How to treat purulent wounds. Purulent wound

Relevance of the topic.The history of the treatment of wounds and a wound infection is rooted in the depths of centuries. Another prehistoric man treated various wounds and damages obtained on the hunt and during military clashes. S.S.Girgolav in the monograph "Firearfish" wrote: "It is unlikely that for any other purpose in medical practice, a greater number of both individual means and their combinations and entire methods and systems than for the treatment of RAS were proposed. As a result of the Scientific and Technical Revolution in the last 30-40 years, new powerful chemotherapy products, antibiotics, immunotherapeutic agents and substances that accelerate the purification of the wound and its regeneration were obtained. The technique of processing wounds has improved significantly. There were new technical capabilities to maintain aseptic during the operation and treatment of the wound. Operating and dressing chambers with sterile air appeared. It became possible to create around the wound favorable for its healing Wednesday. Due to the fact that wounds and wound infection are often found in the practice of a doctor of any specialty, it seems a relevant problem of using modern methods of treatment of wounds.

Purpose of classes

The student must know : Morphology and pathogenesis of the wound process, the microbiology of the Russian Academy of Sciences, the state of local and general immunity with a wound infection, a wound process clinic, local and general treatment of purulent wounds, physical methods to improve the results of the treatment of purulent wounds.

The student must be able to Based on the clinical examination, determine the stage of the wound process, to make a healing algorithm depending on the inflammation stage, to produce secondary surgical treatment, perform a dressing in patients with different stages of the wound process, be able to choose preparations for the treatment of purulent wounds at various steps of the wound process. Apply various methods of anesthesia, choose a drainage method, wounds, solve the question of the shuttering timing.

Purulent (nonspecific) infection - inflammatory diseases of various localization and character caused by the globular microbial flora; It takes one of the main places in surgery and determines the essence of many diseases and postoperative complications.

Factors defining the development of development, features of the course and the outcome of diseases associated with infection in surgery are:

1 state of the immunobiological forces of macroorganism. With high protective forces of the body, even the highlighted flora falling into it may pass without a trace and, on the contrary, with a low potential, even saprophytes can begin to act aggressively and cause a heavy purulent process.

2 Number, virulence, drug stability and other biological properties of microbes that have penetrated into the inner medium of the human body. The greater the dose and above the virulence of penetrated into the organism of the microbes, the greater the likelihood of the development of the disease.

3 Anatomy-physiological features of the focus of the introduction of microorganisms microflora meet significant resistance in body areas with good blood circulation. So, on the head and face, where there is a thick network of blood vessels, purulent processes develop less frequently than in other areas. An important role in the prevention of inflammation is played by local immunity, which is most pronounced in places of permanent contact with infection. For example, inflammatory processes in the crotch area are less common than in other areas, and regeneration processes here develop faster. The critical level in which the inflammatory process develops, 10 5 microbes are considered to be 1 g of tissues. Along with this, it is necessary to adapt the microbes in the wound to the new biological environment. The incubation period is about 6-12 hours, its duration depends on the biological features of micro and macroorganism. In this regard, it is believed that primary surgical treatment is the most appropriate in these terms.

4 state of general and local blood circulation.

In addition, the development of the inflammatory process contributes to the disorder of blood and lymphotok, the presence of necrosis, hemorrhages and a number of other factors.

5 The degree of allergyization of the patient.

The immunobiological state of the organism is important in the development of inflammation, which is due to such concepts as reactivity and resistance.

The organism reactivity, depending on the degree of manifestation, may be normal, hyperogenic, hypergic and aeric.

Normergic reactivity is characterized by an adequate response of the organism on the hearth of irritation, in particular the infectious agent. Hypereergic reactivity is manifested by the progenic pathological, sometimes a torgenic response of the body in some cases on a small stimulus. The classic example is the phenomenon of Artus in pathophysiology, and an anaphyactic shock, malignant hyperthermia and other hypeergic reactions, sometimes on the most innocuous, at first glance, can be given in the clinic area of \u200b\u200bthe example, the factors (receiving analgin tablets, antibiotic, bee bite, wasps, etc.) .

Gyuo- and especially anegic reactivity, manifolding a minor reaction or in its absence even in the presence of a serious inflammatory process, indicates, as a rule, about the serious condition of the patient and is a prognostically unfavorable factor. Examples of such reactivity can serve as a normal and reduced body temperature, reduced. Luxcitosis in the presence of a severe purulent process, sepsis.

Resistance (resistance, or stability) of the body of infection may be normal, elevated or low.

The normal resistance of the body to hit the infectious agent is manifested by an adequate response corresponding to the stimulus.

Increased resistance in contrast to hypeergic reactivity is the positive acquisition of the body, which easily copes with the inflammatory process even in the case of a virulent infection.

The reduced resistance of the body under purulent surgical infection largely predetermines the serious flow of the disease with the generalization of the process, and therefore therapeutic efforts should be aimed at increasing the protective forces of the body.

Resistance, or resistance, may be specific and not specific. Specific resistance is caused by immunity due to the presence of antibodies to a specific microbial antigen, and non-specific - is determined by the activity of phagocytosis, the level of lease-cym, complement and other protective mechanisms that are designed to protect the body from microbial aggression regardless of the type of microflora.

Classification of surgical infection

Depending on the type of microflora

1 Acute Surgical Infection: purulent, rotary, anaerobic, specific (tetanus, Siberian ulcers, etc.).

2 Chronic Surgical Infection:

Nonspecific (glorodic);

Specific (tuberculosis, syphilis, actinomycosis, etc.).

Along with this, acute and chronic infection is advisable to divide on the common and local.

On localization of the lesion Spilled purulent-inflammatory diseases:

Skin and subcutaneous fiber, muscles.

Ferrous organs.

Lymphatic and circulatory systems.

Cover of skull, brain and its contents

Breast wall, pleura, lungs.

Mediastum.

Abdominal and abdominal organs.

Pelvis and its organs.

Bones and joints.

By etiology:

Staphylococcus.

Streptococcus.

Pneumococcal;

Colibacillary.

Syncnaya.

Anaerobic, nonlocostrial.

Mixed and others.

If the inflammatory process is caused by one causative agent, monoinfection takes place, several - polyinfection. It should be noted that the inflammatory process caused by monoinfection, as a rule, flows the lighter of the polyinfection process.

Taking into account the structure of the pathology:

Iphic surgical diseases.

Infectious complications of surgical diseases.

Postoperative infectious complications;

Infectious complications of closed and open injuries

Morbidity and mortality

Surgical infection occupies one of the main places in the surgical clinic. The frequency of wound infectious complications in different areas of surgery reaches 14-20%. About 40% of deaths after the operation is due precisely by purulent-septic complications.

According to the materials of the All-Russian Congress of Surgeons (Krasnodar, 1995), the frequency of purulent complications in cardiac surgery (up to 26%), in urology (up to 30%), and traumatology (up to 40%), rescued. Mortality with such purulent complications, according to some authors, reaches 30-60%.

Acute purulent infection is an acute inflammatory process of various localization and character caused by glorodular microflora. For its development, it is necessary to have three elements:

Pathways of purulent surgical infection

Purulent-inflammatory diseases have an infectious nature, they are caused by various types of pathogens: gram-positive and gram-negative, aerobic and anaerobic, spore-forming and unfortunate, as well as pathogenic fungi. With certain, favorable microorgangic conditions, the inflammatory process may be caused by conditionally pathogenic microbes: Klebsiella Pneumoniae, Enterobacter Aerogenes, saprophitis - Proteus vulgaris. The disease can be caused by one causative agent (monoinfection) or several (mixed infection). A group of microbes that caused the inflammatory process is called a microbial association. Microorganisms can penetrate the wound into the zone of damage to the tissues from the external environment (exogenous infection) or from the foci of microflora accumulation in the human body itself (endogenous infection).

Entrance gate infection

In the development of purulent process, it is important to implement and distribute pathogens.

Epidermis damage or epithelium of mucous membranes, through which microbes may be introduced, may be the result of mechanical injury, the effects of chemicals and other traumatic factors. Damage size has a relative value. On the contrary, often microtraums are a special danger that is that they do not cause significant subjective sensations, often remain not seen and are not processed.

Throughout the disfect of the epithelial of the microbes enter the intercellular slots, lymphatic vessels and a current of lymphs are entered into gpupless fabrics.

Macroorganism reaction

Further proliferation and development of the inflammatory process depends on the number and virulence of the peeled microbes, as well as from the municipal forces of the body. The virulence of microbes is due to the ability to separate toxins (hemolysine, leukocidine, neotoxin, etc.), enzymes (plasmaguagulaz, proteolytic enzymes, etc.) and other biologically active substances.

Based on the foregoing, it can be seen that the form of inflammation depends on the complex interaction of etiological, local and oversized factors and the focus can be observed the predominant predominance of alteration, exudation or proliferation.

Clinical picture and diagnostics

From the combination of the above-mentioned factors, the nature of the manifestation of the local and general response of the body depends, that is, the course of the disease.

The nature of local manifestations The disease is determined by pathophysiological and pathomorphological changes in tissues developing in the focus of inflammation.

In particular, at the site of the introduction of microbes, reactive hyperemia is developing as a protective reaction, which is based on accumulation in the tissues of vasoactive substances, metabolites, a change in the pH in the acidic side. As a result, blood flow accelerates, the influx of blood increases, the metabolism is increasing, respectively, reactive hyperemia has a gean effect and many therapeutic effects are designed for its achievement. Along or, after this, the permeability of the vessels in the lesion is increased, exudation and tissue edema increase due to the extravolution of the plasma component of the blood. This leads to a slowdown in the blood flow in capillaries, the formation of shaped elements, the formation of microtrombov, which causes a disruption of tissue metabolism, tissue hypoxia, the development of necrosis and congestion of hyperemia, clinically manifested by cyanosis of the skin, venous stain.

The leukocytes, macrophages and other uniform elements that provide phagocytosis, proteolysis of germs, dead tissues of proteolytic enzymes of microbes, dead leukocytes and tissues migrate, migrate into the damage zone. This leads to melting and rejection of dead tissues to form a purulent focus, the development of granulation tissue around it and the formation of a pyrogen capsule.

