A set of tools for pho burn wound. Surgical treatment of wounds

GOU VPO Izhevsk State Medical Academy of the Ministry of Health and Social Development of Russia

Department of Hospital Surgery

with a course of resuscitation and anesthesiology

wound treatment

Tutorial

UDC 616-001.4-089.81(075.8)

Compiled by: Candidate of Medical Sciences, Assistant of the Department of Hospital Surgery S.V. Sysoev; MD, Associate Professor, Head of the Department of Hospital Surgery B.B. Kapustin; Candidate of Medical Sciences, Associate Professor of the Department of Traumatology, Orthopedics and Military Field Surgery A.M. Romanov.

Reviewers: Head of the Department of General Surgery, Bashkir State Medical University of Roszdrav, Doctor of Medical Sciences, Professor M.A. Nartailakov; Head of the Department of Surgical Diseases with Courses of Urology, Endoscopy, Radiology of the FPC and PPS of the Tyumen State Medical Academy of Roszdrav, Doctor of Medical Sciences, Professor A.M. Mashkin.

The textbook deals with the issues of surgical treatment of wounds and injuries of soft tissues and cavities. Classifications of the wound process, primary debridement wounds in peacetime and wartime. The issues of prevention of surgical infection were discussed. The textbook is intended for students of medical and pediatric faculty.

Wound treatment: Tutorial / Comp. S.V. Sysoev, B.B. Kapustin, A.M. Romanov. - Izhevsk, 2011. - p. 84.

UDC 616-001.4-089.81(075.8)

General characteristics and basic principles of surgical treatment of wounds

Wound- tissue damage, accompanied by a violation of the integrity of the skin and mucous membranes. Under wounded understand the process of tissue damage, the whole complex and multifaceted set of those pathological changes, which inevitably arise both in the area of ​​the wound channel itself, and throughout the body due to open damage.

The reaction of the body to injury: pain; blood loss (bleeding); shock; resorptive fever; wound infection; wound exhaustion.

Microbial contamination is inevitable with every injury: primary, secondary, hospital.

Wound infection is a pathological process caused by the development of microbes. The development of microbes is facilitated by: blood clots, dead tissue, association of bacteria, poor aeration, poor outflow; tissue hypoxia; BOV defeat; radiation sickness; blood loss, shock; exhaustion; hypovitaminosis.

According to the degree of infection, it is customary to distinguish aseptic, freshly infected (contaminated) and purulent wounds.

Infected (bacterially contaminated) wounds- wounds inflicted outside the operating room within 48-72 hours from the moment of injury. Microorganisms enter the wound with a wounding object or from the skin of the victim. There is a high probability of infection of gunshot wounds and wounds with soil contamination, as well as wounds with significant tissue multiplication. The number of microorganisms in a freshly infected wound does not exceed the "critical level", i.e. 10 5 -10 6 microbial cells, or rather colony-forming units (CFU) in 1 g of tissue, 1 ml of exudate or 1 cm 3 of the wound surface. This fabric contains Clinical signs inflammation, a systemic inflammatory reaction of the body is often observed. In this case, the wound process can develop in two ways: either the inflammation stops and the wound heals by primary intention, or microbial cumulation occurs in the area of ​​the traumatic defect, the contamination reaches and often exceeds the “critical level”. Such a wound is called secondary purulent. O primary purulent the wound is said in those cases when it is formed after surgical treatment of a purulent focus in acute purulent diseases of soft tissues (abscess, phlegmon).

festering wounds differ from freshly infected ones by the presence of an infectious process in them with all the classic signs of inflammation (pain, swelling, hyperemia, fever and dysfunction of the damaged area).

The main method of treatment of wounds is their surgical treatment. This is understood as an operative intervention aimed at creating the most favorable conditions for wound healing and preventing a wound infection that may arise and develop. In practice, surgical treatment of wounds consists of dissecting the wound and excising non-viable and contaminated areas of damaged tissues, stopping bleeding with the removal of blood, blood clots and foreign bodies from the wound cavity.

There are primary and secondary surgical treatment of wounds.

