Vі. Tasks for verification of eventual level of knowledges.

Situation tasks for verification of eventual level of knowledges

At a 70-years-old patient suffering by varicose expansion of hypodermic veins of lower extremities, bleeding from the torn knot on the internal surface of lower third of right shin was suddenly opened. From a wound enough intensively by a languid stream a dark blood is poured out. What volume of the first aid must be rendered to the patient?

Answer: for the temporal stop of bleeding on a right shin it follows to impose a pressing circular or spiral bandage, giving the elevated position to extremity, and to organize transporting of patient in surgical department.

Youth, 17 years, during a journey in a bus, offered a right hand in a window. A freight machine by the side of which the stuck out a hand was touched went to the meet. Traumatic amputation of right overhead extremity at the level of middle third of shoulder happened (extremity hangs on the shred of skin). A scarlet blood to gush from the damaged arteries. How to stop bleeding?

Answer: It follows quickly to produce the finger pinning during a humeral or axillary artery, and after it to impose a standard (Esmarkh) or impromptu styptic plait (plait- twist).

A wound must be concealed by a sterile bandage, put on retaining bandage on extremity, to enter anaesthetic.

A patient needs the urgent transporting in surgical department.

In the surgical department a patient with a stab-wound in popliteal pit is delivered. At the revision of wound the damage of popliteal artery is set, but you do not own the technique of vascular stitch. What actions will you undertake?

Answer: By optimum tactic in this case it follows to acknowledge the temporal shunting of vessel and bringing of vascular surgeon in for implementation of restoration operation.

In receiving rest a man 48 years with complaints about a weakness, dizziness is delivered, moderate pains in left subcostal region. It is known from anamnesis, that 12 hours ago he fell off a stair, a blow was the left costal arc on a region. On the eve of receipt there was a fainting fit.

A patient lies in the forced position. The change of position of body strengthens stomach-aches. Skin covers are pale. Pulse — 120 blows in a minute. Arterial pressure — 90/50 mm of mercury column. Palpation are marked moderate tension of muscles of abdominal wall, dulling of percussional sound in left subcostal region and gently sloping places of stomach. Haemoglobin of blood — 98 g/l.

Your hypothetical diagnosis and tactic?

Answer: at a patient it follows to suspect the traumatic break of spleen with the intraabdominal bleeding. Additionally expediently in receiving rest to do surveying to the X-ray photography abdominal region in position of patient sitting for the exception of presence of free gas in an abdominal region and X-ray photography of ribs. A patient on wheel- stretcher is necessary to be quickly delivered in the surgical department for implementation of urgent operation.

In receiving rest a man is delivered with the closed trauma of thorax on the left. Objectively: skin covers are pale. Pulse — 100 blows in a minute. Arterial pressure — 110/65 mm of mercury column. Are marked sickliness and crepitation bone fragments in a projection the VIII, IX and X ribs on the right on a medioaxillar line. Percussion on the right in lower departments is determined dull sound, breathing is not listened (in position of patient sitting). On a sciagram, except for the breaks of the indicated ribs, intensive shade with a horizontal level to the border of the VII rib is additionally exposed.

Your the diagnosis and tactic?

Answer: at a patient there is the closed break of the VIII-X ribs on the right, complicated by haemothorax. Here the damage of intercostal vessels or lung can be the source of bleeding. A patient on wheel- stretcher must be delivered in the surgical department, where to him medical-diagnostic punction of pleura cavity will be executed and in the general complex of medical measures appointed haemostatic therapy with the dynamic supervision after the state of health.

A patient 30 years, suffering during 7 years by ulcerous illness of stomach, during past days marked an increasing weakness, dizziness. In the morning, showing a leg, he on a few seconds lost consciousness. After it singly there was vomiting as "coffee-grounds" and melena. Skin covers are pale. A stomach is soft, painless.

What Your hypothetical diagnosis? What urgent additional researches must be executed for confirmation of Your supposition? Where and what method you will send a patient to medical treatment?

Answer: at a patient is present bleeding in the overhead departments of gastrointestinal highway, probably from a stomach. Him follows immediately by an ambulance to transport on stretchers in the surgical department. If it will not detain the dispatch of patient, it is necessary to measure arterial pressure and on possibility take at him the blood for determination of quantity of red corpuscles, haemoglobin, hematocrit. The result of blood test can be passed in surgical department by phone.

At a patient to which the operation concerning inguinal hernia was produced in the morning, to evening bandage on the wound of beginning abundantly to get wet a blood. Applied during a hour locally ice-bags and sacs with sand of effect were not given.

What complication in an early postoperative period arose up at a patient? Your further tactic?

