Primary surgical treatment of a wound - what is it, algorithm and principles. Primary surgical debridement (PW): essence, preparation, conduct What is primary surgical debridement

PHO is the first surgery performed on a patient with a wound under aseptic conditions, with anesthesia and consisting in the sequential implementation of the following steps:

1) dissection;

2) revision;

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

4) removal of hematomas and foreign bodies;

5) restoration of damaged structures;

6) if possible, suturing.

The following wound closure options are available:

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

2) suturing the wound leaving drainage;

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

Types of PHO:

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

2) Delayed (from 24-48 hours). During this period, inflammation develops, edema and exudate appear. The difference from early PXO 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 primary delayed sutures.

3) Late (after 48 hours). Inflammation is close to maximum and the development of the infectious process begins. In this situation, the wound is left open and a course of antibiotic therapy is carried out. Perhaps the imposition of early secondary sutures for 7-20 days.

PHO are not subject to the following types of wounds:

1) surface, scratches;

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

3) multiple small wounds without damage to deeper tissues;

4) stab wounds without organ damage;

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

Contraindications to the implementation of PHO:

1) signs of development in the wound purulent process;

2) critical condition of the patient.

Types of seams:

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

Primary delayed. Impose before the development of granulations. Technique: the wound is not sutured after the operation, it is controlled inflammatory process and when it subsides for 1-5 days, this seam is applied.

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

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

Wound toilet. Secondary surgical treatment of wounds.

1) removal of purulent exudate;

2) removal of clots and hematomas;

3) cleansing of the wound surface and skin.

Indications for VMO are the presence of a purulent focus, the lack of adequate outflow from the wound, the formation of extensive areas of necrosis and purulent streaks.

1) excision of non-viable tissues;

2) removal of foreign those and hematomas;

3) opening pockets and streaks;

4) wound drainage.

Differences between PHO and VHO:

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

Types of mechanical injuries:

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

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

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

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

Late complications are revealed in terms 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.

Surgical treatment of wounds

surgical intervention, which consists in a wide dissection, stop bleeding, excision of non-viable tissues, removal of foreign, free bone fragments, blood clots in order to prevent wound infection and create favorable conditions for wound healing. There are two types of H. o. R. primary and secondary.

Primary surgical treatment of the wound- the first about the fabrics. Primary H. o. R. must be comprehensive and comprehensive. Produced on the 1st day after the injury, it is called early, on the 2nd day - delayed, after 48 h from the moment of injury - late. Delayed and late H. o. R. are a necessary measure in case of mass admission of the wounded, when it is impossible to perform surgical treatment in early dates to all those in need. Correct medical sorting is important (Medical sorting) , at which allocate wounded with the continuing bleeding, the imposed plaits, separations and extensive destructions of extremities, signs of a purulent and anaerobic infection requiring immediate H. about. R. The rest of the wounded may be delayed. When transferring primary H. o. p for more late dates provide measures that reduce the risk of infectious complications, prescribe antibacterial agents. With the help of antibiotics, only a temporary suppression of the vital activity of the wound microflora is possible, which makes it possible to delay, rather than prevent, the development of infectious complications. The wounded in a state of traumatic shock (traumatic shock) before H. o. R. carry out a set of anti-shock measures. Only with continued bleeding is it permissible to perform surgical debridement without delay while conducting anti-shock therapy.

The amount of surgery depends on the nature of the injury. Stab and cut wounds with minor tissue damage, but with the formation of hematomas or bleeding, are only subject to dissection in order to stop bleeding and decompress tissues. large sizes, which can be processed without additional dissection of tissues (for example, extensive tangential wounds), are subject only to excision, through and blind wounds, especially with multi-comminuted bone fractures, to dissection and excision. Wounds with complex architectonics of the wound channel, extensive damage to soft tissues and bones are dissected and excised; additional incisions and counter-openings are also made to provide better access to and drainage of the wound.

Surgical processing is carried out, strictly observing the rules of asepsis and. The method of anesthesia is chosen taking into account the severity and localization of the wound, the duration and trauma of the operation, the severity general condition wounded.

