All further fate largely depends on the initial surgical treatment of it.
Basic principles proper treatment wounds:
1. preventing the development of infection in the wound,
2. reduction of bleeding depending on conditions,
3. closing defects,
4. restoration of functions (if possible).
The purpose of primary surgical treatment of the wound peacetime is to close it by applying a primary suture; I.P. Pavlov wrote in his works that this only creates the most favorable conditions for the biological process of wound healing in the shortest possible time.
Any "accidental" wound should be considered infected. The latent period of wound infection usually lasts 6-8 hours. During the initial treatment of a wound, it is necessary to create favorable conditions for its healing, this is achieved by cleansing the skin around the wound, if necessary, excision of the edges of the wound, applying sutures and creating rest for the affected part of the body.
Skin defect longer than 1 cm, when the edges diverge, it is connected with sutures. Methods for suturing a wound are given here only schematically:
A) primary suture with or without excision of the wound edges;
b) primary delayed suture,
c) secondary seam.
Excised, contaminated tissue areas are sent for bacteriological examination.
Technique of wound excision during PHO
Acute scalpel sequential excision of one half of the wound is performed, and only after this can one proceed to excision of its other half, and, if possible, with new, clean instruments. The ideal “one-flap” wound excision proposed by Friedrich can only be performed in the presence of small wounds of the hand.
The edges wounds excised only at a distance of 1-2 mm; Skin excision should be avoided or at least done very carefully, especially on the fingers. When suturing a wound, one should strive to obtain a smooth surface, without leaving a cavity deep in the wound, since the hematoma filling the left cavity creates a good breeding ground for bacteria. Both excision of the wound and suturing it are carried out in compliance with the requirements of asepsis.
Skin around the wound must be shaved and the surrounding skin must be disinfected. The surgeon performs the operation with sterile hands, sterile instruments and works in a mask. Creating rest for the injured limb is absolutely necessary, because movement plays the role of a “lymph pump”, increasing the amount of discharge from the wound, which prevents the isolation of infection and healing of the wound.
General practitioner doctor You should not undertake the treatment of tendon injuries, nerve injuries, crush wounds, skin defects, joint injuries accompanied by bleeding, as well as open fractures. The task of the general practitioner in such cases is to provide first aid (protective pressure bandage, immobilization, giving painkillers, filling out a special card) and sending the patient to a special institution with accompanying personnel.
In the case of the so-called banal, minor injuries, the general practitioner must take into account all the circumstances. Injuries to workers involved in cleaning municipal sewer pipes, in the leather industry and in general coming into contact with decaying materials organic substances, are considered to be infected with extremely virulent bacteria. This also includes street injuries, as well as injuries from veterinarians and medical workers.
Suturing a wound after complete excision of the edges (a) and applying a suture without tension after excision of the edges of a contaminated wound (b)
wounds, soil contaminated(gardeners, peasants) should alert the doctor regarding the possibility of developing tetanus and gas gangrene. It must be remembered that puncture wounds are prone to anaerobic infections.
Flynn After treating 618 hand injuries with primary wound excision, I observed the occurrence of a creeping infection in only 5 cases. After suturing the wound, the damaged hand should be immobilized in a functionally advantageous position. For any serious injury to the hand, the patient is left in the hospital as long as there is a risk of wound infection.
Prevention of tetanus for injuries of the hand does not differ in any way from that specified in the decisions of the Society of Surgeons adopted at the meeting on the issue “On primary treatment of wounds”. Almost all wounds of the hand, especially wounds contaminated with soil, manure or objects of urban transport, as well as punctures, crushed, gunshot wounds, are fraught with the risk of tetanus. Damage upper limb in terms of frequency of occurrence of tetanus they are in second place after lower limb. The mortality rate is still high: for tetanus that develops due to an injury to the upper limb, it is 30-60%.
Therefore to tetanus prevention Hand injuries should be taken seriously. Pre-vaccinated patients are given a “reminding” injection of toxoid (injection rapell), and the remaining patients are given a combined injection of antitoxin and toxoid. Of course, we must not forget about surgical prophylaxis tetanus, that is, the removal of dead tissues not supplied with blood and foreign bodies that are nests of tetanus spores. In tissues well supplied with blood, tetanus bacilli are not capable of reproduction.
Video of the technique of applying a bandage to the hand
You can find other videos on bandaging techniques in the " " section Table of contents of the topic "Surgical treatment of wounds.":1. Wound healing by primary intention. Wound healing by secondary intention. Healing under the scab.
2. PHO. Surgical treatment of the wound. Primary surgical treatment of the wound. Secondary surgical treatment of the wound.
