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Primary surgical debridement —surgical intervention aimed at removing non-viable tissues, preventing complications and creating favorable conditions for wound healing.
Prevention of the development of complications is achieved by a sufficiently wide dissection of the inlet and outlet, removal of the contents of the wound canal and obviously 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 full drainage of the wound. The creation of favorable conditions for wound healing is reduced to the creation of conditions for the regression of pathological phenomena in the zone of secondary necrosis by influencing the general and local links of the wound process.
Primary surgical debridement, if indicated, is performed in all cases, regardless of the timing of the arrival of the wounded. In military field conditions, the primary surgical treatment of a wound may have to be postponed if there are no urgent and urgent indications. In such situations, to prevent the development of purulent-infectious complications, paravulnar and parenteral (preferably intravenous) antibiotics are used.
Depending on the timing, the 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.
The initial surgical debridement of the wound should ideally be comprehensive and immediate... This principle can be optimally implemented in the provision of 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 the primary surgical treatment of gunshot fractures of bones is performed only in cases of damage to the great vessels, infection of wounds with OS, RV, soil contamination and extensive damage to soft fabrics.
Primary surgical treatment of a gunshot wound as a surgical intervention includes six stages.
The first stage is the incision of the wound(Fig. 1) - is made with a scalpel through the inlet (outlet) 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 the topographic and anatomical principles (along the vessels, nerves, Langer's skin lines, etc.). The skin, subcutaneous tissue and fascia are dissected layer-by-layer. The fascia is dissected on the extremities (Fig. 2) and outside the operating wound throughout the entire segment in the proximal and the rest of the Z-shaped directions for decompression of the fascial cases (wide fasciotomy). Focusing on the direction of the wound channel, 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. Technique of primary surgical treatment of a gunshot wound: wound dissection
Rice. 2. The technique of primary surgical treatment of a gunshot wound: wide fasciotomy
The second stage is the removal of foreign bodies: wounding shells 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 canal. To do this, effectively washing the wound with antiseptic solutions with a pulsating stream. Individual foreign bodies are located deep in the tissues and to remove them, special approaches and methods are required, the use of which is possible only at the stage of providing specialized care.
The third stage is excision of non-viable tissues(Fig. 3), that is, excision of the zone of primary necrosis and the formed areas of secondary necrosis (where the tissues have questionable viability). The criteria for the preserved vitality of tissues are: bright color, good bleeding, for muscles - contractility in response to irritation with tweezers.
Rice. 3. The technique of primary surgical treatment of a gunshot wound: excision of non-viable tissue
Excision of non-viable tissues is carried out in layers, taking into account the different reactions of tissues to damage. The skin is the most resistant to damage, therefore it is excised with a scalpel sparingly. Cutting out large round holes ("nickels") around the entrance (exit) hole of the wound channel should be avoided. The subcutaneous tissue is less resistant to damage and therefore is excised with scissors until there are clear signs of vitality. The fascia is poorly supplied with blood, but it is resistant to damage, so only those parts of it that have lost contact with the underlying tissues are excised. Muscles are the tissue where the wound process is fully developed and in which secondary necrosis progresses or regresses. Scissors are methodically removed explicitly non-viable mice: brown, do not shrink, do not bleed when the surface layers are removed... Upon reaching the zone of viable muscles, hemostasis is carried out in parallel with the excision.
It should be remembered that the zone of viable mice is mosaic in nature. Muscle areas where viable tissues clearly predominate, although small hemorrhages occur, foci of reduced vitality are not removed. These tissues constitute the zone of "molecular shock" and the formation of secondary necrosis. It is on the nature of the operation and subsequent treatment that the course of the wound process in this zone depends: the 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 epap - wound drainage(Fig. 4) - creating optimal conditions for the outflow of wound discharge. Drainage of the wound is carried out by installing tubes into the wound formed after surgical treatment and removing them through counter-openings in the places that are lowest in relation to the damaged area. With a complex wound channel, each pocket must be drained with a separate tube.