Excision of the skin edges of the wound should be performed very sparingly; remove only non-viable, crushed areas of the skin. Then they are widely dissected, an additional one is made in the area of ​​​​the corners of the wound in the transverse direction, so that the incision of the aponeurosis has a Z-shape. This is necessary so that the aponeurotic case does not squeeze the edematous after injury and surgery. Next, the edges of the wound are bred with hooks and damaged non-viable muscles are excised, which are determined by the absence of bleeding in them, contractile and characteristic resistance (elasticity) of muscle tissue. When carrying out primary processing in the early stages after injury, it is often difficult to establish the boundaries of non-viable tissues; in addition, late tissues are possible, which may subsequently require re-treatment of the wound.

With forced delayed or late H. o. R. the boundaries of non-viable tissues are determined more precisely, which makes it possible to excise tissues within the outlined demarcations. As the tissues are excised, loose small bone fragments are also removed from the wound. If at X. about. R. large vessels or nerve trunks are found, they are carefully pushed aside with blunt hooks. Fragments of the damaged, as a rule, are not processed, with the exception of sharp ends that can cause secondary trauma to the soft tissues. Rare sutures are applied to the adjacent layer of intact muscles to cover the exposed bone in order to prevent acute traumatic osteomyelitis. Muscles also cover naked main vessels and to avoid vascular thrombosis and nerve death. In case of injuries of the hand, foot, face, genitals, distal parts of the forearm and lower leg, the tissues are excised especially sparingly, because. wide in these areas can lead to permanent dysfunction or to the formation of contractures and deformities. In combat conditions, H. o. R. supplement with reconstructive and restorative operations: suturing of blood vessels and nerves, bone fractures with metal structures, etc. In peacetime conditions, reconstructive and restorative operations are usually an integral part of the primary surgical treatment of wounds. The operation is completed by infiltration of the wound walls with antibiotic solutions. . It is advisable to actively wound discharge using silicone perforated tubes connected to vacuum devices. Active aspiration can be supplemented by irrigating the wound with an antiseptic solution and applying a primary suture to the wound, which is possible only with constant monitoring and treatment in a hospital.

The most essential errors at H. about. R.: excessive excision of unchanged skin in the wound area, insufficient wound, making it impossible to make a reliable revision of the wound channel and complete excision of non-viable tissues, insufficient perseverance in search of the source of bleeding, tight wounds for the purpose of hemostasis, the use of gauze tampons for draining wounds.

Secondary debridement carried out in cases where the primary treatment did not work. Indications of secondary H. about. R. are the development of a wound infection (anaerobic, purulent, putrefactive), purulent-resorptive fever or sepsis caused by delayed tissue discharge, purulent streaks, near-wound abscess or phlegmon. The volume of secondary surgical treatment of the wound may be different. Complete surgical treatment of a purulent wound involves its excision within healthy tissues. Often, however, anatomical and operational conditions (danger of damage to blood vessels, nerves, tendons, articular capsules) allow only partial surgical treatment of such a wound. When the inflammatory process is localized along the wound channel, the latter is widely (sometimes with an additional dissection of the wound) opened, the accumulation of pus is removed, and the foci of necrosis are excised. For the purpose of additional rehabilitation of the wound, it is treated with a pulsating jet, laser beams, low-frequency ultrasound, as well as vacuuming. Subsequently, proteolytic, coal sorbents are used in combination with parenteral administration of antibiotics. After complete cleansing of the wound, with good development of granulations, secondary sutures are acceptable (Secondary suture) . With the development of anaerobic infection, secondary surgical treatment is carried out most radically, and the wound is not sutured. The treatment of the wound is completed by draining it with one or more silicone drainage tubes and suturing the wound.

The drainage system allows postoperative period wash the wound cavity with antiseptics and actively drain the wound when vacuum aspiration is connected (see Drainage) . Active aspiration-washing of the wound can significantly reduce the time of its healing.

Treatment of wounds after their primary and secondary surgical treatment is carried out using antibacterial agents, immunotherapy, restorative therapy, proteolytic enzymes, antioxidants, ultrasound, etc. Effectively wounded under conditions of gnotobiological isolation (see Abacterial controlled environment) , and in case of anaerobic infection - with the use of hyperbaric oxygen therapy (Hyperbaric oxygen therapy) .