3. Vascular suture. Seam according to Carrel. Carrel's vascular suture modified by Morozova. Stages of performing a vascular suture.
4. Operations on the veins of the extremities. Venipuncture. Venous puncture. Venesection. Opening a vein. Technique of venipuncture, venesection.
5. Tendon suture. Indications for suturing the tendon. Tendon suturing technique.
6. Nerve suture. Indications for suturing nerves. Purpose of nerve suturing. Technique for suturing a nerve.
PHO. Surgical treatment of the wound. Primary surgical treatment of the wound. Secondary surgical treatment of the wound.
Under primary surgical treatment gunshot and traumatic wounds are understood as surgical intervention, which consists of excision of its edges, walls and bottom with the removal of all damaged, contaminated and blood-soaked tissues, as well as foreign bodies.
Purpose of debridement- prevention of wound infection and acute suppuration of the wound and, therefore, rapid and complete healing of the wound.
Primary surgical treatment of the wound performed in the first hours after injury. Even with indirect signs of necrosis (crushing, contamination, isolation of damaged tissue), the damaged tissue is excised.
Surgical treatment of the wound in the first days after injury, with direct signs of necrosis (decay, disintegration of necrotic tissue) and suppuration of the wound, it is called secondary.
Excision of wound edges during primary surgical treatment.For good skin access edges of the wound excised with two semi-oval incisions within healthy tissue, taking into account the topography of large anatomical formations in this region and the direction of the skin folds (Fig. 2.29).
When excision of skin its crushed, crushed, thinned and sharply bluish areas should be removed. Cyanosis or severe hyperemia of the skin usually indicates its subsequent necrosis. The criterion for the viability of the skin edges of a wound should be considered profuse capillary bleeding, easily determined when making an incision.
Viable muscle shiny, pink, bleeds profusely, contracts when cut. The dead muscle is often disintegrated, cyanotic, does not bleed when cut, and often has a characteristic “boiled” appearance.
These signs with some experience, they can almost always correctly determine the living-dead boundary and sufficiently completely excise non-viable tissue.
In case of combined injuries, when large vessels, nerves, bones are damaged, primary surgical treatment of the wound produced in a certain sequence.
After excision non-viable tissues stop bleeding: small vessels are ligated, large ones are temporarily captured with clamps.
If large vessels are damaged, the veins are ligated, and a vascular suture is placed on the arteries.
Primary nerve suture in the wound applied if it is possible to create a bed for the nerve from intact tissue.
Bone wound at open fractures of any etiology should be treated as radically as a soft tissue wound. The entire area of crushed bone, devoid of periosteum, must be resected within healthy tissue (usually 2-3 cm away from the fracture line in both directions)
After primary surgical treatment of the wound sutured layer by layer, the limb is immobilized for the period necessary for bone consolidation, nerve regeneration or strong fusion of tendons. In doubtful cases, the wound is not tightly sutured, but the edges of the wound are only tightened with ligatures. After 4-5 days with a favorable course wound process the sutures can be tightened; in case of complications, the wound will heal secondary intention. Drains are left in the corners of the wound, if necessary, using active drainage - insertion through a drainage tube antiseptic solutions and suction of fluid along with purulent exudate.
:
- Planned: primary wound closure within 6-8 hours.
- Contraindications: heavily contaminated wounds, bite wounds inflicted by humans or animals, stab and gunshot wounds, chemical and thermal burns.
- Alternative: healing by secondary intention.
b) Preparation for primary surgical treatment of the wound. Preoperative examination: assessment of peripheral motor function, sensitivity and blood circulation depending on the situation.
Radiography of soft tissues if a foreign body is suspected. Tetanus immunization check. Shave the surgical area if required (but not the eyebrow area).
V) Specific risks, informed consent of the patient. If wound dehiscence occurs, instruct the patient to monitor closely.
G) Anesthesia. Local anesthesia; in children, general anesthesia is possible.
d) Patient position. Depends on the location of the wound.
e) Access. Predetermined by the wound; any possible expansion of the wound must take into account the direction of the skin tension lines.
Avoid perpendicular intersection of the axes of motion of the joints.
and) Stages PSO wounds
:
- Cleansing the wound
- Local anesthesia
- Excision and sanitation of the wound
- Primary wound closure
h) Anatomical features, serious risks, operational techniques:
Always perform a thorough examination of the wound: foreign body? Consider the possibility of performing an X-ray examination during the operation.
To avoid damage to tendons, blood vessels and nerves, ask the patient to move the limb.
All nonviable tissue must be carefully removed. Particular care should be taken when treating wounds on the hands and face.
