Military Surgery with Emergency Surgery - V.Ya. Bilyi 2004

Combined Trauma

Introduction. In modern warfare, combat pathology presents with A wide variety of forms. To the well-known Definition of the founder of military field surgery, N.I. Pirogov, who described war as an "epidemic of trauma," it must be added that warfare involving weapons of mass destruction constitutes not only an "epidemic" of trauma but also an "epidemic" of thermal, chemical, bacteriological, radiological, and combined injuries.

In wartime, combined radiation injuries (CRIs) most frequently occur during nuclear detonations, when multiple destructive factors act simultaneously or sequentially under METABOLISM/18.html">The Influence of radiation and other damaging agents of nuclear and conventional weapons.

The first data on CRIs were reported by the joint commission of American and Japanese specialists that investigated the aftermath of the nuclear attacks on the Japanese cities of Hiroshima and Nagasaki. In Hiroshima, among the survivors on the 20th day following the nuclear blast, approximately 43.5 thousand people sustained a single type of injury and about 28.5 thousand sustained combined injuries; in Nagasaki, these figures were 14.4 and 10.6 thousand, respectively. Thus, The ratio of isolated to combined injuries in both cities was 3:2. The occurrence and frequency of CRIs among casualties depend on numerous factors: the yield of the explosion, its type, Location, meteorological conditions, and the degree of troop protection. CRIs can account for about 30% of combat casualties, and under certain conditions, up to 70-80% of all casualties.

General characteristics of combined trauma (CT). Combined injuries are defined as those resulting from the simultaneous or sequential action of two or more damaging factors from the same weapon type (e.g., nuclear) or multiple weapon types. In this case, The Effect of each individual damaging factor incapacitates the casualty and impairs their performance.

An important feature of combined trauma is The Development of the mutual aggravation syndrome, in which the pathological process caused by each individual factor proceeds more severely than conventional single-factor injuries. The severity of combined injuries is determined by the cumulative impact of all traumatic factors on the body.

The number of possible combinations of damaging factors in modern warfare is quite large. Among CTs, those of greatest practical importance include combined radiation, chemical, and mechanothermal injuries.

Combined radiation injuries (CRIs). CRIs are injuries in which mechanical or thermal trauma is combined with radiation sickness, with radiation injury being an essential component.

CRIs may develop at the moment of a nuclear explosion or during operations by personnel in areas contaminated with radioactive substances (RS).

The MAIN TYPES OF CRIs are radiation-mechanical, radiation-thermal, and radiation-mechanothermal injuries.

The effect of the radiation factor is determined by the type of radiation, the degree of uniformity of its impact on the body, and the absorbed dose. The absorbed dose is measured in grays (Gy). 1 Gy equals 100 rad.

Most commonly, CRIs occur from the detonation of nuclear warheads with a yield of 20-50 kt. Lower-yield detonations typically result in "pure" radiation injuries, whereas detonations exceeding 100 kt are dominated by mechanical and thermal injuries.

Radiation injuries resulting from a radioactive cloud can be caused by the deposition of RS on the Skin or wound surfaces, or by internal intake via the respiratory or gastrointestinal tracts. External remote exposure to radioactive substances leads to the development of acute or subacute radiation sickness, while RS deposition on the skin or in a wound, as well as internal incorporation, causes local radiation injuries and radionuclide retention, leading to chronic radiation sickness.

The pathological process in CRIs does not result from a simple summation of two or more injuries; rather, it represents a complex organismal reaction with specific features known as the mutual aggravation syndrome.

The mutual aggravation syndrome, which depends on the severity of the wound or burn as well as the dose of penetrating radiation, causes each component of the CRI to run a more severe course than it would as an isolated injury. The mutual aggravation syndrome in CRIs manifests when its individual components reach a specific degree of severity (no lower than moderate). In radiation-thermal injuries, this syndrome is more pronounced than in radiation-mechanical ones. With total body uniform irradiation (dose of 1-2 Gy), the clinical course of wounds and Burns does not differ significantly from the conventional course. At higher doses, the frequency and severity of burn and Traumatic Shock increase, mortality rises, wound cleansing and tissue repair are delayed, fracture consolidation slows down, and the number and severity of infectious complications increase.

