Types of primary surgical treatment of wounds. Initial debridement, or pho, of wounds

31.10.2020

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a) Definition, stages
PRIMARY SURGICAL WOUND TREATMENT is the first surgical operation performed on a patient with a wound under aseptic conditions, with anesthesia and consists in the sequential execution of the following stages:

Dissection of the wound.
Revision of the wound channel.
Excision of the edges, walls and bottom of the wound.
Hemostasis.
Restoration of the integrity of damaged organs and structures
Suturing the wound, leaving drainage (if indicated).

Thus, thanks to the PCO, an accidental infected wound becomes cut and aseptic, which makes it possible for its rapid healing by primary intention.
Dissection of the wound is necessary for a complete revision of the zone of distribution of the wound channel and the nature of the damage under the control of the eye.

Excision of the edges, walls and bottom of the wound is performed to remove necrotic tissues, foreign bodies, as well as the entire wound surface infected during injury. After completing this stage, the wound becomes cut and sterile. Further manipulations should be carried out only after changing instruments and processing or changing gloves.
It is usually recommended to dissect the edges, walls and bottom of the wound in a single block approximately 0.5-2.0 cm (Fig. 4.3). In this case, it is necessary to take into account the localization of the wound, its depth and the type of damaged tissue. With contaminated, crushed wounds, wounds on the lower extremities, the excision should be wide enough. With wounds on the face, only necrotic tissues are removed, and with a cut wound, excision of the edges is not performed at all. Viable walls and the bottom of the wound cannot be excised if they are represented by tissues of internal organs (brain, heart, intestines, etc.).
After excision, a thorough hemostasis is performed to prevent hematoma and possible infectious complications.
The recovery stage (suture of nerves, tendons, blood vessels, connection of bones, etc.) is desirable to be performed immediately at PST, if the qualification of the surgeon allows. If not, you can subsequently perform a second operation with a delayed suture of the tendon or nerve, and perform a delayed osteosynthesis. Restoration measures in full should not be carried out at the PWO in wartime.
Suturing the wound is the final stage of the PHO. The following options are available for completing this operation.

Layer-by-layer wound closure

It is performed for small wounds with a small area of \u200b\u200bdamage (cut, stabbed, etc.), lightly contaminated wounds, with localization of wounds on the face, neck, trunk or upper limbs with a short period from the moment of injury.

Suturing the wound leaving drainage (s)

Perform in cases where there is either a risk of developing an infection,
but it is very small, or the wound is localized on the foot or lower leg, or the area of \u200b\u200bdamage is large, or PHO is performed 6-12 hours after the moment of injury, or the patient has a concomitant pathology that adversely affects the wound process, etc.

The wound is not sewn up

This is done with a high risk of infectious complications:

late PHO,
abundant contamination of the wound with earth,
massive tissue damage (crushed, bruised wound),
concomitant diseases (anemia, immunodeficiency, diabetes mellitus),
localization on the foot or lower leg,
old age of the patient.

Gunshot wounds should not be stitched up, as well as any wounds when providing assistance in wartime.
Suturing the wound tightly in the presence of unfavorable factors is a completely unjustified risk and an obvious tactical mistake of the surgeon!
b) Main types
The earlier from the moment of injury the wound PST is performed, the lower the risk of infectious complications.
Depending on the age of the wound, three types of PHO are used: early, delayed and late.
Early PST is performed within 24 hours from the moment of wounding, includes all the main stages and usually ends with the imposition of primary sutures. With extensive damage to the subcutaneous tissue, the inability to completely stop capillary bleeding in the wound, drainage is left for 1-2 days. In the future, the treatment is carried out as in a "clean" postoperative wound.
Delayed PCO is performed from 24 to 48 hours after wounding. During this period, inflammation develops, edema, exudate appears. The difference from early PCO is the implementation of the operation against the background of the introduction of antibiotics and the completion of the intervention by leaving the wound open (not sutured) with the subsequent imposition of primary delayed sutures.
Late PCO is performed later than 48 hours, when the inflammation is close to maximum and the development of the infectious process begins. Even after PHO, the likelihood of suppuration remains high. In this situation, it is necessary to leave the wound open (do not suture) and conduct a course of antibiotic therapy. It is possible to apply early secondary sutures on the 7-20th day, when the wound is completely covered with granulations and acquires relative resistance to the development of infection.

c) Indications
An indication for performing a PHO wound is the presence of any deep accidental wound within 48-72 hours from the moment of application.
PHO are not subject to the following types of wounds:

superficial wounds, scratches and abrasions,
small wounds with a divergence of the edges of less than 1 cm,
multiple small wounds without damage to deeper tissues (shot wound, for example),
puncture wounds without damage to internal organs, blood vessels and nerves,
in some cases, through bullet wounds of soft tissues.

d) Contraindications
There are only two contraindications for performing a PHO wound:

Signs of development in the wound of a purulent process.
Patient's critical condition (terminal condition, shock

degree).

TYPES OF SEAMS

The prolonged existence of the wound does not contribute to the speedy functionally beneficial healing. This is especially true in case of extensive damage, when there are significant losses through the wound surface of fluid, proteins, electrolytes and a large p * rsk of suppuration. In addition, the execution of the wound with granulations and its closure with the epithelium take a rather long time. Therefore, you should strive to reduce the edges of the wound as early as possible using various types of sutures.
Benefits of suturing:

acceleration of healing,
reduction of losses through the wound surface,
reducing the likelihood of repeated wound suppuration,
increasing the functional and cosmetic effect,
facilitating wound treatment.

Allocate primary and secondary seams.
a) Primary seams
Primary sutures are applied to the wound before the development of granulations, while the wound heals by primary intention.
Most often, the primary sutures are applied immediately after the completion of the operation or PCO of the wound in the absence of a high risk of developing purulent complications. Primary sutures are inappropriate to use for late PHO, PHO in wartime, PHO of a gunshot wound.
Removal of sutures is carried out after the formation of dense connective tissue adhesions and epithelialization at a certain time.

