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Primary surgical treatment of the wound —surgical intervention aimed at removing non-viable tissue, preventing complications and creating favorable conditions for wound healing.
Prevention of the development of complications is achieved by a sufficiently wide dissection of the entrance and exit openings, removal of the contents of the wound channel and clearly non-viable tissues that make up the zone of primary necrosis, as well as tissues with questionable viability from the zone of secondary necrosis, good hemostasis, and complete drainage of the wound. Creating favorable conditions for wound healing comes down to creating conditions for the regression of pathological phenomena in the area of secondary necrosis by influencing the general and local links of the wound process.
Primary surgical treatment of the wound, if indicated, is performed in all cases, regardless of the timing of the wounded person’s arrival. In military field conditions, primary surgical treatment of a wound may be forced to be postponed if there are no urgent and urgent indications. In such situations, paravulnar and parenteral (preferably intravenous) administration of antibiotics is used to prevent the development of purulent-infectious complications.
Depending on the timing of the procedure, primary surgical treatment is called early, if performed on the first day after injury; delayed, if performed during the second day; late, if performed on the third day or later.
Primary surgical treatment of the wound should ideally be comprehensive and immediate. This principle can be optimally implemented when providing early specialized surgical care. Therefore, at the stages of evacuation, where qualified surgical care is provided, primary surgical treatment of wounds of the skull and brain is not performed, and primary surgical treatment of gunshot bone fractures is performed only in cases of damage to the great vessels, infection of wounds with agents, radioactive substances, soil contamination and in case of extensive injuries to soft tissues. fabrics.
Primary surgical treatment of a gunshot wound as a surgical intervention includes six stages.
The first stage is wound dissection(Fig. 1) - made with a scalpel through the entrance (exit) opening of the wound canal in the form of a linear incision of sufficient length for subsequent work on the damaged area. The direction of the incision corresponds to topographic and anatomical principles (along the vessels, nerves, Langer's skin lines, etc.). The skin, subcutaneous tissue and fascia are dissected in layers. On the extremities, the fascia is dissected (Fig. 2) and outside the surgical wound throughout the entire segment in the proximal and remaining directions in a Z-shape for decompression of the fascial sheaths (wide fasciotomy). Focusing on the direction of the wound channel, the muscles are dissected along the course of their fibers. In cases where the extent of muscle damage exceeds the length of the skin incision, the latter expands to the boundaries of the damaged muscle tissue.
Rice. 1. Method of primary surgical treatment of a gunshot wound: wound dissection
Rice. 2. Method of primary surgical treatment of a gunshot wound: wide fasciotomy
The second stage is the removal of foreign bodies: wounding projectiles or their elements, secondary fragments, scraps of clothing, loose bone fragments, as well as blood clots, pieces of dead tissue that make up the contents of the wound channel. To do this, it is effective to wash the wound with antiseptic solutions using a pulsating stream. Some foreign bodies are located deep in the tissues and their removal requires special accesses and methods, the use of which is possible only at the stage of providing specialized care.
The third stage is excision of non-viable tissue(Fig. 3), that is, excision of the zone of primary necrosis and formed areas of secondary necrosis (where tissues have questionable viability). The criteria for preserved tissue viability are: bright color, good bleeding, for muscles - contractility in response to irritation with tweezers.
Rice. 3. Method of primary surgical treatment of a gunshot wound: excision of non-viable tissue
Excision of non-viable tissue is carried out layer by layer, taking into account the different tissue reactions to damage. The skin is the most resistant to damage, so it is excised sparingly with a scalpel. You should avoid cutting out large round holes (“nickels”) around the inlet (outlet) of the wound canal. Subcutaneous tissue is less resistant to damage and therefore is excised with scissors until there are clear signs of viability. The fascia has a poor blood supply, but is resistant to damage, so only those parts of it that have lost connection with the underlying tissues are excised. Muscles are the tissue where the wound process fully develops and in which secondary necrosis progresses or regresses. Scissors are methodically removed clearly non-viable mice: brown in color, do not contract, do not bleed when the surface layers are removed. Upon reaching the zone of viable muscles, hemostasis is carried out parallel to the excision.
