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MINISTRY OF HEALTH UKRAINE

BUKOVYNIAN STATE MEDICAL UNIVERSITY

Ratified”

On a methodical conference

Department of surgery

Head of department

Professor I.Yu. Polyanskiy

“___” ___________ 20__y.

METHODICAL DIRECTION

to the students of ІV course medical faculties

FOR INDEPENDENT WORK

AT PREPARATION TO PRACTICAL LESSON

MODULE 4

BASES OF SURGERY

Themantic module 8

";The damage of the chest cavity. Clinic and diagnosis of pneumothorax, hemotorax, hylotorax.Therapeutic approaches";

Educational discipline:

Surgery

a ІV course a medical faculty

6 hours

Methodical direction made and translate:

as. Voytiv Ya.Yu.

Chernivtsi – 2010

1. Scientific-methodical study topics

Nowadays there is increasing frequency of surgical pathology of the lungs and pleura, requiring urgent surgical intervention. This is due, primarily, with the growth of mechanical damage caused by the increasing number of vehicles, mechanization of the economy, the population of the abuse of alcohol and thus increase traffic accidents. Injuries to the chest requiring emergency medical activities, as examination of patients, identify the causes of the pathological condition should be conducted in the most compressed time. This requires extensive knowledge of clinical manifestations of different types of traumatic injuries, their ranniz and late complications.

Pneumothorax - syndrome that develops when air enters the pleural cavity.

Hemotoraks - is the accumulation of blood in the pleural cavity due to damage to the lung parenchyma, intercostal arteries or diaphragm.

Hilotoraksom called progressive accumulation of chyle in the chest cavity - a lymph with a high content of fat. The emergence hilotoraksu associated with violations of intact thoracic duct and pariyentalnoyi pleura and a complication of various pathological processes. With all their diversity appearance hilotoraksu quickly leads to the development of clearly delineated local and general disorders that are leading in the current and forecast diseases or injuries that caused his emergence as a separate allocation hilotoraksu nosological forms reasonably practical terms.

2. Duration: _5_hours.

3.1. The student should know:

• definition of chest trauma, pneumothorax, and hemotoraksu hilotoraksu;

• mechanisms of chest trauma, pneumothorax, and hemotoraksu hilotoraksu;

• diagnostic possibilities of additional methods of research (laboratory, instrumental) injuries of the chest cavity;

• prognosis of chest trauma, pneumothorax, hemotoraksu, hilotoraksu;

• modern conservative and operative treatment methods and principles of surgery for injuries of the chest cavity;

• first aid and medical treatment tactics with injuries of the chest;

• rehabilitation of patients in the postoperative period;

• indications and contraindications and procedure for referral of patients with a spa treatment;

3.2. To be able to:

• examine patients with chest trauma, a plan of survey of the patient;

• Determine an individual model of the pathogenesis of chest trauma, pneumothorax, hemotoraksu, hilotoraksu;

• set the preliminary diagnosis;

• a plan of survey of the patient;

• Conduct clinical and laboratory diagnosis of chest trauma;

• analyze the results of sputum, bronchoscopy data, radiographic studies;

• interpret radiographs: radiography of the chest (pneumothorax, hydro - or hemotoraks);

• carry out differential diagnosis of chest trauma;

• carry out differential diagnosis of pleurisy, atelectasis lung piopnevmotoraksom, pneumothorax, pneumonia, abtsesom, gangrene of the lungs, bronchiectasis;

• formulate a reasonable clinical diagnosis examined the patient in accordance with the terms of modern classification;

• provide first aid and medical treatment to determine tactics for injuries of the chest;

• Identify the shows to puncture treatment and drainage of the pleural cavity injuries of the chest cavity;

• perform puncture of pleural cavity, draining it through the rehabilitation of drainage and puncture;

• prepare patients for surgery and postoperative care to patients;

• Identify and rehabilitation of patients in the postoperative period;

• Identify and tactics issues of medical and social expertise, employment, prevention of diseases of the lungs and pleura;

• draw up medical records (medical history, individual map outpatient, leaf disability sanatorium card).

3.3. Learn practical skills:

• collecting history in the patient with injury of the chest cavity;

• Review patient with damage to the chest cavity;

• of auscultation, percussion and palpation when lesions of the chest cavity;

• method of preparing the patient for radiological and endoscopic investigations;

• reading radiographs: radiography of the chest (pneumothorax, hydro - or hemotoraks).

• providing emergency care to patients with injuries of the chest;

• fulfilling the preoperative preparation and postoperative management of the patient;

• implementation of puncture and drainage of the pleural cavity through the drainage rehabilitation and puncture;

• first aid for injuries of the chest cavity.

4. Basic knowledge, skills, skills needed to study topics (interdisciplinary integration)

The names of previous subjects received skills

1. Anatomy, topographic anatomy (department of human anatomy, topographic anatomy and operative surgery)

2. Pathological anatomy (Department of Pathology and Forensic Medicine)

3. Physiology (Department of Normal and Pathological Physiology)

4. Propedeutics Internal Medicine (Department

Internal Medicine).

5. Faculty therapy (therapy department and Infectious Diseases)

6. General Surgery (Department of General Surgery)

7. Faculty surgery (Department of Surgery)

8. Hospital surgery (Department of Surgery and Urology)

5. Tips student.

5.1. Content topics:

Injuries to the chest can be closed and open.

Closed chest trauma are divided:

1. With or without combined injury:

1.1 isolated chest trauma

1.2 combined injuries of the chest (with a brain injury, with damage to abdominal organs, with damage to the bones of the skeleton)

2. On the mechanism of injury:

2.1 slaughter

2.2 Compression

2.3 shakes

3. By the nature of the anatomical lesions of bone and cartilage framework of the chest:

3.1 without prejudice to the integrity of bones and cartilage of the chest;

3.2 out of violation of the integrity of ribs, sternum.

4. By the nature of injuries of the chest:

4.1 without damage internal organs

4.2 with damage to internal organs

5.1 Early complications: a) pleural, b) lung and c) the mediastinum, d) subcutaneous emphysema, e) ";shock lung";, e) ";flotuyuchy chest"; is) traumatic asphyxia, h) traumatic shock.

5.2 Late complications: a) post-traumatic pneumonia, b) traumatic pleurisy, c) suppurative disease of the lungs and pleura

6. As kardiopulmonalnoyi system:

6.1 without manifestations of respiratory failure (DT)

6.2 Acute respiratory failure (1, 2, 3 tbsp.)

6.3 with no signs of acute heart failure (1, 2, 3 tbsp.)

7. According to the severity of injury:

7.1 light

7.2 average

03/07 heavy

Open chest trauma (injury).