Delayed primary sutures are also placed on the wound before the development of granulation tissue (the wound heals by primary tension). They are used in cases where there is a certain risk of infection.
Technique: the wound after surgery (PCO) is not sutured, the inflammatory process is controlled and when it subsides for 1-5 days, primary delayed sutures are applied.
A variety of primary-delayed sutures are provisional ones: at the end of the operation, sutures are applied, but the threads are not tied, the edges of the wound are not brought together in this way. The threads are tied for 1-5 days when the inflammatory process subsides. The difference from conventional delayed primary sutures is that there is no need for repeated anesthesia and stitching of the wound edges.
b) Secondary seams
Secondary sutures are applied to granulating wounds that heal by secondary intention. The point of using secondary sutures is to reduce (or eliminate) the wound cavity. A decrease in the volume of a wound defect leads to a decrease in the number of granulations required to fill it. As a result, the healing time is shortened, and the content of connective tissue in the healed wound is much less than in open wounds. This has a beneficial effect on the appearance and functional characteristics of the scar, on its size, strength and elasticity. Drawing the wound edges closer together reduces potential entry points for infection.
The indication for the imposition of secondary sutures is a granulating wound after elimination of the inflammatory process, without purulent streaks and purulent discharge, without areas of necrotic tissue. To objectify the subsidence of inflammation, sowing of wound discharge can be used - in the absence of growth of pathological microflora, secondary sutures can be applied.
Allocate early secondary sutures (they are applied on days 6-21) and late secondary sutures (they are applied after 21 days). The fundamental difference between them is that by 3 weeks after the operation, scar tissue forms at the edges of the wound, which prevents both the approach of the edges and the process of their fusion. Therefore, when applying early secondary sutures (before scarring the edges), it is enough to simply stitch the edges of the wound and bring them together by tying threads. When applying late secondary sutures, it is necessary to excise the scar edges of the wound under aseptic conditions ("refresh the edges"), and only after that, suture and tie the threads.
To accelerate the healing of a granulating wound, in addition to suturing, you can use the tightening of the edges of the wound with strips of adhesive plaster. The method does not completely and reliably eliminate the wound cavity, but it can be used even before the inflammation completely subsides. Tightening the edges of the wound with adhesive tape is widely used to accelerate the healing of purulent wounds.

PHO is the first surgical operation performed on a patient with a wound under aseptic conditions, with anesthesia, and consists in the sequential performance of the following steps:

1) dissection;

2) audit;

3) excision of the edges of the wound within the apparently healthy tissues, walls and bottom of the wound;

4) removal of hematomas and foreign bodies;

5) restoration of damaged structures;

6) suturing if possible.

The following options for suturing wounds are possible:

1) layer-by-layer wound suturing tightly (for small wounds, slightly contaminated, with localization on the face, neck, trunk, with a short period from the moment of injury);

2) suturing the wound, leaving drainage;

3) the wound is not sutured (this is done with a high risk of infectious complications: late PST, abundant contamination, massive tissue damage, concomitant diseases, old age, localization on the foot or lower leg).

Types of PHO:

1) Early (up to 24 hours from the moment of wounding) includes all stages and usually ends with the imposition of primary sutures.

2) Delayed (from 24-48 hours). During this period, inflammation develops, edema, exudate appears. The difference from early PCO is the implementation of the operation against the background of the introduction of antibiotics and the completion of the intervention by leaving it open (not sutured), followed by the imposition of delayed primary sutures.

3) Late (later than 48 hours). The inflammation is close to maximum and the development of the infectious process begins. In this situation, the wound is left open and antibiotic therapy is administered. Perhaps the imposition of early secondary sutures for 7-20 days.

PHO are not subject to the following types of wounds:

1) superficial, scratches;

2) small wounds with a divergence of the edges of less than 1 cm;

3) multiple small wounds without damage to deeper tissues;

4) puncture wounds without damage to organs;

5) in some cases, through bullet wounds of soft tissues.

Contraindications to the implementation of the PHO:

1) signs of development of a purulent process in the wound;

2) the critical condition of the patient.

Types of seams:

Primary surgical.Apply to the wound before the development of granulations. Impose immediately after the completion of the operation or PHO wound. It is inappropriate to use in case of late PHO, PHO in wartime, PHO of a gunshot wound.

Primary delayed.Apply until granulations develop. Technique: the wound after the operation is not sutured, the inflammatory process is controlled and when it subsides for 1-5 days, this suture is applied.

Secondary early.Apply to granulating wounds, healing by secondary intention. The imposition is made on days 6-21. By 3 weeks after the operation, scar tissue forms at the edges of the wound, which prevents both the approach of the edges and the process of fusion. Therefore, when applying early secondary sutures (before scarring the edges), it is enough to simply stitch the edges of the wound and bring them together by tying threads.

Secondary late.Apply after 21 days. When applying, it is necessary to excise the scar edges of the wound under aseptic conditions, and only then suture.

Toilet wounds. Secondary surgical treatment of wounds.

1) removal of purulent exudate;

2) removal of clots and hematomas;

3) cleaning the wound surface and skin.

Indications for VHO are the presence of a purulent focus, lack of adequate drainage from the wound, the formation of extensive zones of necrosis and purulent streaks.

1) excision of non-viable tissues;

2) removal of foreign ones and hematomas;

3) opening pockets and streaks;

4) drainage of the wound.

Differences between PHO and WMO:

Signs	PHO	WMO
Deadlines	In the first 48-74 hours	After 3 days or more
The main purpose of the operation	Suppuration prevention	Treating an infection
Wound condition	Does not granulate or contain pus	Granulates and contains pus
Condition of the excised tissue	With indirect signs of necrosis	With clear signs of necrosis
Cause of bleeding	Self-injury and tissue dissection during surgery	Arrosion of a vessel in a purulent process and damage during tissue dissection
The nature of the seam	Closure with a primary suture	Subsequently, it is possible to apply secondary sutures
Drainage	According to indications	Required

Classification by the type of damaging agent: mechanical, chemical, thermal, radiation, fire, combined.

Types of mechanical injuries:

1 - Closed (skin and mucous membranes are not damaged),

2 - Open (damage to mucous membranes and skin; risk of infection).

3 - Complicated; Immediate complications occur at the time of injury or in the first hours after it: Bleeding, traumatic shock, violation of vital functions of organs.

Early complications develop in the first days after the injury: Infectious complications (wound suppuration, pleurisy, peritonitis, sepsis, etc.), traumatic toxicosis.