When severe trauma and burns are combined with radiation injuries, the severity of the latter increases markedly: the height phase of radiation sickness sets in 5-10 days earlier, and pancytopenia, coagulopathy, hemorrhagic manifestations, and a tendency toward generalized infections become more pronounced. It is considered that severe trauma or a burn increases the severity of a radiation injury by 1 grade. The radiation dose at which a successful outcome remains possible in double combinations (acute radiation sickness with a burn or trauma) drops to 4.5 Gy, and in triple combinations (acute radiation sickness with trauma and burns), it drops to 3 Gy.

The severity of CRIs and their medical-tactical characteristics are presented in Table 4.

Periods of the clinical course and General Principles of medical care in CRIs.

Based on the severity of symptoms of the main components, 4 periods of CRI are distinguished (Table 5).

Class="center">Table 5 Periodization of clinical manifestations of CRI

The 1st (acute) period of CRI is characterized by prominent symptoms of traumatic and burn disease (shock, Blood loss, respiratory disorders, etc.). Signs of the primary radiation reaction (nausea, vomiting, adynamia, skin hyperemia, etc.) take a backseat in the presence of severe mechanical and burn trauma. Conversely, they dominate when a significant radiation dose is combined with mild non-radiation injuries.

Dosimetry is essential for assessing the radiation component. During this period, primary efforts should focus on providing emergency medical care for wounds and injuries (relieving asphyxia, stopping bleeding, stabilizing the Functions of the Heart, Lungs, and other vital Organs). Life-saving surgical interventions and intensive care must be performed. In radiation-thermal injuries, medical care consists of pain management, wound dressing, and intensive therapy. It is necessary to prevent and relieve the primary radiation reaction (using etaperazine or dimethcarb, atropine sulfate, dimethpramide, diacafen) combined with detoxification therapy utilizing cardiac Glycosides, diphenhydramine, and phenazepam.

In the 2nd period, the clinical picture of CRI is determined primarily by the nature, severity, and localization of non-radiation injuries. Traumatic and burn diseases in this stage of CRI lead to pronounced intoxication with a high incidence of infectious complications, progressive anemia, and exhaustion. The radiation component primarily manifests as hematological shifts: leukopenia, lymphocytopenia, reticulocyte count reduction, and qualitative blood Cell changes.

This period must be utilized to the maximum extent to provide full-scale qualified and specialized medical care. Early surgical debridement of wounds is performed in combination with antibiotic therapy and The Use of delayed primary or early secondary sutures. Efforts should be made to ensure that wound healing occurs before the onset of acute radiation sickness.

In cases of bone fractures, early reposition and fixation of fragments should be ensured whenever possible, as bone healing may proceed favorably during this time. In radiation-thermal injuries, active Surgical Treatment of burns can be performed for limited burns (not exceeding 3-5% of the body surface) and mild acute radiation sickness. It should be noted that single-stage skin autografting results in successful graft take when performed on viable Tissues.

The 3rd period is dominated by symptoms of radiation sickness. The general condition deteriorates, and signs of endotoxemia increase. Necrotic tonsillitis, gingivitis, enterocolitis, and Pneumonia develop. Numerous hemorrhages and bleeding occur. Wound infection is activated. The zones of necrotic areas in the region of wounds and burns expand, regeneration is sharply suppressed, and pancytopenia increases, reaching its maximum severity. The 3rd period is often critical for the casualties, as many severe and life-threatening complications arise during this time.

During the 3rd period, comprehensive treatment of radiation sickness is administered to relieve hematological, hemorrhagic, gastrointestinal, asthenoneurotic, and toxemic syndromes; Prevention and treatment of infectious complications and cardiopulmonary failure are also carried out.