Classification of wounds of the chest Vishnevsky AA, Schreiber, MI (1968):

1. Gunshot and nevohnepalni.

2. Permeable and impermeable

3. With damage and without damage to bones

4. Blind, cross-cutting, skovzni

Permeable injuries are divided into:

• Without an open pneumothorax

• In open pneumothorax

• The valve pneumothorax

Tsybyrne KA, Milkov BA (1989) divided permeable injury to:

• The damage to internal organs;

• No damage to internal organs;

• Complicated pneumothorax, hemotoraksom, emphysema, isolated, combined;

• thoraco-abdominal.

Classification of chest injuries by ICD - 10

Chest trauma

(S 20-S29)

S20 Superficial injury of the chest

S20.0 bruise breast

S20.1 Other and unspecified superficial injuries of breast

S20.2 chest bruise

S20.3 Other superficial injuries the anterior chest wall

S20.4 Other superficial injuries posterior chest wall

S20.7 Multiple superficial injuries of the chest

S20.8 Superficial injury of other and unspecified parts of thoracic

cells

S21 Open wound chest

Excluded: traumatic:

- Hemopnevmotoraks (S27.2)

- Hemotoraks (S27.1)

- Pneumothorax (S27.0)

S21.0 Open wound of breast

S21.1 Open wound anterior chest wall

S21.2 Open wound back wall of the chest

S21.7 Multiple open wounds of the chest wall

S21.8 Open wound of other parts of the chest

S21.9 Open wound of unspecified chest

S22 Fracture of rib (ribs), sternum and thoracic spine

Included: thoracic:

- Arc vertebra

- Neural processes

- Transverse process

- Vertebra

Excluded: fracture:

- Clavicle (S42.0)

- Scapula (S42.1)

S22.0 Fracture of thoracic vertebra

S22.1 Multiple fractures of thoracic spine

S22.2 Fracture of sternum

S22.3 Fracture of ribs

S22.4 Multiple fractures of ribs

S22.5 Zapadayucha chest

S22.8 Fracture of other parts of bony thorax

S22.9 Fracture of unspecified bone chest

S23 dislocation, stretching and damage joints and capsular-ligamentous

machine chest

S27 Injury of other and unspecified chest cavity

S27.0 Traumatic pneumothorax

S27.1 Traumatic hemotoraks

S27.2 Traumatic hemopnevmotoraks

S27.3 Other injuries of lung

S27.4 Injury of bronchial

S27.5 Injury of the thoracic trachea

S27.6 Injury of pleura

S27.7 Multiple injuries of the chest cavity

S27.8 Injury of other refined the chest cavity

S27.9 unspecified injury of the chest cavity

S28 Rozdavlennya thorax and traumatic amputation of part of the chest

Crushed chest S28.0

S28.1 Traumatic amputation of part of the chest

Excluded: cross section of the trunk at chest level

(T05.8)

S29 Other and unspecified injuries of the chest

S29.0 Injury to muscle and tendon at thorax

S29.7 Multiple injuries of the chest

S29.8 Other specified injuries of the chest

S29.9 unspecified injury of the chest

Closed chest trauma.

Ambulatory diagnosis. Closed chest injury are very diverse, which gave rise to the creation of different classifications. However, common to all the signs are divided into uncomplicated and complicated, with fractures of the ribs, sternum, ribs without fractures, chest.

Simple chest trauma.

The main complaints of chest injury without violating the integrity of the bones is pain at the site of damage. Depending on the nature of injury, location of pain is limited, strictly localized, or spill that covers a large area or the entire half of the thorax. Pain decreases at a fixed thorax. The intensity of pain depends on the strength and nature of injury and the length of it. Sometimes patients difficult to breathe through the pain. On examination may reveal swelling at the site of injury, hemorrhage, hematoma. A full break intercostal muscles may protrusion of lung tissue in the subcutaneous tissue with the formation of so-called pulmonary hernia. With intense painful response observed lag of the affected side of the chest when breathing. Auscultation of the lungs can occur weakening breath. When X-ray of the chest is behind the dome diaphragm during breathing on the side of affected persons.

In cases where damage to the chest accompanied by fractures of the ribs, the pain becomes more intense, depending of course on the number of fractures (injured ribs). Pain increases with vdosi, cough, change of position. In some cases, not the hand, attached to the affected area of ​​the chest wall, feel the bone crepitus, the same feature appears in the listening area at fracture of ribs. Pressing along a single cause rib pain at the site of the fracture. At the film is determined by line fracture rib bone fragment displacement.

It should be noted that radiographically is not always easy to differentiate a fracture from cracks. In doubtful radiological data as well as fractures of the cartilaginous rib diagnosis is crucial in clinical data.

Chest fractures occur as isolated or in combination with fractures of the ribs (with severe trauma), they may shift fragments without them. Patients usually complain of pain at the site of the integrity and strengthen chest pain when breathing, cough impulse. Objectively, in the place of injury is marked swelling and tenderness. Sometimes you can determine the shift of fragments chest.

Diagnosis of severe chest fractures (especially if there is no shift of fragments), and often they appear in the X-ray in lateral projection.

Severity of patients with chest fractures depends on the nature of collateral damage (damage to the internal thoracic artery with the formation of mediastinal hematoma and bruising of the heart).

In some cases, damage to her breast in the lower divisions, often with rib fractures, observed the phenomenon of ";acute abdomen";, which are in pain, muscle tension anterior abdominal wall, can sometimes occur and intestinal paresis.

Difficult chest trauma. The term ";complicated chest injury"; includes, along with damage to the chest defeat thoracic cavity and its organs traumatic and inflammatory nature. The most frequently observed gap pulmonary contusion, pneumonia (the latter is a late complication).

Lung damage occur as a surface, usually accompanied by pneumothorax, minor hemotoraksom and deep with a punctured lung in which the fore hemotoraks, rarely disturbed the integrity of the bronchus, esophagus, thoracic duct lymph.

Cause lung damage may be fragments of ribs, punctured lung as a result of increasing pressure vnutrishnobronhialnoho with a closed glottis and of the integrity of bullous lung formations (as in spontaneous pneumothorax). Diagnosis is based on percussion, auscultation and X-ray examination.

Subcutaneous emphysema in a closed chest trauma produced by a breach of integrity of the lung, pleura, visceral and parietal layer. In the vast majority of cases, subcutaneous emphysema is formed with rib fractures, if sharp end of the rib fragments perelamanoho break through parietal and visceral pleura and lung hurt.

Sometimes subcutaneous emphysema combined with pneumothorax. Widespread subcutaneous emphysema significantly complicates diagnosis of pneumothorax, but the direct and indirect signs of presence of air in the pleural cavity (heartbeat on the side of pneumothorax in the form of ";blast wave";), the presence of liquids - move it into the pleural cavity, horizontal level allowing it to establish pneumothorax. Pronounced subcutaneous emphysema somewhat povazhchuye of patients and a large spreading effect on the psyche of the victim.

Contusions to include those cases of lung damage when, unlike the gap lungs preserved the integrity of the visceral pleura. This may occur in different sizes hemorrhage in the lung tissue, a cavity filled with blood, air, areas of lung atelectasis, alternating with emphysematous.