Primary debridement (PSW)- the first surgical intervention performed according to primary indications, i.e. about the damage itself. The main task is to create unfavorable conditions for the development of wound infection and ensure rapid wound healing.

Primary surgical treatment, depending on the duration of the operation, is divided into early, delayed and late. Under early PST understand an operation performed before the visible development of an infectious wound process, i.e. during the first day (24 hours) from the moment of injury. Surgical treatment performed during the second day (from 24 to 48 hours) is called delayed PHO wounds. In cases where the primary surgical treatment is performed in the presence of a developing wound infection (more often after 48 hours from the moment of injury), the operation is called late PHOR.

Secondary debridement- surgery performed according to secondary indications, i.e. due to changes in the wound caused by wound infection (infiltration, edema, suppuration, phlegmon).

Primary surgical treatment of facial wounds(PHO) is a set of measures aimed at creating optimal conditions for wound healing.

PHO prevents complications, life threatening(external bleeding, respiratory failure), preserves the possibility of eating, speech functions, prevents disfigurement of the face, the development of infection.

Upon admission of the wounded in the face to a specialized hospital (specialized department), their treatment begins already in the emergency department. Render emergency assistance if it is shown. The wounded are registered, medical sorting and sanitization are carried out. First of all, they provide assistance according to vital indications (bleeding, asphyxia, shock). In the second place - the wounded with extensive destruction of the soft tissues and bones of the face. Then - the wounded, with light and moderate injuries.

N.I. Pirogov pointed out that the task of surgical treatment of wounds is "the transformation of a bruised wound into a cut wound."

Dental and maxillofacial surgeons are guided by the provisions of the military medical doctrine and the basic principles of the surgical treatment of wounds maxillofacial region which were widely used during the Great Patriotic War. According to them, surgical treatment of wounds should be early, simultaneous and exhaustive. The attitude to tissues should be extremely sparing.

Distinguish primary surgical debridement (SW) is the first debridement of a gunshot wound. Secondary surgical debridement is the second surgical intervention in a wound that has already undergone debridement. It is undertaken with complications of an inflammatory nature that have developed in the wound, despite the primary surgical treatment of it.

Depending on timing surgical intervention distinguish:

- early PST (conducted up to 24 hours from the moment of injury);

- delayed PHO (conducted up to 48 hours);

- late PHO (conducted 48 hours after injury).

PXO is a surgical intervention designed to create optimal conditions for the healing of a gunshot wound. In addition, its task is the primary restoration of tissues by carrying out therapeutic measures by influencing the mechanisms that ensure the cleansing of the wound from necrotic tissues in the postoperative period and the restoration of blood circulation in the tissues adjacent to it. (Lukyanenko A.V., 1996). Based on these tasks, the author formulated principles specialized surgical care wounded in the face, which are called upon to a certain extent to bring the classical requirements of military medical doctrine into line with the achievements of military field surgery and the features of gunshot wounds to the face inflicted by modern weapons. These include:

1. One-stage comprehensive primary surgical treatment of the wound with fixation of bone fragments, restoration of soft tissue defects, inflow-outflow drainage of the wound and adjacent cellular spaces.

2. Intensive care of the wounded in the postoperative period, including not only the replacement of lost blood, but also the correction of water and electrolyte disorders, sympathetic blockade, controlled hemodilution and adequate analgesia.

3. Intensive therapy postoperative wound, aimed at creating favorable conditions for its healing and including a targeted selective effect on the microcirculation in the wound and local proteolytic processes.

Before surgical treatment, each wounded person should be given an antiseptic (drug) treatment of the face and oral cavity. They usually start with the skin. Especially carefully treat the skin around the wounds. Use a 2-3% solution of hydrogen peroxide, 0.25% solution of ammonia, more often - iodine-gasoline (1 g of crystalline iodine is added to 1 liter of gasoline). The use of iodine-gasoline is preferable, as it dissolves caked blood, dirt, and grease well. Following this, the wound is irrigated with any antiseptic solution, which makes it possible to wash out dirt, small free-lying foreign bodies. After that, the skin is shaved, which requires skills and abilities, especially in the presence of hanging soft tissue flaps. After shaving, you can again rinse the wound and oral cavity with an antiseptic solution. It is rational to carry out such hygienic treatment by preliminarily administering an analgesic to the wounded, since the procedure is quite painful.

