Wounds (definition, classification, clinic). Basic principles of treating open wounds at home Stages of wound healing surgery

The outpatient surgery department of GMS Hospital has everything necessary for high-quality treatment of surgical wounds - competent specialists, modern instruments, sterile and safe conditions in the operating room and dressing room.

Learn more about debridement

Damage to the skin is an entry point for infection and the development of complications. Any open wound requires proper treatment, and large, deep injuries require surgical intervention and suturing. Depending on the time of injury, there are several types of primary surgical treatment (PST):

• early – carried out in the first 24 hours after injury;
• delayed – performed 1-2 days after injury;
• late – carried out 2 days after receiving the injury.

Each type of PSS has nuances of implementation, but the main stages are no different. Surgical treatment of wounds in Moscow is performed in the outpatient surgery department of GMS Hospital. You can make an appointment with a doctor around the clock, by phone or online.

Why choose us

Surgical treatment of wound surfaces at the GMS clinic is performed by experienced doctors with many years of experience. By turning to us for medical help, each patient receives:

• qualified assistance without queues or delays;
• integrated approach to treatment;
• the use of the latest microsurgical techniques aimed at speedy healing of damage (in some cases, wound cleansing is carried out using a vacuum aspiration system);

• modern safe medicines, sutures and consumables;
• treatment of wounds and traumatic injuries of various types;
• if necessary, hospitalization in a hospital (for serious injuries);
• painless intervention.

The use of modern surgical instruments, antiseptics, sutures and consumables, the extensive experience of GMS Hospital surgeons - all this allows for surgical treatment of the wound surface with the highest possible quality and significantly speeds up the healing process.

Cost of surgical treatment of wounds

The prices indicated in the price list may differ from the actual prices. Please check the current cost by calling +7 495 104 8605 (24 hours a day) or at the GMS Hospital clinic at the address: Moscow, st. Kalanchevskaya, 45.

The price list is not a public offer. Services are provided only on the basis of a concluded contract.

Our clinic accepts MasterCard, VISA, Maestro, MIR plastic cards for payment.

Make an appointment We will be happy to answer
for any questions Coordinator Oksana

What indications to use

The main indication for surgical treatment is deep damage to the skin and tissue. That is, a simple abrasion or scratch does not require PSO, but for bitten, deep puncture, cut, bruised or crushed wounds, the participation of a surgeon is required.

Surgical treatment is needed for:

• superficial wounds with damage to the skin, soft tissues and divergence of the wound edges;

• deep stab, cut and crushed wounds;
• extensive wounds with damage to bone structures, tendons, and nerves;
• burn wounds and wounds due to frostbite;
• for contaminated wounds.

Timely PST ensures rapid healing of the wound surface, complete restoration of the mucous membrane, muscles, tendons, nerves and bone structures, and prevents the possibility of infection and the development of serious complications. At the GMS clinic, qualified surgical care is provided seven days a week, at any time convenient for you.

Preparation, diagnostics

In some cases, additional diagnostics may be required before performing PSO:

• Ultrasound of soft tissues to detect leaks, hematomas, pockets;
• probing the wound.

Additional studies allow the surgeon to assess the extent of the intervention as accurately as possible and select the most effective treatment tactics.

How is PHO performed?

There is primary surgical treatment of wounds (PSD) and secondary surgical treatment (SSD). PHO is used for fresh, uncomplicated injuries, VHO is used for already infected, old wounds. Both procedures are performed under sterile conditions using anesthesia. For normal tissue restoration and healing, the doctor removes all damaged non-viable areas (excises the edges, bottom and walls of the wound), stops the bleeding and applies a suture.

The final stage of the intervention has several options:

• layer-by-layer suturing of the wound;
• suturing with drainage left (if there is a risk of infection);
• the wound is not temporarily sutured (in the presence of an infectious process, in case of late seeking help, severe contamination of the wound, massive tissue damage, etc.).

If there is damage to bone structures, nerves, tendons or blood vessels, the surgeon performs manipulations to restore their integrity. In the case of serious injuries, intervention in a hospital setting may be necessary, where the patient will be transferred for care.

