The basis of wound treatment is their debridement. Depending on the timing, surgical treatment can be early (in the first 24 hours after injury), delayed (24-48 hours) and late (over 48 hours).
Depending on the indications, a distinction is made between primary (performed for direct and immediate consequences of damage) and secondary surgical treatment (performed for complications, usually infectious, which are an indirect consequence of damage).
Primary surgical treatment (PST).
For its proper implementation, complete anesthesia (regional anesthesia or anesthesia; only when treating small superficial wounds is it permissible to use local anesthesia) and the participation of at least two doctors (surgeon and assistant) in the operation.
The main tasks of the PHO are:
Dissection of the wound and opening of all its blind cavities, creating the possibility of visual inspection of all parts of the wound and good access to them, as well as ensuring complete aeration;
Removal of all non-viable tissues, loose bone fragments and foreign bodies, as well as intermuscular, interstitial and subfascial hematomas;
Performing complete hemostasis;
Creation of optimal conditions for drainage of all sections of the wound channel.
The operation of PSO of wounds is divided into 3 sequential stages: tissue dissection, excision and reconstruction.
1.Tissue dissection. As a rule, dissection is made through the wound wall.
The incision is made along the muscle fibers, taking into account the topography neurovascular formations. If there are several wounds located close to each other on a segment, they can be connected with one incision. They begin by dissecting the skin and subcutaneous tissue so that all blind pockets of the wound can be clearly examined. The fascia is often cut in a Z-shape. This dissection of the fascia allows not only a good inspection of the underlying sections, but also to ensure the necessary decompression of the muscles in order to prevent their compression by increasing edema. Bleeding that occurs along the incisions is stopped by applying hemostatic clamps. In the depths of the wound, all blind pockets are opened. The wound is washed abundantly with antiseptic solutions, after which it is vacuumed (the contents of the wound cavity are removed with an electric suction).
P. Excision of tissue. The skin is usually excised sparingly until the characteristic whitish color appears on the incision and capillary bleeding. The exception is the area of the face and the palmar surface of the hand, when only obviously non-viable areas of the skin are excised. When treating uncontaminated incised wounds with smooth, unbruised edges, in some cases it is permissible to refuse excision of the skin if there is no doubt about the viability of its edges.
Subcutaneous fatty tissue is excised widely, not only within the limits of visible contamination, but also including areas of hemorrhage and detachment. This is due to the fact that subcutaneous fatty tissue is the least resistant to hypoxia, and when damaged, it is very prone to necrosis.
Disintegrated, contaminated areas of the fascia are also subject to economical excision.
Surgical treatment of muscles is one of the critical stages of the operation.
First, blood clots and small foreign bodies located on the surface and in the thickness of the muscles are removed. Then the wound is additionally washed with antiseptic solutions. Muscles must be excised within healthy tissues until fibrillary twitching appears, their normal color and shine appear, and capillary bleeding occurs. A non-viable muscle loses its characteristic shine, its color changes to dark brown; it does not bleed and does not contract in response to irritation. In most cases, especially in bruised and gunshot wounds, there is a significant imbibition of the muscles with blood. Careful hemostasis is performed as necessary.
The edges of damaged tendons are excised sparingly within the limits of visible contamination and marginal fiber disintegration.
III. Wound reconstruction. If damaged great vessels a vascular suture is performed or bypass surgery is performed.
Damaged nerve trunks, in the absence of a defect, are sutured “end to end” by the perineurium.
Damaged tendons, especially in distal sections the forearms and lower legs should be sewn together, since otherwise their ends will subsequently turn out to be far apart from each other, and it will no longer be possible to restore them. If there are defects, the central ends of the tendons can be sewn into the remaining tendons of other muscles.
The muscles are sutured, restoring their anatomical integrity. However, during PST of crush and gunshot wounds, when there is no absolute confidence in the usefulness of the treatment performed, and the viability of the muscles is questionable, only rare sutures are placed on them in order to cover bone fragments, exposed vessels and nerves.
The operation is completed by infiltrating the tissue around the treated wound with antibiotic solutions and installing drains.
Drainage is mandatory when performing primary surgical treatment of any wound.
For drainage, single- and double-lumen tubes with a diameter of 5 to 10 mm with multiple perforations at the end are used. Drains are removed through separately made counter-apertures. Solutions of antibiotics or (preferably) antiseptics are injected into the wound through the drainages.
A wound is mechanical damage to tissue in the presence of violations of the integrity of the skin. The presence of a wound, rather than a bruise or hematoma, can be determined by such signs as pain, gaping, bleeding, dysfunction and integrity. PSO wounds carried out in the first 72 hours after injury, if there are no contraindications.
Types of wounds
Each wound has a cavity, walls and a bottom. Depending on the nature of the damage, all wounds are divided into puncture, cut, chopped, bruised, bitten and poisoned. This must be taken into account during PSO of a wound. After all, the specifics of first aid depend on the nature of the injury.
- Puncture wounds are always caused by a sharp object, such as a needle. Distinctive feature The damage is deep, but the damage to the integument is small. In view of this, it is necessary to ensure that there is no damage to blood vessels, organs or nerves. Puncture wounds are dangerous due to mild symptoms. So, if there is a wound on the abdomen, there is a possibility of liver damage. This is not always easy to notice when carrying out PHO.
- An incised wound is caused using a sharp object, so tissue destruction is small. At the same time, the gaping cavity can be easily examined and PSO performed. Such wounds are treated well, and healing occurs quickly, without complications.