After the above treatment of the face and oral cavity, the skin is dried with gauze and treated with 1-2% tincture of iodine. After that, the wounded are taken to the operating room.

The volume and nature of the surgical intervention is determined by the results of the examination of the wounded. This takes into account not only the degree of destruction of tissues and organs of the face, but also the possibility of their combination with damage to the ENT organs, eyes, skull and other areas. The issue of the need to consult with other specialists, the possibility of an x-ray examination, taking into account the severity of the wounded person's condition, is being decided.

Thus, the volume of surgical treatment is determined individually. However, if possible, it should be radical and carried out in full. The essence of radical primary surgical treatment involves the implementation of the maximum volume of surgical manipulations in a strict sequence of its stages: treatment of the bone wound, soft tissues adjacent to the bone wound, immobilization of jaw fragments, suturing the mucous membrane of the sublingual region, tongue, vestibule of the mouth, suturing (according to indications) on the skin with mandatory wound drainage.

Surgery can be performed under general anesthesia (about 30% of wounded with severe injuries) or local anesthesia(about 70% of the wounded). About 15% of the wounded admitted to a specialized hospital (department) will not need PST. It is enough for them to carry out the "toilet" of the wound. After anesthesia, loose foreign bodies (earth, dirt, scraps of clothing, etc.), small bone fragments, secondary wounding projectiles (teeth fragments), and blood clots are removed from the wound. The wound is additionally treated with a 3% hydrogen peroxide solution. An audit is carried out along the entire wound channel, if necessary, deep pockets are dissected. The edges of the wound are bred with blunt hooks. Foreign bodies are removed along the wound channel. Then proceed to the processing of bone tissue. Based on the generally accepted concept of gentle treatment of tissues, sharp bone edges are bitten and smoothed with a curettage spoon or cutter. The teeth are removed from the ends of the bone fragments when the roots are exposed. Remove small bone fragments from the wound. Fragments associated with soft tissues are stored and placed in their intended place. However, the experience of clinicians shows that it is also necessary to remove bone fragments, the rigid fixation of which is impossible. This element should be considered mandatory, since the mobile fragments eventually lose their blood supply, become necrotic and become the morphological substrate of osteomyelitis. Therefore, at this stage, "moderate radicalism" should be considered appropriate.

Taking into account the peculiarities of modern high-speed firearms, the provisions set forth in the military medical doctrine require revision

(M.B. Shvyrkov, 1987). Large fragments associated with soft tissues, as a rule, die, turning into sequesters. This is due to the destruction of the intraosseous tubular system in the bone fragment, which is accompanied by the outflow of plasma-like fluid from the bone and the death of osteocytes due to hypoxia and accumulated metabolites. On the other hand, microcirculation is disturbed in the feeding pedicle itself and in the bone fragment. Turning into sequesters, they support acute purulent inflammation in the wound, which can also be caused by bone necrosis at the ends of fragments. mandible.

Based on this, it seems appropriate not to bite and smooth the bone protrusions at the ends of the mandible fragments, but to saw off the ends of the fragments with a zone of supposed secondary necrosis before capillary bleeding. This makes it possible to expose viable tissues containing granules of proteins-regulators of reparative osteogenesis, viable osteoclasts, and pericytes. All this is intended to create the prerequisites for a full-fledged reparative osteogenesis. When shooting the alveolar part of the lower jaw, surgical treatment consists in removing the broken bone section, if it has retained its connection with soft tissues. The resulting bone protrusions are smoothed with a cutter. The bone wound is closed with a mucous membrane, moving it from neighboring areas. If this fails, then it is closed with a swab of iodoform gauze.

During surgical treatment of gunshot wounds of the upper jaw, if the wound channel passes through her body, in addition to the above measures, an audit of the maxillary sinus, nasal passages, and the ethmoid labyrinth is carried out.