Bibliography: Davydovsky I.V. Gunshot of a person, vol. 1-2, M., 1950-1954; Deryabin I.I. and Alekseev A.V. , BME, v. 26, p. 522; Dolinin V.A. and Bisenkov N.P. Operations for wounds and injuries, L., 1982; Kuzin M.I. etc. Wounds and wound, M., 1989.

1. Small medical encyclopedia. - M.: Medical Encyclopedia. 1991-96 2. First aid. - M.: Great Russian Encyclopedia. 1994 3. Encyclopedic Dictionary medical terms. - M.: Soviet Encyclopedia. - 1982-1984.

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Under primary surgical treatment they understand the first intervention (in a given wounded man) performed according to primary indications, i.e., regarding the tissue damage itself as such. Secondary debridement- this is an intervention undertaken according to secondary indications, i.e., regarding subsequent (secondary) changes in the wound caused by the development of infection.

In some types of gunshot wounds, there are no indications for primary surgical treatment of wounds, so that the wounded are not subjected to this intervention. In the future, in such an untreated wound, significant foci of secondary necrosis may form, an infectious process flares up. A similar picture is observed in cases where the indications for primary surgical treatment were evident, but the wounded man came to the surgeon late and the wound infection had already developed. In such cases, there is a need for an operation according to secondary indications - in the secondary surgical treatment of the wound. In such wounded, the first intervention is secondary surgical treatment.

Often, indications for secondary treatment occur if the primary surgical treatment did not prevent the development of a wound infection; such secondary treatment, carried out after the primary (i.e., the second in a row), is also called re-treatment of the wound. Re-treatment sometimes has to be done before the development of wound complications, that is, according to primary indications. This happens when the first treatment could not be fully carried out, for example, due to the impossibility of X-ray examination of a wounded person with a gunshot fracture. In such cases, in fact, the primary surgical treatment is performed in two stages: during the first operation, the soft tissue wound is mainly treated, and during the second operation, the bone wound is treated, fragments are repositioned, etc. The technique of secondary surgical treatment is often the same as the primary one, but sometimes secondary treatment can be reduced only to ensuring the free outflow of discharge from the wound.

The main task of the primary surgical treatment of the wound- create unfavorable conditions for the development of wound infection. Therefore, this operation is the more effective the earlier it is performed.

According to the timing of the operation, it is customary to distinguish between surgical treatment - early, delayed and late.

Early debridement is called the operation performed before visible development infections in the wound. Experience shows that surgical treatments performed in the first 24 hours from the moment of injury, in most cases, "ahead" of the development of infection, that is, they belong to the category of early ones. Therefore, in various calculations for the planning and organization of surgical care in the war, interventions performed on the first day after the injury are conditionally taken as early surgical treatment. However, the situation in which staged treatment of the wounded is carried out often makes it necessary to postpone the operation. The prophylactic administration of antibiotics can in some cases reduce the risk of such a delay - to delay the development of a wound infection and, thus, extend the period during which the surgical treatment of the wound retains its preventive (precautionary) value. Such debridement, albeit with delay, but before the appearance of clinical signs of wound infection (the development of which is delayed by antibiotics), is called delayed debridement. When calculating and planning, interventions performed during the second day from the moment of injury are taken as delayed treatment (provided that antibiotics are systematically administered to the wounded). Both early and delayed wound treatment can, in some cases, prevent wound suppuration and create conditions for its healing by primary intention.

If the wound, by the nature of tissue damage, is subject to primary surgical treatment, then the appearance of clear signs of suppuration does not prevent surgical intervention. In such a case, the operation no longer prevents wound suppuration, but remains a powerful means of preventing more formidable infectious complications and can stop them if they have time to arise. Such treatment, performed with the phenomena of suppuration of the wound, is called late surgical treatment. With appropriate calculations, the category of late includes treatments performed after 48 (and for the wounded who did not receive antibiotics, after 24) hours from the moment of injury.