- Chopped wounds are caused by a sharp but heavy object, such as an axe. In this case, the damage differs in depth, and is characterized by the presence of a wide gaping and bruising of adjacent tissues. Because of this, the ability to regenerate is reduced.
- Bruised wounds occur when using a blunt object. These injuries are characterized by the presence of many damaged tissues, heavily saturated with blood. When performing PSW of a wound, it should be taken into account that there is a possibility of suppuration.
- Bite wounds are dangerous due to the penetration of infection with the saliva of an animal, and sometimes a person. There is a risk of developing acute infection and the emergence of the rabies virus.
- Envenomed wounds usually occur when there is a snake or spider bite.
- differ in the type of weapon used, the characteristics of the damage and the trajectories of penetration. There is a high probability of infection.
When performing PSW of a wound, the presence of suppuration plays an important role. Such injuries can be purulent, freshly infected and aseptic.
The purpose of the PHO
Primary surgical treatment is necessary to remove harmful microorganisms that got into the wound. To do this, all damaged dead tissue, as well as blood clots, are cut off. After this, sutures are placed and drainage is performed, if necessary.
The procedure is needed in the presence of tissue damage with uneven edges. Deep and contaminated wounds require the same. The presence of damage to large blood vessels, and sometimes bones and nerves, also requires surgical work. PHO is carried out simultaneously and exhaustively. The patient needs the help of a surgeon for up to 72 hours after the wound is inflicted. Early PSO is carried out during the first day, carried out on the second day - this is a delayed surgical intervention.
Tools for chemical and chemical treatment
To carry out the initial wound treatment procedure, a minimum of two copies of the kit are required. They are changed during the operation, and after the dirty stage they are disposed of:
- a straight forceps clamp, which is used to process the surgical field;
- pointed scalpel, belly;
- linen pins are used to hold dressings and other materials;
- Kocher, Billroth and “mosquito” clamps are used to stop bleeding; when performing PSO of a wound, they are used in huge quantities;
- scissors, they can be straight, as well as curved along a plane or edge in several copies;
- Kocher probes, grooved and button-shaped;
- set of needles;
- needle holder;
- tweezers;
- hooks (several pairs).
The surgical kit for this procedure also includes injection needles, syringes, bandages, gauze balls, rubber gloves, all kinds of tubes and napkins. All items that will be needed for PSO - suture and dressing kits, tools and medications, intended for treating wounds, are laid out on the surgical table.
Necessary medications
Primary surgical treatment of a wound is not complete without special medications. The most commonly used are:
Stages of PHO
Primary surgical treatment is carried out in several stages:
How is PHO done?
For surgical intervention the patient is placed on the table. Its position depends on the location of the wound. The surgeon should be comfortable. The wound is cleaned and the surgical field is treated, which is delimited by sterile disposable linen. Next, primary tension is performed, aimed at healing existing wounds, and anesthesia is administered. In most cases, surgeons use the Vishnevsky method - they inject a 0.5% novocaine solution at a distance of two centimeters from the edge of the cut. The same amount of solution is injected on the other side. If the patient reacts correctly, a “lemon peel” is observed on the skin around the wound. Gunshot wounds often require the patient to be put under general anesthesia.
The edges of the damage up to 1 cm are held with a Kochcher clamp and cut off en bloc. When performing the procedure, non-viable tissue is cut off on the face or fingers, after which a tight suture is applied. Gloves and tools used are replaced.
The wound is washed with chlorhexidine and examined. Puncture wounds, which have small but deep cuts, are dissected. If the edges of the muscles are damaged, they are removed. Do the same with bone fragments. Next, hemostasis is performed. The inside of the wound is treated first with a solution and then with antiseptic drugs.
The treated wound without signs of sepsis is sutured tightly with primary and covered with an aseptic bandage. The seams are made, uniformly covering all layers in width and depth. It is necessary that they touch each other, but do not pull together. When performing the work, it is necessary to obtain cosmetic healing.
In some cases, primary sutures are not applied. An incised wound may cause more serious damage than meets the eye. If the surgeon has doubts, a primary delayed suture is used. This method is used if the wound has become infected. The suturing is carried out down to the fatty tissue, and the sutures are not tightened. A few days after observation, until the end.
Bite wounds
PCS of a wound, bitten or poisoned, has its differences. When bitten by non-venomous animals, there is a high risk of contracting rabies. On early stage the disease is suppressed by anti-rabies serum. Such wounds in most cases become purulent, so they try to delay PSO. When performing the procedure, a primary delayed suture is applied and antiseptic medications are used.
A wound caused by a snake bite requires the application of a tight tourniquet or bandage. In addition, the wound is frozen with novocaine or cold is applied. To neutralize the poison, anti-snake serum is injected. Spider bites are blocked with potassium permanganate. Before this, the poison is squeezed out and the wound is treated with an antiseptic.
Complications
Failure to thoroughly treat the wound with antiseptics leads to suppuration of the wound. The use of the wrong pain reliever, as well as the infliction of additional injuries, causes anxiety in the patient due to the presence of pain.
Rough treatment of tissues and poor knowledge of anatomy lead to damage to large vessels, internal organs and nerve endings. Insufficient hemostasis causes the appearance of inflammatory processes.
It is very important that the primary surgical treatment of the wound is carried out by a specialist in accordance with all the rules.