In addition to the progression of the process on the above scenario, the focus of inflammation can also be inversely developed, i.e. have an abutient course. In this regard, in the clinical course of the inflammatory process, two stages of development of the local focus are distinguished: serous-infiltrative and purulent-necrotic. The first stage is reversible and subject to conservative therapy, the second is irreversible and needs operational treatment.

Typical local clinical manifestations of the focus of inflammation are:

Ruber. (redness),

Calor (local heat),

Tumor (swelling),

Dolor (pain),

FUNCIO.laesa. (function violation).

In the development of purulent diseases possible local complications development: Inflammation of lymphatic vessels (lymphangitis) and nodes (lymphadenitis), thrombophlebitis.

The formation of necrosis is associated with the activities of microorganisms, as well as a disruption of microcirculation due to the inflammatory process. At the same time, sections of black appear in the inflammation zone.

Lymphangit - secondary inflammation of lymphatic vessels. With stem lymphangitis, hyperemia is observed in the form of individual bands, which come from the focus of inflammation to the zone of regional lymph nodes - to the axillary yam or groin fold. When palpation marked painful seals in the form of heavy, "cords" in the course of lymphatic vessels.

Lymphadenitis - inflammation of lymph nodes, arising as a complication of various purulent inflammatory diseases and specific infections. Lymphadenite begins with pain and increasing lymph nodes. When progressing the process and development of periathenitis, lymph nodes, merging with each other and surrounding tissues, become fixed. The process can switch to destructive form up to the development of adenoflems.

Thrombophlebitis is the inflammation of the veins, according to which blood outflow is carried out from the inflammation zone. Such thrombophlebitis is called ascending. Usually we are talking about surface veins. Clinically determined by the painful infiltration along the vein having a form of a harness, roller. Over it is hyperemic leather, can be somewhat raised.

Along with local signs for surgical infection, the overall response of the body is also characteristic, especially in the case of the development of a severe inflammatory process, which is manifested by a number of symptom cells expressed in one degree or another. Among them should be the general symptoms of toxicosis, manifested by weakness, headache, fragmentation in the joints, bones, muscles, brunce, apathy, as well as the development of fever, increasing heat-product and violation of heat regulation.

In the event of a severe flow of the purulent process, almost all organism systems react to one degree or another to the presence of infectious toxicosis.

In particular, the CNS is noted, euphoria, poor sleep, hallucinations, psychosis, which can change the oppression of consciousness, prostration, delirium.

From the side of the cardiovascular system, tachycardia, hypotension, a decrease in the CLO or its increase in the development of heart failure, a decrease in the BCC, the expansion of the heart boundaries, deaf tones, the appearance of systolic noise, the change in the ECG due to myocar diodesfias;

The reaction of the gastrointestinal tract for intoxication is manifested by a decrease or loss of appetite, nausea, in some cases, disgusting to food and vomiting, diarrhea or constipation, the jaggility of the skin, increasing the size of the liver, disrupting its basic functions.

The urinary system reacts to purulent intoxication of oligores, proteinuria, cylinder, microhematuria, and in some cases anouria and acute renal failure occur.

From the side of the hematopoietic system, an increase in the spleen and lymph nodes, their pain, especially regional nodes, the development of leukocytosis with the formula to be left to the young forms, neutro-filleis and toxic neutrophils, increased ESP, hy-larming anemia with anisocytosis and cane acidosis, hypoproteinemia It is primarily due to hypoalbuminemia with a decrease in alba-min-globulin coefficient, azotemia with an increase in the level of residual nitrogen and creatinine, hyperbilirubineia due to the indirect fraction, fermenttemy with development in a number of cases of the FDS syndrome. The development of polyorgan insufficiency, even with adequate intensive therapy, often leads to the death of the patient.

Changes in laboratory data

The degree of severity of the general reaction of the body on the emergence of a focus of purulent infection is of great importance for the correct assessment of the state of the patient, predicting complications and the choice of optimal treatment methods.

leukocytosis, leukocyte shift to the left, raising ESP.

Changes in biochemical blood test:the increase in nitrogen indicators (creatinine, urea) is determined by the proteins of the acute phase (C-jet protein, ceruloplasmin, haptoglobin), a change in protein fractions (increasing the number of globulins).

Sowing blood for sterility. It is produced at the height of the fever and helps to diagnose sepsis.

Changes in clinical blood test:proteinuria, cylindrury, leukocyturia.

Incitization level integral indicators: Localizing index and hematology indicator of intoxication, the level of medium molecules.

Principles of treatment

The nature of therapeutic measures and their volume is primarily dependent on the stage of the inflammatory process and the degree of severity of common and local manifestations of the disease.

In the serous-infiltrative stage, the patient is subject to conservative, and with purulent-necrotic - surgical treatment. In addition, treatment can be local, directed mainly to the focus of inflammation, and general, designed to reduce intoxication and its harmful effects on the patient's body.

Local treatment

It should be noted that the basic principle of surgical treatment of a purulent process, formed by more hippocratic: "Where is pus, remove, where the pus, there is a cut," and currently not lost its relevance and practical significance.

The main principles of local treatment:

Opening of a purulent focus,

Adequate drainage of glad

Local antiseptic impact

Immobilization.

In the serous infiltrative stage, in order to relieve the inflammatory process and the direction of its abutment flow, a complex of medical measures is applied. First of all, it is necessary to ensure peace of the local hearth and the body as a whole, to perform anesthesia using non-nucleic analgesics, apply the blockages by an antibiotic-novocaine mixture, use antibiotics together with sulfanyl mides, nitrofuran and other antiseptics. Locally shown bandages, baths, compresses with antiseptics, such as chlorhexidine, domexide, dioxidine, furaciline, etc.

The use of physiotherapy procedures (UHF, UFO, diadinic currents, paraffin, ozokerite, etc.), which enhance the reactive hyperemia, improves microcirculation, metabolic processes in tissues and gives a substantial healing effect.

In the purulent-necrotic stage, the main goal of local treatment is to limit the progression of the process, accelerating the liberation of the hearth from the purulent-necrotic contents and improving the wound healing processes. For this, it is necessary to resort to timely surgical treatment, during which the purulent focus is revealed, necritectomy is carried out and adequate drainage of the purulent wound is ensured. It should be distinguished by active and passive wound drainage. Active drainage is carried out with the help of tubular drainage placed in a wound with connecting them to a vacuum sources (water-conductive or electric cover, a centralized vacuum system, devices for autonomous wound vacuum, etc.). Along with this, you can use a constant or fractional lava wound. For passive drainage, tampons with antiseptics, a hypertensive solution of the table salt, hydrophilic-based ointments, as well as tubular drains, rubber strips, cigar tampons, coal tampons and other means are used.

With an antiseptic purpose, the use of proteolytic enzymes, ultrasonic cavitation of purulent cavity, high-energy laser radiation, plasma jet and other methods. After purification of the wound from the purulent necrotic masses to stimulate the regeneration and acceleration of healing of wounds, the use of biostimuding ointments (methyluracil, sodium succeed. Sea buckthorn oil, solicocery. "Rope-Ref-2", etc.), wound coatings, physioprocessed, low-intensity laser radiation (helium neon, semiconductor, etc.), overlaying secondary seams.

General treatment

The overall treatment of a patient with an inflammatory process should begin with the moment of entering it in the hospital. First, preoperative preparation is carried out, after surgery - postoperative treatment, and its intensity and its volume are the greater than pronounced intoxication.

General methods of treating surgical infection can be divided into four types:

Antibacterial therapy

Disintellation therapy,

Immunocorrection

Symptomatic treatment.

Antibacterial therapy.

Antibacterial therapy is carried out taking into account the type and sensitivity of microflora.

Methods for introducing antibiotics.

There is superficial antibiotic therapy (wounds of wounds), intra-freeway (introduction into the chest, abdominal cavity, in the cereal of the joint) and deep antibiotic therapy: intramuscular, intravenous, intraarterial and endolymphatic administration, as well as an oral method. Surface and intra-palpia are applied to local treatment.

The doses of antibiotics must be maximal therapeutic to exclude the production of microflora resistance. The course of treatment should be no more than 8-10 days, and if necessary, its continuation shows the prescription of another drug with a different mechanism of action on the microbial cell. In this case, the complex of treatment should be introduced the anti-chandomic drug (Nystatin, Lev Room, etc.).

Disinfecting therapy.

In order to detoxify the body, first of all is carried out infusion therapy, the speed and volume of which are determined by the control of the CVD. As an infusion medium, first of all, in the absence of ge-modunic disorders, glucose-crystalloid solutions (5% or 10% glucose solution, isotonic sodium chloride solution, ringer-locker solutions, disc, trisole, azesol, etc.), with which In addition to the normalization of electrolyte balance and metabolic disorders, hemodilution and hyper hydrating of the body, leading to a decrease in the concentration of toxins (the principle of breeding), are achieved. Against this background, in the absence of a violation of the kidney function, a large detoxing role can play forced diuresisachieved by the introduction of diuretics (Furosemid, Lazix, etc.). The amount of infusion therapy, especially in people of young age, can reach 5-7 liters per day, provided that adequate diuresis (the principle of removal).

The same purpose (detoxification) promote the binding and neutralization of toxins, for which inhibitors of proteases (conflict, trasilol, Tsalol, Galds, etc.), antihistamines, sorbents (activated carbon, biospecific sorbents, etc.), hemodez. Neocompensen, Polydethee, etc. (binding principle). Intravenous laser therapy, oxy-barotherapy, reinfusion ultraviolet irradiated with its own blood (Rufosk) and others have an indirect detox effect.

Methods of extracorporeal detoxification.

Sorption methods Contribute to the removal of hydrophilic and hydrophobic associated with albumin, substances of medium and high molecular weight.

Main types: hemosorption, plasmaSorption, lymphosorption.

Extraction methods Based on removal from the body along with the blood components of all types of toxic substances. The main method is plasmapheres.

Drainage of breast lymphatic duct Allows removed from the body of lymph, significantly more toxic than blood with many purulent diseases.

Electrochemical blood oxidation. The method is based on the use of carrier of active oxygen.

Methods of quantum therapy. Quantum blood irradiation causes the formation of free radicals, the functional changes in many plasma proteins, changes the charge and shape of blood shaped blood elements, contributes to the release of biologically active substances. These also include large autohemotherapy using ozone and infrared laser.

Immocorrection.