The revision of the maxillary sinus is carried out by access through the wound channel (wound), if it is of considerable size. Blood clots, foreign bodies, bone fragments, and a wounding projectile are removed from the sinus. The altered mucous membrane of the sinus is excised. The viable mucous membrane is not removed, but placed on the bone skeleton and subsequently fixed with an iodoform swab. Be sure to impose an artificial anastomosis with a lower nasal passage, through which the end of the iodoform tampon is brought into the nose from the maxillary sinus. The external wound of soft tissues is treated according to the generally accepted method and sutured tightly, sometimes resorting to plastic techniques with “local tissues”. If this fails, plate sutures are applied.

When the inlet is small, an audit of the maxillary sinus is performed according to the type of classical maxillary sinusectomy according to Caldwell-Luke with access from the vestibule of the oral cavity. Sometimes it is advisable through the imposed rhinostomy to introduce into maxillary sinus perforated vascular catheter or tube for washing it with an antiseptic solution.

If the wound of the upper jaw is accompanied by the destruction of the external nose, middle and upper nasal passages, then it is possible to injure the ethmoid labyrinth and damage the ethmoid bone. During surgical treatment, bone fragments, blood clots, foreign bodies should be carefully removed, free outflow of wound discharge from the base of the skull should be ensured in order to prevent basal meningitis. It should be checked for the presence or absence of liquorrhea. Carry out an audit of the nasal passages according to the above principle. Non-viable tissues are removed. The bones of the nose, vomer and shells are set, check the patency of the nasal passages. In the latter, polyvinyl chloride or rubber tubes wrapped in 2-3 layers of gauze are inserted to the full depth (up to the choanae). They provide fixation of the preserved nasal mucosa, nasal breathing and, to a certain extent, prevent cicatricial narrowing of the nasal passages in the postoperative period. On the soft tissues nose, if possible, sutured. Bone fragments of the nose, after their reposition, are fixed in the correct position with the help of tight gauze rollers and strips of adhesive plaster.

If the wound of the upper jaw is accompanied by a fracture of the zygomatic bone and arch, then after processing the ends of the fragments, the fragments are repositioned and fixed with

bone suture or in another way to prevent the retraction of bone fragments. When indicated, an audit of the maxillary sinus is carried out.

In the case of injury to the hard palate, which is most often combined with a gunshot fracture (shooting) of the alveolar process, a defect is formed that communicates the oral cavity with the nose, maxillary sinus. In this situation, the bone wound is treated according to the principle described above, and the bone wound defect should be tried to be closed (removed) using a soft tissue flap taken in the neighborhood (the remains of the mucous membrane of the hard palate, the mucous membrane of the cheek, upper lip). If this is not possible, the manufacture of a protective, separating plastic plate is shown.

In case of injury eyeball When a wounded person enters the maxillofacial department due to the nature of the prevailing injury, one should be aware of the danger of loss of vision in the undamaged eye due to the spread of the inflammatory process through the chiasm optic nerve to the opposite side. Prevention of this complication is enucleation of the destroyed eyeball. It is desirable to consult an ophthalmologist. However, the dental surgeon must be able to remove small foreign bodies from the surface of the eye, wash the eyes and eyelids. When treating a wound in the region of the upper jaw, it is necessary to maintain the integrity or restore the patency of the nasolacrimal canal.

After completing the surgical treatment of the bone wound, it is necessary to excise non-viable soft tissues along the edges of the wound until capillary bleeding occurs. More often the skin is excised at a distance of 2-4 mm from the edge of the wound, adipose tissue- a few more. The sufficiency of excision of muscle tissue is determined not only by capillary bleeding, but also by the reduction of its individual fibers during mechanical irritation with a scalpel.

It is desirable to excise dead tissues on the walls and bottom of the wound, if this is technically possible and is not associated with the risk of injuring large vessels or branches facial nerve. Only after such tissue excision can any wound on the face be sutured with mandatory drainage. However, recommendations for gentle excision of soft tissues (only non-viable) remain in force. In the process of processing soft tissues, it is necessary to remove from the wound channel foreign bodies that secondarily injure projectiles, including fragments of broken teeth.