You
There is
questions? We will be happy to answer
for any questions Coordinator Tatyana

SMOLENSK STATE MEDICAL ACADEMY

MEDICAL FACULTY
DEPARTMENT OF HOSPITAL SURGERY

Discussed at a methodological meeting

(Protocol No. 3)

METHODOLOGICAL DEVELOPMENT
TO THE PRACTICAL LESSON

Subject: "PURPUS WOUNDS AND METHODS OF THEIR TREATMENT »

Methodological development
made up : Y.I.LOMACHENKO

METHODOLOGICAL DEVELOPMENT

(for students)

for practical training at the Department of Hospital Surgery

Topic: “Purulent wounds and methods of their treatment”

Lesson duration: 5 hours

I. Lesson plan

II. Motivation.

Every year, more than 12 million patients with bruises, wounds, and 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 general structure of surgical diseases, surgical infection is observed in 35-45% of patients and occurs in the form of acute and chronic diseases or suppuration of post-traumatic and postoperative wounds (A.M. Svetukhin, YL. Amiraslanov, 2003).

The problem of surgical infection remains one of the most pressing in modern surgery. This is due to both the high incidence of morbidity and significant material costs, which transfers this problem from the category of medical to the category of socio-economic, i.e. state problems. The problem has acquired particular significance due to the growing number of man-made and natural disasters, military conflicts and terrorist attacks.

Due to the great socio-economic significance of their solution, priority issues include issues of nosocomial infection, the development of which significantly increases mortality, length of stay of patients in the hospital and requires significant additional costs for treatment. Today, nosocomial infections occur in 12 to 22% of patients, the mortality rate of which exceeds 25%.

A retrospective analysis of the causes of the development of severe purulent complications in 15,000 patients transferred from various hospitals for treatment to the specialized department of purulent surgery at the A.V. Vishnevsky Institute of Surgery of the Russian Academy of Medical Sciences (Moscow) revealed in many cases the unjustified use of antibiotics (benzylpenicillin, semisynthetic penicillins, cephalosporins and aminoglycosides of I-II generations), currently ineffective, and outdated drugs for local treatment of wounds (hypertonic sodium chloride solution, Vishnevsky ointment, ichthyol ointment, streptocidal, tetracycline, furacillin, fat-based gentamicin ointment). As a result, the proper antibacterial effect is not provided, and the local treatment of wounds also does not achieve the necessary analgesic, osmotic and anti-edematous effects. As numerous studies show, the structure of causative agents of purulent complications of wounds has also changed (a significant proportion is accounted for by anaerobes and fungi).

The formation of resistance of microorganisms to “old” drugs dictates the need to introduce new groups of drugs with a wide spectrum of activity (not only against aerobes, but also anaerobes) and their use in strict accordance with the phase of the wound process.

1. III.Learning Objectives.

The student must be able to (see point VII):

Evaluate the patient’s complaints, identifying evidence of a complicated course of the wound process (increased pain, the appearance of signs of inflammation, the development of a general reaction of the body in the form of chills, increased body temperature, etc.);

Collect a detailed history of the disease, paying special attention
on the etiological and pathogenetic moments of wound formation, background conditions (stress, alcohol, medication, drug intoxication, violent actions, etc.);

Identify diseases in the medical history that affect the reparative process and immune status of the patient;

Assess lifestyle and working conditions, establish their possible significance in the development of pathology;

Carry out an external examination and interpret the information received (the nature of tissue damage, the size of the wound, the number of injuries, their location, the presence of inflammatory changes, the risk of bleeding, the condition of regional lymph nodes);

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

Interpret the results of bacteriological examination (detail the microbial landscape of the wound, assess its microbial contamination, sensitivity of microflora to antibiotics);

Assess the dynamics of the wound process;

Collect material from the wound for microbiological examination;

Independently bandage patients with purulent wounds and perform necrectomy;

Prescribe antibacterial, immunocorrective, detoxification treatment, physiotherapeutic methods of treatment.