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a) Definition, stages
PRIMARY SURGICAL TREATMENT OF A WOUND is the first surgery performed on a patient with a wound under aseptic conditions, with anesthesia and consisting of the sequential implementation of the following steps:
- Dissection of the wound.
- Revision of the wound channel.
- Excision of the edges, walls and bottom of the wound.
- Hemostasis.
- Restoring the integrity of damaged organs and structures
- Applying sutures to the wound, leaving drainage (if indicated).
Dissection of the wound is necessary for a complete inspection, under eye control, of the area of the wound channel and the nature of the damage.
Excision of the edges, walls and bottom of the wound is carried out to remove necrotic tissue, 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 tools and processing or changing gloves. It is usually recommended to excise the edges, walls and bottom of the wound en bloc for approximately 0.5-2.0 cm (Fig. 4.3). In this case, it is necessary to take into account the location of the wound, its depth and the type of damaged tissue. For contaminated, crushed wounds, wounds on lower limbs the excision should be wide enough. For wounds on the face, only necrotic tissue is removed, and for an incised wound, excision of the edges is not performed at all. It is impossible to excise the viable walls and bottom of the wound if they are represented by tissues of internal organs (brain, heart, intestines, etc.).
After excision, careful hemostasis is carried out to prevent hematoma and possible infectious complications.
It is advisable to perform the restorative stage (suturing nerves, tendons, blood vessels, connecting bones, etc.) immediately during PSO, if the surgeon’s qualifications allow it. If not, you can subsequently perform a repeat operation with a delayed suture of the tendon or nerve, or perform delayed osteosynthesis. Restorative measures should not be carried out in full during PHO in war time.
Suturing the wound is the final stage of PSO. The following options are available for completing this operation.
- Layer-by-layer suturing of the wound tightly
- Suturing the wound leaving drainage(s)
but it is very small, or the wound is localized on the foot or lower leg, or the damage area is large, or PSO is performed 6-12 hours from the moment of injury, or the patient has concomitant pathology, adversely affecting the wound process, etc.
- The wound is not stitched up
- late PHO,
- excessive soil contamination of the wound,
- massive tissue damage (crushed, bruised wound),
- accompanying illnesses(anemia, immunodeficiency, diabetes),
- localization on the foot or lower leg,
- elderly age patient.
Suturing the wound tightly in the presence of unfavorable factors is completely unjustified risk and an obvious tactical mistake by the surgeon!
b) Main types
The sooner PSO of the wound is performed from the moment of injury, the lower the risk of infectious complications.
Depending on the age of the wound, three types of PST are used: early, delayed and late.
Early PST is performed within 24 hours from the moment of wound infliction, includes all the main stages and usually ends with the application of primary sutures. If there is extensive damage to the subcutaneous tissue and it is impossible to completely stop capillary bleeding, drainage is left in the wound for 1-2 days. Subsequently, treatment is carried out as for a “clean” postoperative wound.
Delayed PST is performed from 24 to 48 hours after the wound is inflicted. During this period, inflammation develops, swelling and exudate appear. The difference from early PSO is that the operation is performed while antibiotics are administered and the intervention is completed by leaving the wound open (not sutured) followed by the application of primary delayed sutures.
Late PST is performed after 48 hours, when inflammation is close to maximum and the development of the infectious process begins. Even after PSO, the likelihood of suppuration remains high. In this situation, it is necessary to leave the wound open (not sutured) and administer a course of antibiotic therapy. It is possible to apply early secondary sutures on days 7-20, when the wound is completely covered with granulations and becomes relatively resistant to the development of infection.
c) Indications
The indication for performing PST of a wound is the presence of any deep accidental wound within 48-72 hours from the moment of application.
The following types of wounds are not subject to PST:
- superficial wounds, scratches and abrasions,
- small wounds with edge separation 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.
There are only two contraindications to performing PSO of a wound:
- Signs of development of a purulent process in the wound.
- Patient's critical condition ( terminal state, shock
- degrees).
- TYPES OF SEAMS
Advantages of suturing:
- acceleration of healing,
- reduction of losses through the wound surface,
- reducing the likelihood of repeated wound suppuration,
- increasing functional and cosmetic effect,
- facilitating wound treatment.
a) Primary sutures
Primary sutures are placed on the wound before granulation begins to develop, and the wound heals by primary intention.
Most often, primary sutures are applied immediately after completion of the operation or postsurgical surgical treatment of the wound in the absence of a high risk of development purulent complications. Primary sutures are not advisable to use in late post-surgical treatment, post-surgical treatment in wartime, or post-surgical treatment of a gunshot wound.
Sutures are removed after the formation of a dense connective tissue adhesion and epithelization within a certain time frame.
Primary delayed sutures are also placed on the wound before granulation tissue develops (the wound heals by primary intention). They are used in cases where there is a certain risk of developing an infection.
Technique: the wound after surgery (PSO) is not sutured, controlled inflammatory process and when it subsides, primary delayed sutures are applied on days 1-5.
A type of primary delayed sutures are provisional: at the end of the operation, sutures are placed, but the threads are not tied, thus the edges of the wound are not brought together. The threads are tied for 1-5 days when the inflammatory process subsides. The difference from conventional primary delayed sutures is that there is no need for repeated anesthesia and suturing of the wound edges.
b) Secondary seams
Secondary sutures are applied to granulating wounds that heal secondary intention. The purpose 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, healing time is reduced, and the content of connective tissue in a healed wound, compared to wounds that were treated open method, far less. This has a beneficial effect on the appearance and functional features scar, on its size, strength and elasticity. Bringing the edges of the wound closer together reduces the potential entry point for infection.