Rice. 4. Technique of primary surgical treatment of a gunshot wound: wound drainage
There are three options for draining a gunshot wound. The simplest is passive drainage through a thick, single-lumen tube (s). More difficult - passive drainage through a double-lumen tube: through a small channel, continuous drip irrigation of the tube is carried out, which ensures its constant functioning. Both of these methods are used in the treatment of non-extinguished wounds and are the method of choice during the stages of providing qualified surgical care.
The third method is supply and flow drainage- used for a tightly sutured wound, that is, at the stage of providing specialized surgical care. The essence of the method consists in installing an inlet PVC tube of a smaller diameter (5-6 mm) and an outlet (one or more) silicone or PVC 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 tidal drainage, when the outlet tube is connected to the aspirator and a weak negative pressure of 30-50 cm of water column is recognized in it.
The sixth stage is wound closure. Taking into account the characteristics of the gunshot wound (the presence of a zone of secondary necrosis) the primary suture after the initial surgical treatment of the gunshot wound is not applied.
The exception is superficial wounds of the scalp, wounds of the scrotum, and the penis. Breast wounds with open pneumothorax are subject to suturing, when the defect of the chest wall is small, there are few damaged tissues and there are conditions for closure of the defect without tension after full primary surgical debridement of the wound; otherwise, preference should be given to ointment dressings. During laparotomy, from the side of the abdominal cavity after processing the edges, the peritoneum is tightly sutured in the area of the inlet and outlet of the wound canal, and the wounds of the inlet and outlet themselves 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 main vessels along the length, to large foreign bodies, etc.
After the initial surgical treatment, one or several large gaping wounds form, which must be filled with materials that have a drainage function in addition to the installed drain pipes. The easiest way is to introduce gauze napkins moistened with antiseptic solutions or water-soluble ointments in the form of "wicks" into the wound. A more effective method is filling the wound with carbon sorbents, which accelerate 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 up 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", that is, tubes with a diameter of 10-12 mm cut lengthwise into two halves.
In the absence of infectious complications after 2 ~ 3 days, the wound is sutured delayed primary suture.
After primary surgical treatment, as after any surgical intervention, a protective and adaptive inflammatory reaction develops in the wound, manifested by plethora, edema, exudation. However, since tissues with reduced viability can be left in the 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 wound circumference (the ingredients are calculated 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 IU kontrikala) a broad-spectrum antibiotic - aminoglycoside, cephalosporin, or their combination in a double single dose. Indications for repeated blockades are determined by the severity of the inflammatory process.
Re-debridement of the wound (according to primary indications) performed when identifying on the dressing to progress secondary necrosis in the wound (in the absence of signs of wound infection). The purpose of the operation is to remove the necrosis of the diatostika and eliminate the cause of its development. If the main blood flow is disturbed, large muscle masses, muscle groups are necrotic - in cases of necractomy, they are extensive, but measures are 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 incision and excision of the wound, failure to perform fasciotomy, poor hemostasis and drainage of the wound, the imposition of a primary suture, etc.).
E.K. Gumanenko
Military field surgery
The basis of wound treatment is their surgical treatment. Depending on the timing of the surgical treatment, it 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 is necessary (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 (a surgeon and an assistant) in the operation.
The main tasks of PHO are:
Dissection of the wound and opening of all its blind cavities with the creation of the possibility of visual revision of all sections of the wound and good access to them, as well as providing full aeration;
Removal of all non-viable tissues, free-lying bone fragments and foreign bodies, as well as intermuscular, interstitial and subfascial hematomas;
Complete hemostasis;
Creation of optimal conditions for drainage of all sections of the wound channel.
The operation of PHO wounds is divided into 3 sequentially performed stages: dissection of tissues, their excision and reconstruction.
1.Tissue dissection... As a rule, the incision 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 by one incision. Begin by dissecting the skin and subcutaneous tissue so that all the blind pockets of the wound can be well examined. The fascia is dissected more often in a Z-shape. Such a dissection of the fascia allows not only a good revision of the underlying sections, but also to provide the necessary decompression of the muscles in order to prevent their compression by increasing edema. Bleeding arising along the incisions is stopped by the imposition of hemostatic clamps. In the depths of the wound, all the blind pockets are opened. The wound is washed abundantly with antiseptic solutions, after which it is evacuated (the contents of the wound cavity are removed with an electric suction device).
