheets of pleuras.
The reason: penetrating wounds of a thoracic cell, damage of lung, bronchial tubes.
Classification.
1. Closed pneumothorax - air in a pleural cavity is not connected with atmospheric air.
2. Open pneumothorax - air of a pleural cavity is connected with atmospheric through a
wound of a chest wall.
3. Valvular (intense) pneumothorax - the valve which promotes receipt of air only in one direction - in a pleural cavity is formed.
Valvular pneumothorax it happens external (the valve from a tissue of a chest wall) and internal (the valve from lung tissue).
On volume of air in a pleural cavity pneumothorax share on:
1. Limited - lung it is squeezed on 1/3 volumes.
2. Average - lung it is squeezed on half of volume.
3. Big - lung it is squeezed more than on half of volume.
4. Total - a collapse of all lung.
Pathophysiology.
At a breathe air gets in a pleural cavity, squeezing lung, organs of mediastinum, pushing
aside them in the healthy side. There is a displacement mediastinum with compressing of vessels
and heavy circulatory infringements. There is so-called a paradoxical breathe - at a breathe in
healthy lung the part of air sated with carbonic gas from struck lung, gets and on an exhalation it directs in a return direction. In a result from gas exchange it is switched off not only lung on the side
of defeat, but also healthy lung. Pulmonary-intimate insufficiency, hypoxia of the vital organs and
metabolic ацидоз quickly develops.
The clinic of pneumothorax depends on a kind of it, quantity of air in a pleural cavity and a
degree of a collapse lung. At limited pneumothorax condition of suffering is satisfactory, he is quiet, complains of a pain in a thoracic cell. On the foreground symptoms of fractures of ribs or penetrating wound of a chest wall act. At auscultation the weakened breathe on the side of damage is defined. At sciascopy (graphy) of thoracic cell the congestion of air in a pleural cavity comes to light.
At average and big pneumothorax clinic is brighter. The patient is restless, the complicated
breathe complains of pains in the thoracic cell. The pain amplifies at loading, breathe. The person is
pale-cyanotic colors, is covered cold sweat. The short wind appreciable even in rest. breathe is rapid, superficial. At auscultation - sharp easing of breathe on the side of damage. At percussion the
box sound is defined. Pulse often, weak filling. AP is a little bit reduced, but may be normal. At xray the site of an enlightenment as a zone deprived pulmonary of figure, a collapse lung, displacement mediastinum in the healthy side is defined.
At open pneumothorax, except for set forth above attributes, noise of sucking of air through
a wound of a chest wall, allocation of air with blood is audible,
The heaviest is valvular (intense) pneumothorax. Its clinic is very bright. A condition of the
wounded heavy, he is restless, the asthma feels a pain, a short wind, sometimes. Is in the compelled
position, more often sitting. Integuments is cyanotic colouring, damp. swelling cervical veins are
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visible. Frequently it happens swelling subcutaneous emphysema with distribution of air on a neck
of the person. The thoracic cell on the side of damage is motionless, intercostal intervals are expanded. There is a tachycardia up to 120 and is higher, reduction AP up to 90 and is lower. Raises
CVP. At percussion is defined expressed tympanic sound. At auscultation sharp swelling or full absence of breathe on the side of damage, displacement of an intimate push in the healthy side is defined. At x-ray the congestion of air in a pleural cavity, a subtotal or total collapse lung, displacement mediastinum in the healthy side is defined.
The important and at the same time simple method of diagnostics is the pleural puncture in
II intercostal space.
Hemothorax.
Hemothorax - a congestion of blood between parietal and visceral sheets of pleuras.
Classification of hemothorax (P.A.Kuprijanov, 1946).
1. Small hemothorax - a congestion of blood in pleural sine (quantity of blood 200 - 500 ml).
2. Average hemothorax - a congestion of blood up to a corner scapula (7 intercostal space).
Quantity of blood from 500 up to 1000 ml.
3. Big hemothorax - the congestion of blood is higher than a corner scapula (quantity of
blood more than 1 litre).
Distinguish hemothorax with a stopped bleeding and hemothorax with continuing bleeding,
as criterion test Rouvillour-Gregour serves: at continuing bleeding the blood taken from a pleural
cavity, clottens.
Depending on time of occurrence distinguish fresh hemothorax and chronic hemothorax.
Clotting hemothorax - clotting of the blood which has been given vent in a pleural cavity.
Infected hemothorax - infecting blood in a pleural cavity.