It should be remembered that the zone of viable mice has a mosaic character. Areas of muscle where viable tissue clearly predominates, although minor hemorrhages and areas of reduced viability occur, are not removed. These tissues constitute the zone of “molecular shock” and the formation of secondary necrosis. It is the nature of the operation and subsequent treatment that determines the course of the wound process in this area: progression or regression of secondary necrosis.
The fourth stage is surgery on damaged organs and tissues: skull and brain, spine and spinal cord, on the organs of the chest and abdomen, on the bones and pelvic organs, on the great vessels, bones, peripheral nerves, tendons, etc.
Fifth stage - wound drainage(Fig. 4) - creating optimal conditions for the outflow of wound fluid. Drainage of the wound is carried out by installing tubes into the wound formed after surgical treatment and removing them through counter-apertures in the places lowest located in relation to the damaged area. With a complex wound channel, each pocket must be drained with a separate tube.
Rice. 4. Method of primary surgical treatment of a gunshot wound: drainage of the wound
There are three options for draining a gunshot wound. The simplest is passive drainage through a thick single-lumen tube(s). More complex - passive drainage through a double-lumen tube: The small channel carries out constant drip irrigation of the tube, which ensures its constant functioning. Both of these methods are used in the treatment of unsutured wounds and are the method of choice at the stages of providing qualified surgical care.
The third method is inflow and outflow drainage- used for tightly sutured wounds, that is, at the stage of providing specialized surgical care. The essence of the method is to install an input polyvinyl chloride tube of a smaller diameter (5-6 mm) and an output (one or several) silicone or polyvinyl chloride tube of a larger diameter (10 mm) into the wound. In the wound, the tubes are installed in such a way that the liquid washes the wound cavity through the inlet tube and flows freely through the outlet tube. The best effect is achieved with active influent drainage, when the outlet tube is connected to the aspirator and a weak negative pressure of 30-50 cm of water column is felt in it.
The sixth stage is wound closure. Taking into account the characteristics of a gunshot wound (presence of a zone of secondary necrosis) The primary suture is not applied after initial surgical treatment of a gunshot wound.
The exceptions are superficial wounds of the scalp, wounds of the scrotum, and penis. Chest wounds with open pneumothorax are subject to suturing, when the chest wall defect is small, there is little damaged tissue and there are conditions for closure of the defect without tension after complete primary surgical treatment of the wound; otherwise, preference should be given to ointment dressings. During laparotomy, from the abdominal cavity, after treating the edges, the peritoneum in the area of the entrance and exit openings of the wound canal is tightly sutured, but the wounds themselves at the entrance and exit openings are not sutured. The primary suture is also applied to surgical wounds located outside the wound canal and formed after additional access to the wound canal - laparotomy, thoracotomy, cystostomy of access to the great vessels along the length, to large foreign bodies, etc.
After initial surgical treatment, one or several large gaping wounds are formed, which must be filled with materials that have a drainage function in addition to the installed drainage pipes. The simplest way is to insert gauze pads moistened with antiseptic solutions or water-soluble ointments in the form of “wicks” into the wound. A more effective method is to fill the wound with carbon sorbents, which speed up the process of wound cleansing (used at the stage of providing specialized medical care). Since any dressing in a wound loses its hygroscopicity and dries out after 6-8 hours, and dressings at such intervals are impossible, graduates must be installed in the wound along with napkins - polyvinyl chloride or silicone “half-tubes”, i.e. tubes with a diameter of 10-12 mm , cut lengthwise into two halves.
In the absence of infectious complications, the wound is sutured after 2~3 days delayed primary suture.
After primary surgical treatment, as after any surgical intervention, a protective-adaptive inflammatory reaction develops in the wound, manifested by plethora, swelling, and exudation. However, since tissues with reduced viability can be left in a gunshot wound, inflammatory edema, disrupting blood circulation in the altered tissues, contributes to the progression of secondary necrosis. In such conditions the effect on the wound process is to suppress the inflammatory response.