Surgical interventions at this stage are performed strictly for vital indications using blood-clotting-enhancing agents (epsilon-aminocaproic acid, ambene, fibrinogen, proteolysis inhibitors, leukothrombocytes, etc.). To immobilize bone fragments in fractures, compression-distraction devices and plaster casts are recommended. The use of all types of sutures and skin autoplasty during this period is useless and dangerous.

The 4th period is the recovery phase. Residual effects of radiation and non-radiation injuries are observed: asthenic syndrome, Osteomyelitis, trophic ulcers, contractures, and scarring deformities. The function of the hematopoietic system and the immunobiological status of the Organism recover very slowly, which limits surgical activity in the comprehensive Rehabilitation of patients.

During the 4th period, therapy for residual radiation injury effects and surgical treatment of trauma and burn consequences (skin grafting, elimination of contractures, etc.) are carried out. A comprehensive rehabilitation program is implemented (high-calorie Nutrition combined with anabolic agents, general tonic medications, hematopoiesis stimulants, physical therapy, and physiotherapy).

Provision of medical care to casualties with combined radiation injuries at medical evacuation stations.

First aid measures include:

- relief of asphyxia (clearing the Oral Cavity and Upper Respiratory Tract from vomit, foreign bodies, etc.);

- temporary cessation of external bleeding (tourniquet, improvised tourniquet, pressure bandage);

- application of a dressing to the wound or burn surface, and an occlusive dressing for open pneumothorax using an individual dressing pack;

- immobilization using improvised means or standard splints in case of fractures and severe injuries;

- administration of promedol solution (via syringe tube);

- oral intake of an antiemetic (dimetcarb) in case of severe primary reaction;

- taking an antibiotic from the individual first-aid kit;

- evacuation or extraction of casualties from the affected areas.

Pre-medical care measures include:

- relief of asphyxia (clearing the oral cavity and upper respiratory tract from vomit, artificial lung ventilation via Mouth-to-mouth or mouth-to-Nose Methods, use of the TD-1 airway);

- cessation of external bleeding (tourniquet, pressure bandage, improvised tourniquet), monitoring of previously applied tourniquets and dressings;

- application and adjustment of previously applied dressings;

- immobilization for fractures and major injuries using standard splints from the B-2 kit;

- administration of analgesics and antibacterial drugs (ofloxacin, ciprofloxacin, lefloxacin, fluconazole);

- oral intake of antiemetic drugs (dimetcarb, dimetpramide, atropine sulfate);

- infusion therapy (solutions: Ringer's, sorbilact, reosorbilact);

- evacuation of the casualties.

First medical care measures include:

- management of all types of asphyxia;

- temporary cessation of external bleeding, monitoring of previously applied tourniquets;

- application of an occlusive dressing for open pneumothorax;

- novocaine blocks as indicated;

- transfusion of plasma substitute solutions in traumatic and burn shock;

- catheterization or puncture of the Urinary Bladder;

- transport immobilization of injured extremities;

- administration of Antibiotics, analgesics, tetanus toxoid;

- alleviation of initial radiation reaction (oral dimetcarb, intramuscular dimetpramide, dixafen, 0.1% atropine sulfate solution, diphenhydramine, phenazepam);

- evacuation of casualties to the stage of qualified medical care.

Qualified surgical care for casualties with combined radiation injuries includes 3 groups of measures.

The 1st group includes life-saving surgical interventions:

- management of all types of asphyxia;

- cessation of bleeding of any localization;

- comprehensive therapy for traumatic and burn shock;

- laparotomy for abdominal and pelvic organ trauma;

- thoracotomy for mediastinal organ wounds, prolonged intrapleural bleeding, open pneumothorax, and tension pneumothorax when pleural drainage is ineffective;

- Craniotomy for progressive Brain compression;

- surgery for anaerobic infection.