Late debridement carried out with the same tasks and technically in the same way as early or delayed. The exception is cases when the intervention is undertaken only as a result of a developing infectious complication, and tissue damage by its nature does not require surgical treatment. In these cases, the operation is reduced mainly to ensuring the outflow of the discharge (opening the phlegmon, leakage, imposing counter-opening, etc.). The classification of surgical treatment of wounds depending on the timing of their implementation is largely arbitrary. It is quite possible to develop a severe infection in the wound 6-8 hours after the injury and, conversely, cases of very long incubation of the wound infection (3-4 days); processing, which in terms of execution time seems to be delayed, in some cases turns out to be late. Therefore, the surgeon must first of all proceed from the condition of the wound and from clinical picture in general, and not only from the period that has elapsed since the moment of injury.

Among the means preventing the development of wound infection, an important, albeit auxiliary, role is played by antibiotics. Due to their bacteriostatic and bactericidal properties, they reduce the risk of outbreaks in wounds that have undergone surgical debridement or where debridement is considered unnecessary. Antibiotics play a particularly important role when this operation is forced to be postponed. They should be taken as soon as possible after injury, and by repeated administrations before, during and after surgery, the effective concentration of drugs in the blood should be maintained for several days. For this purpose, injections of penicillin and streptomycin are used. However, under the conditions of [staged treatment, it is more convenient for the affected to administer a prophylactic drug with a prolonged action, streptomycellin (900,000 IU intramuscularly 1-2 times a day, depending on the severity of the injury and the timing of the primary surgical treatment of the wound). If injections of streptomycellin cannot be carried out, biomycin is prescribed orally (200,000 IU 4 times a day.). With extensive muscle destruction and delay in the provision of surgical care, it is desirable to combine streptomycellin with biomycin. With significant damage to the bones, tetracycline is used (in the same dosages as biomycin).

There are no indications for primary surgical treatment of the wound with the following types of injuries: a) penetrating bullet wounds of the extremities with pinpoint inlet and outlet holes, in the absence of tissue tension in the wound area, as well as hematoma and other signs of damage to a large blood vessel; b) bullet or small fragment wounds of the chest and back, if there is no chest wall hematoma, signs of bone fragmentation (for example, scapula), as well as open pneumothorax or significant intrapleural bleeding (in the latter case, a thoracotomy becomes necessary); c) superficial (not usually penetrating deeper subcutaneous tissue), often multiple, wounds by small fragments.

In these cases, the wounds usually do not contain a significant amount of dead tissue and their healing most often proceeds without complications. This, in particular, can be facilitated by the use of antibiotics. If, in the future, suppuration develops in such a wound, then the indication for secondary surgical treatment will be mainly the retention of pus in the wound channel or in the surrounding tissues. With a free outflow of discharge, a festering wound is usually treated conservatively.

Primary surgical treatment is contraindicated in the wounded, who are in a state of shock (temporary contraindication), and in those who are agonizing. According to data obtained during the Great Patriotic War, the total number of those not subject to primary surgical treatment is about 20-25% of all those affected by firearms (S. S. Girgolav).

Military field surgery, A.A. Vishnevsky, M.I. Schreiber, 1968

Primary surgical debridement, or PST, of a wound is an obligatory measure in the treatment of open wounds of various nature. How this procedure will be carried out often depends on the health, and sometimes the life of the injured person. Correctly drawn up algorithm of the doctor's actions is the key to successful treatment.

Damage human body can have varied look and the nature of the occurrence, but the basic principle of PST of the wound remains unchanged - to provide safe conditions for eliminating the consequences of the wound through minor surgical manipulations and decontamination of the affected area. Preparations and instruments may change, but the essence of conducting PST does not change from this.

In the general case, wounds are called mechanical damage to body tissues with a violation of the integrity of the skin, in which gaping occurs and which are accompanied by bleeding and pain. According to the degree of damage, only soft tissue damage is distinguished; tissue damage, accompanied by damage to the bones, blood vessels, joints, ligaments, nerve fibers; penetrating damage - with a lesion internal organs. In terms of extent, pathologies with a small and large affected area differ.

O cut wounds can be found in .

The principle of primary treatment

The first stage of treatment of an open wound is to stop bleeding, eliminate pain, decontaminate and prepare for suturing. The most important is the issue of sterilizing the affected area and removing non-viable cells. If the injuries are not extensive and penetrating, and measures are taken in a timely manner, then decontamination can be carried out by providing a wound toilet. Otherwise, primary methods are used. surgical training(PHO wound).