For this purpose, immediately after the initial surgical treatment of the wound and during the first dressing, an anti-inflammatory blockade is performed (according to I. I. Deryabin - A. S. Rozhkov) by introducing a solution of the following composition into the circumference of the wound (calculation of ingredients is carried out per 100 ml of novocaine solution, and the total volume of the solution is determined by the size and nature of the wound) 0.25% novocaine solution 100 ml glucocorticoids (90 mg prednisolone), protease inhibitors (130,000 ED contrical) is a broad-spectrum antibiotic - an aminoglycoside, a cephalosporin, or a combination of both in a double single dose. Indications for repeated blockades are determined by the severity of the inflammatory process.
Repeated surgical treatment of the wound (according to primary indications) performed when the dressing detects progression of secondary necrosis in the wound (in the absence of signs of wound infection). The purpose of the operation is to remove necrosis of the diatomite and eliminate the cause of its development. If the main blood flow is disrupted, large muscle masses become necrotic, muscle groups - in cases of necrectomy are extensive, but measures must be taken to restore or improve the main blood flow. The reason for the development of secondary necrosis is often errors in the technique of the previous intervention (inadequate dissection and excision of the wound, failure to perform fasciotomy, poor hemostasis and drainage of the wound, application of a primary suture, etc.).
Gumanenko E.K.
Military field surgery
The basis of wound treatment is surgical debridement. Depending on the timing, surgical treatment can be early (in the first 24 hours after injury), delayed (24-48 hours) and late (over 48 hours).
Depending on the indications, a distinction is made between primary (performed for direct and immediate consequences of damage) and secondary surgical treatment (performed for complications, usually infectious, which are an indirect consequence of damage).
Primary surgical treatment (PST).
For its proper implementation, complete anesthesia (regional anesthesia or anesthesia; only when treating small superficial wounds is it permissible to use local anesthesia) and the participation of at least two doctors (surgeon and assistant) in the operation.
The main tasks of the PHO are:
Dissection of the wound and opening of all its blind cavities, creating the possibility of visual inspection of all parts of the wound and good access to them, as well as ensuring complete aeration;
Removal of all non-viable tissues, loose bone fragments and foreign bodies, as well as intermuscular, interstitial and subfascial hematomas;
Performing complete hemostasis;
Creation of optimal conditions for drainage of all sections of the wound channel.
The operation of PSO of wounds is divided into 3 sequential stages: tissue dissection, excision and reconstruction.
1.Tissue dissection. As a rule, dissection is made through the wound wall.
The incision is made along the muscle fibers, taking into account the topography of the neurovascular formations. If there are several wounds located close to each other on a segment, they can be connected with one incision. They begin by dissecting the skin and subcutaneous tissue so that all blind pockets of the wound can be clearly examined. The fascia is often cut in a Z-shape. This dissection of the fascia allows not only a good inspection of the underlying sections, but also to ensure the necessary decompression of the muscles in order to prevent their compression by increasing edema. Bleeding that occurs along the incisions is stopped by applying hemostatic clamps. In the depths of the wound, all blind pockets are opened. The wound is washed abundantly with antiseptic solutions, after which it is vacuumed (the contents of the wound cavity are removed with an electric suction).
P. Excision of tissue. The skin is usually excised sparingly until the characteristic whitish color appears on the incision and capillary bleeding. The exception is the area of the face and the palmar surface of the hand, when only obviously non-viable areas of the skin are excised. When treating uncontaminated incised wounds with smooth, unbruised edges, in some cases it is permissible to refuse excision of the skin if there is no doubt about the viability of its edges.
Subcutaneous fatty tissue is excised widely, not only within the limits of visible contamination, but also including areas of hemorrhage and detachment. This is due to the fact that subcutaneous fatty tissue is the least resistant to hypoxia, and when damaged, it is very prone to necrosis.
Disintegrated, contaminated areas of the fascia are also subject to economical excision.
Surgical treatment of muscles is one of the critical stages of the operation.
First, blood clots and small foreign bodies located on the surface and in the thickness of the muscles are removed. Then the wound is additionally washed with antiseptic solutions. Muscles must be excised within healthy tissues until fibrillary twitching appears, their normal color and shine appear, and capillary bleeding occurs. A non-viable muscle loses its characteristic shine, its color changes to dark brown; it does not bleed and does not contract in response to irritation. In most cases, especially in bruised and gunshot wounds, there is a significant imbibition of the muscles with blood. Careful hemostasis is performed as necessary.
The edges of damaged tendons are excised sparingly within the limits of visible contamination and marginal fiber disintegration.
