DOI: https://doi.org/10.22141/2224-0586.7.94.2018.150817

Medical protection for combined injuries: doctor’s tactics in infection of the wound and burn surface with poisonous substances

L.A. Ustinova, O.A. Yevtodiev, N.V. Kurdil, V.M. Padalka, O.V. Ivashchenko, V.V. Andryushchenko, M.M. Kalish

Abstract


Background. The chemical factor is extremely important in the modern armed conflicts shaping the nature of the traumatic injury and the structure of sanitary losses, and therefore the role of professional training of doctors in case of combined injuries related to the chemical factor is valuable. The purpose was to study modern approaches to medical care in combined injuries caused by a combination of physical and chemical factors. Material and methods. The experience of providing medical care in cases of combined injuries in the wars and armed conflicts of the last century has been investigated. The analysis of scientific sources of Commonwealth of Independent States countries, Europe, the USA and other countries on these issues was carry out. Results. The structure of sanitary losses in modern wars and armed conflicts significantly differs from the structure of sanitary losses during the Great Patriotic War. Today, the structure of injures is characterized by increasing number of mechanical, thermal and combined injures, severe injuries and the number of not military sanitary losses. Thus, during the war in Afghanistan (1979–1989), combined injuries amounted to 1.5 %, during the military conflict in the Chechen Republic (1994–1996) — 2.4 %, in anti-terrorist operations in the North Caucasus (1999–2002) — 3.5 %. Today, one of the peculiarities of wars in Iraq and Syria is the fact that various chemicals and, most likely, the modern chemical weapons are used. The experience of previous wars has proved that the combined action is a one-step action of toxic substances and gunshot wounds and/or nuclear weapons and/or incendiary mixtures (napalm). Combined injures may occur in different ways: contaminations of the wounds or burns by chemical substances; contaminations of the wound or burn and of the body surface; the presence of the resorptive effects of the chemical substances and skin contaminations; combination of mechanical and chemical injuries. Wounds and burns occur as a result of exposure to toxic drops and liquids, aerosols and gases. Most often, chemical substances get into the wound with fragments of chemical shells, aviation chemical bombs, foreign bodies, fragments of clothing, earth, etc. In liquid or gaseous form, chemicals can penetrate through the bandage followed by adsorption from the wound and the burn surface or contamination of the wound and the burn surface with chemical substances present in the surface air layer. Therefore, any wound or burns received due to chemical damage should be considered as potentially infected, and appropriate organizational and therapeutic measures must be carried out. In all combined injures, there are symptoms of local and general action of a chemical substance. The severity of local changes and overall action depends on the localization of the wound, the toxic properties of the toxin, the dose, duration of exposure, the area of the affected area. The combined injures are characterized by a syndrome of mutual encumbrance. Among all poisonous substances, the most dangerous toxic substances are blister agents (mustard gas and lewisite) causing significant degenerative, necrotic changes in living tissues. The methods of chemical indication of toxins in the wound and on the burning surface are relatively simple and must be performed in field conditions. The X-ray examination is of practical significance, it is based on the contrast effects of the some vesicants. Lewisite and phosphorus have especially great contrast effects. Lewisite may be found in the wound 5 hours after the incident, phosphorus — 24 hours after or more. The nature and extent of medical care in the site of damage and at the stages of medical evacuation with combined chemical lesions has peculiarities. The first medical aid is carried out directly on the site of the lesion and includes: stopping bleeding; application of a protective dressing; immobilization of fractures; anesthesia; antidotes; artificial respiration; partial sanitation; evacuation. The first medical aid also includes oxygen therapy; reintroduction of antidotes; administration of antibiotics, anti-viral serum and toxoid; anesthesia; evacuation. In case of mass injuries, the treatment of a wound or burn is carried out only for health reasons. The qualified medical assistance for combined chemical lesions consists of surgical intervention, intensive care and detoxification. Vesicants and nerve agents remain on the burning surface for a long time. The absorption is very slow, so the chemical reaction to mustard gas, lewisite and organophosphorus substances in the area of wound and burn can be positive within 3–4 days after contamination. From the wound area, toxic substances are gradually absorbed and cause severe intoxication. Such wounds pose a great danger not only to the victims, but also to others at all stages of medical evacuation. Conclusions. Medical support in combined injures cases must involve surgical interventions, decontamination, antidotes, and assistance at all stages, but should be provided by medical staff trained in safety rules and treatment of combined injuries.


Keywords


military toxicology; medical support

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