The 2nd group includes urgent first-priority surgical interventions:

- surgery for non-bleeding major vessel injuries, especially those accompanied by extremity ischemia;

- amputations for ischemic Gangrene of the extremities resulting from major vessel injuries;

- epicystostomy for injuries to the Urethra and extraperitoneal urinary bladder;

- creation of an artificial anus for injuries to the extraperitoneal rectum;

- primary surgical debridement of wounds contaminated with radioactive and toxic agents;

- toilet of burn wounds contaminated with radioactive substances and CW agents.

Group 3 includes urgent secondary surgical interventions that can be postponed without the risk of developing severe complications. These measures comprise: primary surgical debridement of small wounds and closed fracture reduction.

Specialized medical care is provided in dedicated multidisciplinary surgical hospitals, each offering optimal conditions for the Diagnosis and comprehensive modern treatment of casualties with RCI. The treatment team involves specialists from various fields: surgeons, internists, radiologists, combustiologists, transfusiologists, psychoneurologists, and anesthesiologists-resuscitators. It must be taken into account that in the event of mass casualty incidents, every TerGB military hospital must be prepared for intensive multidisciplinary operations when receiving casualties with RCI.

Along with surgical treatment, comprehensive therapy aimed at normalizing the functions of vital organs and systems should be administered:

- restoration and replacement of hematopoiesis;

- transfusion of red blood cell mass, Bone Marrow, leukothrombocytic suspension, or platelet concentrate;

- reduction of hemorrhagic syndrome manifestations through the transfusion of epsilon-aminocaproic acid, fibrinogen, and platelet suspension;

- body detoxification via plasma expander infusions and diuresis stimulation;

- enhancement of immunobiological defense factors through the transfusion of protein solutions (albumin, globulin), administration of Vitamins, Hormones, and proteolysis inhibitors, as well as high-nutritional support;

- prevention and treatment of infectious complications (using antibiotics and sulfonamides).

Surgical treatment of casualties with RCI who have wounds contaminated with radioactive substances. When wounds are contaminated with radioactive substances, a portion of these agents remains in the wound for a long time due to delayed absorption. A dressing applied to a wound contaminated with radioactive substances absorbs up to 50% of these agents, and a dressing with a hypertonic solution absorbs even more. Such injuries are considered hazardous to others and are segregated into a separate stream during first aid. Here, they undergo partial sanitation and receive first medical care with mandatory dressing replacement.

During the provision of qualified medical care in the special Processing department (SPD), casualties with radioactive contamination exceeding permissible limits undergo full sanitation. All wounds contaminated above the permissible level are subject to surgical debridement. Tissue excision should be performed early, ideally before the wound is fully cleared of radioactive substances. Thorough radiometry of the patients' bodies, excreta, dressings, instruments, and the surgeon's gloves is also required.

The operating table used for treating wounds contaminated with radioactive substances must be covered with oilcloth. Operating surgeons must be protected from radioactive contamination by long aprons, two gowns (worn overlapping each other), rubber boots, gloves, safety goggles, and eight-layer masks.

The purpose of primary surgical debridement of wounds contaminated with radioactive substances, aside from preventing wound infection, is the maximum removal of radioactive agents from the wound and the reduction of internal radiation hazards. If surgical debridement has not cleared the wound of radioactive substances, as determined by repeated radiometric control, additional tissue excision should be performed. Postoperative wounds are managed openly using absorptive dressings, followed by delayed primary or secondary suturing.

All contaminated dressing Materials and excised tissues are collected and buried in the ground to a depth of at least one meter. To decontaminate instruments, they are washed with hot Water in two basins, wiped with cloths soaked in a 0.5% acetic or Hydrochloric acid solution, washed with water once more, and wiped dry.

Combined chemical injuries (CCI). CCI occur due to the simultaneous or sequential action of chemical agents (toxic agents) and other damaging factors (trauma, burn). The interaction of multiple factors leads to a mutual aggravation syndrome.