Late complications are detected at a time remote from damage: chronic purulent infection; violation of tissue trophism (trophic ulcers, contracture, etc.); anatomical and functional defects of damaged organs and tissues.

4 - Uncomplicated.

A wound is damage of any depth and area, which violates the integrity of the mechanical and biological barriers of the human body, which delimit it from the environment. Patients are admitted to hospitals with injuries that can be caused by factors of various nature. In response to their effect, the body develops local (changes directly in the area of \u200b\u200binjury), regional (reflex, vascular) and general reactions.

Classification

Depending on the mechanism, localization, nature of damage, several types of wounds are distinguished.

In clinical practice, wounds are classified based on a number of characteristics:

origin (, operating, combat);
localization of damage (wounds to the neck, head, chest, abdomen, limbs);
the amount of damage (single, multiple);
morphological features (cut, chopped, stabbed, bruised, scalped, bitten, mixed);
length and relation to body cavities (penetrating and non-penetrating, blind, tangential);
type of injured tissue (soft tissue, bone, with damage to blood vessels and nerve trunks, internal organs).

In a separate group, gunshot wounds are distinguished, which are distinguished by a particular severity of the course of the wound process as a result of exposure to the tissues of significant kinetic energy and a shock wave. They are characterized by:

the presence of a wound channel (tissue defect of various lengths and directions with or without penetration into the body cavity, with the possible formation of blind "pockets");
the formation of a zone of primary traumatic necrosis (an area of \u200b\u200bnon-viable tissues, which are a favorable environment for the development of wound infection);
the formation of a zone of secondary necrosis (tissues in this zone are damaged, but their vital activity can be restored).

All wounds, regardless of origin, are considered contaminated with microorganisms. At the same time, one should distinguish between primary microbial contamination at the time of injury and secondary microbial contamination that occurs during treatment. The following factors contribute to wound infection:

the presence of blood clots, foreign bodies, necrotic tissues in it;
tissue trauma during immobilization;
violation of microcirculation;
weakening of immunity;
multiple injuries;
severe somatic diseases;

If the body's immune defenses are weakened and unable to cope with pathogenic microbes, then the wound becomes infected.

Phases of the wound process

During the wound process, 3 phases are distinguished, systematically replacing one another.

The first phase is based on the inflammatory process. Immediately after injury, tissue damage and vascular rupture occur, which is accompanied by:

platelet activation;
their degranulation;
aggregation and formation of a full-fledged thrombus.

At first, the vessels react to damage with an instant spasm, which is quickly replaced by their paralytic expansion in the area of \u200b\u200bdamage. In this case, the permeability of the vascular wall increases and tissue edema increases, reaching a maximum on 3-4 days. Thanks to this, the primary cleaning of the wound occurs, the essence of which is to remove dead tissue and blood clots.

Already in the first hours after exposure to the damaging factor, leukocytes penetrate through the vascular wall into the wound, a little later macrophages and lymphocytes join them. They phagocytose microbes and dead tissues. This continues the process of cleaning the wound and the so-called demarcation line is formed, which delimits viable tissues from damaged ones.

A few days after the injury, the regeneration phase begins. During this period, granulation tissue is formed. Of particular importance are plasma cells and fibroblasts, which are involved in the synthesis of protein molecules and mucopolysaccharides. They are involved in the formation of connective tissue that provides wound healing. The latter can be done in two ways.

Healing by primary intention leads to the formation of a soft connective tissue scar. But it is possible only with insignificant microbial contamination of the wound and the absence of foci of necrosis.
Infected wounds heal by secondary intention, which becomes possible after cleansing the wound defect from purulent-necrotic masses and filling it with granulations. The process is often complicated by formation.

The highlighted phases are typical for all types of wounds, despite their significant differences.

Primary surgical treatment of wounds

First of all, the bleeding should be stopped, then the wound should be decontaminated, the non-viable tissue should be excised and a bandage should be applied that will prevent infection.

Timely and radical surgical treatment is considered the key to successful wound healing. To eliminate the direct consequences of damage, primary surgical treatment is performed. She pursues the following goals:

prevention of purulent complications;
creation of optimal conditions for healing processes.

The main stages of primary surgical treatment are:

visual inspection of the wound;
adequate pain relief;
autopsy of all its departments (should be performed wide enough to gain full access to the wound);
removal of foreign bodies and non-viable tissues (skin, muscles, fascia are excised sparingly, and subcutaneous fatty tissue - widely);
stopping bleeding;
adequate drainage;
restoration of the integrity of damaged tissues (bones, muscles, tendons, neurovascular bundles).

In a serious condition of the patient, reconstructive operations can be performed delayed after the stabilization of the vital functions of the body.

The final stage of the surgical treatment is the suturing of the skin. Moreover, this is not always possible immediately during the operation.

Primary sutures are imposed without fail in case of penetrating cavity wounds, damage to the face, genitals, hand. Also, the wound can be sutured on the day of the operation in the absence of microbial contamination, the surgeon's confidence in the radical nature of the intervention and the free approach of the wound edges.
On the day of the operation, provisional sutures can be applied, which do not tighten immediately, but after a certain time, provided that the course of the wound process is uncomplicated.
Often, the wound is sutured several days after the operation (primary delayed sutures) in the absence of suppuration.
Secondary early stitches are applied to the granulating wound after it has been cleansed (after 1-2 weeks). If the wound has to be sutured later and its edges are cicatricially changed and rigid, then the granulation is first excised and the scars are dissected, and then the actual suturing is started (secondary-late sutures).

It should be noted that a scar is not as strong as intact skin. He acquires these properties gradually. Therefore, it is advisable to use slowly absorbable suture materials or tighten the edges of the wound with an adhesive plaster, which prevents the dehiscence of the edges of the wound and changes in the structure of the scar.

Which doctor to contact

For any wound, even a small one, it is necessary to contact the emergency room. The doctor should assess the degree of tissue contamination, prescribe antibiotics, and also treat the wound.

Conclusion

Despite the different types of wounds in origin, depth, localization, the principles of their treatment are similar. At the same time, it is important to carry out the primary surgical treatment of the damaged area on time and in full, which will help to avoid complications in the future.

Pediatrician E.O. Komarovsky tells how to properly treat a child's wound.

