Local and general symptoms
The clinical picture of any injury is traditionally divided into two large groups of signs.
Local symptoms include:
- Pain in the zone of tissue damage.
- Bleeding of varying degrees of intensity.
- Wound gaping (separation of the edges of damaged skin and underlying structures).
General symptoms do not have a specific "wound-related" character. It is important to understand that the patient's general condition is entirely determined by the developed complications. The main conditions forming the general clinical picture include acute anemia against the background of massive blood loss, development of shock, and the onset of a surgical infection. It is these factors that dictate the severity of systemic disorders in the victim's body.
Factors determining the intensity of pain and bleeding
The sensation of pain during trauma occurs due to direct damage to pain receptors, as well as due to trauma or compression of nerve trunks. The severity of the pain syndrome is not always directly proportional to the size of the wound. It depends on several key factors:
- Number of involved nerve elements. The richer the innervation of the damaged zone, the stronger the pain impulse will be.
- Individual reactivity of the body. The initial neuropsychic state of the victim at the time of the injury plays a huge role.
- Characteristics of the wounding weapon and the speed of injury delivery. There is an important regularity: if the injury is inflicted very quickly and the wounding object has a high degree of sharpness, a significantly smaller number of nerve cells is destroyed. As a result, the patient experiences less intense pain.
- Psychological factor. The emotional background is critically important. In a state of panic or tense anticipation of the moment of injury, the perception of pain is amplified many times over.
The intensity of bleeding, in turn, directly depends on the nature and total amount of destroyed vascular structures. The most life-threatening conditions develop when major arterial trunks are injured.
Assessment of general condition and anamnestic data collection
A proper examination begins with assessing the patient's vital functions and general status. First, the physician checks the victim's level of consciousness. Then, the skin is visually assessed, with special attention paid to its color (identifying pathological pallor as a marker of blood loss). The most important hemodynamic parameters are pulse (it is necessary to determine its rate and volume) and respiration (the respiratory rate is counted and its depth is assessed).
Concurrently with the assessment of vital signs, a thorough anamnesis is collected. The physician needs to find out the following details:
- What was the volume of first aid provided at the scene (whether self-help, mutual aid, or assistance was provided by arrived medical personnel).
- What type of transport was used to evacuate the victim to the medical facility.
- Available information about the wounding object itself.
- Approximate estimation of potential blood loss at the scene and en route.
Rules of physical examination
Physical examination is divided into general and regional. The main principle of surgical examination of the limbs is a comparative approach, in which the affected part of the body is necessarily compared with the healthy symmetrical side. This allows for the rapid identification of potential deformations of anatomical structures.
Next, a systematic assessment of structural status is carried out:
- Functional assessment: the physician checks the preservation and range of both active and passive movements in the joints.
- Neurological status: superficial and deep sensation are checked to rule out nerve trunk damage.
- Vascular status: includes a mandatory palpation check of the pulse on peripheral arteries distal to the wound site.
Depending on the localization of the trauma, specific diagnostic methods are applied. For chest wounds, auscultation and percussion of the lungs are performed. If abdominal injury is suspected, the classic approach is used: palpation, percussion, and auscultation of the abdominal cavity.
The main goal of all these manipulations is to obtain comprehensive information about potential damage to nerves, major arteries, and the thoracic and abdominal organs even before the surgeon proceeds to a direct visual inspection of the wound itself.
Briefly: answers to topical questions
Which anatomical factors determine the severity of wound gaping?
The severity of wound gaping depends on its size, depth, and the direction of damage to the elastic fibers of the skin. The key anatomical factor is the location of the wound relative to Langer's lines (the direction of elastic fibers):
- Transverse direction — causes wide gaping of the wound.
- Longitudinal direction (parallel to the fibers) — accompanied by less gaping.
How does primary wound bleeding differ from secondary bleeding?
The main difference lies in the time of onset of bleeding relative to the moment of injury.
| Characteristic | Primary bleeding | Secondary bleeding |
|---|---|---|
| Time of development | Occurs immediately at the moment of vessel damage | Develops some time after the primary one has stopped |
| Timeline | Immediately upon injury | Early (within the first 3 days) and late (from 3 days to several weeks) |
What symptoms of peritoneal irritation are checked during abdominal palpation in an injured person?
During abdominal palpation, tenderness and tension of the muscles of the anterior abdominal wall are assessed to detect peritoneal irritation. The Shchetkin-Blumberg sign is also checked: after cautious pressure and a sharp release of the hand, the pain increases.
How are wound infections classified?
Wound infections are classified according to the nature of the pathogen and the prevalence of the process. According to the nature of the pathogen, the following are distinguished:
- Nonspecific infection — includes purulent, putrid, and anaerobic.
- Specific infection — includes tuberculosis, tetanus, gas gangrene, actinomycosis, anthrax, and wound diphtheria.
According to prevalence (within purulent infection), a distinction is made between:
- Local infection — wound suppuration, peritonitis, pleurisy.
- General infection — sepsis, gas gangrene, tetanus.
On which specific peripheral arteries is the pulse checked in limb injuries?
The pulse in limb injuries is checked in the projections of the following peripheral arteries: On the upper limb:
- Axillary artery — in the axillary region.
- Brachial artery (a. brachialis) — medial to the biceps muscle.
- Radial artery (a. radialis) — on the palmar surface of the forearm.
In the lower extremity:
- Femoral artery (a. femoralis) — inferior to the inguinal ligament.
- Popliteal artery (a. poplitea) — in the popliteal fossa.
- Posterior tibial artery (a. tibialis posterior) — posterior to the medial malleolus.
- Dorsalis pedis artery (a. dorsalis pedis) — between the 1st and 2nd metatarsal bones.
Local symptoms are easy to remember by the acronym BPS: Pain, Bleeding, Gaping.
Class and exam questions
Why can acute trauma cause less pain?
At a high impact velocity and great sharpness of the wounding object, a significantly smaller number of nerve cells is destroyed, which paradoxically reduces the intensity of the initial pain impulse.
What determines general symptoms in a wound?
They are non-specific in nature and depend entirely on developed complications, such as acute blood loss (anemia), traumatic shock, or secondary infection.
What must be ascertained when taking an anamnesis in a wounded patient?
It is essential to clarify details regarding the wounding object, the estimated volume of blood loss, the mode of transportation, as well as who provided first aid and to what extent (self-help, buddy aid, or medical personnel actions).
What is the main goal of physical examination prior to inspecting the wound itself?
The main goal is to assess functions, neurological and vascular status in order to evaluate nerve, arterial, and internal thoracic or abdominal organ injuries prior to exploring the wound tract.
What else to study on this topic
- Pathogenesis of shock development in isolated and polytrauma wounds
- Mechanisms of acute anemia formation in massive blood loss
- Specifics of wound infection: pathogens and clinical manifestations
- Methods for assessing deep and superficial sensitivity in nerve trunk injuries
- Interpretation of auscultation and percussion data in penetrating chest and abdominal injuries
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Other topics in "CHAPTER 10. GENERAL ISSUES IN TRAUMATOLOGY"
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