Toxic agents may be delivered using aerial bombs, artillery shells, mines, chemical landmines, missiles, and special spray devices. Determining whether the skin, clothing, and wounds of casualties are contaminated with toxic agents is not always straightforward. One should consider the enemy's use of chemical weapons and uniform Complaints from casualties evacuated from the same combat sector. Upon examination of the wounded, traces of toxic agents on dressings and uniforms, an unusual odor, tissue Swelling around wounds, and other signs may be detected.

Supplementary diagnostic methods may include: chemical indication of toxic agents in the wound, histological examination of affected tissue, and radiography of the wound area. When examining a casualty with CCI, attention should be paid to the following symptoms:

- pain sensations. The entry of lewisite or phosphorus compounds into the wound causes severe burning pain;

- odor. When sulfur mustard enters the wound, a mustard-like odor can be detected. Lewisite smells of geranium, diphosgene smells of rotting hay, and hydrocyanic acid imparts the odor of bitter almonds to the wound;

- discoloration of tissues. Mustard gas in the wound appears as brownish-gray spots, lewisite as ash-gray spots, and phosphorus causes deep burns; in hydrocyanic acid poisoning, the tissues in the wound are red;

- bleeding. Wounds contaminated with lewisite, carbon monoxide, and hydrocyanic acid bleed more profusely;

- tissue edema. Rapid onset of edema is characteristic of wounds contaminated with vesicant toxic agents;

- Changes in the skin around the wound. Skin contact with lewisite causes bullous dermatitis, whereas exposure to mustard gas produces blisters filled with yellow fluid that appear on the skin only by the end of the first day;

- tissue necrosis. Tissues in the wound exposed to vesicant toxic agents undergo rapid necrosis, with the extent of tissue death depending on The Nature of the poison, its quantity, and the duration of exposure;

- resorptive action. Poisoning with high concentrations of lewisite and mustard gas is accompanied by pulmonary edema and Central Nervous system disorders.

There are several methods for identifying CWAs that have entered a wound. Chemical detection methods are universally available and, if a PKhR-MV device is present, can be used in the field. Microscopic tissue examination and wound radiography require specialized equipment and expertise.

Material for examination from a wound or other sites should be collected prior to the application of decontamination agents. The material is placed in a test tube and filled with alcohol, in which the CWA is then determined. The presence and Nature of the CWA are judged by the appearance of a specific coloration of the extract when special indicators are applied.

X-ray Examination has a certain practical significance in identifying vesicant CWAs, especially lewisite. Some vesicant CWAs absorb X-rays and act as radiopaque agents; therefore, this method is used to diagnose the presence of CWAs, monitor quantitative changes in the toxic agent at various intervals after wounding, and control the adequacy of surgical debridement of a contaminated wound.

Treatment of wounds contaminated with CWAs. Primary surgical debridement remains the main treatment for wounds contaminated with vesicant CWAs. Its objectives include not only the prevention of wound infection, but also the removal of the toxic agent from the body. All firearm wounds contaminated with CWAs, including multiple shrapnel wounds, require surgical debridement with the removal (if possible) of all foreign bodies.

Before initiating PSD, the skin around the wound should be decontaminated: for mustard gas contamination, with a 10% alcoholic chloramine solution; for lewisite contamination, with a 5% iodine solution. In both cases, the wound surface is treated with a 5% hydrogen peroxide solution. Decontamination of the skin and wound surface can also be performed using the IPP-10 kit.

All manipulations in contaminated wounds are performed wearing gloves, using the necessary amount of instruments and dressing materials, which must be sufficient due to their frequent replacement during the operation. During the Procedure, gloves should be rinsed every 15-20 minutes with a decontaminating solution, followed by isotonic sodium chloride solution. Instruments are disinfected by wiping them with a napkin moistened with gasoline, and then boiled for 20-30 minutes in a 2% sodium bicarbonate solution. Contaminated surgical gloves are washed with warm water and soap, then immersed for 20-30 minutes in a 5% alcoholic chloramine solution and boiled in water (without adding sodium bicarbonate) for 20-30 minutes. Contaminated dressing materials used during the operation are discarded into containers with a decontaminating agent and subsequently destroyed.