Every person from time to time is faced with such an unpleasant problem as wounds. They can be shallow and deep, in any case, wounds require timely treatment and competent treatment, otherwise there is a risk of serious and even life-threatening complications.

Sometimes there are situations when earth, chemicals, foreign objects get into the wound, such situations require special actions, so each person needs to familiarize himself with the rules of first aid for injuries. In addition, it has been proven that wounds that are treated in the first hour heal much faster than those that were treated later.

A wound is a mechanical injury in which the integrity of the skin, subcutaneous layers and mucous membranes is disrupted. The skin performs a protective function in the human body, does not allow pathogenic bacteria, dirt, harmful substances to get inside, and when its integrity is violated, the access of harmful substances and microbes to the wound opens.

The wound can provoke various complications that may appear immediately after the injury or after a while, especially if the initial surgical debridement of the wound has not been performed:

Infection. This complication occurs quite often, its cause is the reproduction of pathogenic microflora. The presence of a foreign object, damage to nerves, bones, tissue necrosis, blood accumulation promotes wound suppuration. Most often, the infection is associated with improper or untimely processing.
Hematomas. If the bleeding is not stopped in time, a hematoma may form inside the wound. This condition is dangerous because it significantly increases the risk of infection, since blood clots are a favorable environment for bacteria. In addition, a hematoma can interfere with blood circulation in the affected area, resulting in tissue death.
Traumatic shock. With severe injuries, severe pain and heavy blood loss may occur, if a person is not helped at this moment, he may even die.
Magnification. If the wound becomes chronic and does not heal for a long time, there is every chance that one day the cells will begin to change and turn into a cancerous tumor.

If you do not deal with the infection in the wound in time, then the risk of serious complications is high. Any, even the smallest, suppuration is a pathology that can lead to sepsis, phlegmon, gangrene. Such conditions are severe, require long and urgent treatment, and can be fatal.

First aid

Any wound, small or large, requires urgent treatment to stop bleeding. If the injury is minor, it is enough to provide the victim with first aid and regularly change the dressings, but if the wound is large and bleeds heavily, then it is imperative to go to the hospital.

There are a number of basic rules that must be followed when carrying out a PHO wound:

Before you start providing medical care, you should wash your hands well, preferably wear sterile gloves, or treat your skin with an antiseptic.
If there are small foreign objects in a small wound, they can be removed with tweezers, which are recommended to be washed with water, and then with an antiseptic. If the object is deep, if it is a knife or something large, then you should not remove the object yourself, you need to call an ambulance.
You can rinse only with clean boiled water and an antiseptic solution; you cannot pour iodine and brilliant green into it.
To apply a bandage, you need to use only a sterile bandage; if you need to cover the wound before the doctor arrives, you can use a clean diaper or a handkerchief.
Before bandaging the wound, you need to attach a napkin moistened with an antiseptic to it, otherwise the bandage will dry out.
Abrasions should not be bandaged, they heal faster in the air.

First aid procedure:

Minor cuts and abrasions should be washed with boiled warm or running water; deep wounds should not be washed with water.
To stop bleeding, you can apply cold to the affected area.
The next step is to flush the wound with an antiseptic solution, for example, hydrogen peroxide or chrohexidine. Peroxide is more suitable for primary treatment, it foams and pushes dirt particles out of the wound. For secondary processing, it is better to use chlorhexidine, as it does not injure tissue.
Zelenka treat the edges of the wound.
At the last stage, a bandage is applied, which must be changed regularly.

Deep wound treatment

It is very important to know how to properly treat a wound if it is deep. Severe injuries can cause painful shock, severe bleeding and even death. For this reason, help should be provided immediately. In addition, if the wound is deep, it is necessary to take the victim to the hospital as soon as possible. The rules for providing first aid for deep wounds are as follows.

The main goal is to stop the blood loss. If a large foreign object, such as a knife, remains in the wound, it is not necessary to remove it before the arrival of the doctors, as it inhibits bleeding. In addition, if the object is incorrectly removed, internal organs can be injured and the victim's death can be provoked.

If there are no foreign objects in the wound, it is necessary to press on it through a clean, and preferably sterile cloth or gauze. The victim can do it on their own. You need to put pressure on the wound before the doctors arrive, without letting go.

To stop severe bleeding from the limb, a tourniquet must be placed above the wound. It should not be very tight, in addition, it is necessary to do it correctly. The tourniquet is applied to clothing and quickly, and removed slowly. You can hold the tourniquet for an hour, after which it must be loosened for 10 minutes and bandaged slightly higher. It is very important to make a record on the patient's clothing or body about the time of the tourniquet application in order to remove it in time, otherwise there is a risk of provoking tissue necrosis. A tourniquet is not necessary if the bleeding is mild and can be stopped with a pressure bandage.

You need to pay attention to whether there are symptoms of pain shock. If a person panics, screams, makes sudden movements, then perhaps this is a sign of traumatic shock. In this case, after a few minutes, the victim may lose consciousness. From the very first minutes, it is necessary to lay the person down, slightly raise his legs and ensure silence, cover him, give him warm water or tea, if the oral cavity is not injured. It is necessary to inject the patient with painkillers as soon as possible to relieve the pain, and in no case should he be allowed to go anywhere, to get up.

If the victim is unconscious, do not give him pills, water, or place any objects in the mouth. This can lead to suffocation and death.

Medicines

It is very important to know how to treat the wound; for these purposes, antiseptics are always used - these are special disinfectants that prevent and stop putrefactive processes in the tissues of the body. Antibiotics are not recommended for treating wounds, as they only kill bacteria, and there may be a fungal or mixed infection in the wound.

It is very important to use antiseptics correctly, since they do not contribute to the speedy healing of the wound, but only disinfect it. If such medicines are used incorrectly and uncontrollably, the wound will heal for a very long time.

Consider a few of the most popular antiseptics.

Hydrogen peroxide... This agent is used for the primary treatment of wounds and for the treatment of suppuration, it is important to note that only a 3% solution is suitable for these purposes, a large concentration can provoke a burn. Peroxide should not be used if a scar appears, as it will begin to corrode it and the healing process will be delayed. Peroxide is not treated with deep wounds; it cannot be mixed with acid, alkali and penicillin.

Chlorhexidine... This substance is used both for primary treatment and for the treatment of suppuration. It is best to rinse the wound with peroxide before using chlorhexidine to remove dust and dirt particles with the foam.