The student must know:

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

n for the development of infection in a wound, a so-called “critical” level of bacterial contamination is required, corresponding to the concentration of microorganisms - 10 5 -10 6 microbial bodies per 1 gram of tissue (under certain conditions the “critical” level may be lower);

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

n anaerobic infection is the most severe type of surgical infection;

n treatment of purulent wounds involves multidirectional therapeutic effects, which are carried out in accordance with the phase of the wound process;

n the principles of active surgical treatment of purulent wounds include a set of measures aimed at minimizing the duration of all phases of the wound process in order to bring it as close as possible to an uncomplicated course;

n microbiological examination of the contents from the wound is mandatory and involves direct microscopy of native material, bacterial culture and determination of the sensitivity of microflora to antibiotics;

n the results of a microbiological study make it possible to correct the treatment of a purulent wound;

n modern preparations for local treatment of wounds have a combined therapeutic effect (antimicrobial, analgesic, osmotic, decongestant, wound healing, necrolytic), and the use of wound coverings, due to their structure, contributes to the least traumatic and painless dressings;

n any dressing change must take place under sterile conditions;

n the doctor performing the dressing must take special measures to protect himself from infection - latex gloves, eye protection, and a mask for the mouth and nose are required;

n a carefully applied dressing, being a visible completion of wound treatment, gives the patient the feeling that he is being treated and served with high quality.

IV-A. Basic knowledge.

1. Pathophysiology of the wound process.

1. The doctrine of inflammation.

Lectures on pathological physiology.

1. Morphology of the wound process.

Lectures on pathological anatomy.

1. Microbiology of wounds.

Lectures on microbiology.

1. Asepsis and antiseptics.

Lectures on general surgery.

1. Types of wound healing.

Lectures on general surgery.

6. Primary and secondary surgical treatment of wounds.

Lectures on general surgery, traumatology.

1. Methods of wound drainage.

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 of the Ministry of Health. – Publishing house “Medicine”, 2002.
2. Surgery / Ed. Yu.M. Lopukhina, V.S. Savelyeva (RGMU). Textbook UMO MZ. – Publishing house “GEOTARMED”, 1997.
3. Surgical diseases / Ed. Yu.L. Shevchenko. Textbook MZ. – 2 volumes. – Publishing house “Medicine”, 2001.
4. General surgery / Ed. V.K. Gostishcheva (MMA). Textbook UMO MZ. –
   Publishing house "Medicine", 1997 (2000).
5. General surgery / Ed. Zubarev, Lytkin, Epifanov. Textbook MZ. – SpetsLit Publishing House, 1999.
6. Course of lectures on general surgery / Ed. V.I. Malyarchuk (RUDN University). Manual UMO MO. – RUDN Publishing House, 1999.
7. Guide to practical training in general surgery / Ed. V.K. Gostishcheva (MMA). – Publishing house “Medicine”, 1987.
8. Military field surgery / Yu.G. Shaposhnikov, V.I. Maslov. Textbook MZ. – Publishing house “Medicine”, 1995.
9. Lectures on the course of hospital surgery.

Additional:

1. Wounds and wound infection / Ed. M.I.Kuzina, B.M. Kostyuchenka. – M.: Medicine, 1990.
2. Svetukhin A.M., Amiraslanov Yu.A. Purulent surgery: current state of the problem // 50 lectures on surgery. – Ed. Academician V.S. Savelyev. – M.: Media Medica, 2003. – P. 335-344.
3. Methodological development of the department on the topic “Purulent wounds and methods of their treatment.”
   1. V.Questions for self-study:

a) on basic knowledge;

1. Signs of inflammation.
2. Pathogenesis of the wound process.
3. Histogenesis of the wound process.
4. Microbiological characteristics of wounds.
5. Types of wound healing.
6. Primary and secondary surgical treatment of wounds.
7. Types of surgical infection.
8. Methods of wound drainage.
9. Principles of bandaging.

b) on a new topic:

1. The concept of a wound, classification of wounds.
2. Phases of the wound process.
3. Characteristics of a purulent wound.
4. General principles of wound treatment.
5. Treatment of wounds depending on the stage of the wound process.
6. Principles of active surgical treatment of purulent wounds.
7. Applying sutures to a purulent wound.
8. Rules for collecting material from a wound for microbiological examination.
9. “Physical methods of influence” on the wound process.

10. Anaerobic infection.

11. Practical implementation of changing the dressing.

1. VI.Contents of the lesson.
2. Wounds– mechanical damage to tissue with violation of their integrity.

Classification of wounds.