Treatment of patients with uncomplicated chest trauma. The vast majority of victims with closed chest trauma without breaking bones intact enough to limit the appointment of analgesics, which is caused by nerezkim pain at the site of injury. If everything is intense pain persists, held novocaine blockade. Drugs used in patients with intense pain. A good result obtained by the use of drugs in combination with analgesics, antihistamines, novocaine blockade. In some cases, especially when bilateral bruises, conducted zahrudnynna novocaine blockade.

In the presence of large hematomas in the chest wall puncture is performed last, if they can not be empty, made small autopsies skin. Patients with lung hernias performed suturing intercostal muscles that ordnance.

Treating bruises sternum without a violation of its integrity is the same as the treatment of bruises ribs.

When rib fractures are appointed analgesics in cases satisfactory state of patients. But most often used blockades: local novocaine, alcohol-novocaine, retrosternal novocaine and peryduralnu anesthesia.

In addition to the blockade pain syndrome appointed analgesics, drugs, antihistamines, 3-4th day - эlektroforez with novocaine, therapeutic exercises.

Sternum fractures depending on the intensity of pain intended analgesics, drugs, conducted novocaine, alcohol-novocaine blockade mezhreberiy in the area of ​​the fracture. A small shift of fragments does not require special reposition. With strong shift of novocaine anesthesia is recommended after the patient lay on the bed with a shield, under across enclose roller. The patient in this position should be 2-3 weeks. Applied also surgery.

Treatment of patients with complicated trauma chest. Therapeutic measures for complicated closed chest trauma depend on the nature of the injuries of the chest wall and internal organs complications.

When pneumothorax is necessary as soon as possible to remove air from the pleural cavity, lung stretch. When collapse lehkeni 1 / 3 and more effective drainage of the pleural cavity.

With a large defect in the lungs, when it comes intense air and drainage of the pleural cavity does not give effect and prolonged pneumothorax, surgical treatment is indicated, the amount of which depends on the nature of a pulmonary (lung at break - suturing the defect, its economical resection).

When hemotoraksi to blood removed from the pleural cavity. In total hemotoraksi and small in terms of bleeding after an injury that lasts, you need an urgent thoracotomy, but if you test negative Ruvilua-Gregoire, is not formed clots, thoracotomy is shown anyway, but may be deferred to prepare for surgery. At this time should be conservative measure - the introduction of hemostatic drugs, blood transfusion, etc.

Medium (subtotal) hemotoraks with bleeding that continues to show a surgical treatment in emergency procedures, terms which depend on the general condition of the patient, size hemotoraksu. In the absence of bleeding in the short time after the injury can be limited to puncture, but it is better to establish drainage of the pleural cavity with a constant content of active aspiration pleural cavity. At the same time should be all ready for operation in case of re-bleeding.

At a low (limited) hemotoraksi usually limited to puncture the pleural cavity with fluid aspiration or drainage of the pleural cavity do, especially if there is hemopnevmotoraks.

In addition to special treatments hemotoraksu hold conservative measures to stop bleeding. Apply calcium chloride, vikasol, in severe cases - fibrinogen, thromboplastin, zhelatynol, aminokapronovuyu acid, and transfusion of blood plasma.

In the hemo-pneumothorax and thoracoscopy has great value. This method of survey, carried out under local anesthesia, malotravmaticheskih, allows in some cases to determine the nature of the damage to the lungs, the intensity of bleeding, right to decide on the choice of treatment.

Patients with breast flotation (vikonchati fractures) are classified as severe in need of intensive care. In addition to anesthetic, protyshokovoyi therapy needed fixing perelamanyh multiple ribs. When expressed flotation anterior, anterior-lateral surface of the chest shows the surgical fixation of mobile ribs.

When bilateral rib fractures vikonchatyh used for pulling the breast. In severe damage to the frame of the chest used osteosynthesis ribs. Paradoxical respiration can be removed also by ALV.

In the treatment of shock lung used cardiac facilities, oxygen, antihistamines, and conducted therapeutic measures aimed at eliminating or reducing pain, chest flotation, air-and hemotoraksu, fixing rib fragments with ";vikonchatyh"; fractures. It is mandatory toilet bronchial tree, the release of its mucus.

Hemotoraks - is the accumulation of blood in the pleural cavity due to damage of lung parenchyma intercostal arteries or diaphragm.

By PA Kupriyanov hemotoraks divided into:

-Small - only blood in the sinus;

-Medium - blood reaches the angle of scapula;

-Large - higher blood level of the middle blade;

-Total - all the pleural cavity filled with blood.

The blood, which resulted in the pleural cavity, partially offset, but at night it becomes liquid again. In some cases (for reasons not unknown) blood is not diluted and formed the so-called collapsed hemotoraks. Continuing bleeding in the pleural cavity compresses the lungs, it excludes from the act of breathing and displaces the mediastinum. Violated respiratory and cardiac activity on background of increasing anemia and hypovolemia.

Along with clinical symptoms to diagnose hemotoraksu used x-ray and puncture of the pleural cavity. The latter is often curative and manipulation.

Technology puncture the pleural cavity at hemotoraksi

Puncture the pleural cavity performed in sitting or reclining position the patient in V or VII intercostal space on the back aksilyarniy line. Between the needle and suction device (syringe) must be valve mechanism, the simplest rubber tube, which periodically peretyskayut clamp. After tissue infiltration 0.5% solution of novocaine, puncture needle is injected into the intercostal space on the upper edge of the rib. At the moment of puncture the parietal pleura elastic resistance of the soft tissues of the chest wall changes the feeling of free space (failure). The blood from the pleural cavity and aspirating slowly as possible fully. At the time of disconnecting the syringe from the rubber tube last peretyskayut clamp. Before removing the needle from the pleural cavity to enter the solution recommended antibiotics. Place puncture closed sterile cloth.

Continuing to diagnose bleeding in the pleural cavity can test Rivilua - Gregoire: coagulation obtained by puncture of the pleural cavity, shows the continuing bleeding, if the blood does not clot - the bleeding stopped. If pleural puncture can only get a small amount of light yellow fluid, and small blood clots (";worms";), corresponding to the lumen of the needle, it is obvious diagnosis hemotoraksu collapsed.

Pneumothorax - syndrome that develops when air enters the pleural cavity.

I. Depending on the damage to anatomical structures are defined:

1) closed pneumothorax - air in the pleural cavity gets damaged from the lungs through the visceral pleura;

2) open pneumothorax - air enters from the environment through the damaged chest wall and parietal pleura.

II. On the mechanism of occurrence:

1) traumatic pneumothorax - a result of trauma is damage to the lungs or chest wall;

2) spontaneous pneumothorax - occurs as a result of the pathological process in the lung tissues;

3) iatrogenic:

a) accidental - while performing various manipulations (torakotsentez, subclavian vein catheterization, etc..)

b) ";natural, expected"; - always takes place after thoracotomy, thoracoscopic surgery;

c) treatment - still widely used in the treatment of pulmonary tuberculosis.