Ethanol... The most accessible and well-known antiseptic, it cannot be used on mucous membranes, but must be applied to the edges of the wound. For disinfection, you need to use alcohol from 40% to 70%. It should be noted that with large wounds, alcohol cannot be used, since it provokes severe pain, this can cause pain shock.

Potassium permanganate solution... It needs to be made weak, slightly pink. Potassium permanganate is used for primary treatment and washing of suppurations.

Furacilin solution... You can prepare it yourself in the proportion of 1 tablet per 100 ml of water, it is better to crush the tablet into powder beforehand. You can use the tool for washing mucous membranes and skin, for treating suppuration.

Zelenka and iodine smear only on the edges of the wound. You can not use iodine if you are allergic to it or if you have problems with the thyroid gland. If these solutions are applied to a wound or fresh scars, the injury will take longer to heal, since the substance will provoke tissue burns.

Chlorhexidine, peroxide, furacilin, and potassium permanganate can be used to wet the dressing napkin to prevent the bandage from sticking to the wound.

PHO wounds in children

I would like to pay special attention to PHO wounds in children. Babies react violently to any pain, even a small abrasion, therefore, first of all, the child needs to be seated or laid down, and reassured. If the wound is small and the bleeding is weak, it is washed with peroxide or treated with chlorhexidine, smeared around the edges with brilliant green and covered with adhesive plaster.

In the process of providing first aid, you should not panic, you need to show the child that nothing terrible has happened, and try to translate the whole process into a game. If the wound is large, there are foreign objects in it, then it is necessary to call an ambulance as soon as possible. Do not remove anything from the wound, especially with dirty hands, it is very dangerous.

The child needs to be immobilized as much as possible, not to allow him to touch the wound. In case of severe bleeding, when the blood gushes with a fountain, a tourniquet must be applied. It is very important to get the child to the hospital as soon as possible and to prevent a lot of blood loss.

Video: PHO - primary surgical debridement

Wounds. Primary surgical treatment. Drainage of wounds.

Wounds. Classification of wounds.

Wound

The main signs of a wound

Bleeding;

Functional impairment.

Elements of any woundare:

The bottom of the wound.

Wounds are classified on various grounds.

Puncture wounds

Cut wounds

Chopped wounds

Scalped wounds patchwork.

Bitten wounds

Poisoned wounds

Gunshot wounds -

- wound channel area

- bruised area

Secondary necrosis zone;

3. By infection

The course of the wound process

During the healing of wounds, the resorption of dead cells, blood, lymph occurs, and due to the inflammatory reaction, the process of cleansing the wound is carried out. The wound walls close to each other are glued together (primary gluing). Along with these processes in the wound, connective tissue cells multiply, which undergo a number of transformations and turn into fibrous connective tissue - a scar. On both sides of the wound, there are opposite processes of neoplasm of blood vessels, which grow into a fibrin clot that sticks together the walls of the wound. Simultaneously with the formation of a scar and blood vessels, the epithelium multiplies, the cells of which grow on both sides of the wound and gradually cover the scar with a thin layer of the epidermis; in the future, the entire layer of the epithelium is completely restored.

Signs of wound suppuration correspond to the classic signs of inflammation, as a biological response of the body to a foreign agent: dolor (pain);

calor (temperature);

tumor (swelling, edema);

rubor (redness);

functio lesae (dysfunction);

INFLAMMATION

The stage is characterized by the presence of all signs of a purulent wound process. In a purulent wound, there are remnants of non-viable and dead tissue of its own, foreign objects, dirt, accumulation of pus in cavities and folds. Viable tissues are edematous. There is an active absorption of all this and microbial toxins from the wound, which causes the phenomena of general intoxication: an increase in body temperature, weakness, headache, lack of appetite, etc.

Stage treatment objectives: drainage of the wound to remove pus, necrotic tissue and toxins; fighting infection. Wound drainage can be active (using devices for aspiration) and passive (drainage tubes, rubber strips, gauze wipes and turundas moistened with water-salt solutions of antiseptics. Therapeutic (medicinal) agents for treatment:

Hypertonic solutions:

The most commonly used by surgeons is a 10% sodium chloride solution (the so-called hypertonic solution). Besides him, there are other hypertonic solutions: 3-5% boric acid solution, 20% sugar solution, 30% urea solution, etc. Hypertonic solutions are designed to ensure the outflow of wound discharge. However, it was found that their osmotic activity lasts no more than 4-8 hours, after which they are diluted with wound secretions, and the outflow stops. Therefore, recently, surgeons refuse to use a hypertonic solution.

In surgery, various ointments are used on a fatty and petrolatum base; Vishnevsky ointment, synthomycin emulsion, ointments with a / b - tetracycline, neomycin, etc. But such ointments are hydrophobic, that is, they do not absorb moisture. As a result, tampons with these ointments do not provide an outflow of wound secretions, they become only a cork. At the same time, antibiotics present in ointments are not released from ointment compositions and do not have a sufficient antimicrobial effect.

Pathogenetically justified the use of new hydrophilic water-soluble ointments - Levosin, Levomikol, mafenide-acetate, oflokain. Such ointments contain antibiotics that easily pass from the composition of the ointments into the wound. The osmotic activity of these ointments exceeds the effect of a hypertonic solution by 10-15 times, and lasts for 20-24 hours, therefore, one dressing per day is enough for an effective effect on the wound.

Enzyme therapy (enzyme therapy):

For the speedy removal of dead tissue, necrolytic drugs are used. Proteolytic enzymes are widely used - trypsin, chymopsin, chymotrypsin, terrilitin. These drugs cause lysis of necrotic tissue and accelerate wound healing. However, these enzymes also have disadvantages: in the wound, enzymes retain their activity for no more than 4-6 hours. Therefore, for effective treatment of purulent wounds, the dressings must be changed 4-5 times a day, which is almost impossible. It is possible to eliminate such a lack of enzymes by including them in ointments. So, Iruksol ointment (Yugoslavia) contains the enzyme pentidase and the antiseptic chloramphenicol. The duration of enzyme action can be increased by immobilizing them in dressings. So, trypsin immobilized on napkins acts for 24-48 hours. Therefore, one dressing per day fully provides a therapeutic effect.