The indication for the application of secondary sutures is a granulating wound after the elimination of the inflammatory process, without purulent streaks and purulent discharge, without areas of necrotic tissue. To objectify the subsidence of inflammation, seeding of wound discharge can be used - if there is no growth of pathological microflora, secondary sutures can be applied.
There are 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 surgery, scar tissue forms at the edges of the wound, preventing both the rapprochement of the edges and the process of their fusion. Therefore, when applying early secondary sutures (before the edges become scarred), it is enough to simply stitch the edges of the wound and bring them together by tying the threads. When applying late secondary sutures, it is necessary to excise the scarred edges of the wound under aseptic conditions (“refresh the edges”), and after that apply sutures and tie the threads.
To speed up the healing of a granulating wound, in addition to suturing, you can use tightening the edges of the wound with strips of adhesive tape. The method does not completely and reliably eliminate the wound cavity, but it can be used even before the inflammation has completely subsided. Tightening the edges of a wound with an adhesive plaster is widely used to speed up the healing of purulent wounds.
Surgical treatment of the wound can be primary or secondary.
The purpose of primary surgical treatment of a wound is to prevent the development of suppuration, to create favorable conditions for wound healing and restoration of the function of the damaged part of the body in the shortest possible time.
Secondary surgical treatment of the wound is performed to treat infectious complications that have developed in it.
Primary surgical treatment of the wound
During primary surgical treatment of a wound, five or more surgical techniques are performed in total.
Dissection of the wound.
Excision of dead tissue and tissue of questionable viability.
Detection and removal from the wound of small bone fragments devoid of periosteum, foreign bodies, and blood clots.
Final stop bleeding, i.e. ligation of bleeding vessels, vascular suture or prosthetics of large wounded vessels.
If conditions exist, various options for osteosynthesis, suture of tendons and nerve trunks.
Primary skin suture or wound tamponade.
During surgical treatment of a wound, detection of its penetration into the pleural, abdominal or other natural cavity of the body serves as an indication for changing the surgical plan. Depending on the specific clinical situation, suturing of an open pneumothorax, closed drainage of the pleural cavity, wide drainage, suture of the joint capsule and other surgical interventions are performed.
The provisions stated above convince us that surgical debridement is largely diagnostic. Complete and accurate diagnosis of injuries and foreign bodies is one of the most important conditions for a successful operation and an uncomplicated course of the postoperative period.
Dissection of the fascia is necessary for full manipulation in the depths of the wound. Uncut fascia prevents the separation of the edges and inspection of the bottom of the wound canal.
If there is a suspicion that the wound has penetrated into the serous cavity, the lumen of a hollow organ, and it is impossible to reliably establish this by examination, vulneography is indicated. A catheter is inserted into the wound channel without force. The patient is placed on the operating table in a position in which the contrasted area is below the wound. From 10 to 40 ml of water-soluble contrast agent is injected through the catheter and radiography is performed in one or two projections. Vulneography greatly facilitates the diagnosis of deep, tortuous wound channels penetrating into cavities.
In the case of multiple, especially shotgun wounds in the projection of large vessels, there is an indication for intraoperative angiography. Neglecting this rule can have dire consequences. We present a clinical observation.
F., 26 years old, wounded from a distance of 30 meters by a charge of buckshot. Delivered to the Central District Hospital 4 hours later in a state of stage III hemorrhagic shock. There were 30 shot wounds on the anterior wall of the abdomen and the anterior internal surface of the left thigh. There was no pulse in the arteries of the left leg. There were symptoms of widespread peritonitis and intra-abdominal bleeding. After anti-shock measures, an emergency laparotomy was performed and 6 shot wounds of the ileum were sutured. Blood clots were removed from the retroperitoneal space, and the marginal defect in the wall of the left external iliac artery was sutured. Pulsation of the femoral artery appeared. However, no pulse was detected in the arteries of the left foot. not carried out. The absence of a pulse in the arteries of the foot was explained by spasm of the arteries. The patient was transferred to the hospital 3 days after the operation in extremely serious condition with grade 3A ischemia of the left leg. and anuria. During the operation, a wound of the left femoral artery measuring 1.5×0.5 cm, thrombosis of the femoral artery and vein were discovered. It was not possible to restore the main blood flow in the limb. Performed at the level upper third hips. The patient died from acute renal failure.
Thus, during the first operation, an injury to a large artery located outside the intervention zone was not recognized. Arteriography after suturing the external wound iliac artery would allow diagnosing injury to the femoral artery.
Stab wounds are subject to meticulous examination chest wall, located on the front surface below the 4th rib, on the lateral surface - below the 6th rib and on the back - below the 7th rib. In these cases, there is a high probability of injury to the diaphragm. If during PSO it is established that the wound has penetrated into the pleural cavity, the defect in the intercostal space should be expanded by tissue dissection to 8-10 cm to examine the adjacent part of the diaphragm. The elastic diaphragm is easily moved by tuffers in different directions and can be examined over a large area. Rare doubts about the integrity of the diaphragm can be resolved using diagnostic laparoscopy.