P. Excision of tissues. The skin is usually excised sparingly, until the characteristic whitish color appears on the incision and capillary bleeding. An 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 cut wounds with smooth, unsealed 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 adipose tissue is excised widely, not only within the visible contamination, but also including areas of hemorrhage and detachment. This is due to the fact that the subcutaneous adipose tissue is the least resistant to hypoxia, and in case of damage it is highly prone to necrotization.
Loose, contaminated areas of the fascia are also subject to economical excision.
Surgical treatment of muscles is one of the crucial stages of the operation.
First, blood clots, 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. Excision of the muscles is necessary within the limits of healthy tissues, until the appearance of fibrillar twitching, the appearance of their normal color and shine, and capillary bleeding. An unviable muscle loses its characteristic luster, its color changes to dark brown; it does not bleed, it does not shrink in response to irritation. In most cases, especially in bruised and gunshot wounds, there is muscle imbibition with blood over a considerable extent. Careful hemostasis is performed as needed.
The edges of the injured tendons are sparingly excised within the limits of visible contamination and marginal fiber separation.
III. Wound reconstruction... In case of damage to the great vessels, a vascular suture is performed or shunting is performed.
Damaged nerve trunks, in the absence of a defect, are sutured end-to-end for the perineurium.
Damaged tendons, especially in the distal parts of the forearm and lower leg, should be sutured, since otherwise their ends will subsequently be far removed from each other, and it will no longer be possible to restore them. In the presence of 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, with PCO crushed 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 applied to them in order to cover bone fragments, exposed vessels and nerves.
The operation is completed by infiltration of tissues around the treated wound with antibiotic solutions and the installation of drains.
Drainage is a must when performing the initial surgical debridement of any wound.
For drainage, use single and double-lumen tubes with a diameter of 5 to 10 mm with multiple perforations at the end. The drains are led out through separately made counter-openings. Through the drains, solutions of antibiotics or (which is preferable) antiseptics begin to be injected into the wound.
Abscess. Concept. Clinic. FAP paramedic tactics for purulent-inflammatory diseases.
Abscess- This is a limited form of purulent inflammation, which is characterized by the formation of a cavity filled with pus in tissues and various organs.
Abscesses on etiology can be non-specific and anaerobic.
The causative agent of the infection is streptococcus, staphylococcus, purulent bacillus, etc. The causes of formation are, as complications of the above purulent inflammatory diseases, and various wounds, microtrauma, foreign bodies. Particularly noteworthy are the abscesses that occur after injections carried out without observing the rules of asepsis and antiseptics, or with the introduction of 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 abscesses secrete local symptoms of inflammation, which are more pronounced when the abscess is localized in superficial tissues.
The main feature an abscess is a symptom of fluctuation. When the abscess is located deep in the underlying tissues, these symptoms do not always appear, the signs of intoxication are more pronounced: remitting T, with a range of 1.5-2 C, chills, pain; with careful palpation, a limited compaction in the tissues, soreness, edema is determined.
For an accurate diagnosis use a diagnostic puncture.
Treatment: an abscess is an absolute indication for surgery: open the abscess, cleanse - rinse, drain and carry out further dressings depending on the stage of the inflammatory process. Rational antibiotic therapy, detoxification, symptomatic treatment are shown.
FAP paramedic tactics: diagnose the process. Cold at the site of inflammation. Symptomatic therapy, for example, the introduction of a lytic mixture in / m (metamizole 50% -2 ml. + Diphenhydramine-1 ml.).
Arrange for qualified transportation of the patient to the surgical department.
PHO wounds, goals, stages, terms.
PHO (primary surgical treatment) is a surgical intervention performed in order to prevent wound infection and create conditions for the most perfect wound healing in the shortest possible time.
PHO stages:
Ø examination of the wound;
Ø toilet wounds;
Ø dissection of the wound;
Ø excision of the wound;
Ø hemostasis (stopping bleeding);
Ø closure or drainage of the wound
The timing of the PHO 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 revealed and a plan of action is drawn up.