The reason of hemothorax: penetrating wounds of a chest wall, damage of intercostal vessels, an internal mammary artery, vessels of lung, mediastinum, damages of heart.
Clinic. The clinic of hemothorax combines attributes of acute bloodloss, infringements of
breathe, displacement mediastinum. Weight of a condition depends on size of hemothorax.
Small hemothorax: symptoms poor. Attributes of acute bloodloss or respiratory insufficiency are absent. The small pain and swelling of breathe in the bottom departments lung is kept. At
roentgenography blood in a sine comes to light. At a puncture in 7-8 intercostal space we receive
blood.
Average hemothorax: a pain in a thoracic cell, cough, a short wind. There is a pallor of integuments. At percussion it is defined dull sound on the side of damage. At auscultation: swelling
of breathe. AP is reduced up to 100, a tachycardia - 90-100 in one minutes.
At x-ray the level of a liquid up to a corner of scapula is defined. At a puncture of a pleural
cavity in 7 intercostal space we receive blood.
Big hemothorax. A condition of the wounded is heavy. Attributes of acute bloodloss are
brightly expressed: pallor of integuments, a hypotonia (AP is 70 and lower), a tachycardia with
pulse of weak filling (up to 110 - 120 in one minutes). There is a pain in a thoracic cell, a short
wind, cough. At percussion - dull sound. At auscultation acute swelling breathe or its absence is defined.
At x-ray the level of a liquid above a corner scapula and a collapse lung is defined.
At USI the free liquid in a pleural cavity is defined. A pleural puncture: we receive blood.
Subcutaneous emphysema.
This congestion of air in subcutaneous cellular of the chest wall, a body, extending on other
area is pathognomonic symptom of damage of lung.
Subcutaneous emphysema may be the different sizes from a small site which is defined only
at palpation, up to expressed at which air distributes upwards to a head and a neck and downwards,
down to scrotum. At a congestion of a significant amount of air in subcutaneous cellular necks occurs compressing blood vessels and difficulty of breathe.
Subcutaneous emphysema on size shares on: limited, widespread, total.
Clinic. Depends on size of emphysema. At limited emphysema there is a local morbidity in a
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place of damage and the characteristic crepitating in a place of a congestion of air in cellular is palpated. At widespread emphysema clinic is brighter. Emphysema is defined visually and at palpation. Breathe on the side of damage weakened. At expressed emphysema of necks there is a short
wind, skin cyanosis of the person.
Emphysema of the mediastinum. This congestion of air in cellular mediastinum. Arise at
damage of a trachea, the main bronchial tubes, a gullet. An early attribute of emphysema mediastinum is occurrence of air on a neck, above jugular cutting. At the further receipt of air the neck is increased in the sizes, the person becomes bloated. At a significant congestion of air in mediastinum
arises compressing large vessels and extrapericardial tamponade of heart.
Clinic: the condition of the wounded is heavy, prevails clinic of respiratory and cardiovascular insufficiency. The wounded complains of a pain behind a brest, a short wind, cough. There is a
short wind (up to 40 in one minutes), cyanosis persons, a swelling of a neck, a tachycardia, reduction AP up to 80. At presence of pneumothorax breathe is weakened. Tones of heart deaf persons.
Visually and at palpation the congestion of air on a neck is defined. At roentgenography a thoracic
cell: expansion of borders mediastinum, a congestion of air in mediastinum.
Main principles of treatment of damages of a breast.
1. Elimination of a pain.
2. Early and adequate draining of pleural cavity.
3. The actions directed on prompt expanding of lung.
4. Restoration and maintenance of passableness of respiratory ways.
5. Hermetic sealing and stabilization of a chest wall.
6. A final stop of a bleeding and completion bloodloss.
7. Infusion, antimicrobic and supporting therapy.
8. Early activization of the patient, realization of exercise therapy and respiratory gymnastics.
Performance of these principles and their sequence may vary on weight of a condition of the
wounded.
Methods of elimination of a pain.
1. Narcotic analgetics.
2. Not narcotic analgetics.
3. Novocain blockade: intercostal, paravertebral, retrosternal.
4. Peridural anesthesia. The combination of analgetics is rather effective with novocain
blockade.
Draining a pleural cavity.
Indications: pneumothorax, hemothorax, hemopneumothorax.
For liquidation pneumothorax in 2 intercostal space on middle-clavicular lines in a pleural
cavity the elastic tube in diameter of 0,5 sm (a pleural drainage on Bulau-Subbotin) is entered
through троакар.