III. Depending on the severity:

1) partial (limited) - in the pleural cavity is a small amount of air, lung kolabovana part;

2) total - lung kolabovana completely;

3) tense - the air in the pleural cavity is under excessive pressure to atmospheric, lung kolabovana usually fully observed shift of the mediastinum in the opposite direction

On the mechanism of pneumothorax is closed and valve open.

Closed pneumothorax (sometimes denoted as a simple pneumothorax) - occurs when closed trauma (damage to the lungs, resulting in a sudden increase in pressure vnutrishnobronhialnoho or rib fragments) when the lung partially kolabuyetsya and its wound edges stick together, and with penetrating chest wound when the wound channel itself closes displaced tissue or blood convolution and admission of air in the pleural cavity stops. Symptoms: dyspnea tachypnea, cyanosis sometimes, lag in respiration affected parties, weakened or even absent breathing during auscultation, percussion sound timpanichesky, radiographically - layer of gas between the chest wall and lungs that slept.

Open pneumothorax occurs mainly in the wounds of the chest and is characterized by the fact that air from the environment enters through the wound channel in the pleural cavity for as long as the lung is not fully kolabuye. This air pressure in the pleural cavity becomes equal air pressure in the external environment. Later in the breath of air from the environment further falls in the pleural cavity, and Vidoz - comes out. Inspiration is accompanied by increased pressure in the pleural cavity, lungs and spadinnyam vytyskannyam air with it in the opposite lung. On the exhale - pressure in the pleural cavity and lungs is reduced to the damaged party ";partly rozpravlyayetsya"; sucking in ";spent"; air of the opposite lung. Spadinnya lungs to inhale and exhale rozpravlennya it was called ";paradoxical breathing"; and variations of air from one lung to another - ";air flotation.";

With each inhalation and exhalation there's a shift of the mediastinum. As a result of reduced blood flow and zatrudnyayetsya through veins to the heart by eliminating prysmoktuyuchoyi forces pleural cavity on the side of injury and pleural podraznyuyutsya nerve receptors that can cause plevropulmonalnyy shock.

Moreover, in the development of pathophysiological disorders in open pneumothorax significant role played by bypass surgery (reset) neoksyhenovanoyi blood in the large circulation through arteriovenous anastomoses opened kolabovanoyi damaged lungs on the side.

Thus, the open pneumothorax is dominated by the following pathological changes:

-Excluded from the breathing lung on the side of injury;

-Significantly reduced the efficiency of the respiratory function of healthy lungs (mediastinal shift, ";air flotation";);

-Hampered blood flow through veins to the heart;

Neoksyhenovanoyi-bypass blood into a large circulation.

Clinically definite sign of an open pneumothorax is a wound of the chest through which air passes from the noise in both directions. Radiologically vializuyetsya kolabovana lung and shift of the mediastinum.

Valvular pneumothorax may be external and internal. External valve pneumothorax occurs during the formation of the valve with soft tissue wound channel chest wall. When you inhale valve opens and air is sucked into the pleural cavity during expiration wound edges come together and prevents the entry of air. Internal valve pneumothorax occurs when damage to the bronchus, when formed lasting connections between the lung and pleural cavity. When you inhale air freely enters the pleural cavity of lung wounds, and during expiration can not go through this wound, because the wound edges spadayutsya lungs. At each subsequent breath of air in the pleural cavity increases.

Higher degree of valve pneumothorax - pneumothorax busy. High pressure in the pleural cavity pressure on the heart and blood vessels, shifting the mediastinum and compresses the opposite lung. Compression of pulmonary veins leads to congestion in the lungs. Displacement of the aortic arch baroreceptors and irritate it is Circulatory disorder.

Hilotoraksom called progressive accumulation of chyle in the chest cavity - a lymph with a high content of fat. The emergence hilotoraksu associated with violations of intact thoracic duct and pariyentalnoyi pleura and a complication of various pathological processes. With all their diversity appearance hilotoraksu quickly leads to the development of clearly delineated local and general disorders that are leading in the current and forecast diseases or injuries that caused his emergence as a separate allocation hilotoraksu nosological forms reasonably practical terms.

Despite the fact that the first description hilotoraksu made almost 370 years ago (Bartolett F., 1633), its systematic study of restrained relative rarity of this severe complication. Thus, A. Bargebuhr in 1895 was able to compile information about only 25 cases hilotoraksu published to date by 260 years. Another long thoracic duct remained available for study and surgical interventions.

Even with the development of thoracic surgery experience treating patients with hilotoraksom in large specialized hospitals were represented by single or few cases.

Etiology. The causes that give rise to hilotoraksu are the basis of its classification criteria.

Only in cases where such a link set is not possible, hilotoraks called ";spontaneous"; or ";idiopathic."; Depending on the occurrence hilotoraksu in one or both pleural cavities it is divided into one-or two-sided. With the development of diagnostic capabilities and deepening knowledge of pathology lymph system frequency ";spontaneous"; hilotoraksu steadily declining: his appearance is increasingly unable to bind to a specific etiologic factor: disease or pathological condition.

Most often (in 65-70% of all observations hilotoraksu) violation intact thoracic duct is the result of direct or indirect violence, and then taken to mean it as traumatic. Injuries to the thoracic duct with possible chest injuries firearms or knives, as well as during surgical interventions on the organs of the breast - cancer of the lung, esophagus, mediastinal tumors, diseases of the heart and great vessels of this region.

Nontraumatic hilotoraks occurs much less frequently as a complication of diseases of the chest cavity or pathological processes that cause destruction of the thoracic duct wall, and its compression, which prevents the promotion of chyle, which leads to severe hypertension in the Straits. Before the advent of nontraumatic hilotoraksu can also cause various degenerative-dystrophic changes that reduce the mechanical strength, resistance of the chest wall duct.

Originally from a defect in the chest Strait hilus results in mediastinal tissue and accumulate there. This formed the so-called mediastinal hiloma that with increasing even at low voltage causes the gap pleura. A hole that formed chyle poured into the pleural cavity. So there hilotoraks. Most often it is from this moment to arise and begin to grow painful disorders characterized by this pathological condition.

The period of formation of mediastinal hilomы considered to be asymptomatic, latent, and the accumulation of chyle in the pleural cavity - a period of clinical manifestations hilotoraksu. It should be noted that since the damage to the thoracic duct until hilotoraksu may take up to 3-5 days.

Clinical picture and diagnostics. Development hilotoraksu causes peculiar clinical manifestations, which for a short time become the leading, often vidsovuyuchy into the background other, previously existing disorders caused by the existence of serious illness, wounds received, or transferred to chest trauma surgery.

In the first growing out of the severity of local changes in the chest cavity caused by the constant accumulation of this large number of chyle, and general disorder - a consequence of progressive loss of body large quantities of fat, protein, electrolytes, trace elements, fluid - are characterized by depletion of these patients, up to cachexia.