All wounds in the mouth should be carefully examined, regardless of their size. Foreign bodies present in them (fragments of teeth, bones) can cause severe inflammatory processes in soft tissues. Be sure to examine the tongue, examine the wound channels in order to detect foreign bodies in it.

Next, reposition and immobilization of bone fragments are performed. To do this, use conservative and surgical methods(osteosynthesis) of immobilization, as in non-gunshot fractures: splints of various designs (including dental splints), bone plates with screws, extraoral devices with various functional orientations, including compression-distraction ones. The use of a bone suture and Kirschner wires is inappropriate.

In case of fractures of the upper jaw, they often resort to immobilization according to the Adams method. Reposition and rigid fixation of bone fragments of the jaws is an element of the reconstructive operation. It also helps to stop bleeding from a bone wound, prevents the formation of a hematoma and the development of a wound infection.

The use of splints and osteosynthesis involves fixing fragments in the correct position (under bite control), which, in case of a gunshot defect of the lower jaw, contributes to its preservation. This further makes it necessary to carry out multi-stage osteoplastic operations. The use of a compression-distraction apparatus (CDA) makes it possible to bring the fragments closer together before their contact, creates optimal conditions for suturing the wound in the mouth due to its reduction in size and allows

start osteoplasty almost immediately after the end of PST. It is possible to use various options for osteoplasty, depending on the clinical situation.

Having immobilized the fragments of the jaws, they begin to suture the wound - first, rare sutures are applied to the wounds of the tongue, which can be localized on its lateral surfaces, tip, back, root, and lower surface. Sutures should be placed along the body of the tongue, not across it. Sutures are also applied to the wound of the sublingual region, which is made accessible through the external wound under the conditions of immobilization of fragments, especially with bimaxillary splints. After that, blind sutures are applied to the mucous membrane of the vestibule of the mouth. All this is designed to isolate the external wound from the oral cavity, which is essential for preventing the development of wound infection. Along with this, you should try to cover exposed areas of the bone with soft tissues. Next, sutures are placed on the red border, muscles, subcutaneous adipose tissue and skin. They can be deaf or lamellar.

Blind sutures, according to military medical doctrine, after PXO can be applied to the tissues of the upper and lower lips, eyelids, nasal openings, auricle(around the so-called natural holes), on the mucous membrane of the oral cavity. In other areas of the face, lamellar sutures or others (mattress, nodal) are applied, with the aim of only bringing the edges of the wound closer together.

Depending on the timing of suturing the wound tightly distinguish:

- early suture(applied immediately after PST of a gunshot wound),

- delayed primary suture(imposed on 4-5 days after the PST in cases where either a contaminated wound was treated, or a wound with signs of incipient purulent inflammation in it, or it was not possible to completely excise necrotic tissues when there is no certainty in the course postoperative period on best option: no complications. It is applied until active growth of granulation tissue appears in the wound),

- secondary seam early(impose on the 7th - 14th day on a granulating wound, which is completely cleared of necrotic tissues. Excision of the edges of the wound and mobilization of tissues are possible, but not necessary),

- secondary suture late(applied for 15-30 days on a scarring wound, the edges of which are epithelialized or already epithelialized and become inactive. It is necessary to excise the epithelialized edges of the wound and mobilize the tissues approaching to contact with a scalpel and scissors).

In some cases, to reduce the size of the wound, especially in the presence of large hanging soft tissue flaps, as well as signs of inflammatory tissue infiltration, a plate suture can be applied. By functional purpose plate seam divided into:

bringing together;

unloading;

guide;

Deaf (on a granulating wound).