III. Wound reconstruction. If the great vessels are damaged, a vascular suture is performed or bypass surgery is performed.
Damaged nerve trunks, in the absence of a defect, are sutured “end to end” by the perineurium.
Damaged tendons, especially in the distal parts of the forearm and lower leg, should be sutured, otherwise their ends will subsequently be pulled far apart and cannot be restored. If there are defects, the central ends of the tendons can be sewn into the remaining tendons of other muscles.
The muscles are sutured, restoring their anatomical integrity. However, during PST of crush and gunshot wounds, when there is no absolute confidence in the usefulness of the treatment performed, and the viability of the muscles is questionable, only rare sutures are placed on them in order to cover bone fragments, exposed vessels and nerves.
The operation is completed by infiltrating the tissue around the treated wound with antibiotic solutions and installing drains.
Drainage is mandatory when performing primary surgical treatment of any wound.
For drainage, single- and double-lumen tubes with a diameter of 5 to 10 mm with multiple perforations at the end are used. Drains are removed through separately made counter-apertures. Solutions of antibiotics or (preferably) antiseptics are injected into the wound through the drainages.
Abscess. Concept. Clinic. Tactics of a medical assistant at a medical assistant for purulent-inflammatory diseases.
Abscess is a limited form of purulent inflammation, which is characterized by the formation of a cavity filled with pus in the tissues and various organs.
Abscesses by etiology may be nonspecific and anaerobic.
The causative agent of infection is streptococcus, staphylococcus, purulent bacillus, etc. The causes of formation are both complications of the above-mentioned purulent inflammatory diseases, as well as various wounds, microtraumas, and foreign bodies. Particularly noteworthy are abscesses that occur after injections performed without observing the rules of asepsis and antisepsis, or when administering medicinal substances without taking into account anatomical indications, for example, the introduction of metamizole into the subcutaneous tissue, and not intramuscularly, these abscesses - aseptic.
In the clinic abscess produces local symptoms of inflammation, which are more pronounced when the abscess is localized in superficial tissues.
The main feature abscess is a symptom of fluctuation. When the abscess is located deep in the underlying tissues, these symptoms do not always appear; signs of intoxication are more pronounced: remitting T, with a range of 1.5-2 C, chills, pain; Upon careful palpation, limited compaction in the tissues, pain, and swelling are determined.
To make an accurate diagnosis use a diagnostic puncture.
Treatment: an abscess is an absolute indication for surgery: open the abscess, clean - rinse, drain and carry out further dressings depending on the stage of the inflammatory process. Rational antibiotic therapy, detoxification, and symptomatic treatment are indicated.
Tactics of a FAP paramedic: diagnose the process. Cold to the site of inflammation. Symptomatic therapy, for example, administration of a lytic mixture intramuscularly (metamizole 50% -2 ml. + diphenhydramine - 1 ml.).
Organize qualified transportation of the patient to the surgical department.
PCP of wounds, goals, stages, deadlines.
PSO (primary surgical treatment) is a surgical intervention performed to prevent wound infection and create conditions for the most perfect wound healing in the shortest possible time.
Stages of PHO:
Ø examination of the wound;
Ø toilet wound;
Ø wound incision;
Ø excision of the wound;
Ø hemostasis (stopping bleeding);
Ø closing or draining the wound
The timing of the emergency treatment is 6-8 hours from the moment of injury, but no later than 12 hours.
When examining the wound, the degree of damage, the type of wound, its contamination are identified and an action plan is drawn up.
Wound cleaning is done in the usual way, as an independent measure for minor superficial incised wounds, especially on the face and fingers. The skin around the wound must be cleaned of contamination and treated with iodonate or 5% iodine solution. An aseptic bandage is applied to the wound.
Wound dissection is indicated if a thorough inspection is not possible. It is performed under local or general anesthesia depending on the severity of the injury. The wound is washed with a solution of hydrogen peroxide.
Excision of the wound can be complete (within healthy tissue) or partial (excision of non-viable or crushed tissue). Contraindications to excision are wounds of the hand, face and incised wounds.
Then careful hemostasis is performed with suturing. According to indications, the wound is drained.