Excision of non-viable tissue is the most important stage of surgical treatment of a wound. Unremoved necrotic tissue causes prolonged suppuration in the wound with a possible outcome in wound exhaustion and sepsis. When treated in the first hours after injury, devitalized tissues are less noticeable, which makes it difficult to perform necrectomy in full. Unreasonable radicalism leads to the loss of viable tissue. Necrosis is recognized by the loss of anatomical connection with the body, macroscopic destruction of the structure, and the absence of bleeding from the incision. Primary skin necrosis in a bruised, gunshot wound usually does not extend further than 0.5-1.5 cm from the edge of the defect. Subcutaneous fatty tissue imbibed with blood, contaminated with foreign particles, and deprived of a reliable blood supply must be excised. Non-viable fascia lose their characteristic color and shine and become dull. A non-viable muscle loses its natural bright pink color and elasticity and does not respond to intersection. The cut line does not bleed. Small, loosely lying, often numerous bone fragments must be removed. Gentle option primary operation often entails the need to re-treat a gunshot, crushed wound after 2-3 days in conditions of more clearly defined boundaries between living and dead structures.
Secondary surgical treatment of the wound
With the development of suppuration, except common symptoms purulent infection, skin hyperemia, local fever, swelling and infiltration of tissues, purulent discharge, lymphangitis and regional lymphadenitis are observed. In the wound, areas of tissue necrosis and fibrin deposition are identified.
An anaerobic non-spore-forming infection complicates the course of a wound of the neck, abdominal walls, pelvis when contaminated with the contents oral cavity, pharynx, esophagus, colon. This infectious process usually occurs in the form of phlegmon: cellulitis, fasciitis, myositis. The areas of necrosis of subcutaneous fat and fascia have a gray-dirty color. The fabrics are saturated with brown exudate with a pungent unpleasant odor. Due to thrombosis of blood vessels, the affected tissues hardly bleed during excision.
With clostridial infection, significant tissue growth is noticed. The tissues have a lifeless appearance. Swollen skeletal muscles have a dull color and lack firmness, elasticity and natural pattern. When grabbed by instruments, the muscle bundles tear and do not bleed. There is no unpleasant odor, unlike a non-spore-forming infection.
An operation to remove the substrate of suppuration and ensure complete drainage of purulent exudate from the wound is a secondary surgical treatment, regardless of whether the primary surgical treatment of the wound was preceded or not. The direction of the incision is determined by inspection and palpation of the damaged area. Diagnostic information about the localization and size of purulent leaks is provided by radiography, fistulography, CT, etc.
The article was prepared and edited by: surgeonWounds. Primary surgical treatment. Drainage of wounds.
Wounds. Classification of wounds.
Wound
Main signs of a wound
Bleeding;
Functional impairment.
Elements of any wound are:
Bottom of the wound.
Wounds are classified according to various criteria.
Puncture wounds
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 thorough examination of the patient’s wound is necessary, also because microorganisms are introduced into the depths of the tissues with the wounding weapon, and the wound discharge does not find a way out , serves as a good nutrient medium for them, which creates especially favorable conditions for the development of purulent complications.
Incised wounds
Chopped wounds
Scalped wounds patchwork.
Bite wounds
Poisoned wounds
Gunshot wounds -
- wound channel zone
- bruise area
Area of secondary necrosis;
3. By infection
Course of the wound process
When wounds heal, dead cells, blood, and lymph are reabsorbed and, due to the inflammatory reaction, the process of cleansing the wound occurs. The walls of the wound close to each other are glued together (primary gluing). Along with these processes, connective tissue cells multiply in the wound, which undergo a number of transformations and turn into fibrous tissue. connective tissue- scar. On both sides of the wound there are counter processes of new formation of blood vessels, which grow into the fibrin clot that glues the walls of the wound. Simultaneously with the formation of the 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 epidermis; subsequently the entire epithelial layer is completely restored.
Signs of wound suppuration correspond to the classic signs of inflammation, as a biological reaction of the body to a foreign agent: dolor (pain);
calor(temperature);
tumor (swelling, swelling);
rubor (redness);
functio lesae (dysfunction);
INFLAMMATION
The stage is characterized by the presence of all the signs of a purulent wound process. In a purulent wound there are remnants of non-viable and dead tissue, foreign objects, contamination, 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: increased body temperature, weakness, headache, lack of appetite, etc.
Stage Treatment Objectives: drainage of the wound to remove pus, necrotic tissue and toxins; fight against infection. Wound drainage can be active (using devices for aspiration) and passive (drainage tubes, rubber strips, gauze pads and turundas moistened with water-salt solutions of antiseptics. Medicinal (medicinal) agents for treatment:
Hypertonic solutions:
The most commonly used solution by surgeons is 10% sodium chloride solution (the so-called hypertonic solution). Besides it, 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 fluid. However, it has been established that their osmotic activity lasts no more than 4-8 hours, after which they are diluted with wound secretion and the outflow stops. Therefore in Lately surgeons refuse hypertonic solution.
In surgery, various ointments based on fat and vaseline-lanolin are used; Vishnevsky ointment, syntomycin 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 ensure the outflow of wound secretions and become only a plug. At the same time, the antibiotics contained in the ointments are not released from the ointment compositions and do not have a sufficient antimicrobial effect.
The use of new hydrophilic water-soluble ointments - Levosin, levomikol, mafenide acetate, oflocaine - is pathogenetically justified. Such ointments contain antibiotics, which easily transfer from the ointments to 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, so one dressing per day is enough for an effective effect on the wound.