Before the operation, the surgeon puts on: a cap, goggles, an eight-layer mask, a oilcloth apron, rubber boots, 2 sterile gowns (fastened in opposite directions), and surgical gloves.

During the PSD of wounds contaminated with CWAs, it is necessary to excise crushed, necrotic, and poison-contaminated tissues. Subcutaneous adipose tissue must be excised with particular care because it readily absorbs and retains CWAs for a long time. The excision of affected Muscles must also be radical, as retracted Muscle fiber segments can draw CWAs deeper into the wound. Blood Vessels directly affected by vesicant CWAs are ligated to prevent potential massive recurrent Hemorrhage. If a nerve trunk is contaminated with CWAs, it should be treated with a decontaminating solution and covered with healthy tissue. Bone wounds also require thorough treatment, as Bone tissue rapidly absorbs and persistently retains vesicant CWAs. Bones affected by CWAs rapidly develop necrosis, followed by The formation of sequestra and osteomyelitis with a severe and protracted clinical course.

All sources of contamination in penetrating (blind) wounds must be removed, as they act as reservoirs for CWAs. Radiography is performed to pinpoint their location, and a specialized device—a metal detector—facilitates the search for metallic foreign bodies.

The final step of PSD is wound drainage using tubular drains and infiltration of the tissues surrounding the wound tract with an antibiotic solution. Primary wound closure is strictly prohibited. To accelerate wound healing, delayed primary or secondary sutures should be applied.

PSD of CWA-contaminated wounds in various anatomical locations has its own specific features:

- surgical debridement of contaminated cranial and brain wounds must be accompanied by continuous irrigation of the wound with a 5% hydrogen peroxide solution. All tissues contaminated with CWAs, as well as bone fragments, are removed. The dura mater is treated with a decontaminating solution, incised, and the hematoma is evacuated. Brain detritus is carefully aspirated using a bulb syringe, followed by gentle flushing of its remnants with a bulb syringe filled with warm isotonic sodium chloride solution. Searching for foreign bodies deep within the brain, even if contaminated with CWAs, is strictly prohibited. At the end of the procedure, the wound is rinsed with a 5% hydrogen peroxide solution, drained, and an aseptic dressing is applied;

- surgical debridement of contaminated chest wall wounds, and thoracotomy when indicated, involves the excision of non-viable and contaminated tissues. Traumatized rib segments must be resected beyond the boundaries of CWA contamination. Surgical debridement of lung wounds involves sparing excision of the lung tissue (it is relatively resistant to CWAs), removal of bone fragments from destroyed Ribs, and, ideally, removal of contamination sources in blind wounds. The pleural cavity must be drained with tubular drains to evacuate pleural contents, irrigate the pleural cavity, and administer antibiotics;

- in penetrating abdominal wounds contaminated with vesicant CWAs, PSD of abdominal wounds is indicated in all cases. Laparotomy through the wound itself is not recommended. Intestinal loops adjacent to the affected peritoneal area exhibit a bright crimson color, sometimes with areas of necrosis that can become a source of Peritonitis. Such areas should be excised and sutured; if There is a large area of necrosis in the Small Intestine, resection of that intestinal segment with an end-to-end anastomosis is performed. If an area of necrosis is detected in the Large Intestine, it is excised, and the bowel is brought out onto the abdominal wall as a colostomy. Laparotomy is concluded by placing a perfusion tube into the pelvic cavity for continuous irrigation of the peritoneal cavity, peritoneal dialysis, and antibiotic administration;

Scope of care at a medical station during chemical weapons use (CWU). The provision of medical care to casualties from CWU begins on the battlefield. Self-aid and buddy-aid are of crucial importance in this regard.

First aid includes: rapidly donning a gas mask; temporary cessation of bleeding; administration of antidotes; initial decontamination using the individual chemical prophylaxis packet; applying a wound dressing; immobilization of injured limbs; administration of analgesics via a syringe-tube; prompt evacuation or removal from the contamination zone.