There are several variants of clinical course hilotoraksu: chronic, acute and subacute.

Chronic course with the entry and partial resorption hilus harakternishe for hilotoraksu caused by various diseases and long existing tumors of the chest of five lo stimulus that led to the destruction of thoracic duct

Subacute and especially the development of acute hilotoraksu often associated with injury, closed chest trauma that led to disruption of intact thoracic duct. In subacute current clinical signs hilotoraksu grow relatively slowly, gradually - from several days to a week after thoracic duct injury. Immediately after development of acute hilotoraksu arisen - the breakout ";hilomy"; and simultaneously rapid admission of mediastinal chyle into the chest cavity - patients feel intense pain in the chest, marked shortness of breath, palpitations, sometimes - a brief fainting.

Already in the examination of patients with hilotoraksom Note the significantly reduced body weight, marked pallor and dry skin, sometimes - Crocq's disease, signs of dehydration. Often they prefer to lie on the patient side, giving a somewhat elevated position of the breast. Can notice the lag in the act of breathing from the chest wall hilotoraksu, increased volume is lower breast enlargement and even some vybuhannya intercostal spaces. Skopychennya in the pleural cavity to 2-3 liters of chyle often accompanied kolaptoyidnym condition and requires assistance in an emergency procedure.

Laboratory studies show progressive hipolipoproteyinemiyu, immunosuppression, and especially lymphopenia.

Instrumental methods. For detection of fluid in the pleural cavity, usually enough to use traditional X-ray method in the form of X-ray and X-ray. Small amounts of liquids with high reliability are recognized at Ultrasound. More clearly and reliably the changes can be detected using CT. Visualization of the thoracic lymphatic duct is possible only by its contrast. In clinical practice for this is the most appropriate method of direct antegrade limfoduktohrafiyi.

Decisive role in the recognition plays hilotoraksu diagnostic puncture. In patients admitted to hospital with respiratory failure and hemodynamic disorders caused by accumulation of fluid in the pleural cavity puncture should be performed in order to provide emergency care. In the absence of express indications to perform during the examination of patients in the first 1-2 days.

In place scheduled for X-ray, performed under local anesthesia puncture of the chest wall and remove fluid from the pleural cavity. This provides restoration of normal relations between thoracic organs: lungs straightening, removal of mediastinal shift, improving the general condition of patients.

The final diagnosis after hilotoraksu set of laboratory research. Hilozna liquid is pretty much stable, characteristic figures. Its relative density greater than 1.012, the reaction - alkaline, it is well emulhuyetsya, forming fatty particles. When coloring Sudan III in chyle are droplets of neutral fat.

Treatment. In treating hilotoraksu used as a conservative and surgical methods.

Removal of chyle from the pleural cavity for therapeutic purposes often reach the re punktsiy behind in seventh or eighth intercostal space.

Indications for them is partial kollabuvannya lungs, usually the lower lobe. Some patients have to perform puncture every day, others - 2-3 times a week or less. If necessary, frequent pleural punktsiy safe drainage of pleural cavity in the lower divisions dvoprosvitnym drainage. Drainage is injected into the pleural cavity above the diaphragm, between the middle and posterior axillary line, pushing it inside her rear end to the divisions. Dilution 60-80 mm of water. century. generated in an airtight system of pleural cavity - a vacuum aspirator, provides evacuation hilus and straightening lungs. Complete restoration of lung volume and eliminate residual pleural cavity promote measures to improve the airway: sanatsiyni fibrobronhoskopiyi, inhalation of bronchodilators means and mukolitykamy.

When coagulation chyle and the impossibility or difficulty of its complete removal by punktsiy recommended entering into the pleural cavity of enzyme preparations (streptazy, fibrinolysin, hlyukuronidazy, himopsynu).

For the prevention of empyema every puncture of pleural cavity and removal of chyle complete introduction of broad-spectrum antibiotics. If the pleural cavity is drained, the antibiotics are administered regularly, using the drainage tube.

Indications for surgical intervention on hilotoraksu now clearly defined and include: hiloreyu - which remains stable, progressive lymphopenia and fall of protein in blood plasma. Some researchers (Hurbanalyev IG, Hajiyev SH.M., 1988) refer to the indications for surgical treatment of the formation hilotoraksu that curled.

Surgery on hilotoraksu focused on thoracic duct ligation at the site of his injury or in a typical spot and stop leakage of chyle. For the first time it performed in 1948, R. Lamrson. In place of thoracic duct injury often seek to tie up at his wounds. Then the operation's success is largely determined by precision targeting in complex topohrafoanatomichnyh conditions. In characteristic changes mediastinal pleura (edema, ryhlist) and determining the spillage hilus exhibit thoracic duct injury and his league. This success must be determined on peratsyy ligation and lower, caudal parts of the damaged thoracic duct. In the trunk of the thoracic duct at a distance of 2-2.5 cm apart impose two ligatures. Between ligatures of ducts crossing. It is recommended to remove a small piece of thoracic duct for subsequent histological verification.

Injuries chest. Open the chest injury more often stab or gunshot. They are divided into penetrating into pleural, pericardial cavity and nepronykayuchi. In penetrating wounds of patients complain of chest pain, breathing difficulties, weakness. If damaged lungs may be hemoptysis. Sometimes hear suction air in the pleural cavity.

Please be aware that in cases of injury to the chest wound may pass through the aperture in the peritoneal cavity. When wound especially the left half of the chest may be damage to the heart. In penetrating wounds may be pneumothorax, hemotoraks.

An examination of the patient, except for physical methods of investigation used X-ray (or vertical position of the patient napivvertykalne), which helps identify pneumothorax, hemotoraks, haemopericardium, pulsation of the heart. If you suspect damage to the esophagus given vodorozchynenyy radiographic drug. It is used as puncture.

Treatment. When nepronykayuchyh chest wounds spend debridement. In other cases, after the imposition of a bandage on the wound (if an open pneumothorax - occlusal) patients urgently referred to hospital for surgery. Especially need urgent hospital patients with suspected cardiac injury, as well as vnutrishnoplevralniy bleeding. Transporting these patients must be accompanied by a constant intravenous protyshokovyh krovozaminnyh drugs.

In pneumothorax, small hemotoraksi - puncture the pleural cavity drainage. In total hemotoraksi, suspected injury to the heart, esophagus, bronchi, diaphragm - thoracotomy.

The first medical aid at a serious condition of the patient includes the introduction of warm, painkillers (for suspected damage to the abdominal drugs are contraindicated). When pneumothorax pleural cavity should punktuvaty thick needle, to drainage (for Petrov-Byulau, Subotin-Pertesom). A protyshokova therapy. In bilateral hemotoraksi and ";flotuyuchiy"; chest with the seal of the chest immediately conduct intubation and take measures for rozpravlennya lungs (pleural cavity puncture, mechanical ventilation). In shock and blood loss the patient immediately transported to a specialized thoracic department with multiple trauma - in trauma centers or trauma department in the absence of - the nearest hospital, where a surgical department.