The distal end of a drainage tube is immersed in a solution antiseptics or makes active aspiration at under pressure of 30-40 mm Hg. an item. Criterion of correct installation of a drainage is
releasing of air drops on a tube.
The basic mistakes arising at installation of a pleural drainage on Bulau-Subbotin.
1. The drainage tube is entered in a pleural cavity on the big depth, thus the tube is bent,
turned off and does not carry out drainage function. For avoidance of it is necessary to enter a
drainage tube on depth 2-3 see from last aperture. Lateral apertures on a tube should be not so much
- up to 3. If it is difficult for doctor to establish depth of introduction of a drainage, it is necessary to
mark a drainage tube.
2. Inadequate fixation of a drainage tube. The drainage completely leaves a pleural cavity or
drops out in part. At last situation lateral apertures appear in subcutaneous cellular with development of subcutaneous emphysema. If the lateral aperture appears above a skin, occurs atmospheric
air in a pleural cavity to occurrence of a collapse lung. The drainage tube is necessary for fixing to a
skin of a chest wall two silk strings at each edge of a wound.
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At too strong tightening of ligature on a drainage tube occurs it compressing down to full
compressing a gleam. It is necessary to cut off ligature and again to fix a drainage tube. At open
pneumothorax before installation of a pleural drainage it is necessary to hermetic a chest wall.
Next day after installation of a drainage it is made control by x-ray (graphy) of thoracic cell.
At full expanding of lung and absence of circulation of air on a pleural drainage a drainage tube delete on 4 days thus the x-ray control is obligatory. There are no precise criteria for duration of draining a pleural cavity at pneumothorax. The drainage needs to be held up to full expanding of lung. At
a pathological condition lung tissues is tightened for 2-3 weeks.
At noncontrolling conservatively intense pneumothorax thoracotomy is indicate.
Draining a pleural cavity at hemothorax.
The basic purpose: duly and adequate removal of blood from a pleural cavity and expanding
lung. For this purpose establish a pleural drainage on Bulau-Subbotin.
Engineering: under local anesthesia in 7-8 intercostal space on an average axillary line the
puncture of soft tissues is made by a scalpel, being guided on the top edge of a underlaying edge. Of
1-1,5 sm with several lateral apertures enter a drainage tube in diameter in a pleural cavity with help
of dressing forceps or trocar. The tube is fixed by two seams to edges of a skin wound. The bottom
end of a tube with the valve falls to a bottle with an antiseptic tank or to vacuum system for active
aspiration.
Blood from a pleural cavity is necessary for collecting for reinfusion.
Mistakes at installation of a pleural drainage on Bulau.
1. Use for a drainage a tube in diameter not less than 10 mm. The thin drainage tube is
hammered by clots of blood and does not function.
2. Use for a drainage soft rubber tubes. Such tubes deform and are squeezed by ligature, tissues of a chest wall. It is necessary to use silicon and polychlorvinil tubes.
3. Leaving in a pleural cavity too long end of a drainage tube. Proximal end of tube settles
down in the top part of pleural cavity and not drained the bottom parts where there is a blood. It is
necessary to tighten a drainage tube on some see.
4. Mistakes at fixing a drainage tube to a skin are in detail described in section about pneumothorax.
Draining of pleural cavity is indicate only at average and big hemothorax. At small hemothorax the pleural puncture is made.
After installation of a pleural drainage on Bulau dynamic supervision is necessary.
Thus the quantity of the blood allocated on a drainage is established and further medical tactics defines. The main problem of the doctor to define: proceeds intrapleural bleeding, or it has
stopped? For diagnostics of continuing intrapleural bleedings serve: clinic, quantity of blood on a
pleural drainage, test Rouvillour-Gregour. Intensive receipt of blood on a drainage which quickly
clottens, on a background of clinic of an anemia. Presence proceeding intrapleural bleedings is the
indication to thoracotomy. In the event that the bleeding has stopped, will be carried out control
roentgenoscopy of thoracic cell the next day after installation of a pleural drainage. A drainage tube
delete not earlier than 4 day, at full expanding of lung and absence disharge on a drainage.
Presence pneumothorax and hemothorax is the indication to double draining of a pleural
cavity (in 2 and 7 intercostal spaces).