As tissue edema decreases or the degree of their infiltration decreases, the edges of the wound can be gradually brought closer together with the help of a lamellar suture, in which case it is called “converging”. After complete cleansing of the wound from detritus, when it becomes possible to bring the edges of the granulating wound into close contact, that is, suturing the wound tightly, this can be done using a lamellar suture, which in this case will serve as a “blind suture”. In the case when conventional interrupted sutures were applied to the wound, but with some tissue tension, it is additionally possible to apply a plate suture, which will reduce tissue tension in the area of ​​interrupted sutures. In this situation, the plate seam performs the function of "unloading". For fixation of soft tissue flaps in a new location or in an optimal position, which

imitates the position of tissues before injury, you can also use a laminar suture, which will act as a "guide".

To apply a laminar suture, a long surgical needle is used, with which thin wire(or polyamide, silk thread) to the entire depth of the wound (to the bottom), retreating 2 cm from the edges of the wound. A special metal plate is strung on both ends of the wire until it comes into contact with the skin (you can use a large button or a rubber stopper from a penicillin bottle), then 3 lead pellets each. The latter are used to fix the ends of the wire after bringing the wound lumen to the optimal position (the upper pellets located further from the metal plate are first flattened). Free pellets, located between the already flattened pellet and the plate, are used to regulate the tension of the seam, to bring the edges of the wound closer together and reduce its lumen as the inflammatory edema in the wound stops.

Lavsan or polyamide (or silk) thread can be tied in a knot in the form of a "bow" over the cork, which can be untied if necessary.

Principle radicalism According to modern views, primary surgical treatment of a wound involves excision of tissues not only in the area of ​​primary necrosis, but also in the area of ​​supposed secondary necrosis that develops as a result of a “side impact” (not earlier than 72 hours after injury). The sparing principle of PHO, although it declares the requirement of radicalism, involves an economical excision of tissues. In case of early and delayed PST of a gunshot wound, in this case, tissues will be excised only in the area of ​​primary necrosis.

Radical primary surgical treatment of gunshot wounds of the face can reduce the number of complications in the form of suppuration of the wound and divergence of sutures by 10 times compared with PHO wounds using the principle of gentle treatment of excised tissues.

It should be noted once again that when suturing a wound on the face, first sutures are placed on the mucous membrane, then the muscles, subcutaneous fat and skin. In case of injury to the upper or lower lip, the muscles are first sutured, then a suture is placed at the border of the skin and the red border, the skin is sutured, and then the mucous membrane of the lip. In the presence of an extensive soft tissue defect, when the wound penetrates the mouth, the skin is sutured to the oral mucosa, which creates more favorable conditions for the subsequent plastic closure of this defect, significantly reducing the area of ​​scar tissue.

An important point in the primary surgical treatment of facial wounds is their drainage. Two methods of drainage are used:

1. supply-and-flow method, when a leading tube with a diameter of 3-4 mm with holes is brought to the upper section of the wound through a puncture in the tissues. A discharge tube with an inner diameter of 5–6 mm is also brought to the lower section of the wound through a separate puncture. With the help of a solution of antiseptics or antibiotics, long-term lavage of the gunshot wound is carried out.

2. Preventive drainage cellular spaces of the submandibular region and neck adjacent to the gunshot wound with a double-lumen tube according to the method of N.I. Kanshin (through an additional puncture). The tube approaches the wound but does not communicate with it. Washing solution (antiseptic) is injected through the capillary (narrow lumen of the tube), and washing liquid is aspirated through its wide lumen.

Based on modern views on the treatment of wounded in the face in the postoperative period, intensive therapy is indicated. And it must be ahead of the curve. Intensive care includes several fundamental components (A.V. Lukyanenko):

1. Elimination of hypovolemia and anemia, microcirculation disorders. This is achieved by conducting infusion-transfusion therapy. In the first 3 days, up to 3 liters of media are transfused (blood products, whole blood, saline crystalloid

solutions, albumin, etc.). In the future, the leading link in infusion therapy will be hemodilution, which has exclusively importance to restore microcirculation in injured tissues.

2. Postoperative analgesia.

A good effect is the introduction of fentanyl (50-100 mg every 4-6 hours) or tramal (50 mg every 6 hours - intravenously).