5.3. Test question:

1. Anatomical and physiological information about the lungs and bronchi.

2. Features of conservative treatment piopnevmotoraksu.

3. Classification of posttraumatic hemotoraksu.

4. Therapeutic tactics in closed chest trauma, complicated by a large hemotoraksom.

5. The technique of puncture of the pleural cavity.

6. Engineering drainage of pleural cavity.

7. Signs vnutrishnoplevralnoyi bleeding. Indications for thoracotomy.

8. Therapeutic tactics in convolute hemotoraksi.

9. Classification of posttraumatic pneumothorax.

10. The mechanism of occurrence, clinical picture with valvular pneumothorax

11. The causes of subcutaneous emphysema. Methods of treatment.

12. Causes and clinical course of mediastinal emphysema.

13. Treatment of mediastinal emphysema.

14. Treatment of posttraumatic pneumothorax. Types of aspiration systems.

15. Treatment of open pneumothorax.

16. Therapeutic tactics in intense (valve) pnevmotora ¬ Xi.

17. Types of novocaine blockade in closed chest trauma.

18. Methods of fixation of the chest wall at flotuyuchomu rib fractures.

19. Therapeutic tactics in flotuyuchomu rib fractures.

20. Clinic double fracture of ribs.

21. Therapeutic tactics in limited pneumothorax.

22. Early complications of closed chest trauma.

23. Late complications of closed chest trauma

24. Clinical and radiological signs of small hemotoraksu.

5.3. Practical work (tasks) that are performed in class:

1. History taking in patients with damage to the chest cavity.

2. Review of the patient with damage to the chest cavity.

3. Conducting auscultation, percussion and palpation for injuries of the chest cavity.

4. Mastering the methods of preparing the patient for X-ray and endoscopic examination.

5. Reading radiographs: Plain radiography of the chest (pneumothorax, hydro - or hemotoraks).

6. Mastering the methods of preoperative preparation and postoperative management of patients.

7. Mastering the technique of pleural puncture and drainage of the pleural cavity methods.

8. Providing emergency care for injuries of the chest cavity.

5.4. Question to self:

1. Anatomic-topographic features of the structure of the lungs and pleural cavity.

2. The most frequent source of bleeding into the chest cavity.

3. Diagnostic program in hemotoraksi.

4. Classification of injuries of the chest.

5. The first medical aid for injuries of the chest ..

6. Indications and contraindications to puncture, drainage, surgical intervention for lesions of the chest cavity.

7. Basic principles of treatment programs for traumatic hemotoraksi.

8. Postoperative course, possible complications and their prevention.

5.5. The tasks for self-control:

1. Patient 36 years old, about 3 hours ago received a penetrating stab wounds left half of the chest. Delivered in a serious condition: euphoria, skin pale. Cardiac deaf, tachycardia 130 beats. / Min. AT -80/70 mm Hg. century. Pulse at the wrist barely defined. The wound of the chest 2 cm, located on the left parasternal line at the third intercostal intervals. Breath of the left lung weakened in the posterior-inferior parts shortened percussion sound. What are the most appropriate therapy?

A. Pleural puncture.

B. Complex resuscitation

C. Emergency thoracotomy .*

D. Puncture of the pericardium

E. Transfusion of blood.

2. The victim in '40 during the accident hit the right half of the chest to the steering. For 1 hour knap shortness of breath, general weakness. Auscultation of the lungs on the right - no breathing, left - vesicular. Pulse 110 beats per minute., Rhythmic. BP - 110/70 mm Hg What complication has developed in a patient?

A. Fracture of ribs on the right

B. Closed pneumothorax on the right. *

C. Bruising of the chest on the right.

D. Right-sided hemotoraks.

E. Plevropulmonalnyy shock.

3. 38-year old victim was hospitalized in a surgical hospital in 4 days after injury during the earthquake. Diagnosed a closed head injuries, chest bruise, closed fracture of V-VI ribs on the left, massive collapsed hemotoraks. Held conservative therapy. On the fifth day hemotoraks not eliminated. What further therapeutic tactics?

A. Thoracotomy .*

B. Continue conservative therapy.

C. Pleural drainage with active aspiration.

D. Puncture of the pleura and sucking blood.

E. None of the above.

4.Chastist breathing - 28/hv. tahykardiya - to 100/hv, signs of intoxication. In the area of ​​the right shoulder blade dulling tone percussion, bronchial breathing, single dribnopuzyrchati krepituyuchi and wheezing. Radiologically - massive inflammatory infiltration in the middle pulmonary field. After three days on the background of treatment that was conducted, there was an attack of cough with purulent sputum 200ml release, after which the body temperature dropped to subfebrilnoyi, state level polehshav.Na angle blades found in background lung infiltration round illumination with a horizontal level.

A. Cancer of lung collapse.

B. Brush lungs.

C. Limited empyema pleural cavity.

D. Bronhoektaziyi.

E. Acute lung abscess *

5. Woman '55 delivered in hospital for surgery after falling in an explosion at work, got injured right half of the chest. Diagnosis of pneumothorax, kolabovanu lungs, subcutaneous emphysema, broken V-VI ribs on the left. It was drained pleural cavity by Byulau. After 48 hours of lung not rozpravylasya, drainage works. What further therapeutic tactics?

A. Sew primary drainage, analgesia.

B. Re-drain the pleura.

C. Shown thoracotomy .*

D. Suck air puncture.

E. Conservative therapy.

6. Healthy to the man in '32 during exercise suddenly heard nehvatku breath, weakness, pain in the right half of breast-impact in the right shoulder, shortness of breath, feeling nehvatky air heartbeat. Condition severe, tachycardia to 100/hv. Breathing 28/hv., The right half of the chest behind breathing. Percussion right high tympanitis, breath sounds are not audible. Body temperature - normal.

A. Mediastinitis.

B. Myocardial infarction.

C. Lung abscess.

D. Empyema pleural cavity.

E. Spontaneous pneumothorax .*

7. The patient in '40 suddenly appeared pain in the left half of the breast, choking. Ob-no: Status of moderate severity, pulse - 110 beats. in 1 min, blood pressure 90/60 mm Hg. century., breath left does not listen. when radiography of the chest - the collapse of the left lung to 1 / 2. What treatment should be patient?

A. Peace, resolution therapy

B. Passive drainage of the pleural cavity. *

C. Pleural puncture

D. Surgery

E. Active drainage of pleural cavity

8. The patient arrived in '32 surgical department within 6 hours after disease diagnosis: spontaneous pneumothorax. Treatment by passive drainage of the pleural cavity for 3 days gave no effect. What is the most reliable research will reveal the cause of no effect of treatment?

A. Bronhografiya

B. Plain radiography of the chest

C. Bronchoscopy

D. Thoracoscopy *

E. Ultrasound

9. The patient flotuyuchi 5,6,7 fractures of ribs on the right, middle hemotoraksom complicated. What tactics of treatment?