What is a wound toilet?

The principles of the wound toilet are based on the treatment of the affected area with an antiseptic preparation with increased hygiene requirements. Small and fresh wounds do not have dead tissue around the injury, so it will be sufficient to sterilize the site and the surrounding area. Purulent wound toilet algorithm:

1. Consumables are being prepared: wipes, sterile cotton balls, medical gloves, antiseptic compounds (3% hydrogen peroxide solution, 0.5% potassium permanganate solution, ethyl alcohol), necrolytic ointments (“Levomekol” or “Levosin”), 10% sodium chloride solution.
2. The previously applied bandage is removed.
3. The area around the lesion is treated with a solution of hydrogen peroxide.
4. The state of the pathology and possible complicating factors are being studied.
5. The toilet of the skin around the damage is carried out with the help of sterile balls, moving from the edge of the damage to the side, treatment with an antiseptic.
6. The wound is cleaned - removal of the purulent composition, wiping with an antiseptic.
7. The wound is drained.
8. A bandage with a necrolytic preparation (ointment) is applied and fixed.

Essence of PST wound

Primary surgical treatment is a surgical procedure that includes dissection of the marginal tissue in the area of ​​damage, removal of dead tissue by excision, removal of all foreign bodies, installation of cavity drainage (if necessary).

Thus, along with drug treatment, a mechanical antiseptic is used, and the removal of dead cells accelerates the process of regeneration of new tissues.

The procedure begins with a dissection of the injury. The skin and tissues around the destruction are dissected with a cut up to 10 mm wide in the longitudinal direction (along the vessels and nerve fibers) to a length that allows you to visually examine the presence of dead tissues and stagnant zones (pockets). Then, by making an arcuate incision, the fascia and aponeurosis are dissected.

The remnants of clothing, foreign bodies, blood clots; by excision, crushed, contaminated and blood-soaked non-viable tissue areas are removed. Lifeless areas of muscles (dark red), blood vessels and tendons are also eliminated. Healthy vessels and fibers are sewn together. With the help of nippers, the sharp spike-like edges of the bone are bitten out (in case of fractures). After complete cleaning, the primary suture is applied. In the treatment of penetrating gunshot wounds, PST is carried out separately, both from the side of the inlet and from the side of the outlet.

Youtube.com/watch?v=WWFZCNFD6Dw

PHO wounds of the face. Jaw injuries are the most common of facial wounds. PHO of such wounds has a certain algorithm of actions. First, a medical antiseptic treatment of the skin on the face and oral cavity is performed.

A solution of hydrogen peroxide, a solution of ammonia, iodine-gasoline is applied around the damage. Next, an abundant washing of the wound cavity with an antiseptic is performed. Skin covering the face is carefully shaved and disinfected again. The patient is given an analgesic.

After the preliminary procedures, PST of facial wounds is performed directly according to an individual plan, but with the following sequence of manipulations: treatment of the bone area; processing of soft adjacent tissues; fixation of splinters and fragments of the jaw; suturing in the sublingual zone, oral vestibule and in the region of the tongue; wound drainage; placement of the primary suture soft tissues wounds. The procedure is carried out under general anesthesia or under local anesthesia depending on the severity of the damage.

Algorithm for PST of bitten wounds. A fairly common occurrence, especially among children, are wounds resulting from the bites of domestic animals. The PHO algorithm in this case is as follows:

1. Providing first aid.
2. Washing the damaged area with water laundry soap in copious amounts to completely remove the saliva of the animal.
3. Chipping around the wound with a solution of lincomycin with novocaine; injection of drugs for rabies and tetanus.
4. Processing of damage boundaries with iodine solution.
5. Carrying out PST by excising damaged tissues and cleaning the wound; the primary suture is applied only in the case of a bite by a vaccinated animal, if this fact is actually established; if in doubt, a temporary bandage with mandatory drainage is applied.

Youtube.com/watch?v=l9iukhThJbk

Primary surgical treatment of wounds is effective way treatment of open injuries of any complexity.