Use of antiseptic solutions.

Solutions of furacillin, hydrogen peroxide, boric acid, etc. are widely used. It has been established that these antiseptics do not have sufficient antibacterial activity against the most frequent causative agents of surgical infection.

Among the new antiseptics, it should be noted: iodopyrone, a preparation containing iodine, is used to treat the hands of surgeons (0.1%) and treat wounds (0.5-1%); dioxidine 0.1-1%, sodium hypochlorite solution.

Physical treatments.

In the first phase of the wound process, quartzing of wounds, ultrasonic cavitation of purulent cavities, UHF, hyperbaric oxygenation are used.

Laser application.

In the phase of inflammation of the wound process, high-energy or surgical laser is used. With a moderately defocused beam of a surgical laser, pus and necrotic tissues are evaporated, thus complete sterility of wounds can be achieved, which in some cases allows a primary suture to be applied to the wound.

GRANULATION

The stage is characterized by complete cleansing of the wound and the execution of the wound cavity with granulations (tissue of bright pink color with a granular structure). It first performs the bottom of the wound, and then fills the entire wound cavity. At this stage, its growth should be stopped.

Stage objectives: anti-inflammatory treatment, protection of granulations from damage, stimulation of regeneration

These tasks are answered by:

a) ointments: methyluracilic, troxevasinic - to stimulate regeneration; fat-based ointments - to protect granulations from damage; water-soluble ointments - anti-inflammatory effect and protection of wounds from secondary infection.

b) herbal preparations - aloe juice, sea buckthorn and rosehip oil, Kalanchoe.

c) use of a laser - in this phase of the wound process, low-energy (therapeutic) lasers with a stimulating effect are used.

EPITHELIZATION

The stage occurs after the completion of the bottom of the wound and its cavity with granulation tissue. Stage objectives: to accelerate the process of epithelialization and scarring of wounds. For this purpose, sea buckthorn and rosehip oil, aerosols, troxevasin-jelly, low-energy laser irradiation are used. At this stage, the use of ointments that stimulate the growth of granulations is not recommended. On the contrary, it is recommended to switch back to water-salt antiseptics. It is helpful to allow the dressing to dry to the wound surface. In the future, it should not be torn off, but only cut off along the edges, as it detaches due to epithelialization of the wound. It is recommended to moisten such a bandage from above with iodonate or other antiseptic. In this way, a small wound under the scab is healed with a very good cosmetic effect. In this case, a scar is not formed.

With extensive skin defects, long-term non-healing wounds and ulcers in the 2nd and 3rd phases of the wound process, i.e. after cleansing the wounds from pus and the appearance of granulations, dermoplasty can be performed:

a) artificial leather

b) a split displaced flap

c) walking stem according to Filatov

d) autodermoplasty with a full-thickness flap

e) free autodermoplasty with a thin-layer flap according to Thirsh

At all stages of the treatment of purulent wounds, one should remember about the state of immunity and the need to stimulate it in patients of this category.

The first and main stage in the treatment of wounds in a medical institution is the primary surgical treatment.

Primary surgical treatment of wounds (PCO). The main thing in the treatment of wounds is their primary surgical treatment. Its purpose is to remove non-viable tissue, the microflora in them and thereby prevent the development of wound infection.

Primary surgical treatment of wounds:

It is usually performed under local anesthesia. Stages:

1. Inspection of the wound, toilet of the skin edges, their treatment with aetiseptic (tincture of iodine 5%, do not get into the wound);

2. Revision of the wound, excision of all nonviable tissues, removal of foreign bodies, small fragments of bones, dissection of the wound, if necessary, to eliminate pockets;

3. The final stop of bleeding;

3. Drainage of the wound, if indicated;

4. Primary wound suture (according to indications);

Distinguish between early primary surgical treatment, carried out in the first day after injury, delayed - during the second day and late - 48 hours after injury. The earlier the primary surgical treatment is performed, the more likely it is to prevent the development of infectious complications in the wound.

During the Great Patriotic War, 30% of wounds were not surgically treated: small superficial wounds, through wounds with small inlet and outlet openings without signs of damage to vital organs, blood vessels, multiple blind wounds.

Primary surgical treatment must be instantaneous and radical, that is, it must be performed in one stage and in the process, non-viable tissues must be completely removed. First of all, they operate on the wounded with an imposed hemostatic tourniquet and extensive shrapnel wounds, with soil contamination of the wounds, in which there is a significant risk of anaerobic infection.

Primary surgical debridement consists in excision of the edges, walls and bottom of it within healthy tissues with the restoration of anatomical relationships.

Initial surgical treatment begins with incision of the wound. With a bordering incision 0.5 - 1 cm wide, the skin and subcutaneous tissue around the wound are excised and the skin incision is extended along the axis of the limb along the neurovascular bundle for a length sufficient to inspect all the blind pockets of the wound and excise non-viable tissues. Further along the skin incision, the fascia and aponeurosis are dissected. This provides a good examination of the wound and reduces muscle compression due to their swelling, which is especially important for gunshot wounds.

After cutting the wound, scraps of clothing, blood clots, free-lying foreign bodies are removed and the excision of crushed and contaminated tissues is started.

Muscles are excised within healthy tissues. Muscles that are not viable are dark red, dull, do not bleed when cut, and do not contract when touched with forceps.

Intact large vessels, nerves, tendons should be preserved during wound treatment, and contaminated tissues should be carefully removed from their surface. (Small bone fragments freely lying in the wound are removed, sharp, devoid of periosteum, the ends of the bone fragments protruding into the wound are bite off with nippers. If damage to vessels, nerves, tendons is found, their integrity is restored. non-viable tissues and foreign bodies are completely removed, the wound is sutured (primary suture).

Late surgical treatment is performed according to the same rules as the early one, but with signs of purulent inflammation, it boils down to removing foreign bodies, cleaning the wound from dirt, removing necrotic tissue, opening leaks, pockets, hematomas, abscesses in order to provide good conditions for the outflow of wound discharge.

Tissue excision, as a rule, is not performed due to the danger of generalization of the infection.

The final stage of the primary surgical treatment of wounds is the primary suture, restoring the anatomical continuity of tissues. Its purpose is to prevent secondary wound infection and to create conditions for wound healing by primary intention.