Immocillary therapy is divided into:

- Immunostimulation (Activation of immunity) which happens specific - is stimulated by a certain clone of cells, and nonspecific - increases the overall enhancement of immune defense. As immunostimulants, vaccines, serums, preparations of bacterial origin (bronchomunal, ribomunyl), Pyrohenal, Prodigiosan and others are used.

- Immunomodulation -drug, non-drug (UFO, laser, magnetic field) or other effects aimed at restoring altered immunity links, and non-touched normally functioning cells and fully flowing reactions. Immunomodulators are divided into drugs of synthetic and natural origin (drugs of thymus, bone marrow and plant).

- Immunopotation - Impact on the immune system in order to activate immunological mechanisms through immunopotentiating agents and non-immunological regulatory mechanisms. Preparations of plant origin (chamomile, Melissa, Sage, Eucalyptus), as well as drugs of synthetic origin (diucifon, levamizol).

Immunosuppression - The form of immunotherapy aimed at suppressing the activity of the immune system. Used in the treatment of autoimmune, lymphoproliferative diseases, during the transflection of organs and tissues.

Wound can be obtained at any age. Being children, we often fall and. As adults, we are also not able to avoid various damage on your own body. The wound can even be internal - after surgery, for example. But we are all accustomed to the fact that the wounds themselves are tightened and pass through. But what happens if the healing process does not pass?.

What is it - suppuration?

The combination of three components gives suppuration. What it is? The suppuration is, which is formed by the pussy, accumulating in soft tissues. What are the three components to this lead? Open wound, pollution and infection. The penetration of various infections through an open wound leads to the development of corrosive inflammations, abscesses, phlegmon, lymphadenitis, lymphangitis, purulent thrombophlebitis, and sometimes general purulent infection.

Void is a secondary disease. Primary education develops as a cluster of blood clots in the wound bed. Inflammation in this case is a natural process that in 5 days should go through and begin healing. Bacteria in this case penetrate passively and their activities are insignificant. The body copes with infection, destroys it, after which the wound heals. However, the massive contact of microorganisms proceeds to the second stage - inflammation. This is usually happening for 2 days.

For the forms of suppuration divide on:

1. Sharp - manifestation of all major symptoms;
2. Chronic.

According to the causative agent, divide:

• Bacterial (infectious);
• Viral;
• Purulent.

Phases of the wound process

1. It all begins with a hydration phase with a wound process. It consists in an enhanced inflow of blood, the formation of exudate, inflammatory edema, leukocyte infiltration, and a circular stag. The wound oxidation occurs in order to further prepare for healing. The wound is cleaned and dismissed from dead tissues and cells, bacteria and products of their livelihoods, toxins. Healing process accelerates due to the formation of lactic acid in the wound.
2. The phase of the dehydration of the wound process is characterized by a decrease in inflammation, a decrease in edema, blood outflow, the elimination of the exudate.
3. The regeneration phase is to form granulation tissue and ripening it to form a scar. At this stage, the bacteria are pushed out. If the destruction of this tissue occurred, then the bacteria have the ability to penetrate into the wound, which leads to the suppuration.

Thus, lay out the stage of a purulent-infected wound process:

1. Infection and inflammation;
2. Granulation and recovery;
3. Maturation;
4. Epithelialization.

The abundant desire of the body to get rid of the infection, which penetrated large quantities, leads to a cluster in the wound of dead leukocytes - this is a pus. The suppuration is a side effect of the body's struggle with the bacterium. The body continues to get rid of pus, which leads to an additional inflammatory process.

According to the formations that arise at the scene of the wound are divided into types:

• Pustoral - Education Pustulus, which are visible through the skin, their breakthrough and excuses exudate.
• Abssert - the formation of a glandy deep under the skin. It can provoke the formation of gangrens, which will lead to amputation of part of the body.

The reasons

The causes of the wound suppuration are infections that penetrate the tissue. How do they penetrate there? Either through an open wound, for example, a man was injured - an open wound was formed, or during the operation, in the midst. However, there are cases of infection penetration when the blood clutch has already been formed, closing the wound, but the person (or doctors) does not conduct any antiseptic and aseptic procedures. The absence of any wound processing leads to its suppuration, if it comes to deep or massive penetration.

In rare cases, the suppuration occurs without penetrating any infection. This is the reaction of the body that responds negatively to those drugs and dressings that are superimposed on the wound.

People who are reduced by immunity fall into the risk group. Often it can be traced in the presence of infectious diseases or in venereically patients.

Symptoms and signs of wound suppuration

The symptoms of wound suppuration are manifested in the fact that an inflammatory process occurs, which is characterized by such signs:

• Vascular expansion of arterioles, capillaries.
• Exquidative education.
• Cellular changes in the properties of phagocytes, leukocytes.
• Metabolic and lymphogenic reaction: tissue necrosis, acidosis, hypoxia.

In abscess embodiment, characteristic symptoms are observed:

1. Pain, which is one of the main symptoms of abscess embodiment. She does not pass for several days;
2. Ripple;
3. Self of cutting;
4. Raising local, and then a total temperature, usually for evening time;
5. Not passing inflammation around the wound, redness and swelling persists;
6. You can observe the pussy inside the wound, blood and tissue of dirty gray;
7. There is a risk of distribution of infection.

Emptying in children

Enthancing in children often arises due to the dismissive relationship of parents to the wounds, which occur in a child literally every day. If the wound does not handle, then it can be bothering. Here the accompanying factors become small forces of the immune system, which is not yet developed in the kids.

Empty of adults

In adults, the suppuration occurs often due to the reluctance to handle wounds, they say, heals itself. If we are talking about a small wound, then she may cope herself. However, with deep wounds, it is still necessary to carry out primary processing and ligation of the wound so as not to allow infections to penetrate inside.

Diagnostics

The diagnosis of suppuration occurs through a general inspection, in which all major signs are visible. Additional procedures are carried out to estimate the wound state:

• The most important procedure for evaluating the state of the wound is a blood test.
• Analysis of the inequalized pus.
• Analysis of wound tissue.

Treatment

Treatment of purulent inflammation of the wound depends on the field of damage and severity. Small wounds can be heated independently at home. How to treat?

• Washed wound with warm water and soap.
• Special healing ointments.
• Antibiotics and antiseptics.
• Making bandages that prevent infection into wound penetration.
• Using compresses that are pulled out from the wound.
• Do not tear the Strap, if it is easily separated from the skin.

When the wound only appeared, emergency help should be provided. This can be done at home, if the wound is shallow. What can you help?

1. Rinse with wedge with warm water, hydrogen peroxide or manganese.
2. To stop the blood, you need to cover the wound of gauze moistened in warm water, and tie tightly.
3. Wound is better to lubricate with boric acid or alcohol, rivocal ointment.
4. With no discarding tumor, use a zinc ointment.
5. From gangrene will help black or rye bread, confused and converted to the cleaner. The mixture is put on the wound with a thick layer.
6. To prevent the bleeding and penetration of infection in a fresh wound, it is better to press for a few minutes with a finger, and then applay a thick layer moistened with a thick layer, moistened in cold water.
7. For rapid blood clotting to the wound applied hot stone or iron.
8. With deep cuts and abundant bleeding on hand or legs, you need to create an unnatural position to reduce the blood flow. Hands or legs raise up.
9. Cleaning and healing the wound can be aloe juice. Copy blood on the wound can be removed using acid cabbage.

What medications need to have in a home first aid kit?

• Iodine is considered the most important medicine that must be in the first-aid kit of any person;
• Petrolatum;
• Turpentine water;
• Zelenka;
• Glycerol;
• Powder or ointment of strepticide, which is imposed on a fresh wound before the suppuration;
• Lanolin ointment.

Hospitalization is produced when a person cannot cope with the spread of suppuration. The infection was transferred to nearby fabrics, redness spreads, the wound does not heal - this is the main signs that you need to cause ambulance. While she arrives, you need to impose on the affected area moistened in warm water.

In the surgical department there is an opening of the wound and the elimination of the pus. The affected area is processed by antiseptics. In the presence of infection, antibiotics and vitamins are given. By the way, there is good use in the menu of patient vegetables and fruits that support and enhance immunity.

Forecast of Life

How much do you live in suppuration? The forecast of life can be comforting, especially if in time to move to the elimination of purulent education. However, the launched form of the disease can lead to the spread, infection of blood and even death. This happens literally in the months.

If at least a minimum amount of white, yellow or green substance appeared in the wound - it is a pus. It can be rare or thick, but equally dangerous for a person. Such a faded wound to cure is much more complicated than ordinary damage, and time for treatment is required much more.

Even with a small scratch, a multitude of bacteria that cause an inflammatory process in damaged tissues fall into the open wound. The duration and intensity of this process directly depends on how quickly and correctly processed and disinfected the wound. The processing of wounds in hollow, dirty hands or using non-sterile materials not only will not help, but even more will aggravate the situation.

In addition to the unqualified or late first aid, the appearance in the wound of the pus leads the microparticles of foreign objects: soil, wood, rust, etc. It is not the immediate cause of suppuration, but it makes it much difficult to treatment if the body of the victim is weakened due to chronic diseases, primarily sugar diabetes, and is not able to independently deal with the spread of infection. In this case, even with small wounds, in order to prevent the dissemination of the inflammatory process, antibiotics have to be applied.

It should be taken into account that the fact that is large in the area, but a shallow wound has more chances to be infected than a small area of \u200b\u200bthe area. Damage to the deep layers of soft tissues, but the latter in the case of the suppuration is much more difficult.

2 Preparation of Tools and Materials

An purulent wound may appear on any plot of our body: hands, legs, torso and even face. Treatment of purulent wounds has a number of features, without complying with very large chances of helping the victim, how much to harm. Before processing a purulent wound, you need to prepare all the necessary tools and materials:

• tweezers;
• scissors;
• several pairs of sterile gloves;
• sterile bandage;
• gauze napkins;
• patch;
• capacity with hydrogen peroxide or furaticiline solution;
• a solution of manganese
• vishnevsky ointment.

The main tasks that must be completed during the processing of the wound is to remove dead tissues and clean it from the accumulated pus. In order for the treated wound to heal faster, it is very important to prevent new malicious bacteria from entering it. Therefore, before proceeding with the processing and removal of pus, you need to take care so that all materials are sterile, and immediately before starting processing, sterilize the tools. The fact that hands should be thoroughly washed using soap, do not even speak.