Enzyme therapy (enzyme therapy):
To quickly remove 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, the enzymes remain active for no more than 4-6 hours. Therefore for effective treatment For purulent wounds, the dressings must be changed 4-5 times a day, which is almost impossible. This lack of enzymes can be eliminated by including them in ointments. Thus, Iruksol ointment (Yugoslavia) contains the enzyme pentidase and the antiseptic chloramphenicol. The duration of action of enzymes can be increased by immobilizing them in dressings. Thus, trypsin immobilized on napkins acts for 24-48 hours. Therefore, one dressing per day fully ensures the 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 common pathogens of surgical infections.
Of the new antiseptics, the following should be highlighted: iodopirone, a preparation containing iodine, is used for treating surgeons’ hands (0.1%) and treating wounds (0.5-1%); dioxidin 0.1-1%, sodium hypochloride solution.
Physical methods treatment.
In the first phase of the wound process, wound quartz is used, ultrasonic cavitation purulent cavities, UHF, hyperbaric oxygenation.
Application of laser.
In the inflammation phase of the wound process, high-energy or surgical lasers are used. Moderately defocused beam surgical laser evaporation of pus and necrotic tissue is performed, in this way it is possible to achieve complete sterility of the wounds, which in some cases makes it possible to apply a primary suture to the wound.
GRANULATION
The stage is characterized by complete cleansing of the wound and filling of the wound cavity with granulations (bright pink tissue with a granular structure). She first fills the bottom of the wound and then fills the entire wound cavity. At this stage, its growth should be stopped.
Stage tasks: anti-inflammatory treatment, protection of granulations from damage, stimulation of regeneration
These tasks are answered by:
a) ointments: methyluracil, troxevasin - 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) laser use - in this phase of the wound process, low-energy (therapeutic) lasers are used, which have a stimulating effect.
EPITHELIZATION
The stage begins after filling the bottom of the wound and its cavity with granulation tissue. Objectives of the stage: accelerate the process of epithelization and scarring of wounds. For this purpose, sea buckthorn and rosehip oil, aerosols, troxevasin - jelly, and low-energy laser irradiation are used. On at this stage The use of ointments that stimulate the growth of granulations is not recommended. On the contrary, it is recommended to switch again to water-salt antiseptics. It is useful to ensure that the dressing dries to the surface of the wound. In the future, it should not be torn off, but only cut off at the edges as it detaches due to epithelization of the wound. It is recommended to moisten the top of such a bandage with iodonate or another antiseptic. In this way, small wounds under a scab can be healed with a very good cosmetic effect. In this case, no scar is formed.
For extensive defects skin, long-term non-healing wounds and ulcers in phases 2 and 3 of the wound process, i.e. After cleansing the wounds of pus and the appearance of granulations, dermoplasty can be performed:
a) artificial leather
b) 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 Thiersch
At all stages of treatment of purulent wounds, one should remember the state of the immune system and the need for its stimulation in patients of this category.
The first and main stage of wound treatment in a medical institution is primary surgical treatment.
Primary surgical treatment of wounds (PSW). The main thing in the treatment of wounds is their primary surgical treatment. Its goal is to remove non-viable tissues and the microflora found in them and thereby prevent the development of wound infection.
Primary surgical treatment of wounds:
Typically carried out under local anesthesia. Stages:
1. Inspection of the wound, cleaning the skin edges, treating them with an antiseptic (tincture of iodine 5%, do not allow it to get into the wound);
2. Inspection of the wound, excision of all non-viable tissues, removal of foreign bodies, small bone fragments, dissection of the wound if necessary, to eliminate pockets;
3. Final stop of bleeding;
3. Drainage of the wound, according to indications;
4. Primary suture of the wound (according to indications);
A distinction is made between early primary surgical treatment, carried out on 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 greater the likelihood of preventing the development of infectious complications in the wound.
During the Great Patriotic War, 30% of wounds were not subjected to surgical treatment: small superficial wounds, through wounds with small entry and exit holes without signs of vital damage important organs, vessels, multiple blind wounds.
Primary surgical treatment must be immediate and radical, i.e. it must be performed in one stage and during the process non-viable tissue must be completely removed. First of all, the wounded are operated on with a hemostatic tourniquet and extensive shrapnel wounds, with wounds contaminated with soil, in which there is a significant risk of developing an anaerobic infection.
Primary surgical treatment of the wound consists in excision of its edges, walls and bottom within healthy tissues with restoration of anatomical relationships.
Primary surgical treatment begins with incision of the wound. Using 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 allow all blind pockets of the wound to be examined and non-viable tissue to be excised. Next, the fascia and aponeurosis are dissected along the skin incision. This provides a good inspection of the wound and reduces compression of the muscles due to their swelling, which is especially important for gunshot wounds.
After dissecting the wound, scraps of clothing, blood clots, and loose foreign bodies are removed and the excision of crushed and contaminated tissue begins.
The muscles are excised within healthy tissue. Non-viable muscles are dark red, dull, do not bleed on a cut and do not contract when touched with tweezers.
When treating a wound, intact large vessels, nerves, and tendons should be preserved, and contaminated tissue should be carefully removed from their surface. (small bone fragments lying freely in the wound are removed, the sharp, devoid of periosteum, protruding ends of the bone fragments into the wound are bitten off with pliers. If damage to blood vessels, nerves, and tendons is detected, their integrity is restored. When treating a wound, careful stoppage of bleeding is necessary. If during surgical treatment of the wound non-viable tissue and foreign bodies are completely removed, the wound is sutured (primary suture).