Human skin has an enormous reserve of self-healing capacity, and additional excision to thoroughly clean the wound will not harm the healing process, and the removal of non-viable tissues will accelerate the process of regeneration of new skin tissue.

Wound - damage of any depth and area, in which the integrity of the mechanical and biological barriers of the human body, delimiting it from environment. AT medical institutions patients are admitted with injuries that can be caused by factors of various nature. In response to their impact, local (changes directly in the wounded area), regional (reflex, vascular) and general reactions develop in the body.

Classification

AT clinical practice wounds are classified taking into account a number of signs:

• origin (, operational, combat);
• localization of damage (wounds of the neck, head, chest, abdomen, limbs);
• the number of injuries (single, multiple);
• morphological features (cut, chopped, chipped, 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 the particular severity of the course of the wound process as a result of exposure to 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");
• formation of a zone of primary traumatic necrosis (an area of ​​non-viable tissues that are a favorable environment for the development of a wound infection);
• the formation of a zone of secondary necrosis (the tissues in this zone are damaged, but their vital activity can be restored).

All wounds, regardless of origin, are considered to be contaminated with microorganisms. At the same time, it is necessary to distinguish between primary microbial contamination at the time of injury and secondary, occurring during treatment. The following factors contribute to wound infection:

• the presence in it of blood clots, foreign bodies, necrotic tissues;
• tissue trauma during immobilization;
• violation of microcirculation;
• weakening of the immune system;
• multiple damage;
• 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 the injury, tissue damage and vascular rupture occurs, which is accompanied by:

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

First, the vessels react to damage with an instant spasm, which is quickly replaced by their paralytic expansion in the area of ​​damage. This increases the permeability vascular wall and tissue edema increases, reaching a maximum for 3-4 days. Thanks to this, the primary cleansing of the wound occurs, the essence of which is to remove dead tissues and blood clots.

Already in the first hours after exposure to a damaging factor, leukocytes penetrate the wound through the vessel wall, a little later macrophages and lymphocytes join them. They phagocytose microbes and dead tissues. Thus, the process of wound cleansing continues 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 ensures 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 a slight microbial contamination of the wound and the absence of foci of necrosis.
• Infected wounds heal by secondary intention, which becomes possible after the wound defect is cleansed of purulent-necrotic masses and filled with granulations. The process is often complicated by the formation.

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

Primary surgical treatment of wounds

Timely and radical surgical treatment is considered the key to successful wound treatment. To eliminate the immediate consequences of damage, primary surgical treatment is carried out. It pursues the following goals:

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

The main stages of primary surgical treatment are:

• visual revision of the wound;
• adequate anesthesia;
• opening of all its departments (should be performed widely enough to obtain full access to the wound);
• removal of foreign bodies and non-viable tissues (skin, muscles, fascia are excised sparingly, and subcutaneous fatty tissue - widely);
• stop bleeding;
• adequate drainage;
• restoration of the integrity of damaged tissues (bones, muscles, tendons, neurovascular bundles).

When the patient is in serious condition reconstructive operations can be performed delayed after the stabilization of the vital functions of the body.

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

• Primary sutures are necessarily applied for penetrating abdominal wounds, injuries to the face, genitals, and hands. Also, the wound can be sutured on the day of surgery in the absence of microbial contamination, the surgeon's confidence in the radicalness of the intervention and the free convergence of the edges of the wound.
• On the day of the operation, provisional sutures can be applied, which are not tightened immediately, but after a certain time, provided that the course of the wound process is not complicated.
• Often the wound is sutured a few days after the operation (primarily delayed sutures) in the absence of suppuration.
• Secondary early sutures 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 granulations are first excised and the scars are dissected, and then the actual suturing is started (secondary-late sutures).

It should be noted that the scar is not as durable as intact skin. It acquires these properties gradually. Therefore, it is advisable to use slowly absorbable suture materials or tighten the edges of the wound with adhesive tape, which helps prevent the divergence of the edges of the wound and changes in the structure of the scar.

Which doctor to contact

For any wound, even at first glance, a small one, you need to go to the emergency room. The doctor must assess the degree of tissue contamination, prescribe antibiotics, and treat the wound.

Conclusion

In spite of different kinds wounds by 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 wound to a child.