Pre-medical care includes: repeated administration of antidotes; applying or readjusting dressings; checking applied tourniquets; administration of analgesics; non-sondage gastric lavage and administration of an adsorbent in cases of mustard gas and lewisite poisoning; washing the eyes with water or a 2% sodium bicarbonate solution in mustard gas and lewisite poisoning; administration of cardiac and respiratory stimulants; taking oral antibiotics.

First medical care includes: - repeated administration of organophosphate CWAs antidotes — intramuscular injection of 1-2 ml of budoxime, 2-3 ml of a 15% dipyroxime solution; - partial special processing, if possible, with a change of underwear, uniform, and dressings; - chemical decontamination of wounds (burns) in the dressing room: for organophosphate CWA contamination — Treatment of the skin around wounds with a mixture of equal parts 8% sodium bicarbonate and 5% hydrogen peroxide solutions, and the wound itself with a 5% sodium bicarbonate solution; for mustard gas contamination — treatment of the skin around wounds (burns) with a 10% chloramine solution, and the wounds with a 5% hydrogen peroxide solution; for lewisite contamination — treatment of the skin around wounds (burns) with a 5% iodine solution, and rinsing the wounds with a 5% hydrogen peroxide solution;

- for the prevention of wound infection — administration of antibiotics and tetanus toxoid (0.5 ml);

- carrying out urgent first medical care measures for wounds, injuries, and burns;

- for seizures or psychomotor agitation in casualties poisoned by organophosphate CWAs — administration of 1 ml of a 3% phenazepam solution or 5 ml of a 5% barbamyl solution;

- administration of cardiac, vascular, and analgesic agents.

Morphine is contraindicated in organophosphate CWA poisonings; it is advisable to use analgin with diphenhydramine.

Qualified surgical care includes: complete special processing; administration of antidotes; surgical interventions for life-saving indications — progressive intracranial compression, persistent hemorrhage of any localization, asphyxia, open and tension pneumothorax, major limb vessel injuries, anaerobic infection; PSD of CWA-contaminated wounds; infusion and detoxification therapy; evacuation of casualties from the CWU zone.

Specialized surgical care for COMB is provided in specialized hospitals.

Combined thermomechanical injuries (CTMI). CTMI occur As a result of a combination of burns caused by the light radiation of a nuclear explosion, fire flames, or incendiary mixtures, together with mechanical trauma caused by a blast wave (mine-blast injuries) or various damaging elements (bullets, shrapnel, arrows). The severity of the mechanical trauma, its localization, as well as the area and depth of the burn collectively determine the Features of the Pathogenesis and clinical course of thermomechanical injuries.

In multiple and combined mechanical injuries associated with burns, clinical symptoms depend on the predominance of damage to specific organs, as well as the area and depth of the burn. A complex burn-traumatic shock develops. Bleeding from damaged tissues and organs, along with plasma and Lymph loss from traumatized and burned tissues, causes hypovolemia, hemodynamic disorders, and impaired Oxygen transport. Dysfunction of damaged organs, including burned skin areas, is of critical importance. Reduced Blood supply to tissues and organs due to hypotension contributes to increasing Hypoxia, the onset of acidosis, and the appearance of toxic substances in the blood. Intoxication is exacerbated by the absorption of breakdown products from traumatized, burned, and ischemic tissues, leading to impaired renal and hepatic function. The mutual aggravation syndrome in such injuries manifests as an increasing severity of the general reaction to combined trauma, especially in its early period. Shock develops more rapidly and is more pronounced than in isolated burns or mechanical INJURIES OF THE same magnitude.

In CTMI, mechanical trauma (cavity wounds, multiple musculoskeletal injuries) initially causes signs of traumatic shock to predominate in the clinical picture, followed by a more prolonged and severe burn shock.

Burns and mechanical injuries continue to aggravate each other even after the casualty is resuscitated from shock.