Wound toilet is performed in the usual way, as an independent measure, carried out with minor superficial cut 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.
Dissection of the wound is indicated if it is impossible to conduct a thorough revision. 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 tissues) and partial (excision of non-viable or crushed tissue). Contraindications to excision are wounds of the hand, face and cut wounds.
Then a thorough hemostasis is performed with suturing. According to indications, the wound is drained.
There are wounds that are not subject to PHO: multiple, non-penetrating, finely splintered, uncomplicated punctate, through bullet wounds.
47. Principles and rules of primary surgical treatment of wounds. Types of seams.
Primary surgical debridement (PCO) of wounds - the main component of surgical treatment for them. Its purpose 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 in carrying out the PHO of the wound is to remove non-viable tissues and the microflora in them from the wound. PHO, depending on the type and nature of the wound, consists either in complete excision of the wound, or in its dissection with excision.
Complete excision is possible provided that no more than 24 hours have passed since the moment of injury and if the wound has a simple configuration with a small area of damage. In this case, the PHO of the wound consists in 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 food and contaminated soft tissue in the wound;
4) removal of free-lying foreign bodies and bone fragments devoid of the periosteum;
5) drainage of the wound;
6) immobilization of the injured limb.
PHO wounds begin with processing the operating field and delimiting it with sterile linen. If the wound is on the scalp, then pre-shave the hair 4-5 cm in circumference. For small wounds, local anesthesia is usually used.
The treatment begins with the fact that in one corner of the wound with tweezers or Kocher clips they grasp the skin, slightly raise it and from here produce a gradual excision of the skin along the entire circumference of the wound. After excision of the crushed edges of the skin and subcutaneous tissue, the wound is expanded with hooks, the cavity is examined and the non-viable areas of the aponeurosis are removed. The existing pockets in the soft tissues are opened with additional incisions. During the initial surgical treatment of the wound, it is necessary to periodically change scalpels, tweezers and scissors during the operation. PHO is produced 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. In case of PCO of open fractures of bones, it is necessary to remove with bone forceps the sharp ends of fragments protruding into the wound, which can cause secondary injury to soft tissues, blood vessels and nerves.
The final stage of PHO wounds, depending on the time from the moment of injury and the nature of the wound, may be the suture of its edges or its drainage. Sutures restore anatomical tissue continuity, prevent secondary infection and create conditions for healing by primary intention.
Along with the primary distinguish secondary surgical wound treatment, which is undertaken for secondary indications due to complications and insufficient radicalization of primary treatment in order to treat wound infection.
There are the following types of seams.
Primary seam - applied to the wound within 24 hours after injury. The primary suture ends surgical interventions during aseptic operations, in some cases and after opening abscesses, phlegmon (purulent wounds), if good conditions for wound drainage are provided in the postoperative period (the use of tubular drains). If more than 24 hours have elapsed after the injury, then after the PST, the wounds are not applied, the wound is drained (with tampons with 10% sodium chloride solution, Levomi-Kol ointment, etc., and after 4-7 days before the appearance of granulations, provided Delayed sutures can be applied in the form of provisional sutures - immediately after PST - and tie them after 3-5 days if there are no signs of wound infection.
Secondary seam impose on a granulating wound, provided that the danger of wound suppuration has passed. There is an early secondary suture, which is applied to the granulating PSU.
Late secondary suture impose in terms of more than 15 days from the date of operation. The convergence of the edges, walls and bottom of the wound in such cases is not always possible, in addition, the growth of scar tissue along the edges of the wound prevents healing after they are juxtaposed. Therefore, before the imposition of late secondary sutures, excision and mobilization of the wound edges are performed and hypergranulation is removed.
Primary surgical treatment should not be carried out when:
1) small superficial wounds and abrasions;
2) small puncture wounds, including blind wounds, without damage to the nerves;
3) with multiple blind wounds, when the tissues contain a large number of small metal fragments (shot, fragments of grenades);
4) through bullet wounds with smooth inlet and outlet openings in the absence of significant damage to tissues, blood vessels and nerves.
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