To unleash purulent wounds, it is necessary in surgical gloves, and, by removing the bandage, it is necessary to change the gloves: there were certainly bacteria on its surface, and they should not get into the open wound.

Starting to unbelieving, it should be borne in mind that the pussy formed in the wound has impregnated the lower layers of the dressing, "sticking" it to the body. Therefore, if necessary, it will definitely be necessary to smoother several times the bandage by furacilin or hydrogen peroxide, otherwise, overlooking the bandage, reserve the wound.

After removing the dressing, you need to moisten in the hydrogen peroxide gauze napkin and carefully, but most carefully wipe it the skin around the wound to protect the damaged place from re-entering the microbes. The wound should also be treated 3-4 times, alternating hydrogen peroxide and 1% a solution of manganese.

Having finished processing, it is necessary to put a gauze tampon on the wound with the ointment of Vishnevsky and gently stabbing it. It is possible instead of Mazi Vishnevsky for processing to use a tetracycline or syntomic acid ointment.

3 Removal of pus from hard-to-reach places

How to treat open purulent wounds, more or less understandable to everyone. But often there are situations where the pussy is recruited in hard-to-reach places: under the skin or under the nail. This happens when in the finger will head the off-therange: damage to the skin in this case is minimal, and purulent bacteria fell into soft tissues.

Most often, such a trouble happens to fingers, and for lovers to walk everywhere barefoot in the risk zone also falls. In the passing inflammatory process and the formation of pm, the pulsating incessant pain in a damaged place is evidenced, sharply amplified when trying to move them. In this case, the only right solution is to try to maximize the ripening of pus to then remove it.

For the faster maturation of pus on hand, you need to fix the injured brush to protect against acute pain in the unexpected movement and prevent the spread of infection. An ointment of Vishnevsky or ichthyol ointment impose on the damaged area of \u200b\u200bthe skin. During the aging of the pus to help the body deal with the infection, it is advisable to apply antibiotics, but it can be done only after consulting a doctor.

You can accelerate the aging of the pus and the infringement means - onion or garlic. Such a means are preparing: in the oven, they bake the bulb of the medium size, cut it and the scene is applied to the patient, fixing the bandage. One such dressing is enough for 3-4 hours, after which the bulb change.

With strong inflammation it is better to use garlic. It is also baked in the oven, then triturated in a mortar and mixed with grated economic soap. From this mixture, the cake is formed, which is applied to a patient and primed by a bandage. You also need to change this compress in 3-4 hours.

If the pussy is recruited under the nail, then such a recipe will help to get rid of it. Chamomile, lilac leaves, sage and plantain are mixed in equal proportions, a little food soda is added to the resulting mixture, after which they are poured with water and put on fire. By bringing water to a boil, removed from the fire and allow you to cool to room temperature. After that, all contents poured into the appropriate vessel and lowered there for 10 minutes a sore hand or leg.

If there is an opportunity to raise nail at least a little, then that the pine needed to come out, you just need to press the patient's pillow, squeezing the pus. You need to push, how much can suffer, then a seafront leaf or a piece of aloe is taken to the sore thumb and leave for 12 hours. Usually, such a procedure has to be repeated 3-4 times, until the pus does not completely come out of the nail.

4 Treatment of folk remedies

It is possible to treat a purulent wound by folk remedies in cases where the lesions are superficial and small. In all other cases, such treatment is allowed as additional to traditional treatment, but not an alternative to him.

If antibiotics are applied during treatment, the treatment of folk remedies is possible only from the knowledge and approval of the attending physician.

It is not worth a risks, because it is not known how antibiotics will behave to apply not tested for compatibility with them.

In addition to the already mentioned onions and garlic, other recipes can be applied. Most often, pushing baths and pulling compresses are used for the faster maturation and exit. For the bath you need to dissolve chopped outhouse soaps in hot water and omitted a damaged body area into the resulting solution for 25-30 minutes. All this time you need to constantly pour boiling water so that water remains hot.

Swinging the wound, you need to applied to it the cashis from the crushed bow and be bandaged for 3-4 hours. The procedure is repeated 3-4 times a day. It effectively helps to mature and exit in pus the treatment of wounds by aloe juice or a row of it. If the aloe was not at hand, it is possible to use freshly broken grape leaves for a grain. Effectively pull the pus and fresh leaves of strawberries, but they need to be changed every 10-15 minutes, so they are used mainly to get rid of small boils when they do not need to binting the wound.

With large purulent wounds, it is necessary to refer to the surgeon to remove the pus. No need to forget that not only soft tissues are damaged in such wounds, but also blood vessels. Trying to independently clear this wound extremely undesirable, because if at least the minimum amount of pus remains in the wound, the process of inflammation can begin with a new force, involving new fabrics. This may cause partial disability, and in some cases lead to blood infection.

- These are damage to the skin and subject to fabrics with the formation of a purulent focus. Pathology is manifested by significant edema, hyperemia surrounding tissues and intense pain syndrome. Pains can be twitching, driving, depriving sleep. In the wound are visible dead fabrics and accumulations of pus. There is general inxication, accompanied by an increase in temperature, chills, headache, weakness and nausea. Treatment complex, includes washing and drainage of the Russian Academy of Sciences (if necessary, an opening of purulent illuminations), therapeutic bandages, antibiotic therapy, disinfecting therapy, immunocorrorizing therapy and stimulation of rehabilitation processes are performed.

MKB-10.

T79.3. Post-traumatic wound infection, not classified in other categories

General

An purulent wound - a defect of the tissues, in which the purulent exudate is contained, and signs of inflammation are determined along the edges. Purulent wounds are the most common complication of pure wounds, both random and surgical. According to various data, despite the strict observance of sterility during operations, the number of suppurations in the postoperative period ranges from 2-3 to 30%. The causative agents of the purulent process in random and surgical wounds are most often the so-called global microbes (staphylococci, streptococci, etc.). The treatment of previously untreated purulent wounds is engaged in surgeons, the treatment of random wounds, arrogant after PHO, is carried out by orthopedic traumatologists. Treatment of jointing surgical wounds is under the jurisdiction of specialists who carried out surgeons: surgeons, traumatologists, vascular surgeons, thoracic surgeons, neurosurgeons, etc.

The reasons

It is best to heal wounds in the head and neck. Somewhat more often, the suppuration occurs when the wounds of the berry region, back, chest and abdomen, even more often - during damage to the upper and lower extremities. Worst of all the wound wounds. Good immunity reduces the likelihood of the development of purulent wounds with a minor bacterial insemination. With a significant insemination and satisfactory state of the immune system, the suppuration proceeds more violently, but the process is usually localized and faster is completed with recovery. Immune disorders cause more sluggish and long healing of purulent wounds. The probability of distribution of infection and the development of complications increases.

Heavy somatic diseases affect the overall condition of the body and, as a result, on the likelihood of suppuration and the rate of healing of wounds. However, sugar diabetes has a particularly strong negative impact due to vascular and exchange disorders. In patients suffering from this disease, purulent wounds may occur even with small injuries and minor bacterial insemination. Such patients have poor healing and a pronounced trend towards the spread of the process. In healthy young people, the wounds, on average, caught up with less often than the elderly, thin - less often than full. The probability of wound suppuration increases in the summer, especially in hot and wet weather, so the planned operations are recommended in the cold season.

Symptoms of purulent Ran.

Local and general symptoms of pathology are distinguished. Local symptoms include tissue defect with the presence of purulent exudate, as well as classic signs of inflammation: pain, local temperature increase, local hyperemia, swelling of surrounding tissues and disruption. Pain with a purulent wound may be a gouring or cutting. With the difficulty of the outflow (due to the formation of the crust, the formation of the beetles, the spread of the purulent process), the accumulation of pus and increase the pressure in the inflamed area of \u200b\u200bpain becomes very intense, twitching and often deprives patients of sleep. The skin around the wound is hot. In the initial stages, during the formation of pus, there is redness of the skin. With a long existence of the Wounds of the Reds, the bugger or bugs and blue skin can be replaced.

In the place of the defeat, two types of edema can be distinguished. In the edges of the wound - warm inflammatory. Coincides with the zone of hyperemia, due to impaired blood flow. Distalier wounds - cold jet. Hyperemia in this zone is absent, and the swelling of soft tissues is caused by a violation of the outflow of lymph due to the compression of lymph nodes in the field of inflammation. The violation of the function of the affected department is associated with swelling and pain, the severity of the violation depends on the size and localization of the purulent wound, as well as on the volume and phase of inflammation.

The main sign of the purulent wound is a pus - liquid containing bacteria, tissue deriters, globulins, albumin, enzymes of leukocyte and microbial origin, fats, cholesterol, DNA admixtures and deceased leukocytes. The color and consistency of the pus depend on the type of pathogen. For staphylococcus, a thick yellow or white puss is characterized, for streptococcus - liquid greenish or yellowish, for intestinal sticks - liquid brown-yellow, for anaerobic microbes - a brown slicer, for a blue-eyed infection - a yellowish, molting blue-green on the bandage (this shade of pus acquires When contacting oxygen in an external environment). The amount of pus may differ significantly. Under the pus can be found areas of necrotic tissue and granulation.

From the wound to the patient's body, toxins come, which causes the emergence of symptoms of general intoxication. It is characterized by an increase in temperature, loss of appetite, sweating, weakness, octvinations, headache. In the blood tests, the acceleration of ESP and leukocytosis with a shift to the left is detected. In the urine analysis detected protein. In severe cases, it is possible to increase the level of urea, creatinine and bilirubin in the blood, anemia, leukopenia, disproteinemia and hypoproteinemia. Clinically, with severe intoxication, there may be a sharp weakness and disturbances of consciousness up to coma.

Depending on the prevailing process, the following stages of the purulent process are distinguished: the formation of purulent focus, purification and regeneration, healing. All purulent wounds are healing by secondary tension.

Complications

With purulent wounds, a number of complications are possible. Lymphangitis (inflammation of the lymphatic vessels located proximal than wounds) is manifested by red stripes directed from the wound to regional lymph nodes. With lymphadenitis (inflammation of lymph nodes), regional lymph nodes increase and become painful. Thrombophlebitis (veins inflammation) is accompanied by the appearance of painful red seewers along the subcutaneous veins. In case of contact propagation, pus may be the development of purulent chambers, periostite, osteomyelitis, purulent arthritis, abscess and phlegmon. The most severe complication of purulent wounds is sepsis.