Late surgical treatment performed according to the same rules as the early one, but if there are signs purulent inflammation it comes down to removing foreign bodies, cleaning the wound from dirt, removing necrotic tissue, opening leaks, pockets, hematomas, abscesses to ensure good conditions for the outflow of wound discharge.
Tissue excision, as a rule, is not performed due to the risk of generalization of infection.
The final stage of primary surgical treatment of wounds is the primary suture, which restores the anatomical continuity of the tissue. Its purpose is to prevent secondary infection of the wound and create conditions for wound healing by primary intention.
The primary suture is placed on the wound within 24 hours after the injury. As a rule, surgical interventions during aseptic operations are also completed with a primary suture. Under certain conditions, purulent wounds are closed with a primary suture after opening subcutaneous abscesses, phlegmons and excision of necrotic tissue, providing in the postoperative period good conditions for drainage and long-term washing of wounds with solutions of antiseptics and proteolytic enzymes.
The primary delayed suture is applied up to 5–7 days after the initial surgical treatment of wounds until granulation appears, provided that the wound has not become suppurated. Delayed sutures can be applied as provisional sutures: the operation is completed by suturing the edges of the wound and tightening them after a few days, if the wound has not become suppurated.
In wounds sutured with a primary suture, the inflammatory process is mild and healing occurs by primary intention.
To the Great Patriotic War Due to the risk of developing infection, primary surgical treatment of wounds was not performed in full - without applying a primary suture; Primary delayed, provisional sutures were used. When acute inflammatory phenomena subsided and granulations appeared, a secondary suture was applied. Widespread use of the primary suture in peacetime, even when treating wounds in late dates(12 − 24 h) is possible thanks to targeted antibacterial therapy and systematic monitoring of the patient. At the first signs of infection in the wound, it is necessary to partially or completely remove the sutures. The experience of the Second World War and subsequent local wars showed the inappropriateness of using a primary suture for gunshot wounds, not only due to the characteristics of the latter, but also due to the lack of possibility of systematic observation of the wounded in military field conditions and during the stages of medical evacuation.
The final stage Primary surgical treatment of wounds, delayed for some time, is a secondary suture. It is applied to a granulating wound in conditions when the danger of wound suppuration has passed. The period of application of the secondary suture ranges from several days to several months. It is used to speed up the healing of wounds.
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 date (after 2 weeks), when cicatricial changes have occurred in the edges and walls of the wound. Bringing the edges, walls and bottom of the wound closer together in such cases is impossible, so the edges are mobilized and scar tissue is excised. In cases where there is a large skin defect, skin grafting is performed.
Indications for the use of a secondary suture are: normalization of body temperature, blood composition, satisfactory general condition of the patient, and from the side of the wound, the disappearance of swelling and hyperemia of the skin around it, complete cleansing of pus and necrotic tissue, the presence of healthy, bright, juicy granulations.
Apply different kinds sutures, but regardless of the type of suture, the basic principles must be observed: there should be no closed cavities or pockets left in the wound, adaptation of the edges and walls of the wound should be maximum. The sutures must be removable, and there should be no ligatures left 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 suppuration of the wound. During early secondary sutures, granulation tissue must be preserved, which simplifies the surgical technique and preserves the barrier function of granulation tissue, which prevents the spread of infection to surrounding tissues.
Healing of wounds sutured with a secondary suture and healed without suppuration is usually called healing by primary intention, in contrast to true primary intention, since, although the wound heals with a linear scar, 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 indications for this procedure are determined by the surgeon. According to modern concepts, wound drainage, depending on its type, should ensure:
Removing excess blood (wound contents) from the wound and thereby preventing wound infection (any type of training);
Tight contact of wound surfaces, helping to stop bleeding from small vessels (vacuum drainage of spaces located under the flaps);
Active cleansing of the wound (with 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
Rice. left. Types of wound drainage and their characteristics
Passive drainage
It involves removing wound contents directly through the line of skin sutures and is able to provide drainage of only the superficial parts of the wound. This involves the application, first of all, of an interrupted skin suture with relatively wide and leaky suture spaces. It is through them that drainages are installed, for which parts of drainage pipes and other available material can be used. By spreading the edges of the wound, drainages improve the outflow of wound contents. It is quite clear that such drainage is most effective when installing drains taking into account the action of gravity.
In general, passive wound drainage is simple, reverse side which is its low efficiency. Drainage with a piece of glove rubber in the photo on the left. Obviously, passive drainages are not capable of providing drainage to wounds that have a complex shape, and therefore can be used primarily for superficial wounds located in 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, sealing the skin wound, and on the other, the presence of special drainage devices and tools for inserting drainage tubes (Fig. 2).
Standard devices for active wound drainage with a set of conductors for passing drainage tubes through tissue.
Figure 2. Standard devices for active wound drainage with a set of conductors for passing drainage tubes through tissue.
An important difference between the method of active wound drainage is its high efficiency, as well as the possibility of floor-by-floor drainage of the wound. In this case, the surgeon can use the most precise skin suture, the quality of which is completely preserved when the drainage tubes are removed away from the wound. It is advisable to select exit points for drainage tubes in “hidden” areas where additional pinpoint scars do not impair aesthetic characteristics (scalp, axilla, pubic area, etc.).
Active drains are usually removed 1-2 days after surgery, when the volume of daily wound discharge (through a separate tube) does not exceed 30-40 ml.