A. Draining the pleural cavity in VII mizhrebir'yi on l.axillaris dext. post., skeletal stretching .*

B. Draining the pleural cavity in the second mizhrebir'yi on l.axillaris dext. post., INTRAMEDULLARY osteosynthesis ribs.

C. Thoracotomy, osteosynthesis, liquidation hemotoraksu.

D. Thoracotomy, osteosynthesis, drainage of the pleural cavity of l.axillaris dext. post.

E. Verhnobokova thoracotomy, osteometalosyntez, drainage of the pleural cavity on the right.

10. In patients with acute abscess left leheni arose total piopnevmotoraks. What tactics of treatment?

A. Draining the pleural cavity in VII mizhrebir'yi on l.medioclavicularis sin., In the second mizhrebir'yi on l.axillaris sin. med.

B. Draining the pleural cavity in the second mizhrebir'yi on l.medioclavicularis sin, in VII mizhrebir'yi on l.axillaris sin. post *

C. Nearside verhnobokova thoracotomy, closure of the defect lungs

D. Nearside nyzhnobokova thoracotomy, closure of the defect lungs

E. Nearside verhnobokova thoracotomy, lung resection.

11. Patient '30 injured in accidents breast. At the patient-no heavy, cyanosis of the skin, palpation tenderness and crepitus in section IV - VI ribs on the right rear pidpahvoviy line. Breath of the law sharply weakened. Subcutaneous emphysema. On plain film the collapse of the right lung in 1 / 2 volume. Location of diagnostic pleural puncture?

A. In pleural Sinus

B. In the second mizhreberyi by mid-clavicular line *

C. In VI mizhreberyi zadnopidpahvoviy on line

D. In VII mizhreberyi lopatochniy on line

E. The city's largest percussion dullness determined

12. Patients in '67 for 4 weeks complaining about a cough with a discharge to 80-100 ml of purulent sputum, shortness of breath, general weakness, recurrent pains in the left half of the chest, raising body temperature to 38-39 (. Two weeks before this suffered from SARS . During the last 6 days occurred a sudden increase in wheezing, chest pain, temper-ra body does not decrease during the day below 38 (C. Ob-no: the general condition of the patient difficult. Skin pale grayish tint. From mouth odor. The provisions of the forced - semisitting. blood pressure 110/60 mm Hg. Art., pulse 114 per minute, regular, low. Breathing shallow involving auxiliary m (BH yaziv. 34 per minute. Auscultatory: The Case of vesicular breathing, variegated with moist rales, left - sharp reduce respiratory noise. percussion sound from the left clavicle to the third rib boxes below - suddenly becomes shorter with the upper horizontal, making the contours of the heart is not defined. What is the most likely diagnosis?

A. Gangrene left lung

B. Nearside pleuropneumonia Peste.

C. Nearside piopnevmotoraks

D. Gangrene left lung. Piopnevmotoraks *

E. Gangrenous abscess of the lower part of left lung

13. The patient was made in '42 pulmonektomiya on multiple chronic abscesses of the right lung. Operation complicated the development of empyema. Treatment of patients within 8 months. pleural puncture, irrigation and drainage of the pleural cavity it does not eliminate empyema. The general condition of the patient is satisfactory. He is not exhausted. No evidence of amyloidosis is not present. As a further treat the patient?

A. Drainage and sanitation pleural cavity

B. Dekortykatsiya pleura *

C. Muscular torakoplastyka

D. Torakoplastyka by Shade.

E. Torakoplastyka on Linberhu

14. The patient in '32 in the morning suddenly against a background of full health (I've emerged a strong pain in the left half of the chest, shortness of breath. Rev. (objectively: CHDD 30 per min., Cyanosis, participating auxiliary m (muscles in breathing, chest asymmetry. Above left tympanitis lungs is observed, the absence of respiratory noise, weakening voice trembling. What is the most likely diagnosis?

A. Lung atelectasis

B. Piopnevmotoraks.

C. Spontaneous pneumothorax .*

D. Pleural effusion.

E. Post-traumatic pneumothorax

15. The victim, 32 years old, taken to hospital after hooligan trauma complaining of pain in the left half of the chest, shortness of breath. OBJECTIVE: the patient moderate. Blood pressure 110/70, PS-98/hv., ChD-32/hv. The left half of the chest behind breathing, serednopahvoviy line on the left - bone pain and crepitus in the projection of V-VIII edges, with percussion (in vertical position) to level VI left rib - tympanitis below - blunting percussion sound, Auscultation - the lack of respiratory noise. What X-ray picture of the left (straight projection, the vertical position of the patient) you expect to get?

A. Fracture V-VIII ribs, lung atelectasis, homogeneous darkening of the oblique level (line Damuazo).

B. Fracture V-VIII edges, homogeneous complete darkening the pleural cavity.

C. Fracture V-VIII ribs, lung atelectasis, high standing of the left dome of the diaphragm.

D. Fracture V-VIII ribs, collapse lungs, homogeneous darkening of the horizontal level .*

E. Fracture V-VIII edges, shock lung, homogeneous darkening of the oblique level (line Damuazo).

16. The patient in '35 after hypothermia fever to 40 C, with ";pain appeared in the left half of the chest, dry cough. Temperature lasted 10 days, despite intensive care. In the evening when coughing patient vykashlyav 800 ml thick purulent sputum. Increased breathlessness. An examination of the patient's acrocyanosis, shallow breathing (27 in 1 minute). Pulse 110 beats per 1 minute, blood pressure 95/60 mm Hg Auscultatory case to VI rib amforychne breathing, wheezing not vysluhuyutsya. Percussion to V rib box sound. Radiograph: right-hand hydro pneumothorax. The collapse of the lung 1 tbsp. What complications arose in the patient.

A. Acute pneumothorax

B. Breakthrough acute abscess in the bronchus

C. Hemopnevmotoraks.

D. Breakthrough bronhohennoyi cysts.

E. Piopnevmotoraks *

17. In patients with left-side pneumonia nyzhnodolovoyu increased pain in the chest, fever. Auscultation lower angle of scapula breath sharply weakened, percussion - stupidity. At that complications can we speak?

A. Myocardial infarction

B. Piopnevmotoraks

C. Lung abscess

D. Empiema pleura *

E. Piddiafrahmalnyy abscess

18. The patient after a fall from a tree was a pain in the right half of the chest, breathlessness, subcutaneous emphysema. Auscultation - it dramatically weakened breathing, with percussion - tympanitis. When that complication closed injury to think?

A. Closed pneumothorax *

B. Open pneumothorax

C. Hemotoraks

D. Hemopnevmotoraks

E. Rupture of diaphragm

19. The patient in '38 after inflicted stab wounds of the chest in the left half of the chest revealed admission frothy fluid from the wound, and a sharp weakening tympanitis breath left. Blood pressure 80/40 mm. Hg. century. Pulse 120 for 1 min., NV - 20 g / liter. Radiologically - kolabovana left lung, horizontal fluid level at the third rib. What therapeutic tactics to choose?