The primary suture is applied to the wound within 24 hours after injury. The primary suture, as a rule, also ends with surgical interventions during aseptic operations. Under certain conditions, purulent wounds are closed with a primary suture after opening subcutaneous abscesses, phlegmons and excision of necrotic tissues, providing in the postoperative period good conditions for drainage and prolonged washing of wounds with solutions of antiseptics and proteolytic enzymes.

The primary delayed suture is applied within 5 - 7 days after the primary surgical treatment of wounds before the appearance of granulations, provided that there is no wound suppuration. Delayed sutures can be applied in the form of provisional sutures: the operation is completed by stitching the edges of the wound and tightening them after a few days, if the wound has not suppurated.

In wounds sutured with a primary suture, the inflammatory process is poorly expressed and healing occurs by primary intention.

During the Great Patriotic War, the primary surgical treatment of wounds due to the risk of infection was not performed in full - without the imposition of a primary suture; primary delayed, provisional seams were used. When acute inflammation subsided and granulations appeared, a secondary suture was applied. The widespread use of the primary suture in peacetime, even when treating wounds at a later date (12-24 hours), is possible due to targeted antibacterial therapy and systematic observation of the patient. At the first signs of infection in the wound, it is necessary to partially or completely remove the stitches. The experience of the Second World War and subsequent local wars showed the inexpediency of using a primary suture for gunshot wounds, not only due to the characteristics of the latter, but also due to the lack of the possibility of systematic observation of the wounded in military field conditions and at the stages of medical evacuation.

The final stage of the primary surgical treatment of wounds, delayed for some time, is the secondary suture. It is applied to a granulating wound in conditions when the danger of wound suppuration has passed. Terms of application of the secondary suture from several days to several months. It is used to accelerate wound healing.

An early secondary suture is applied to granulating wounds within 8 to 15 days. The edges of the wound are usually mobile, they are not excised.

A late secondary suture is applied at a later time (after 2 weeks), when cicatricial changes have occurred in the edges and walls of the wound. The convergence of the edges, walls and bottom of the wound in such cases is impossible, therefore, the edges are mobilized and the scar tissue is excised. In cases where there is a large skin defect, a skin transplant is performed.

Indications for the use of a secondary suture are: normalization of body temperature, blood composition, a satisfactory general condition of the patient, and from the side of the wound, the disappearance of edema and hyperemia of the skin around it, complete cleansing of pus and necrotic tissues, the presence of healthy, bright, juicy granulations.

Various types of sutures are used, but regardless of the type of suture, the basic principles must be observed: there should not be any closed cavities or pockets in the wound, the adaptation of the edges and walls of the wound should be maximized. The sutures should be removable, and ligatures should not remain in the sutured wound, not only from non-absorbable material, but also from absorbable material, since the presence of foreign bodies in the future can create conditions for wound suppuration. With early secondary sutures, the granulation tissue must be preserved, which simplifies the surgical technique and preserves the barrier function of the granulation tissue, which prevents the spread of infection to the surrounding tissues.

Healing of wounds sutured with a secondary suture and healed without suppuration is usually called healing by the type of primary tension, in contrast to true primary tension, since, although the wound heals with a linear scar, the processes of scar tissue formation occur in it through the maturation of granulations.

Drainage of wounds

Wound drainage plays an important role in creating favorable conditions for the course of the wound process. It is not always carried out, and the surgeon determines the indications for this procedure. According to modern concepts, wound drainage, depending on its type, should provide:

Removal of excess blood (wound contents) from the wound and thereby the prevention of wound infection (any training pitchfork);

Tight contact of wound surfaces, which helps to stop bleeding from small vessels (vacuum drainage of the spaces located under the flaps);

Active cleansing of the wound (during its drainage with constant postoperative irrigation).

There are two main type of drainage: active and passive (Fig. 1).

Types of wound drainage and their characteristics

Figure: left. Types of wound drainage and their characteristics

Passive drainage

It involves the removal of wound contents directly through the line of skin sutures and is able to ensure drainage of only the superficial sections of the wound. This provides for the imposition, above all, of an interrupted skin suture with relatively wide and leaky inter-suture gaps. It is through them that drainages are installed, which can be used as parts of drainage pipes and other available material. By moving the edges of the wound apart, drainages improve the outflow of wound contents. It is quite understandable that such drainage is most effective when installing drains taking into account the action of gravity.

In general, passive wound drainage is simple, the downside of which is its low efficiency. Drainage with a piece of glove rubber in the photo on the left. Obviously, passive drains are not able to provide drainage of wounds with a complex shape, and therefore can be used, first of all, for superficial wounds located in those areas where the requirements for the quality of the skin suture can be reduced.

Active drainage

It is the main type of drainage of wounds of complex shape and involves, on the one hand, the sealing of a skin wound, and on the other, the presence of special drainage devices and instruments for carrying out drainage tubes (Fig. 2).

Standard devices for active drainage of wounds with a set of wires for passing drainage tubes through tissues.

Fig 2. Standard devices for active drainage of wounds with a set of guides for passing drainage tubes through tissues.

An important feature of the active wound drainage method is its high efficiency, as well as the possibility of floor-by-floor wound drainage. In this case, the surgeon can use the most precise skin suture, the quality of which is fully preserved when removing the drainage tubes away from the wound. It is advisable to choose the places where the drainage tubes exit in "hidden" areas, where additional punctate scars do not worsen the aesthetic characteristics (scalp, axillary cavity, pubic region, etc.).

Active drains are usually removed 1-2 days after the operation, when the volume of daily wound discharge (through a separate tube) does not exceed 30-40 ml.

The greatest drainage effect is obtained from tubes made of a non-wettable material (for example, silicone rubber). The lumen of the PVC tubing can quickly become blocked by clotting. The reliability of such a tube can be increased by its preliminary (before installation in the wound) washing with a solution containing heparin.

Drainage of panaritium: a) drainage tube; b) the introduction of the tube into the wound; c) washing; d) removing the tube.

Failure to drain or its lack of efficiency can lead to the accumulation of a significant amount of wound contents in the wound. The further course of the wound process depends on many factors and can lead to the development of suppuration. However, even without the development of purulent complications, the wound process in the presence of a hematoma changes significantly: all phases of scar formation are lengthened due to a longer process of organizing an intra-wound hematoma. A very unfavorable circumstance is a prolonged (several weeks or even months) increase in the volume of tissues in the area of \u200b\u200bthe hematoma. The scale of tissue scarring increases, and the quality of the skin scar may deteriorate.