If the healing does not occur, the purulent wound can go into a chronic form. Foreign specialists consider wounds without a tendency to healing within 4 or more weeks, as chronic. Such wounds include breakdowns, trophic ulcers, random or operational long-lasting wounds.

Diagnostics

Due to the presence of explicit local signs, the diagnosis of purulent wounds does not represent difficulties. To eliminate the involvement of the subjects of anatomical structures, X-ray, MRI or CT of the affected segment can be performed. In general blood test, signs of inflammation are determined. To determine the species and sensitivity of the pathogen, sowing separated on the nutrient media is made.

Treatment of purulent Ran.

Tactics of treatment depends on the phase of the wound process. At the stage of formation of a purulent focus, the main task of surgeons is the purification of wounds, the limitation of inflammation, the fight against pathogenic microorganisms and detoxification (if there is indications). In the second stage, measures to stimulate regeneration are carried out, possibly the overlapping of early secondary seams or the conducting of skin plastics. At the wound closure stage, the epithelium formation is stimulated.

In the presence of a pus, surgical treatment is carried out, which includes dissection of the edges of the wound or skin above the hearth, the removal of the pus, the study of the wound to detect the chapels and, if necessary, is the opening of these undertaking, the removal of necrotic tissues (necrectomy), stopping bleeding, washing and draining wounds. The seams on purulent wounds are not imposed, the imposition of rare seams is allowed only when organizing flow-washing drainage. Along with traditional methods of treatment of purulent wounds, modern techniques are applied: vacuum therapy, local oxyherapy, hyperbaric oxygenation, treatment with the use of a laser, ultrasonic processing, crying effect, treatment of a pulsating jet of antiseptic, introduction to the wound of sorbents, etc.

According to the testimony, detoxification is carried out: forced diuresis, infusion therapy, extracorporeal hemocorrection, etc. All listed activities, both traditional and modern, are carried out against the background of rational antibiotic therapy and immunocorrection. Depending on the severity of the antibiotic process can be administered orally, intramuscularly or intravenously. In the first days, the preparations of a wide range of action are used. After determining the causative agent, the antibiotic is replaced with the sensitivity of microorganisms.

After purification of purulent wounds, measures are taken to restore anatomical relationships and wound closures (early and late secondary seams, skin plastic). The imposition of secondary seams is shown in the absence of pus, necrotic tissues and pronounced inflammation of the surrounding tissues. In this case, it is necessary that the edges of the wound can be compared without tension. In the presence of a defect of the tissues and the inability to compare the edges of the wound, skin plastic is performed using islet and marking methods, plastic on the counter flap, plastic free skin flap or plastic skin flap on a vascular leg.

Smolensk State Medical Academy

MEDICAL FACULTY
Department of Hospital Surgery

Discussed at the Methodological Meeting

(Protocol No. 3)

Methodical development
To a practical session

Subject: "Purulent wounds and Methods of their treatment »

Methodological development
amounted to : Yu.I.Lomachenko

Methodical development

(for students)

to the practical lesson at the Department of Hospital Surgery

Topic: "Purulent wounds and methods of their treatment"

Duration of classes - 5 hours

I.. Work plan

	Et and p s z a n i t and i	Location
	Participation in the Morning Conference of the Doctors of Hospital Surgery Clinic	Conference Hall of the Department
	Organizational events	Academic room
	Check the source knowledge on the topic
	Curacy of patients	Chambers, dressing
	Collapse of the supervised patients
	Discussion theme lesson	educational Chamber
	Control of mastering material
	Test control of knowledge
	Solution of situational tasks
	Determination of the task to the next lesson

II.. Motivation.

Every year more than 12 million patients with bones, wounds, fractures of the bones of the upper and lower extremities are registered in the country, which very often leads to the development of purulent processes. In the overall structure of surgical diseases, surgical infection is observed in 35-45% of patients and proceeds in the form of acute and chronic diseases or the suppuration of post-traumatic and postoperative wounds (A.M. Svetubino, Yul. Amiraslanov, 2003).

The problem of surgical infection remains one of the relevant in modern surgery. This is due to both the high frequency of morbidity and with significant material costs, which translates this problem from the discharge of medical into the category of socio-economic, i.e. state problems. The problem of particular importance has acquired due to the increasing number of man-made and natural disasters, military conflicts and terrorist acts.

The priority issues due to the great socio-economic significance of their decision should include issues of intra-hospital infection, the development of which significantly increases mortality, the time of stay of patients in the hospital and requires significant additional treatment costs. Today, an intra-hospital infection is transferred from 12 to 22% of patients, mortality among which exceeds 25%.

Retrospective analysis of the reasons for the development of severe purulent complications in 15,000 patients translated from various hospitals for treatment in a specialized branch of the purulent surgery of the Institute of Surgery named after A.V. Vishnevsky Ramna (Moscow), identified in many cases the unjustified use of antibiotics (benzylpenicillin, semi-synthetic penicillins, Cephalosporins and aminoglycosides of I-II generations), ineffective currently, and obsolete drugs for local treatment of wounds (hypertensive solution of sodium chloride, ointment of Vishnevsky, ichthyol ointment, streptocidoy, tetracycline, folcyllin, gentamicine ointment compound). As a result, the proper antibacterial effect is not ensured, and during local treatment of wounds, the necessary painkillers, osmotic and anti-ethnic effects is also not achieved. As numerous studies show, the structure of the pathogens of purulent complications of the Russian Academy of Sciences has changed (a significant proportion falls on the anaerobes, mushrooms).

The formation of the stability of microorganisms to the "old" drugs dictates the need to introduce new groups of drugs with a wide range of activity (not only in relation to airbones, but also anaerobov) and their use in strict accordance with the phase of the wound process.

1. III.Objectives of study.

The student must be able to (See paragraph VII):

Evaluate the patient's complaints, detecting data for the complicated course of the wound process (increased pain, the appearance of signs of inflammation, the development of the body's overall response in the form of chills, increase body temperature, etc.);

In detail to collect anamnesis of the disease, paying special attention
on the etiological and pathogenetic moments of the formation of wounds, background conditions (stress, alcoholic, drug, narcotic intoxication, violent actions, etc.);

Identify in history of diseases affecting the reparative process and immune status of the patient;

Estimate the lifestyle and working conditions, establish their possible importance in the development of pathology;

To make an external inspection and interpret the information obtained (the nature of damage to the tissues, the size of the wound, the number of damage, their localization, the presence of inflammatory changes, the risk of bleeding, the state of regional lymph nodes);

Evaluate the general condition of the patient, the degree of intoxication of the body, the nature and volume of the lesion (the depth of the wound, the ratio of the wound channel to the body cavities, the presence of damage to bones and internal organs, the presence of inflammatory changes in the depths of the wound);

Interpret the results of bacteriological research (detailing the microbial scenery of the wound, estimate its microbial dissemination, microflora sensitivity to antibiotics);

Evaluate the dynamics of the flow of the wound process;

Carry out the fence of the material from the wound for the microbiological research;

Independently tie the patients with purulent wounds, to produce necrectomy;

Appoint antibacterial, immunocorrorizing, disinfect treatment, physiotherapeutic treatment methods.

The student must know:

n wound process is a complex complex of local and general reactions of the body developing in response to tissue damage and the introduction of infection;

n For the development of infection in the wound, the so-called "critical" level of bacterial dissemination is needed, corresponding to the concentration of microorganisms - 10 5 -10 6 microbial bodies per grams of tissue (under certain conditions "Critical" level may be lower);

n Surgical infection has features of clinical manifestations depending on the pathogen or association of microorganisms in the wound, which determines the strictly individual approach in the treatment against the background of the recognition of the uniform principles for the treatment of purulent wounds;

n anaerobic infection is the hardest type of surgical infection;

n treatment of purulent wounds provides for a multidirectional treatment of therapeutic effects, which is carried out in accordance with the phase of the wound process;

n Principles of active surgical treatment of purulent wounds include a set of measures aimed at the maximum reduction of the course of the flow of all phases of the wound process in order to limit it to the uncomplicated flow;

n Microbiological research of the content from the wound is mandatory and provides for direct microscopy of native material, bakposposev and determination of microflora sensitivity to antibiotics;

n The results of microbiological research make it possible to correlate the treatment of purulent wound;

n Contemporary preparations for local treatment of wounds have a combined therapeutic effect (antimicrobial, painkillers, osmotic, anti-ethro, invalid, necrolitic), and the use of wound coatings, due to their structure, contribute to the least traumatic and painless dressing;

n any change of dressings should occur in sterile conditions;

n Dressing physician must take special measures for own protection against infection - Latex gloves are needed, eye protection, as well as mouth mask and nose;

n Gently imposed bandage, being a visible completion of the processing of the wound, creates a patient a feeling that it is qualitatively treated and serviced.

IV-A.. Basic knowledge.

1. Pathophysiology of the wound process.

1. Teaching about inflammation.

Lectures on pathological physiology.

1. Morphology of the wound process.

Lectures on pathological anatomy.

1. Microbiology wounds.

Lectures on microbiology.

1. Aseptics and antiseptics.

Lectures on general surgery.

1. Types of healing wounds.

Lectures on general surgery.

6. Primary and secondary surgical processing of the Russian Academy of Sciences.

Lectures for general surgery, traumatology.

1. Methods of drainage wounds.

Lectures on general surgery.

1. Desmurgy.

Lectures on general surgery.

1. Surgical infection.

Lectures on general surgery.

IV-B. Literature on a new topic.