A. Draining the left pleural cavity

B. Hold protyshokovi activities and after stabilization of blood pressure - thoracotomy

C. Emergency thoracotomy *

D. Put a bandage on the wound occlusion

E. Transfuse blood odnohrupnu to stabilize the hemodynamic and blood

20. The patient delivered brigade ambulance from the scene to hospital in shock. Consciousness blighted, pale, swollen neck veins, audible breathing on both sides, heart rate - 120/hv, AT = 60/40 mmHg, blood pressure maintained infusion adrenomimetychnyh means. On examination - stab to the left edge of the sternum with no signs of external bleeding. The next step will be the hospital medical teams:

A. Radiography

B. Emergency anterior-lateral thoracotomy *

C. Probing heart anhiokardiohrafiya

D. Via esophagus echocardiography

E. Puncture of the pericardium

5.6. Tests for self-control:

1. In the diagnosis of primary lung abscess are:

A. Thoracoscopy

B. Bronchoscopy

C. Radioisotope scanning of the lungs

D. Radiography DC *

E. Ultrasound

2. Radiographic indication posttraumatic hemopnevmotoraksu:

A. The collapse of the lungs, the presence of air and fluid in the pleural cavity

B. The collapse of the lungs, the presence of horizontal liquid level in the pleural cavity *

C. The collapse of the lung with an oblique liquid level

D. Subcutaneous emphysema, oblique level of fluid in the pleural cavity

E. The collapse of the lung, the absence of air and fluid in the pleural cavity

3. What threatens the patient who suffers from chronic yempiyemu pleura?

A. Multiple organ failure

B. purulent intoxication

C. Development of lung gangrene

D. Chronic pulmonary insufficiency

E. Amyloidosis of the internal organs *

4. Clinical recovery in acute lung abscess is:

A. The disappearance of clinical symptoms and radiological

B. The disappearance of clinical symptoms, but radiographically is ";dry"; thin-walled cavity *

C. It remains low-grade fever and a small amount of sputum

D. Absence of fever 2 weeks

5. Postural drainage - is:

A. A special type of drainage tube

B. The special position of the patient *

C. CAV drainage tube

D. Drainage from the introduction of drugs

6. Lung abscess often suffer from:

A. Men *

B. Women

C. Children

D. Equally often, men and women

7. Empyema is considered acute if lasts no more than:

A. 2 weeks

B. 4 weeks

C. 8th week *

D. 12 weeks of

E. 16 weeks of

8. Sputum in bronchiectasis is divided into layers:

A. Mucus, serous fluid, pus *

B. Pus, mucus, serous fluid

C. Foam, serous fluid mucus

D. Not divided

9. Chronic abscess can be treated by:

A. Drainage of abscess

B. Remediation of bronchial

C. Abscess drainage and antibiotic therapy

D. Surgical treatment *

E. Comprehensive conservative treatment

10. The most informative method of research in bronchiectasis are:

A. Bronchoscopy

B. Bronhografiya *

C. Chest radiography

D. Plevrohrafiya

E. Thoracoscopy

11. Radiological picture of acute pulmonary abscess-like focal pneumonia, observed:

A. And in the period *

B. In the second period

C. In both periods

D. Not observed

12. Gangrene of the lungs are:

A. Delimited necrosis of lung tissue

B. Nevidmezhovanyy necrosis of lung tissue *

C. Multiple distinct ulcers of the lungs

D. Spadinnya lungs

13. In the presence of large numbers of pus in the pleural cavity (acute empyema) mezhystinnya shifts:

A. In the healthy side *

B. As a side injury

C. Not shifted

D. In any

14. Voice tremor in pleural empyema:

A. Growing

B. Reduced *

C. Unchanged

15. Lung abscess is considered chronic if the disease has passed since:

A. 2 weeks

B. 4 weeks

C. 8th week *

D. 12 weeks of

16. The classic symptom of the disease in Bronchoectatic III .. development:

A. Hectic flush on her cheeks

B. Fingers in the form of drum sticks and nails in a watch glass *

C. Chest pain and breathlessness

D. Cyanosis nasolabial triangle

E. Swelling of limbs

17. Where a pleural puncture with posttraumatic hemotoraksi:

A. In VII mizhrebir'yi on l.axillaris post .*

B. In VII mizhrebir'yi on l.medioclavicularis.

C. In the second mizhrebir'yi on l.axillaris post.

D. In the second mizhrebir'yi on l.medioclavicularis.

E. In the place of maximum percussion dullness

8. Recommended literature:

Basic:

  1. Навчально-екзаменаційна автоматизована комп’ютерна система з факультетської хірургії (навчальний посібник з тестовими завданнями та еталонами відповідей) /Під ред. І.Ю.Полянського.- Чернівці, 1999.- 38 с.

  2. Хирургические болезни /Под ред. М.И.Кузина.- М.: Медицина, 1995.- С.61-63, 76-86.

  3. Клиническая хирургия: Справочное руководство / Под ред. Ю.М.Панцырева. - М.: Медицина, 1988. - С.109-117, 119-122.

  4. Хирургические манипуляции / Под ред. Б.О.Милькова, В.Н.Круцяка.- К.: Вища школа, 1985. - С. 18-25, 103-106.

  5. Шідловський В.О., Захараш М.П., Полянський І.Ю. та ін. Факультетська хірургія / За ред. В.О.Шідловського, М.П.Захараша. - Тернопіль: Укрмедкнига, 2002. – С. 322-334.

  6. Березницький Я.С.,.Захараш М.П, Мішалов В.Г., Шидловський В.О. Хірургія, Том І, - 2006, Підручник , 491 с.

  7. Березницький Я.С.,.Захараш М.П, Мішалов В.Г. Хірургія, Том ІІ,- 2007.- Підручник, 628с.

  8. Хірургія. Підручник // Захараш М.П., Пойда О.І., Кучер М.Д..-К.:Медицина, 2006.-656с.

Additional:

  1. Клинические задачи /Под ред. Б.О.Милькова. - Черновцы, 1987. - С. 27-32, 53-55.

  2. Неотложная хирургическая помощь в условиях сельской врачебной амбулатории. - К.: Здоров’я, 1987. - С. 80.

  3. Романенко А.Е., Чухриенко Д.П., Мильков Б.О. Закрытые повреждения органов грудной клетки. - К.: Здоров’я, 1982. - 160 с.

  4. Цыбырнэ К.А., Мильков Б.О., Кулачек Ф.Г. Неотложная торакальная хирургия. - Кишинев: “Штиинца”, 1989. - С. 126-136.

  5. Міжнародна класифікація хвороб 10 перегляду. – Москва, 1996. – 150 с.

Methodical direction made ______________ Assistant, PhD Voytiv YA.YU.

Signature

Review ____________

Signature



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