General Principles and Methods of Medical care for casualties with CTMI. The Scope of medical care and The sequence of therapeutic measures in CTMI are determined by the type of injury and the primary component for a given period. In the early stages, emergency care must address the consequences of mechanical trauma. Vital-indication surgical Procedures are performed for wounds and trauma of the abdomen, thoracic cavity, Skull, and brain, as well as for hemorrhage and anaerobic infection. In the early stages, a burn wound usually does not require surgical intervention, except for escharotomy in deep (IIIb–IV degree) circular burns of the extremities, chest, and neck. Treatment of burn-traumatic shock should begin before surgery and continue during and after the operation.

The treatment of shock in CTMI of various localizations has the following specific features:

- for burns and trauma with massive blood loss, transfusion of Ringer's solution, rheosorbilact, sorbilact, and packed red Blood Cells is required;

- if the burn is combined with craniocerebral trauma, infusion therapy including dehydrating agents (lasix, mannitol, magnesium sulfate) is indicated;

- for a burn combined with a penetrating abdominal wound, fluids must be administered solely parenterally;

- respiratory tract involvement in burn shock is not a contraindication to infusion therapy. When inhalation injury is combined with chest trauma and Acute Respiratory Failure, a tracheostomy is performed followed by sanitation of the tracheobronchial tree;

- in combinations of burns with bone fractures, reliable fixation of bone fragments significantly reduces The impact of mechanical trauma and simplifies the treatment of the burn wound.

As the consequences of mechanical damage are addressed, the primary objective shifts to the surgical restoration of skin cover lost as a result of deep burns, which largely concludes the comprehensive surgical treatment of combined trauma.

To stimulate reparative processes and prevent or treat traumatic and burn disease, antibacterial and Transfusion Therapy is administered, and corticosteroid and anabolic hormones, as well as immune system stimulants, are widely used.

To accelerate the rejection of tissues devitalized by burns, necrolytic agents (40% salicylic acid ointment, Proteolytic Enzymes) and gentle necrectomy are used. During the debridement of burned wounds from necrotic tissues, surgical skin restoration is performed (autoplasty of granulating wounds using mesh grafts or stamp grafts).

Provision of medical care to casualties with CTMI at the medical staging areas (MSA). In a mass casualty zone, during the provision of first aid and pre-medical care, it is necessary to: extinguish burning clothing; stop external bleeding; apply a dressing to the burn surface and wound; administer an analgesic using a syringe-pen; apply a transport splint to the injured extremity; quench thirst (in the absence of contraindications).

First-line medical aid includes urgent first-aid measures: arresting external bleeding, checking the correct application of the tourniquet (where feasible at this stage), anti-shock treatment (Ringer's solution, sorbilact, rheosorbilact), applying an occlusive dressing for open pneumothorax, and performing a pleural puncture with a Dufault needle in case of tension pneumothorax.

The full scope of first-line medical aid additionally includes: drinking a salt-alkali solution; correcting improperly applied dressings and transport immobilization; administering antibacterial drugs (ofloxacin, ciprofloxacin, fluconazole, ciprofloxacin), 0.5 ml of tetanus toxoid; conduction or segmental novocaine blockades; filling out the primary medical record.

Qualified medical care includes: emergency surgical interventions: definitive arrest of bleeding, elimination of asphyxia, relief of brain compression, laparotomy for penetrating abdominal wounds, wide incisions for anaerobic infection, amputation of extremities in cases of traumatic avulsion and destruction; comprehensive therapy for traumatic and burn shock; escharotomy for circular burns of the neck and chest that impede Respiration; escharotomy for circular burns of the extremities complicated by Circulatory Disorders.

Specialized surgical treatment for COMB is provided in specialized hospitals.

When providing specialized medical care, the decision is made regarding the evacuation of COMB casualties—those unlikely to return to duty and requiring prolonged treatment—to rear hospitals of the Ministry of Health of Ukraine.