Thoracotomy at damages of a breast. The approach to operative treatment of damages of a
breast has very much changed for last years. Indications to thoracotomy were sharply narrowed,
they became more proved. According to different authors thoracotomy at damages of a breast took
place in 6-10% of cases. At the majority of wounded the good effect is achieved by conservative
therapy and draining of pleural cavity. At the decision of a question about thoracotomy it is necessary to take into account: conditions in which is assisted to the wounded, qualification of the doctor.
Kinds of thoracotomy (on Kolesov A.P., Bisenkov L.N., 1986).
1. Urgent thoracotomy: are carried out at once at receipt of the wounded. Indications.
1.
For revival of the wounded at cardiac arrest.
2.
Wound of heart and large vessels.
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3.
Profuse intrapleural bleeding.
Thoracotomy is carried out simultaneously with reanimation actions and is their component.
The task of the surgeon within several minutes to diagnose and immediately operate the wounded.
2. Early thoracotomy: are carried out within the first day after a trauma.
Indications.
1. Suspicion on damage of heart and an aorta.
2. Big hemothorax.
3. Proceeding intrapleural a bleeding with volume bloodloss 300 ml at one o'clock and
more.
4. nontreated conservatively intense pneumothorax.
5. Damages of esophag.
Operation is made after preliminary reanimation actions including restoration of passableness of respiratory ways, adequate ventilation, completion bloodloss, infusion-transfusion therapy.
Make draining a pleural cavity, suturing of open hemothorax.
Operation should be made within several hours from the moment of receipt of the wounded.
At clinic proceeding intrapleural a bleeding time before operation should not exceed 1,5 - 2 hours.
4. Late thoracotomy: are carried out through 3 - 5 day and more from the moment of a trauma. They are indicate at.
1. Clotting hemothorax.
2. Recurrent pneumothorax.
3. Large alien organs lung and pleuras.
4. Empyema of pleuras and other purulent complications.
The closed trauma of a breast.
There are much more often, than wounds of a breast. The basic kind of damage fractures of
ribs. We shall consider in detail each kind of damage.
Bruise of a thoracic cell.
At the given kind of a trauma there are no infringements of integrity of a skeleton of a thoracic cell and damage of organs.
Clinic: complaints to pains in the thoracic cell, the complicated breathe. A condition of the
patient satisfactory, it(he) is quiet. Integuments and mucous usual colouring. breathe is listened in
all departments. AP and pulse within the limits of norm. At паль-пации local morbidity in a place
of a bruise is defined. The hematoma here is defined.
Diagnostics: circumstances of a trauma, anamnesis, palpations, auscultation, roentgenoскопия a thoracic cell. The diagnosis is put on the basis of set forth above symptoms at absence at
sciascopy fractures of ribs and attributes of damage of organs.
Treatment.
1. Analgetics.
2. Respiratory gymnastics.
3. Physiotherapy.
4. Novocain blockade.
Hematomas of a thoracic cell.
Represent haemorrhages in subcutaneous or intermuscular cellular.
Clinic same, as at a bruise of a thoracic cell. Locally there is a hematoma of the various sizes
from small up to widespread. The size of a hematoma depends on the size of the damaged vessel. At
a significant haemorrhage in subcutaneous cellular or between muscles the cavity filled with liquid
blood and clots is formed. The organized hematoma is formed.
Diagnostics: the anamnesis, anamnesis, palpations, rentgenoscopy a thoracic cell.
Treatment.
1. Analgetics.
2. Respiratory gymnastics.
3. Resolving therapy.
At the organized hematoma its puncture with removal of blood is made.
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At absence of effect from a puncture opening and evacuation of hematomas is made.
Fractures of ribs.
Classification
1. solitary.
2. plural.
3. flotation.
Unilateral, bilateral.
Except for that distinguish: the not complicated fractures of ribs and complicated (with subcutaneous emphysema, hemothorax, pneumothorax.)
The not complicated fractures of ribs.
There is no damage of a pleura and internal organs.
Clinic: the basic symptom is the pain in a place of fractures. The pain amplifies at breathe,
cough, physical loading. Position of the wounded compelled, more often sitting. At anamnesis restriction of breathe is defined, at plural and bilaterial fractures - a short wind, cyanosis of skin. At
palpation sharp morbidity in a place of fractures and crepitation fragments of ribs is defined. In a
place of fractures of an edge frequently there are hematomas. At compressing a thoracic cell in sagittal and a frontal plane the pain sharply amplifies. At auscultation at single fractures breathe vesicular, is listened in all parts. At multiple fractures there is an swelling breathe on the side of damage,
small rattles.