1. By type of wounding agent

Bullet

Fragmentation

From the impact of a blast wave

From a secondary fragment

From edged weapons

From accidental causes (trauma)

Surgical

2. By the nature of tissue damage

Spot

Crushed

Bruised

Cut

Chopped

Stabbed

Sawn

Bitten

Scalped

3. By length and ratio
to body cavities

Tangent

Through

Non-penetrating

Penetrating into the cavity

1. By number of damages
   one wounded

Single

Multiple

Combined

Combined

1. By type of damaged tissue -
   with damage:

Soft tissue

Bones and joints

Large arteries and veins

Internal organs

1. Anatomically

Limbs

1. According to microbial contamination

Bacterial-contaminated

Aseptic

Fresh wounds, until they are completely covered with granulation, are able to absorb toxins, bacteria, and tissue breakdown products. Wounds covered with granulations have virtually no absorption capacity.

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

A.M. Svetukhin 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 has been developed, regardless of the origin, size, location and nature of the wound.

2. Phases of the wound process.

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

I - inflammation phase

Period of vascular changes;

The period of cleansing of necrotic tissue;

II - phase of regeneration and development of granulation tissue;

III - phase of scar reorganization and epithelization.

3. Characteristics of a purulent wound.

It has been proven that for the development of infection in a wound, the presence of 10 5 -10 6 microbial bodies per 1 gram of tissue is necessary. This is the so-called “critical” level of bacterial contamination. But the “critical” level can also be low. Thus, for the development of infection in the presence of blood, foreign bodies, ligatures in the wound, 10 4 (10,000) microbial bodies are sufficient; when tying ligatures in the area of ​​ligature tissue ischemia, 10 3 (1000) microbial bodies per 1 gram of tissue is sufficient. The combination of tissue damage with shock reduces the threshold value of the microbial number to 10 3 (1000) per 1 g of tissue, and with radiation damage - to 10 2 (100).

Wound exudate from a purulent wound is rich in protein, consists of cellular elements, mainly neutrophilic leukocytes, a large number of bacteria, remains 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 mononuclear leukocytes and the absence of phagocytosis in pus indicate an unfavorable course of wound healing.

The development of the inflammatory response depends on the degree of tissue resistance, the reactivity of the body and the virulence of the infection.

I. Pathogens high level priority:

Streptococcus pyogenes;

Staphylococcus aureus.

II. Pathogens mid-level priority:

Enterobacteriaceae;

Pseudomonas and other non-fermenting gram-negative bacteria;

Clostridia;

Bacteroides and other anaerobes;

Streptococci (other species).

III. Pathogens low level priority:

Bacillus anthracis;

Mycobacterium tuberculosis, Mulcerans, etc.;

Pasteurella multocida.

The causative agents of viral infections, unlike fungi and bacteria, very rarely produce purulent exudate.

4. General principles of wound treatment.

n Surgical methods: surgical treatment of the wound, opening of leaks, necrectomy, decompression incisions, suturing, skin grafting (artificial skin, split displaced flap, walking stem according to Filatov, autodermoplasty with a full-thickness flap, free autodermoplasty with a thin-layer flap according to Thiersch).

n Local wound treatment using various types of drainage, dressings and medications.

n Physiotherapeutic treatment: laser therapy, magnetic therapy, UHF, ultraviolet irradiation, controlled abacterial environment, etc.

n General treatment: antibacterial therapy; correction of dysfunctions of organs and systems, metabolic disorders; detoxification therapy;
increasing nonspecific resistance of the body and immunocorrective therapy; stimulation of reparative processes.

5. Treatment program depending on the stage of the wound process.

Inflammation phase (exudation) characterized by abundant wound discharge, a pronounced perifocal inflammatory reaction of soft tissues and bacterial contamination of the wound, therefore, the medicinal preparations used must have high osmotic activity in order to ensure intensive outflow of exudate from the depths of the wound into the dressing, must have an antibacterial effect on infectious agents, cause rejection and melting of necrotic fabrics. For this purpose, antiseptic dressings are used (wet-drying with chemotherapy and antiseptics, water-soluble ointments), during the period of vascular changes - drainage and hydrophilic dressings (hypertonic, absorbent and adsorbent), during the period of cleansing from necrotic tissue - necrolytic agents (proteolytic enzymes, hydrogel dressings) ; to stimulate the rejection of necrotic tissues - ointments on a water-soluble basis with high osmotic activity (levomekol, levosin, dioxykol, etc.).