In potentially or obviously contaminated wounds, introduce a (mini-) active or Penrose drain, or even open wound management.
And) Measures for specific complications. Immediate and thorough wound exploration and open wound management for wound infections that develop after initial wound closure.
To) Postoperative measures:
- Medical care: the drainage is removed on the 2nd day after surgery.
- Activation: Early activation is usually possible.
- Physiotherapy: required in selected cases.
- Period of incapacity: depends on the degree of damage.
l) Operative technique of primary surgical treatment of wounds:
- Cleansing the wound
- Local anesthesia
- Excision and sanitation of the wound
- Primary wound closure
1. Cleansing the wound. Surgical treatment of wounds is the most common operation in surgical practice. It can be quite complex. However, the treatment of all types of wounds is based on the same principles - achieving maximum safety and cosmetic results with minimal additional trauma.
General rules for any type of wound care include preventing the development of infection and recognizing deeper and less obvious injuries to important structures. For these reasons, wound treatment should always be accompanied by thorough cleansing and revision. The operation always begins with thorough disinfection of the wound and its edges.
2. Local anesthesia. After complete disinfection of the wound area, infiltration anesthesia of 1% is performed. local anesthetic outside the edges of the wound, with the minimum possible number of injections. For wounds of the phalanges of the fingers, a ring blockade is recommended.
3. Excision and debridement of the wound. Non-viable tissue of the wound edges must be excised. For wounds on the face and fingers, as well as for clean wounds, extensive excision of the edges is not required.
4. Primary wound closure. After excision of the wound, careful hemostasis of the wound bed is performed. The wound is then closed with deep, separate sutures. If cavity formation is unavoidable, drainage is recommended for 48 hours. The operation ends with repeated disinfection of the skin and application of a bandage.
Time required for preliminary instruction and demonstration of the skill on a mannequin – 15 minutes
Time required to independently master the skill(in minutes, per student) – 17 min
Necessary theoretical knowledge to master a clinical skill:
Anatomy and physiology of the skin, serous and mucous membranes.
Types of wounds
Indications for primary surgical treatment of wounds.
Basics of asepsis and antiseptics.
Surgical instruments.
Wound infection.
Tetanus vaccine.
Fundamentals of anesthesiology.
List of mannequins, models, visual aids, interactive computer programs necessary to master a clinical skill:
“Model of a hand for manipulation of the arteries and veins of the upper limb”
List of medical products and equipment:
Tools
forceps - 2 pcs.
clothes tacks - 4 pcs.,
surgical tweezers - 2 pcs.,
anatomical tweezers - 2 pcs.,
syringe (10 ml) - 2 pcs.
scalpel - 1 piece,
scissors - 2 pcs.
hemostatic clamps - 4-6 pcs.,
Farabefa hooks - 2 pcs.
sharp-toothed hooks - 2 pcs.,
cutting needles - 4 pcs.
piercing needles - 4 pcs.,
grooved probe - 1 piece,
button probe - 1 piece,
suture material,
bixx dressing material,
gloves,
Drugs
skin antiseptics (cutasept, iodonate),
antiseptics for wounds (3% hydrogen peroxide solution, 0.06% sodium hypochlorite solution),
70% ethyl alcohol, preparation for disinfection of instruments (dezaktin, neochlor),
drug for local anesthesia (lidocaine, novocaine).
Description of the execution algorithm:
Before PSO of the wound, prophylactic administration of antitetanus serum and tetanus toxoid is carried out.
To wash hands
Dry your hands with a towel
Wear a mask
Wear gloves
Treat your hands with antiseptic
Treat the injection sites for local anesthesia with antiseptics.
Produce local anesthesia wounds.
Excise the wound using surgical instruments.
Stop the bleeding.
Delete foreign bodies, necrotic tissue, blood clots, dirt, etc.
Treat the wound with an antiseptic.
If necessary, administer local antibiotics.
Depending on the nature of the damage, drain the wound.
Apply a closed seam.
Apply an aseptic bandage.
Scheme of primary surgical treatment of a wound: 1 - wound before treatment; 2 - excision; 3 - blind seam.
Criteria for assessing skill performance:
Washed my hands
Dried my hands with a towel
Put on a mask
Wearing gloves
Treated hands with antiseptic
Treated the injection sites for local anesthesia with antiseptics.
He performed local anesthesia on the wound.
Excision of the wound using surgical instruments.
He stopped the bleeding.
Removed foreign bodies, necrotic tissue, blood clots, dirt, etc.
I treated the wound with an antiseptic.
If necessary, administered local antibiotics.
Depending on the nature of the damage, the wound was drained.
I placed a blind stitch.
He applied an aseptic dressing.