Answer: At a patient in an early postoperative period there was the second bleeding. It follows to take patient in an operating-room, to conduct the revision of wound, to ligate bleeding vessel or additionally to impose on a wound 1-2 stitches with the purpose of haemostasis.

Youth with complaints about pains in a right shin and increasing slight swelling of her after falling from a motorbike appealed to you. A trauma happened near a half-hour backwards. At examination on the front surface of middle third of shin is present slight swelling by sizes 10×6×5 sm. A skin above her cyanotic. At palpation are marked sickliness and fluctuation. A pulse on the back artery of right foot is stored.

Your diagnosis? What help will you give to the victim?

Answer: At the victim there is the hypodermic haematoma of right shin. It is necessary to impose a pressing bandage on a shin, to recommend ice-bags locally, rest for extremity. In subsequent a patient necessarily must be examined by a surgeon.

In receiving rest of hospital a patient with complaints on pain in the left knee-joint after the receipt of trauma is delivered. Motions in a joint are limited, sickly. A joint has a spherical form. The ballot of patella is marked. On the sciagram of damage bones are not set.

Your the diagnosis and medical measures?

Answer: At a patient is present haemartrosis of the left knee-joint. It is necessary to produce punction of joint, to impose a pressing bandage, immobilize extremity, additionally to recommend a cold on a joint.

Clinic a patient with the closed trauma of stomach entered. At the receipt the symptoms of the intra-abdominal bleeding are expressed. As a result of urgent operation (laparotomy) are set break of front surface of right stake of liver measuring 6×3×4 sm, hemoperitoneum.

How to produce the final stop of bleeding from the damaged liver? What to do with the blood poured out in an abdominal region?

Answer: For final hemostasis the site of damage of liver follows to take in by the rectangular stitches, it is desirable with pulling to them of stuffing-box up. Stitches are laid on by a dull needle with a double filament through all thickness of liver.

A poured out in an abdominal region blood is collected, filter through 8 layers of gauze in small bottles with stabilizing solution containing sodium of citrate or heparin, and pour to back sick.

During amputation of lower extremity at the level of lower third of thigh after imposition of ligature on a femoral artery with the last a clamp was taken off. From a wound under large pressure by pulsating motions began to gush blood of scarlet.

What the reason of bleeding is in? How to produce the temporal and final stop of bleeding? How to prevent such complication?

Answer: after the removal of clamp from a femoral artery, sliding of ligature happened off and was opened arterial bleeding. The temporal stop of bleeding can be produced by the finger pinning of artery against the horizontal branch of share bone with subsequent imposition of clamp on stump of femoral artery. The final stop of bleeding can be executed by a ligate of artery with preliminary its sewing, that will prevent in future sliding of ligature off.

During diagnostic punction of tumular formation in lower third of shin in a syringe began under constraint to take blood of dark-cherry blossom. Where did the needle of syringe get? How to stop bleeding?

Answer: a needle got in a vein. For the stop of bleeding it is needed to impose a pressing bandage.

During work with a circular saw a failure on a machine-tool happened and works by the splinter of saw the sword-cut of lower third of shoulder was inflicted. To the patient with the purpose of temporal stop of bleeding a styptic plait was imposed. Transporting of patient in traumatology department took 3 hours. What error was assumed? What can arise up complication and as him prevent?

Answer: in summer a plait needs to be laid on maximum on 2 hours continuously. At lengthening of term of stay of plait on extremity there can be its ischemia and numbness. For warning of the protracted ischemia a plait needs in 2 hours on a few minutes to be unstrung, stopping bleeding by the finger pinning, and repeatedly to impose higher than place of previous his location.

At a patient K., 65 years old, the operation of deleting of foreign body of the left lumbar region was executed. In the same day in the evening the bandage of patient abundantly got wet a blood, a wound bleeds on all surface. A patient reported that to him the day before during a month anticoagulant therapy which halted a week ago was conducted. At determination of time of rolling up of blood for the Lee-White index made 11 minutes. Name the reason of bleeding and method of final his stop.

Answer: the coagulopathic bleeding developed at sick on a background application of anticoagulants. Wound plug is needed tightly, sewing underneath a gemostatic tampon to the edges of wound, and to the patient to appoint gemostatic therapy.

At sick E., 62 years, the operation is executed cholecystectomy, choledoholytotomy, outward drainage of common bile-duct concerning the mechanical icterus caused by violation of outflow of bile because of hit of calculus in a common bile-duct. During the operation considerable bleeding of fabrics pays on itself the attention. What the reason of such state is in? What additional medical measures must be conducted?

Answer: at a patient on a background the violation of outflow of bile the cholemic bleeding related to the insufficient receipt in general bloodstream of vitamin K developed. In the complex of medical treatment it is necessary to add gemostatic preparation of vikasol (solution of vitamin K).