Considering the high cost of absorbent wound coverings (hydrophilic dressings), children's diapers or sanitary pads can be successfully used in everyday medical practice.

During the period of cleansing the wound from necrotic tissue, ointments are used for enzymatic cleansing of wounds, a worthy representative of which is the Iruksol ointment, containing enzymes from Clostridium hystolyticum and a broad-spectrum antibiotic “Chloramphenicol” (chloramphenicol).

If there is perifocal dermatitis around the wound, it is advisable to apply zinc oxide ointment (Lassar paste).

Semi-bed rest is recommended for all patients for 10-14 days. The main components of therapy are broad-spectrum antibiotics of the fluoroquinolone (maxaquin, tarivid, tsiprobay, tsifran, etc.) or cephalosporin (dardum, duracef, kefzol, mandol, cefamezin, etc.) series, administered parenterally (less preferably orally). Considering the frequent associations of pathogenic microorganisms with bacteroid and fungal flora, in some cases it is advisable to strengthen antibacterial therapy by including antifungal drugs (Diflucan, Nizoral, Orungal, etc.) and nitroimidazole derivatives (Flagyl, Metranidazole, Trichopolum, Tinidazole, etc.).

Active inflammation and severe pain determine the advisability of systemic use of nonspecific anti-inflammatory drugs, such as diclofenac (Voltaren, Ortofen), ketoprofen, Oruvel, etc.

Systemic and local hemorheological disorders should be corrected by infusions of antiplatelet agents (reopolyglucine in combination with pentoxifylline).

Sensitization of the body as a result of massive resorption of structures with antigenic activity (fragments of microbial proteins, degradation products of soft tissues, etc.), synthesis of a large number of inflammatory mediators (histamine, serotonin, etc.) are absolute indications for desensitizing therapy (diphenhydramine, suprastin, diazolin , Claritin, Ketotifen, etc.).

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

Water-soluble ointments: levomekol, levosin, dioxykol, dioxidin 5% ointment, mafenide acetate ointment 10%, sulfamekol, furagel, quinifuryl ointment 0.5%, iodopirone 1% ointment, iodometrikselen, streptonitol, nitacid, miramistin ointment 0.5%, lavendula ointment, ointment lipacanthin, methyluracil ointment with miramistin.

Sorbents and hydrogels: helevin, celosorb, immosgent, carbonet, Multidex Gel, AcryDerm, Carrasin Hydrogel, Hydrosorb, Elasto— Gel, Purilon.

Enzymes: chymopsin, crab callagenase, caripazim, terrilitin (protease C), protogentin (sipraline, lysoamidase), enzyme-containing dressings (teralgym, immosgent), trypsin + urea, trypsin + chlorhexidine, profezim, sipralin, lysosorb, collavin.

Antiseptic solutions: iodopirone solution, 02% furagin potassium solution, suliodopirone, 15% dimephosphone solution, 30% PEG-400 solution, 0.01% miramistin solution.

Aerosols: nitazol, dioxysol, gentazol.

Wound dressings: "TenderVet", "Sorbalgon".

Reparation phase(regeneration, formation and maturation of granulation tissue) is characterized by cleansing of the wound surface, the appearance of granulations, subsidence of perifocal inflammation and a decrease in exudation. The main goal of treatment is to stimulate the growth and maturation of connective tissue, along with the suppression of the remaining microbes in a small number or their newly emerging hospital strains. Regeneration stimulants such as vinylin, vulnuzan, polymerol, as well as antiseptic dressings with fat-soluble ointments and hydrophilic dressings (polyurethane, foaming, hydrogel) are widely used.

Systemic therapy is corrected by prescribing antioxidants (Aevit, tocopherol, etc.) and antihypoxants - deproteinized derivatives of calf blood (Actovegin, solcoseryl). To accelerate the growth of connective tissue, it is advisable to prescribe curiosin. It is an association of hyaluronic acid and zinc. Hyaluronic acid increases the activity of phagocytosis in granulocytes, activates fibroblasts and endothelial cells, promotes their migration and proliferation, increases the proliferative activity of epithelial cells, creating favorable conditions for the remodeling of the connective tissue matrix. Zinc, having 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:

Ointments on a controlled osmotic basis: methyldioxylin, sulfargin, fusidine 2% gel, lincomycin 2% ointment.