Main:

1. Surgical diseases / textbook MW. - Publishing house "Medicine", 2002.
2. Surgery / Ed. Yu.M.lopukhina, V.S. Savelyva (RGMU). Textbook UMO MW. - Publishing house "Goeotarmed", 1997.
3. Surgical diseases / ed. Yu.L.Shevchenchenko. Textbook MH. - 2 volumes. - Publishing house "Medicine", 2001.
4. Total surgery / ed. V.K. Gostisheva (MMA). Textbook UMO MW. -
   Publishing house "Medicine", 1997 (2000).
5. Total surgery / ed. Zubareva, Lykina, Epifanova. Textbook MH. - Publishing house "Speclit", 1999.
6. Course of lectures on general surgery / ed. V.I. Malyachuk (RUDN). Benefit UMO Mo. - Publishing house Rudn, 1999.
7. Guide to practical exercises in general surgery / Ed. V.K. Gostisheva (MMA). - Publishing house "Medicine", 1987.
8. Military Field Surgery / Yu.G.Shaposhnikov, V.I. Maslov. Textbook MH. - Publishing house "Medicine", 1995.
9. Lectures at the rate of hospital surgery.

Additional:

1. Wounds and wound infection / ed. M.I.Kuzina, B.M. Dresuten. - M.: Medicine, 1990.
2. Sveubin A.M., Amiraslanov Yu.A. Purulent surgery: the current state of the problem // 50 lectures on surgery. - Ed. Academician V.S. Sweelleva. - M.: Media Medica, 2003. - P. 335-344.
3. Methodical development of the department on the topic "Purulent wounds and methods of their treatment".
   1. V.Questions for self-preparation:

a) on basic knowledge;

1. Signs of inflammation.
2. Pathogenesis of the wound process.
3. Histogenesis of the wound process.
4. Microbiological characteristics of the Russian Academy of Sciences.
5. Types of healing wounds.
6. Primary and secondary surgical processing of wounds.
7. Types of surgical infection.
8. Methods of drainage wounds.
9. The principles of imposition of dressings.

b) on the new topic:

1. The concept of wound, classification of wounds.
2. Phase of the flow of the wound process.
3. Characteristics of purulent wound.
4. General principles of treatment of wounds.
5. Treatment of RAS, depending on the stage of the wound process.
6. Principles of active surgical treatment of purulent wounds.
7. The imposition of seams on a purulent wound.
8. Rules for the collection of material from the wound for microbiological research.
9. "Physical impact methods" on the wound process.

10. Anaerobic infection.

11. Practical campaign change.

1. Vi.Content classes.
2. Wounds - Mechanical damage to the tissue with a violation of their integrity.

RAS Classification.

1. According to the view of a wound agent

Bullet

Splitter

From exposure to an explosive wave

From secondary fragl

From cold weapons

From random causes (injury)

Surgical

2. By the nature of tissue damage

Pottle

Swimmed

Bruised

Rezana

Chilled

Kolotany

Sawn

Bite

Scalp

3. in length and attitude
To body cavities

Tangent

Through

Impermeal

Cavity penetrating

1. By number of damage
   At one wounded

Single

Multiple

Combined

Combined

1. By type of damaged tissues -
   With damage:

Soft fabrics

Bones and joints

Large arteries and veins

Internal organs

1. According to anatomical sign

Limbs

1. By microbial seeding

Bacterial-polluted

Aseptic

Fresh wounds until the full coverage of their granulations are capable of sucking toxins, bacteria, tissue decay products. Wounds covered with granulations practically do not have a suction ability.

Theoretical studies show that the most important factor in the development of infection is the structure and functional state of the wound tissues. The presence in the wound of closed cavities, foreign bodies, deadly, devoid of blood supply to fabrics contributes to the development of the wound infection. The development of pathogenic microflora in the wound and absorption of the decay products of non-viable tissues contribute to the stimulation of blood cells and connective tissue, lead to the release of cytokines and other inflammation mediators with a wide range of biological action (systemic changes in metabolism, immunity, vascular wall states, hematopoease, regulatory systems).

A.M. Sveubin and Yu.L. Amiraslanov (2003) indicate that there are no qualitative differences during the wound process, depending on etiological factors. Based on this, the concept of the unity of the pathogenesis of the wound process was developed, regardless of the origin, size, localization and nature of the wound.

2. Phases of the flow of the wound process.

The course of the wound process can be divided into three main phases:

I - inflammation phase

Period of vascular changes;

Period of purification from necrotic tissues;

II - the phase of regeneration and the development of granulation tissue;

III - the reorganization phase of the scar and epithelialization.

3. Characteristics of purulent wound.

It is proved that for the development of infection in the wound, it is necessary to have 10 5 -10 6 microbial bodies per 1 gram of tissue. This is the so-called "critical" level of bacterial dissemination. But the "critical" level can be low. So, for the development of infection in the presence of blood, foreign bodies, ligatures in the wound increases 10 4 (10,000) microbial bodies; When tie ligatures in the zone of ligatural ischemia of tissues - enough 10 3 (1000) microbial bodies per 1 gram of tissue. The combination of tissue damage with shock reduces the microbial threshold value to 10 3 (1000) in 1 g of tissue, and with radiation lesions - to 10 2 (100).

The wound exudate from the purulent wound is rich in protein, consists of cell elements, mainly neutrophilic leukocytes, a large amount of bacteria, residues of destroyed cells and a mixture of transudate with fibrin.

A large number of microorganisms, pronounced degeneration of neutrophilic leukocytes, the presence of plasma cells, a decrease in the number of single-core leukocytes and the absence of phagocytosis in the PNU indicate an unfavorable flow of wound healing.

The development of an inflammatory reaction depends on the degree of resistance to the tissues, the reactivity of the body and the virulence of infection.

I. Pathogens high level priority:

Pyrogen streptococcus;

Golden Staphylococcus.

II. Pathogens medium level priority:

Enterobacteria;

Pseudomonades and other non-enzyme gram-negative bacteria;

Klostridia;

Bacteroids and other anaerobes;

Streptococci (other species).

III. Pathogens low level priority:

Bacillus Anthracis;

Mycobacterium tuberculosis, Mulcerans et al.;

Pasteurella Multocida.

The pathogens of viral infections in contrast to mushrooms and bacteria are very rarely produced by purulent exudate.

4. General principles of treatment of wounds.

n Surgical methods: Surgical processing of wounds, disclosure of increments, neccectomy, performing decompression cuts, seamping, skin plastic (artificial leather, split displaced flap, stepping stem in Filatovo, Autodermoplasty Complete flap, free autodermoplasty thin-layer flap for tiresha).

n Local treatment of wounds using various types of drainage, dressings and drugs.

n Physiotherapeutic treatment: Laser therapy, magnetotherapy, UHF, UFO, controlled abacterial environment, etc.

n General treatment: antibacterial therapy; correction of violations of functions of organs and systems, metabolic disorders; detoxification therapy;
an increase in non-specific resistance of the body and immuno-corrective therapy; Stimulation of reparative processes.

5. Therapeutic program, depending on the stage of the wound process.

Phase inflammation (exudation) It is characterized by an abundant wound-separated, expressed perifocal inflammatory reaction of soft tissues and bacterial disseminance of the wound, therefore the healing drugs must have high osmotic activity in order to provide an intense excessive outflow from the depth of the wound into the bandage, should have an antibacterial effect on infection pathogens, cause rejection and melting of necrotic fabrics. For this purpose, antiseptic dressings are used (moisture-drying with chemotherapypapers and antiseptics, water-soluble ointments), during vascular changes - drainage and hydrophilic bandages (hypertonic, absorbent and adsorbing), during the period of purification from necrotic tissues - necrolitic means (proteolytic enzymes, hydrogel dressings) ; For stimulation of rejection of necrotic tissues - ointment on a water-soluble basis, which have high osmotic activity (levomexol, levosin, diaoxycol, etc.).

Given the high cost of sorbing wound coatings (hydrophilic bandages), children's diapers or hygienic gaskets can be used in everyday medical practice.

In the period of purification of wounds from necrotic tissues, ointments are used for enzymatic cleansing of wounds, a decent representative of which is the Iruxol ointment containing enzymes from Clostridium Hystolyticum. and an antibiotic of a wide range of "Chloramphenic" (Levomycetin).

In the presence of peripocal dermatitis around the wound, it is advisable to impose a zincoxide ointment (lassary paste).

To all patients for 10-14 days recommended a semi-sending mode. The main components of therapy are antibiotics of a wide range of fluoroquinolone (Maksquin, Tarivide, Cyphrobia, Digger, etc.) or Cephalosporin (Dardum, Duacef, Cefzol, Mandol, Cefhamesin, etc.) of a series introduced by parenterally (less preferably - orally). Considering the frequent associations of pathogenic microorganisms with bacteroid and fungal flora, antibacterial therapy in some cases it is advisable to increase, including antifungal drugs (dieflucan, nitrogen, manungal, etc.) and nitroimidazole derivatives (flagil, metranoidazole, trichopol, tinidazole, etc.).

The active inflammation and pronounced pain syndrome determine the feasibility of systemic use of non-specific anti-inflammatory agents, such as diclofenac (voltaren, orthofen), ketoprofen, erovel, etc.

Systemic and local hemorological disorders should be corrected by infusion of antiagregants (Reopolyglyukin in combination with pentoxyfall).

Sensitization of the body as a result of massive resorption of antigenic activity structures (fragments of proteins of microorganisms, soft tissue degradation products, etc.), the synthesis of a large number of inflammation mediators (histamine, serotonin, etc.) are absolute testimony to conduct desessitis therapy (DIMEDROL, Suprastin, diazoline , Claritin, ketotifen, etc.).

The main drugs for the treatment of wounds in the 1st phase of the wound process:

Ointment on a water-soluble basis: levomecol, Levosin, Dioxiscol, Dioxidic 5% ointment, ointment 10% Mafenide acetate, Sulfamecol, Furagel, Ointment 0.5% County, iodopourium 1% ointment, iodmetryxylelen, streptonitol, nitacid, mirograms ointment 0.5%, ointment Lavendula, ointment Lipakantine, methyluracyl ointment with Miramistin.

Sorbents and hydrogels: gelevin, intelligence, immature, carbonet, Multidex. GEL, Acryderm., Carrasin. Hydrogel., Hydrosorb., Elasto.— GEL, Purilon.

Enzymes: himopcin, Callagenase Crab, Caripzim, Territine (Proteasa C), Protegentin (Sipralin, Lizoamidase), Enzyme-containing dressings (teraulgim, immemgent), trypsin + urea, trypsin + chlorhexidine, tradeheism, Sipralin, Lizosorb, Collabin.

Antiseptic solutions: solution of iodopíron, 02% Furagin solution of potassium, suliodropyrone, 15% Dimphosphon solution, 30% PEG-400, 0.01% Mozymistine solution.