There are wounds that are not subject to PSO: multiple, non-penetrating finely splintered, uncomplicated punctate wounds, and through bullet wounds.
47. Principles and rules of primary surgical treatment of wounds. Types of seams.
Primary surgical treatment (PST) of wounds - the main component of surgical treatment for them. Its goal is to create conditions for rapid wound healing and prevent the development of wound infection.
Distinguish early PHO, carried out in the first 24 hours after injury, delayed - during the second day and late - after 48 hours.
The task when performing PCS of a wound is to remove non-viable tissues and the microflora found in them from the wound. PSO, depending on the type and nature of the wound, consists of either complete excision of the wound or its dissection with excision.
Complete excision is possible provided that no more than 24 hours have passed since the injury and if the wound has a simple configuration with a small area of damage. In this case, PST of the wound consists of excision of the edges, walls and bottom of the wound within healthy tissues, with the restoration of anatomical relationships.
Dissection with excision is performed for wounds of complex configuration with a large area of damage. In these cases Primary wound treatment consists of the following points;
1) wide dissection of the wound;
2) excision of deprived and contaminated soft tissues in the wound;
4) removal of loose foreign bodies and bone fragments devoid of periosteum;
5) wound drainage;
6) immobilization of the injured limb.
PSO of wounds begins with treatment of the surgical field and delimiting it with sterile linen. If the wound is on the scalp of the body, then first shave the hair 4-5 cm in circumference. For small wounds, local anesthesia is usually used.
Treatment begins by grasping the skin in one corner of the wound with tweezers or Kocher clamps, lifting it slightly, and from there gradually excising the skin along the entire circumference of the wound. After excision of the crushed edges of the skin and subcutaneous tissue, the wound is widened with hooks, its cavity is examined and non-viable areas of the aponeurosis are removed. Existing pockets in the soft tissues are opened with additional incisions. During primary surgical treatment of a wound, it is necessary to periodically change scalpels, tweezers and scissors during the operation. PSO is performed in the following order: first, the damaged edges of the wound are excised, then its walls, and finally, the bottom of the wound. If there are small bone fragments in the wound, it is necessary to remove those that have lost contact with the periosteum. During PST of open bone fractures, the sharp ends of fragments protruding into the wound, which can cause secondary injury to soft tissues, blood vessels and nerves, should be removed with bone forceps.
The final stage of PST of wounds, depending on the time from the moment of injury and the nature of the wound, may be suturing its edges or draining it. Sutures restore anatomical continuity of tissue, prevent secondary infection and create conditions for healing by primary intention.
Along with the primary, there are secondary surgical wound treatment, which is undertaken for secondary indications due to complications and insufficient radicality of primary treatment for the purpose of treating wound infection.
The following types of seams are distinguished.
Primary seam - applied to the wound within 24 hours after injury. The primary suture is used to complete surgical interventions during aseptic operations, in some cases also after opening abscesses, phlegmons (purulent wounds), if good conditions for drainage of the wound are provided in the postoperative period (use of tubular drainages). If more than 24 hours have passed since the injury, then after PSO of the wound, no stitches are applied, the wound is drained (with tampons with a 10% sodium chloride solution, Levomi-kol ointment, etc., and after 4-7 days until granulation appears, provided that the wound has not become suppurated, primary delayed sutures are applied.Delayed sutures can be applied as provisional sutures - immediately after PSO - and tied after 3-5 days, if there are no signs of wound infection.
Secondary seam applied to a granulating wound, provided that the danger of wound suppuration has passed. There is an early secondary suture, which is applied to granulating PCS.
Late secondary suture applied more than 15 days from the date of surgery. Bringing the edges, walls and bottom of the wound closer together in such cases is not always possible; in addition, the growth of scar tissue along the edges of the wound prevents healing after their comparison. Therefore, before applying late secondary sutures, the edges of the wound are excised and mobilized and hypergranulations are removed.
Primary surgical treatment should not be performed if:
1) minor superficial wounds and abrasions;
2) small puncture wounds, including blind ones, without damage to the nerves;
3) with multiple blind wounds, when the tissues contain a large number of small metal fragments (shot, grenade fragments);
4) through bullet wounds with smooth entry and exit holes in the absence of significant damage to tissues, blood vessels and nerves.
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