The basic method of diagnostics is anamnesis rentgenoscopy (graphy) a thoracic cell. But it
is not necessary to forget, that fractures хрящевой on the roentgenogram are not visible to a part of
an edge. In this case the diagnosis is based only on clinic.
Treatment.
1. Removal of a pain. At receipt to the wounded Novocain blockade is made intercostal or
paravertebral. For removal of a pain use analgetics narcotic (promedol, omnopon) and not narcotic
(analginum, tramal, ketarol, toradol, etc.) lines. It is not necessary to appoint the big dozes narcotic
analgetics, the Patient becomes languid, sleepy, inactive. It results in a congestion of a secret in a
bronchial tree and development of complications. It is possible to apply analgetics locally, as ointments, alcohol solutions: menovasin, finalgon, etc. For removal of a pain use physiotherapeutic
procedures: electrophoresis with analginum, novocain, ketarol.
2. Maintenance of normal passableness of respiratory ways and drainage function of bronchial tubes. Activization of the patient is necessary for this purpose, exercise therapy, respiratory
gymnastics. To improvement draining a bronchial secret apply: massage and tapping massage of
thoracic cells, inhalation, expectorate means, the means diluting sputum, stimulation of cough.
The bandage on area of the struck edge is imposed leucoplaster.
The main task of the doctor at treatment of fractures of ribs: to not allow development of the
main complication - hypostatic pneumonia. Preventive maintenance is necessary for this purpose
hypoventilation and atelectasis of lung.
Antibacterial therapy at fractures of an rib (not complicated) does not apply. Exception are
woundeds with accompanying pathology lung: a chronic bronchitis, bronchoectatic illness etc. Taking into account a high probability of development of a pneumonia after a trauma, assignment of
antibiotics is indicate.
Windows-like (flotation) fractures of ribs.
It is fractures of ribs on several anatomic lines, with formation of a shutter of a chest wall. A
shutter flotate at breathe: during a breathe it sinks down, during an exhalation prolapsed. Infringement of a skeleton of a thoracic cell conducts to infringement of the bio-mechanics of respiratory
movements and development of acute respiratory insufficiency.
The clinic and condition of the wounded is defined by the size of a shutter of a thoracic cell.
The more the sizes of a shutter, the it is heavier a condition.
The clinic of windows fractures of ribs develops of symptoms of a shock, respiratory insufficiency and local symptoms of fractures.
The basic complaint - a strong pain in a place of fractures of the ribs, the complicated
26
breathe.
At anamnesis: a short wind, cyanosis the skin, the compelled position of the patient, restriction of respiratory excursions. There is a reduction AP up to 100 and is lower, a tachycardia up
to 110-120 in one minutes. At auscultation in lung on the side of damage breathe is weakened, define variated rattles. The shutter of a window of a chest wall, sharp morbidity and crepitation in
places of fractures of ribs is locally defined flotating.
Diagnostics is under construction on the basis of clinic, x-ray research of a thoracic cell. Diagnostic actions will be carried out together with medical (antishock therapy, analgetics, reanimation actions). These actions carry out(spend) in conditions antishock with participation of reanimatologist, the therapeutist.
Treatment: the wounded from an accident ward is located in chamber of reanimation and intensive therapy under supervision reanimatologist. The following actions will be carried out(spent):
1. Restoration of passableness of respiratory ways and treatment of acute respiratory insufficiency:
auxiliary ventilation lung, insuflation of oxygen, AVL, thracheostomy with adequate draining and
sanitation of tracheobronchial tree, medicative bronchoscopy.
2. Infusion, antishock therapy.
3. Medication of painful syndrome: novocain blockade, analgetics, narcosis, long Peridural
anesthesia.
4. Antibacterial therapy.
5. Stabilization of a bone skeleton of a thoracic cell. Methods and ways of stabilization are
various. This question остаётся дискутабельным until recently. Duly and adequate conservative
therapy results in improvement of a condition suffering and disappears necessity for stabilization of
a chest wall. "Internal stabilization" will be carried out so-called - the patient is long keeps on AVL,
it is desirable on ultrahighfrequency.
After deducing the patient from a shock, medicating of acute respiratory insufficiency and
stabilization of a condition, it is translated in surgical branch. Further the therapy described in section about fractures of ribs will be carried out.
Complications.
1. A respiratory dystress-syndrome (shock lung)
2. A posttraumatic pneumonia.
3. Atelectasis lung.
4. Purulent complications.