Aerosols: nitazol, Dioxisol, Gentazol.

Wound bandages: "Tenderur", "Sorbalgon".

Phase Reparation (regeneration, formation and ripening of granulation tissue) is characterized by purification of a wound surface, the appearance of granulations, anemia of perifocal inflammation and a decrease in exudation. The main task of treatment becomes stimulation of growth and ripening of the connective tissue, along with the suppression of the remaining microbes remaining in a small number or their hospital strains. Such stimulants of regeneration, as vinyline, vulnuzane, polymerol, as well as antiseptic bandages with fat-soluble ointments and hydrophilic bandages (polyurethane, foaming, hydrogel) are widely used.

Systemic therapy is corrected by imposing antioxidants (aevit, tocopherol, etc.) and antihypoxants - deproteinated blood derivatives of calves (Actovegin, SolkoSeril). To accelerate the growth of the connective tissue, it is advisable to assign Curizin. It is an association of hyaluronic acid and zinc. Hyaluronic acid increases the activity of phagocytosis in granulocytes, activates fibroblasts and endotheliocytes, contributes to their migration and proliferation, increases the proliferative activity of the epithelium cells, creating favorable conditions for remodeling the connective tissue matrix. Zinc, possessing an antimicrobial effect, activates a number of enzymes involved in regeneration.

The main drugs for the treatment of wounds in the 2nd phase of the wound process:

Output on an adjustable osmotic basis: methyldioxylin, sulfargin, 2% gel fusidine, lincomycinic 2% ointment.

Polymer coatings: combutek-2, Digispon, Algipov, Algimaf, Algikov, Algico-ACF, Colokhit, Colokhet-F, Cisorb, Gidroshrb.

Hydrocolloids: galagran, Galacton, Hydrocol.

Oils: wick oil (Meliacyl), sea buckthorn butter, rosehip oil.

Aerosols: dioxiplast, Dioxisol.

In the phase of epithelizationcharacterized by the beginning of the epithelialization and ripening of the connective tissue scar (formation and reorganization of the scar), among the topics of local exposure optimal is the use of polymer wound coatings, which significantly accelerate the epithelization process, as well as silicone semi-permeable bandage.

Polymeric wound coatings can be conditionally (one bandage can be multipurpose) to divide into absorbent, protective, insulating, atraumatic and biodegraders. The sorption capacity of the coating (degree and rate of binding of the wound exudate) depends on the size of the pores of the coatings.

6. Principles of active surgical treatment of purulent wounds (A.M. Svetukhin, Yu.L. L. Amraslanov, 2003).

? Wide dissection and disclosure of purulent focus. Already at this stage of treatment (purulent surgery and traumatology), elements of plastic surgery should be contained. When performing cuts of tissues and choosing access to a purulent heartbell, it is necessary to foresee the possibility of forming future bloodstanding flaps from the neighboring parts of the body.

Excision of all non-visual and dubious, impregnated soft tissues within healthy tissues (in one or more stages). Removing all bone sequesters and necrotized bone fragments. The performance of the edge, end or segmental resection of the affected bone area is also within the limits of healthy tissues.

Removal of submersible metal locks, which do not perform their purpose, and vascular prostheses.

? Application of additional physical methods of wound processing.

? Use during surgical processing of elements of plastic or reconstructive operations In order to restore or closing important anatomical entities.

? Outdoor osteosynthesis of long bones(According to indications), it provides the possibility of dynamic distraction-compression manipulations.

1. 7. The imposition of seams on a purulent wound.

Primary-delayed seam- Apply 5-6 days after surgical treatment, before the granulation wound appears (more precisely during the first 5-6 days).

Early secondary seam - The wound with moving edges covered with granulations coated to the development of scar tissue in it. Early secondary seams are imposed within the 2nd week after surgical treatment.

Late secondary seam - impose on a granulating wound, in which scar tissue has already developed. The closure of the wound is possible in these cases only after the pre-excision of the scar tissue. The operation is performed on the 3-4 week after injury and later.

An indispensable condition for the imposition of seams on a purulent wound is to ensure sufficient outflow of the wound separated, which is achieved by active drainage, and rational antibacterial therapy aimed at the destruction of the microflora remaining in the wound.

8. Rules for the fence of material from the wound for microbiological research.

After careful processing of the operating field, the surgeon determines the place where the pus accumulates is accumulated, necrotic tissues are located, gas (attitation) is released or other signs of infection are observed. Particles of affected fabrics intended for laboratory tests are placed in sterile gauze and then in sterile capacity. Pump or other exudate must be carefully assembled and placed in a sterile test tube. If possible, you should not use a cotton swab. Exudate must be selected with a sterile syringe with a needle. If a cotton swab is used, you should select the exudate as much as possible and place the entire tampon in the container to send to the laboratory.

9. "Physical impact methods" on the wound process.

one). Methods based on the use of mechanical oscillations:

• Processing of a pulsating fluid stream,
• Handling low-frequency ultrasound.

2). Methods based on the change in the external pressure of the air environment:

• Vacuum processing and vacuum therapy,
• controlled abacterial environment
• Hyperbaric oxygenation.

3). Methods based on temperature change:

Cryovozoa.

four). Methods based on the use of electric current:

• Low voltage constant currents (electrophoresis, electrostimulation),
• Modulated currents (electrostimulation).

five). Methods based on the use of the magnetic field:

• Low frequency magnetotherapy,
• Impact of a permanent magnetic field.

6). The use of electromagnetic oscillations of the optical range:

Laser radiation:

a) high-energy,

b) low intensity,

Ultraviolet radiation.

7). Combined methods of exposure.

The use of plasma flows. The effect of high-temperature plasma flows on the wound surface allows bloodlessly and accurately perform adequate surgical treatment of the wound. The advantage of the method, in addition, is aseptic and atraumatic dissection of fabrics, which is important in a surgical infection.

Ozone therapy.Local ozone therapy in the form of ozonized solutions with a concentration of ozone 15 μg / ml leads to a decrease in the microbial semination of purulent focus, an increase in microflora sensitivity to antibacterial drugs, stimulates reparative processes in the wound. Systemic ozone therapy has an anti-inflammatory, detoxification, antihypoxic effect and normalizes metabolic processes in the body.

Use of nitrogen oxide.The discovery of endogenous nitrogen oxide (NO), which is produced by cells using NO-synthase and performs the functions of a universal messenger regulator, was a major event of biology and medicine. The experiment establishes the role of endogenous NO in the oxygenation of tissues and its deficiency in purulent wounds. Combined use of surgical treatment of purulent-necrotic lesions of soft tissues and a complex of physical exposure factors (oms, ozone and no? Therapies) contributes to the acceleration of the purification of the wound from microflora and necrotic masses, the weakening and disappearance of inflammatory manifestations and microcirculatory disorders, activating the macrophage reaction and the proliferation of fibroblasts, The growth of granulation tissue and edge epithelialization.

10. Anaerobic infection.

Anaeroba make up the absolute majority of human microflora. They live: in the oral cavity (in the gantry pockets of the flora, it consists of 99% from anaerobov), in the stomach (with hypo-and ancidal states, the microbial landscape of the stomach is approaching intestinal), in the small intestine (anaerobes are contained in smaller quantities than aerobes), In the colon (the main habitat of the anaerobov). According to etiology, the anaerobes are divided into clostridial (forming disputes), noncommunicated (non-controversy), bacterioid, peptacekococcal, fuzobacteral.

One of the general symptoms of anaerobic infection is the absence of microflora in the crops with standard methods for their release (without the use of anaerostates). Since the microbiological identification of anaerobic microflora requires special equipment and a long time, important acquire express Diagnostics Methodsallowing you to confirm the diagnosis within an hour:

Microscopy of native smear, painted in gram;

The urgent biopsy of the affected fabrics (characterized by a pronounced focal swelling of tissues, destruction of the stroma of the dermis, focal necrosis of the basal layer of epidermis, subcutaneous fiber, fascia, miosis and the destruction of muscle fibers, perivascular hemorrhages, etc.)

Gas-liquid chromatography (volatile fatty acids are determined - acetic, propionic, oil, isomaslyanny, valerian, isovalarian, phenol, phenol, and its derivatives produced in the growth environment or in pathologically modified tissue anaerobes in the process of metabolism).

According to gas-liquid chromatography and mass spectrometry, not only caogenic anaerobes can be identified, but also a clostridial microflora (gas goggle pathogens), which is characteristic of which is the presence of 10? Oxycoslot (10-oxycyterain).

Regardless of the localization of the focus, the anaerobic process has a number of common and characteristic features:

Unpleasant shuttle smell of exudate.

Sniffle character defeat.

Dirty meager exudate.

Gas formation (gas bubbles from wounds, attitudes of subcutaneous fiber, gas above the level of pus in the abscess cavity).

The proximity of the wound to the places of natural habitat of the anaerobov.

From the anaerobic processes that occur in the surgical clinic, it is necessary to note a special form - the epiphacial cleansing phlegmon of the anterior abdominal wall, which develops as a complication after operations (more often after appendectomy with gangrenous-perforative appendicitis).

Anaerobic clostridial infection - acute infectious disease caused by the penetration into the wound and reproduction in it sporing anaerobes of the genus Klostridy ( Clostridium Perfringens., Clostridium Oedematiens., Clostridium septicum, Clostridium Hystolyticum.). The disease is more often evolving in the first 3 days after injury, less often - after a few hours or a week, it is observed in gunshot wounds, in surgical departments - after amputation of the lower limbs for atherosclerotic gangrenes and even after appendectomy, etc. The likelihood of an anaerobic infection increases dramatically in the presence of foreign bodies, bone fractures and damaged large arteries, because there are many styled, necrotic tissues in such wounds, deeply aerated pockets.

Anaerobic clostridiums are distinguished by a number of strongest exotoxins (neuro-, necros, enterotoxin, hemolysis) and enzymes (hyaluronidase, neuraminidase, fibrinolysin, collagenase and elastasis, lecithinase, etc.), which cause tissue edema, sharp permeability of vessels and hemolysis, necrosis and melting. Tissues, severe inxication of the body with damage to the internal organs.