Factors contributing to wound healing:

General condition of the body;

The nutritional status of the body;

Age;

Hormonal background;

Development of wound infection;

Oxygen supply condition;

Dehydration;

Immune status.

Types of wound healing:

Healing primary intention- fusion of the edges of the wound without visible scar changes;

Healing secondary tension - healing through suppuration;

- healing under the scab -under the formed crust, which should not be removed prematurely, further traumatizing the wound.

Wound dressing steps:

1. Removing the old bandage;

2. Inspection of the wound and surrounding area;

3. Toilet of the skin surrounding the wound;

4. Toilet of the wound;

5. Manipulation of the wound and preparing it for the imposition of a new bandage;

6. Applying a new bandage;

7. Fixation of the bandage (see section Desmurgy)

Wounds. Classification of wounds.

Wound (vulnus) - mechanical damage to tissues or organs, accompanied by a violation of the integrity of their integuments or mucous membranes. It is the violation of the integrity of the integumentary tissues (skin, mucous membrane) that distinguishes wounds from other types of damage (contusion, rupture, stretching). For example, a rupture of the lung tissue caused by blunt trauma to the chest is considered a rupture, and in the case of damage with a knife - a lung wound, because there is a violation of the integrity of the skin.

It is necessary to distinguish between the concept of "wound" and "injury". In essence, a wound is the end result of tissue damage. The concept of injury (vulneratio) is understood as the process of damage itself, the entire complex and multifaceted set of pathological changes that inevitably arise during the interaction of tissues and a wounding projectile both in the area of \u200b\u200bdamage and throughout the body. However, in everyday practice, the terms wound and wound are often used interchangeably and are often used interchangeably.

The main signs of a wound

The main classic signs of wounds are:

Bleeding;

Violation of tissue integrity;

Functional impairment.

The severity of each sign is determined by the nature of the injury, the volume of damaged tissues, the peculiarities of the innervation and blood supply of the wound channel zone, the possibility of injury to vital organs.

Elements of any woundare:

Wound cavity (wound channel);

The bottom of the wound.

A wound cavity (cavum vulnerale) is a space bounded by the walls and bottom of the wound. If the depth of the wound cavity significantly exceeds its transverse dimensions, then it is called a wound channel (canalis vulneralis).

Wounds are classified on various grounds.

1. By the nature of tissue damage:

Puncture wounds applied with a piercing weapon (bayonet, needle, etc.). Their anatomical feature is their considerable depth with little damage to the integument. With these wounds, there is always a danger of damage to vital structures located deep in the tissues, in the cavities (vessels, nerves, hollow and parenchymal organs). Appearance and presentation of puncture wounds Does not always provide sufficient data for a diagnosis. So, with a puncture wound of the abdomen, it is possible to injure the intestine or the Liver, but the discharge of intestinal contents or blood from the wound usually cannot be detected. With a puncture wound, in an area with a large array of muscles, a large artery may be damaged, but external bleeding may also be absent due to muscle contraction and displacement of the wound channel. An interstitial hematoma is formed with the subsequent development of a false aneurysm.

Puncture wounds are dangerous because, due to the small number of symptoms, damage to deep-lying tissues and organs can be seen, therefore, a particularly careful examination of the patient's wounds is also necessary by the fact that microorganisms are introduced into the depths of the tissues with a wounding weapon, and the wound discharge, not finding a way out , serves as a good breeding ground for them, which creates especially favorable conditions for the development of purulent complications.

Cut wounds applied with a sharp object. They are characterized by a small number of destroyed cells; the surrounding letters are not damaged. The gaping of the wound allows you to inspect the damaged tissue and creates good conditions for the outflow of the discharge. With a cut wound, there are the most favorable conditions for healing, therefore, when treating any fresh wounds, they tend to turn them into cut wounds.

Chopped wounds applied with a heavy sharp object (checker, ax, etc.). Such wounds are characterized by deep tissue damage, wide gaping, bruising and concussion of the surrounding tissues, which reduces their resistance and regenerative abilities.

Bruised and lacerated wounds (crushed) are the result of exposure to a blunt object. They are characterized by a large number of crushed, bruised, blood-soaked tissues with impaired vitality. Bruised blood vessels often rhombus. In bruised wounds, favorable conditions are created for the development of infection.

Scalped woundstangent to the surface of the body of the wound, caused by a sharp cutting object. If the flap remains on the leg, then such a wound is called patchwork.

Bitten wounds characterized not so much by extensive and deep damage as by severe infection with the virulent flora of the human or animal mouth. The course of these wounds is more often than others complicated by the development of an acute infection. Bite wounds can be infected with the rabies virus.

Poisoned wounds - these are wounds into which poison gets into (with a bite of a snake, scorpion, penetration of toxic substances), etc.

Gunshot wounds - special among the wounds. They differ from all others in the nature of the wounding weapon (bullet, splinter); the complexity of the anatomical characteristics; the peculiarity of tissue damage with areas of complete destruction, necrosis and molecular shock; a high degree of infection; a variety of characteristics (through, blind, tangent, etc.).

I distinguish the following elements of a gunshot wound:

- wound channel area - the area of \u200b\u200bdirect impact of the traumatic projectile;

- bruised area - area of \u200b\u200bprimary traumatic necrosis;

- molecular shock zone- area of \u200b\u200bsecondary necrosis;

A special approach in the treatment of such wounds, and, moreover, very different in peacetime and in wartime, at the stages of medical evacuation.

2. Due to wound damage divided into operational (intentional) and accidental.

3. By infectionsecrete wounds aseptic, freshly infected and purulent.

Purulent wound (burn) with areas of necrosis

4. In relation to body cavities (cranial cavity, chest, abdomen, joints, etc.) distinguish between penetrating and non-penetrating wounds. Penetrating wounds pose a great danger due to the possibility of damage or involvement in the inflammatory process of the membranes, cavities and organs located in them.

5. Allocate simple and complicated wounds, in which there is any additional tissue damage (poisoning, burns) or a combination of soft tissue injuries with damage to bone, hollow organs, etc.