3. Prevention of adult respiratory distress syndrome and pneumonia. Achieved by effective anesthesia, rational infusion-transfusion

ion therapy, improvement of the rheological properties of blood and artificial ventilation of the lungs. Leading in the prevention of adult respiratory distress syndrome is mechanical artificial lung ventilation (ALV). It is aimed at reducing the volume of pulmonary extravascular fluid, normalizing the ventilation-perfusion ratio, and eliminating microatelectasis.

4. Prevention and treatment of disorders of water-salt metabolism.

It consists of calculating the volume and composition of daily infusion therapy, taking into account the initial water-salt status and fluid loss by the extrarenal route. More often in the first three days of the postoperative period, the dose of liquid is 30 ml / kg of body weight. With a wound infection, it is increased to 70 - 80 ml / kg of body weight of the wounded.

5. Elimination of excess catabolism and providing the body with energy substrates.

Energy supply is achieved through parenteral nutrition. Nutrient media should include glucose solution, amino acids, vitamins (group B and C), albumin, electrolytes.

Intensive therapy of a postoperative wound is essential, aimed at creating optimal conditions for its healing by influencing microcirculation and local proteolytic processes. To do this, use reopoliglyukin, 0.25% novocaine solution, Ringer-Lock solution, trental, contrycal, proteolytic enzymes (solution of trypsin, chemotripsin, etc.).

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

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

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

The wound can provoke various complications that may appear immediately after the injury or after some time, especially if the primary surgical treatment of the wound has not been performed:

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

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

First aid

Any wound, small or large, requires urgent treatment to stop bleeding. If the injury is minor, it is enough to give the victim first aid and change the bandages regularly, but if the wound is large, it bleeds heavily, then you must definitely go to the hospital.

There are a number of basic rules that must be observed when conducting PST of a wound:

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

First aid procedure:

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

Deep wound treatment

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

The main goal is to stop blood loss. If a large foreign object remains in the wound, for example, a knife, you do not need to remove it until the doctors arrive, as it restrains bleeding. In addition, if the object is not removed correctly, it is possible to injure the internal organs and provoke the death of the victim.

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

To stop heavy bleeding from a limb, you need to apply a tourniquet above the wound. It should not be very tight, in addition, it is necessary to do it correctly. The tourniquet is applied to clothing and quickly, but removed slowly. You can hold the tourniquet for an hour, after which it must be loosened for 10 minutes and tied up a little higher. It is very important to make a note on the patient's clothing or body about the time the tourniquet was applied in order to remove it in time, otherwise there is a risk of provoking tissue necrosis. Do not apply a tourniquet if the bleeding is mild and can be stopped with a pressure bandage.

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

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

Medications

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

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

Consider some of the most popular antiseptics.

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

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

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

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

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

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

Chlorhexidine, peroxide, furatsilin and potassium permanganate can be used to wet the dressing wipes so that the bandage does not stick to the wound.

PHO wounds in children

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

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

The child must be immobilized as much as possible, not allowed to touch the wound. With severe bleeding, when the blood spurts with a fountain, you need to apply a tourniquet. It is very important to deliver the child to the hospital as soon as possible and to prevent large blood loss.

Video: PHO - primary surgical treatment of the wound

A wound is mechanical damage to tissues in the presence of integrity violations. skin. The presence of a wound, rather than a bruise or hematoma, can be determined by signs such as pain, gaping, bleeding, impaired function and integrity. PST of the wound is carried out in the first 72 hours after the injury, if there are no contraindications.

Varieties of wounds

Each wound has a cavity, walls and bottom. Depending on the nature of the damage, all wounds are divided into stab, cut, chopped, bruised, bitten and poisoned. During the PST of the wound, this must be taken into account. After all, the nature of the injury depends on the features of first aid.