Patients primarily feel painful pain in the wound, quickly increases the swelling of the tissues around it. On the skin, the foci of crimson-blue color, propagating often at a significant distance from the wound in the proximal direction, and bubbles filled with muddy hemorrhagic contents. When palpation of tissues around the wound, crepitiation is determined.

Simultaneously with local manifestations, deep general disorders are marked: weakness, depression (less often - excitation and euphoria), an increase in body temperature to febrile numbers, sharply pronounced tachycardia and breathing, pallor or the jaundice of the skin, progressive anemia and intoxication, while lesion of the liver - the scleps .

When radiography of the affected limb, gas is found in tissues. The diagnosis of anaerobic infection is based mainly on clinical data. Therapeutic tactics are also built on the clinical picture of the disease.

In anaerobic infection, necrotic changes prevail in tissues and virtually no inflammatory and proliferative.

Anaerobic nonlocostrial infection (Rifle infection) is caused by anaerobes that do not form a dispute: B. Coli, B. Putrificus, Proteus, Bacteroids ( Bacteroides Fragilis, Bacteroides Melanogenicus.), fuzobacteria ( Fusobacterium.) And others, often in combination with staphylococci and streptococci.

By local tissue changes and the general reaction of the body, a putrid infection is close to anaerobic clostridial infection. It is characteristic of the predominance of necrosis processes over inflammation processes.

The clinically local process in soft tissues usually proceeds in the form of noncompretal phlegmon, destroying subcutaneous fatty tissue (cellulite), fascia (fascia), muscles (myiositis).

The overall condition of the patient is accompanied by pronounced toxhemia, quickly leads to a bacterial-toxic shock with frequent fatal outcome.

Sniffling infection is more often observed with severe infected ribbon-bruised wounds or with open fractures with extensive destruction of soft tissues and pollution of the wound.

Surgical intervention In an anaerobic clostridial and non-sliprial infection, it consists in broad dissection and complete excision of dead tissues, above all muscles. Wound after treatment is abundantly washed with solutions of oxidizers (hydrogen peroxide, a solution of potassium mangartee-cancer, ozonized solutions, sodium hypochlorite), produce additional "lamp" cuts in the area of \u200b\u200bpathological changes outside the wound, the edges of the "lampasny" cuts over the boundaries of the focus of inflammation, additionally excised necrosis The wounds are not sewn and not tampony, ensure that their aeration subsequently. After operation, use hyperbaric oxygenation.

Antibiotic therapy of anaerobic infections.

For empirical use in anaerobic infections is recommended Clindamycin (DELOCHED C). But considering that most of such infections are mixed, therapy is usually carried out by several drugs, for example: clindamycin with aminoglycoside. Many anaerobov strains suppresses rifampin, Lincomycin (Linkzin). On gram-positive and gram-negative anaerobic cocci acts well bezylpenicillin. However, it is often intolerance. His substitute is erythromycinbut he acts badly on Bacteroides Fragilis and fuzobacteria. Effective with regard to anaerobic cocci and sticks is an antibiotic fortum (combined with aminoglycosides), cefobid (cephalosporin).

A special place among drugs used to influence the anaerobic microflora occupies metronidazole. - Metabolic poison for many strict anaerobes. The gram-positive forms of bacteria metronidazole acts much weaker than the gram-negative, so its use in these cases is not justified. Close by action metronidazole Found others imidazole – niridazole.(more than metronidazole), ornidazole., tinidazole..

1% solution also applies dioxidine (up to 120 ml in / in adults)
as well as karbenicillin (12-16 g / day in / in adults).

11. Practical campaign change.

Any dressing change should occur in sterile conditions. You must always use the so-called "non-touch technique" (non-contact technique). The wound or bandage is not allowed to touch without gloves. A dressing doctor must take special measures for its own protection against infection: Latex gloves are needed, eye protection, as well as mask on mouth and nose. The patient should be conveniently located, and the wound area should be well available. A good source of lighting is required.

If the bandage is not removed, it can not be broken. The bandage is wetted by asepta solution (hydrogen peroxide, ringer solution) until it breaks.

With infected wounds, the wound region is purified in the direction of the outside inside, if necessary, disinfectants are used. Necrosis in the wound can be removed by mechanical path with the help of a scalpel, scissors or curetles (preference should be given to the scalpel, the removal of scissors or curette entails the risk of crushing tissues and repeated trauma).

It is fairly effective for cleaning wagging a aseptic solution of a syringe with a slight pressure of the piston. With deep wounds, the washing is carried out using a coordinated groove probe or through a short catheter. The liquid should be collected using a napkin in the tray.

Granulation tissue sensitively reacts to external influences and damaging factors. Well contributes to the formation of granulation tissue continuous maintenance of wounds in a wet state and protection against injuries when changing bandages. Excessive granulation is usually removed using an ignition pencil (LAPIS).

If the edges of the wounds show a tendency to epithelization and wrapping inside, then the surgical treatment of the edges of the wound is shown.

A well-developed epithelium does not require other departure other than maintaining in a wet state and protection against injury when changing the dressings.

The surgeon must ensure that the selected wound bandage is optimally suitable for the wound surface - the wound secret can be absorbed only under the condition of good contact between the bandage and the wound. Unreliable fixed dressings when moving can cause irritation of the wound and slow down its healing.

VII.Survey diagram of the patient.

When identifying complaints in the patient, identify the data of the complicated flow of the wound process (signs of inflammation, an increase in body temperature, etc.).

Anamnesis of the disease Collect detail, paying special attention
on the etiological and pathogenetic moments of the formation of wounds, background conditions (stress, alcoholic, drug, drugs, violent actions, etc.).

In a remote history, reveal the suffering diseases or the existing suffering affecting the reparative process and immune status, to establish possible importance in the development of the pathology of the lifestyle and the working conditions of the patient.

To make an external inspection and interpret the information obtained (the nature of damage to the tissues, the size of the wound, the number of damage, their localization, the presence of inflammatory changes, the danger of the development of bleeding, state of regional lymph nodes).

Assess the general condition of the patient, the degree of intoxication of the body, to clarify the nature and volume of the lesion (the depth of the wound, the ratio of the wound channel to the body cavities, the presence of damage to bones and internal organs, the presence of inflammatory changes in the depths of the wound).

Conduct the material from the wound for the microbiological research or interpret the existing results (microbial scenery of the wound, the degree of microbial semination, microflora sensitivity to antibiotics).

Packing the patient, if necessary, produce necritomy, washing the wound, drainage, physiotherapeutic treatment.

When re-dressing, estimate the flow rate of the wound process.

Assign antibacterial, immunocorrorizing, disinfect treatment, physiotherapeutic treatment methods.

VIII.Situational tasks.

1. Patient 46 years old received a impenetrating knife wound of the chest from unknown. In early terms, he applied for medical care, the primary surgical treatment of the wound was performed, with its subsequent drainage and imposition of seams, a tetanus was carried out by antitoxic anti-resistant serum and tetanus anatoxin. When examination through
5 days marked hyperemia of skin, tissue edema, local temperature rise, painful infiltrate in the wound area. Drainage has a separated purulent nature.

Specify the phase of the wound process, define the medical tactics.

Relief standard: In the clinical example, the phase of purulent inflammation in the embedded and drained wound after the surgical treatment of impenetrable chest injuries is described. It should be removed the seams, to carry out a revision of the wound, examine it on purulent stakes, select the sterile syringe with a needle or cotton swab material from the wound on a microbiological study (direct microscopy of native material, bakpospose, and determining the sensitivity of microflora to antibiotics), perform a rehabilitation of a 3% hydrogen peroxide solution , set drainage and impose an antiseptic bandage with antibacterial water-soluble ointment (for example: with "Levosin" or "Levomecole" ointment). Assign a re-dressing one after a day.

2. Patient 33 years has received a random ribbon-bruised wound of the left leg with damage to the skin, subcutaneous fiber and muscles. In the surgical department, the primary surgical treatment of the wound was carried out, with the imposition of rare seams, the prevention of the tetanus with antitoxic anti-tetanus serum and tetanus anatoxin was carried out. Due to the development of purulent inflammation at the stages of healing, the seam wound were removed. At the time of inspection, the wound defect has improper dimensions, performed by granulations, in the region of the wound areas there are areas of the tissue necrosis.

Specify the type of wound healing, the stage of the wound process, the volume of assistance on the dressing and the methodology for its implementation.

Response Standard: The wound heals the secondary tension, the exudation step (rejection of necrotic tissues) is completed, there are signs of the reparation stage (the formation of granulation tissue). It is necessary to suspend the wound with antiseptics, necrectomy, impose a bandage that has antimicrobial, anesthetic, osmotic, anti-ethricular, wound-healing, necrolitical effect (for example: hydrophilic wound coating or antibacterial water-soluble ointment "Levosin", "Levomekol"). In sterile conditions, remove the bandage; Clean the wound in the direction outside inside, applying one of the antiseptic solutions; It is possible to remove necrosis with a scalpel, rinse the wound from the syringe with a slight pressure of the piston, apply and firmly fix the dressing.

3. After appendectomy, about acute gangrenous appendicitis, the patient began to make complaints about painting pain in the wound. In viewing, a pronounced swelling of tissues around the wound was revealed, on the skin - the foci of the crimson-blue color, propagating from the wound in different directions, is greater - on the side wall of the abdomen, as well as separate bubbles filled with muddy hemorrhagic content. When palpation of tissues around the wound, crepitiation is determined. The patient is somewhat euphoric, there is a febrile temperature, tachycardia.

Your estimated diagnosis? How can you refine the diagnosis? What will be the priority

Reference standard: The postoperative period was complicated by the development of anaerobic infection in the operating wound after appendectomy. The diagnosis is set according to characteristic clinical signs, a microscopy of a native smear, painted in gram, an urgent biopsy of the affected tissues, gas-liquid chromatography and mass spectrometry can be clarified. Should be removed the seams; dilute the edges of the wound; provide wide access by additional dissection and complete excision of dead tissues; Conduct additional "lamp" cuts in the zone of pathological changes in the abdominal wall outside the wound; After excision of necrosis, rinse the wounds with solutions of oxidizers (hydrogen peroxide, potassium permanitated solution, ozonized solutions, sodium hypochlorite); wounds do not sew and not to tampony; Provide aeration of wounds. Must be corrected antibacterial and disinfecting therapy, if possible, hyperbaric oxygenation is prescribed.

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