The greatest drainage effect is provided by tubes made of non-wettable material (for example, silicone rubber). The lumen of a polyvinyl chloride tube can quickly become blocked due to the formation of blood clots. The reliability of such a tube can be increased by preliminary (before installation in the wound) rinsing with a solution containing heparin.
Drainage of felon: a) drainage tube; b) inserting a tube into the wound; c) washing; d) removing the tube.
Refusal of drainage or its insufficient effectiveness 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 the longer process of organizing an intrawound hematoma. A very unfavorable circumstance is a long-term (several weeks or even months) increase in the volume of tissue in the area of the hematoma. The extent of tissue scarring increases, and the quality of the skin scar may deteriorate.
Factors promoting wound healing:
General condition of the body;
Nutritional status of the body;
Age;
Hormonal background;
Development of wound infection;
Oxygen supply status;
Dehydration;
Immune status.
Types of wound healing:
Healing primary intention- fusion of wound edges without visible scar changes;
Healing secondary intention- healing through suppuration;
- healing under a scab - under the formed crust, which should not be removed prematurely, further injuring the wound.
Stages of wound dressing:
1. Removing the old bandage;
2. Inspection of the wound and surrounding area;
3. Toilet the skin surrounding the wound;
4. Toilet wound;
5. Manipulation of the wound and preparing it for application of a new dressing;
6. Applying a new bandage;
7. Fixation of the bandage (see section Desmurgy)
Wounds. Classification of wounds.
Wound(vulnus) – mechanical damage tissues or organs, accompanied by a violation of the integrity of their integument or mucous membrane. It is the violation of the integrity of the integumentary tissues (skin, mucous membrane) that distinguishes wounds from other types of damage (bruise, rupture, sprain). For example, a rupture of lung tissue that occurs as a result of blunt trauma to the chest is considered a rupture, and in the case of damage caused by a knife blow, it is considered a lung wound, because there is a violation of the integrity of the skin.
It is necessary to distinguish between the concepts of “wound” and “injury”. In essence, a wound is final result tissue damage. The concept of wounding (vulneratio) is understood as the process of injury 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 injury and in the entire body. However, in everyday practice, the terms wound and injury often replace each other and are often used as synonyms.
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 tissue, the characteristics of the innervation and blood supply to the wound canal area, and the possibility of injury to vital organs.
Elements of any wound are:
Wound cavity (wound canal);
Bottom of the wound.
The wound cavity (cavum vulnerale) is a space limited by the walls and bottom of the wound. If the depth of the wound cavity significantly exceeds its transverse dimensions, then it is called the wound canal (canalis vulneralis).
Wounds are classified according to various criteria.
1. According to the nature of tissue damage:
Puncture wounds inflicted with a piercing weapon (bayonet, needle, etc.). Anatomical feature they are of 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 cavities (vessels, nerves, hollow and parenchymal organs). The appearance of puncture wounds and discharge from them do not always provide enough data to make a diagnosis. Thus, with a puncture wound to the abdomen, injury to the intestine or Liver is possible, but 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 there may be no connection with 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, so a particularly thorough examination of the patient is necessary. 
This is also true of wounds in that microorganisms are introduced into the depths of the tissues with the wounding weapon, and the wound discharge, not finding a way out, serves as a good nutrient medium for them, which creates especially favorable conditions for the development of purulent complications.
Incised wounds applied with a sharp object. They are characterized by a small number of destroyed cells; surrounding Pishi are not damaged. The gaping of the wound allows for inspection of damaged tissues and creates good conditions for the outflow of discharge. With an incised wound, there are the most favorable conditions for healing, therefore, when treating any fresh wounds, they strive to turn them into incised 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 surrounding tissues, reducing 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 a violation of their viability. Bruised blood vessels often diamond-shaped. Bruised wounds create favorable conditions for the development of infection.
Scalped wounds wounds tangent to the surface of the body, inflicted by a sharp cutting object. If the flap remains on the leg, then such a wound is called patchwork.
Bite wounds are characterized not so much by extensive and deep damage, but by severe infection by the virulent flora of the mouth of a person or animal. The course of these wounds is more often than others complicated by the development of acute infection. Bite wounds can become infected with the rabies virus.
Poisoned wounds- these are wounds into which poison enters (from the bite of a snake, scorpion, penetration of toxic substances), etc.
Gunshot wounds -
special among wounds. They differ from all others in the nature of the wounding weapon (bullet, fragment); complexity of anatomical characteristics; feature of tissue damage with areas complete destruction, necrosis and molecular concussion; high degree of infection; variety of characteristics (through, blind, tangent, etc.).
I distinguish the following elements of a gunshot wound:
- wound channel zone- zone of direct impact of the traumatic projectile;
- bruise area- zone of primary traumatic necrosis;
- molecular shock zone- zone of secondary necrosis;
Special approach and in the treatment of such wounds, moreover, it is 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 infection distinguish aseptic, freshly infected and purulent wounds.
Purulent wound(burn) with areas of necrosis
4. In relation to body cavities(cavities of the skull, chest, abdomen, joints, etc.) a distinction is made 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. Simple and complicated wounds are distinguished, in which there is any additional tissue damage (poisoning, burn) or a combination of soft tissue injuries with damage to bone, hollow organs, etc.
Course of the wound process
The development of changes in the wound is determined by the processes occurring in it and the general reaction of the body. In any wound there is dying tissue, hemorrhage and lymphatic effusions. In addition, wounds, even clean operating wounds, receive one or another number of microbes.