• Stab wounds are always caused by a piercing object, such as a needle. A distinctive feature of the damage is a great depth, but small damage to the integument. In view of this, it is necessary to make sure that there is no damage to blood vessels, organs or nerves. Stab 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 see during PST.
• incised wound applied with a sharp object, so tissue damage is small. At the same time, the gaping cavity is easy to inspect and perform PST. Such wounds are well treated, and healing is carried out quickly, without complications.
• Chopped wounds are caused by cutting with a sharp but heavy object, such as an axe. In this case, the damage differs in depth, the presence of a wide gaping and bruising of neighboring tissues is characteristic. Because of this, the ability to regenerate is reduced.
• Bruised wounds appear when using a blunt object. These injuries are characterized by the presence of many damaged tissues heavily saturated with blood. When conducting PST of a wound, it should be borne in mind that there is a possibility of suppuration.
• Bite wounds are dangerous for 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.
• Poison wounds usually result from 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 chance of infection.

When conducting PST of a wound, the presence of suppuration plays an important role. Such injuries are purulent, freshly infected and aseptic.

The purpose of the PST

Primary surgical treatment is necessary to remove harmful microorganisms that have entered the wound. For this, all damaged dead tissues, as well as blood clots, are cut off. After that, sutures are applied 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 assistance of a surgeon is necessary for the patient for up to 72 hours after the wound has been inflicted. Early PST is carried out during the first day, the second day is a delayed surgical intervention.

Pho tools

A minimum of two copies of the kit is required for the initial wound treatment procedure. They are changed during the operation, and after the dirty stage they are disposed of:

• clamp "Korntsang" straight, which is used to process the surgical field;
• scalpel pointed, belly;
• linen hoes are used to hold dressings and other materials;
• clamps Kocher, Billroth and "mosquito", are used to stop bleeding, when conducting PST of a wound, they are used in large quantities;
• scissors, they are straight, as well as curved along a plane or edge in several copies;
• Kocher's probes, grooved and bellied;
• a 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 PST - suture and dressing kits, tools and medications, intended for the treatment of wounds - are laid out on the surgical table.

Necessary medicines

Primary surgical treatment of the 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 surgery, the patient is placed on the table. Its position depends on the location of the wound. The surgeon must be comfortable. The wound is toileted, the operating field is processed, which is delimited by sterile disposable underwear. Next, the primary intention is performed, aimed at healing existing wounds, and anesthesia is administered. In most cases, surgeons use the Vishnevsky method - they inject a 0.5% solution of novocaine at a distance of two centimeters from the edge of the cut. The same amount of solution is injected from the other side. With the correct reaction of the patient, a "lemon peel" is observed on the skin around the wound. Gunshot wounds often require the patient to be given general anesthesia.

The edges of the damage up to 1 cm are held with a Kochcher clamp and cut off in a single block. 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. Stab wounds with small but deep incisions 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 preparations.

The treated wound without signs of sepsis is sutured tightly with primary and covered with an aseptic bandage. Seams are performed, evenly capturing all layers in width and depth. It is necessary that they touch each other, but do not pull together. When doing work you need to get cosmetic healing.

In some cases, primary sutures are not applied. A cut wound can be more serious than it seems at first glance. If the surgeon is in doubt, a primary delayed suture is used. This method is used if the wound has been infected. Suturing is carried out to fatty tissue, and the seams do not tighten. A few days after observation, until the end.

bite wounds

PST of a wound, bitten or poisoned, has its own differences. When bitten by non-venomous animals, there is a high risk of contracting rabies. On the early stage the disease is suppressed by anti-rabies serum. Such wounds in most cases become purulent, so they try to delay the PHO. During the procedure, a primary delayed suture is applied and antiseptic drugs are applied.

A snake bite wound requires a tight tourniquet or bandage. In addition, the wound is frozen with novocaine or cold is applied. Anti-snake serum is injected to neutralize the venom. Spider bites are blocked by potassium permanganate. Before that, poison is squeezed out, and the wound is treated with an antiseptic.

Complications

Careless treatment of the wound with antiseptics leads to suppuration of the wound. Incorrect anesthetic, as well as causing additional injuries, causes anxiety in the patient due to the presence of pain.

Rough attitude to tissues, 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.

PXO is the first surgical operation performed on a patient with a wound under aseptic conditions, under anesthesia, and consists 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. Impose immediately after the completion of the operation or PST of the wound. 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 to suture.

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, violation of 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.