Polymer coatings: combutek-2, digispon, algipor, algimaf, algicol, algico-AKF, kolahit, kolahit-F, sisorb, hydrosorb.

Hydrocolloids: galagran, galactone, hydrocoll.

Oils: millet oil (meliacil), sea buckthorn oil, rosehip oil.

Aerosols: dioxyplast, dioxysol.

During the epithelization phase, characterized by the beginning of epithelization and maturation of the connective tissue scar (formation and reorganization of the scar), among the means of local action, the use of polymer wound coverings, which significantly accelerate the process of epithelization, as well as a silicone semi-permeable dressing, is optimal.

Polymer wound coverings can be conditionally (one dressing can be multi-purpose) divided into absorbent, protective, insulating, atraumatic and biodegradable. The sorption capacity of coatings (the degree and rate of binding of wound exudate) depends on the pore size of the coatings.

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

? Wide dissection and opening of the purulent focus. Already at this stage of treatment (purulent surgery and traumatology) elements of plastic surgery should be contained. When making tissue incisions and choosing access to a purulent focus, it is necessary to foresee the possibility of forming future blood-supplied flaps from areas of the body adjacent to the wound.

Excision of all non-viable and questionable soft tissues soaked in pus within healthy tissues (in one or more stages). Removal of all bone sequestra and necrotic bone fragments. Performing marginal, end or segmental resection of the affected area of ​​bone, also within healthy tissue.

Removal of submersible metal clamps that do not fulfill their purpose and vascular prostheses.

? The use of additional physical methods of wound treatment.

? Use during surgical treatment of elements of plastic or reconstructive operations for the purpose of restoration or closure of important anatomical structures.

? External osteosynthesis of long bones(according to indications), provides the possibility of dynamic distraction-compression manipulations.

1. 7. Applying sutures to a purulent wound.

Primary delayed suture– used 5-6 days after surgical treatment, until granulations appear in the wound (more precisely, during the first 5-6 days).

Early secondary suture– applied to a wound covered with granulations with moving edges until scar tissue develops in it. An early secondary suture is applied within the 2nd week after surgery.

Late secondary suture– applied to a granulating wound in which scar tissue has already developed. Closing the wound is possible in these cases only after preliminary excision of the scar tissue. The operation is performed 3-4 weeks after injury and later.

An indispensable condition for suturing a purulent wound is to ensure sufficient outflow of wound fluid, which is achieved by active drainage and rational antibacterial therapy aimed at destroying the microflora remaining in the wound.

8. Rules for collecting material from a wound for microbiological examination.

After carefully cleaning the surgical site, the surgeon determines the location where pus has accumulated, necrotic tissue is located, gas is released (crepitus), or other signs of infection are observed. Particles of affected tissue intended for laboratory research are placed in sterile gauze and then in a sterile container. Pus or other exudate should be carefully collected and placed in a sterile tube. If possible, avoid using a cotton swab. Exudate must be collected with a sterile syringe and needle. If a cotton swab is used, remove as much exudate as possible and place the entire swab in a container for sending to the laboratory.

9. “Physical methods of influence” on the wound process.

1). Methods based on the use of mechanical vibrations:

• treatment with a pulsating jet of liquid,
• low frequency ultrasound treatment.

2). Methods based on changes in external air pressure:

• vacuum treatment and vacuum therapy,
• controlled abacterial environment,
• hyperbaric oxygenation.

3). Methods based on temperature change:

Cryotherapy.

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

• low voltage direct currents (electrophoresis, electrical stimulation),
• modulated currents (electrical stimulation).

5). Methods based on the use of a magnetic field:

• low frequency magnetic therapy,
• exposure to a constant magnetic field.

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

Laser radiation:

a) high energy,

b) low intensity,

Ultraviolet radiation.

7). Combined methods of influence.

Application of plasma flows. The effect of high-temperature plasma flows on the wound surface allows bloodless and precise surgical treatment of the wound. The advantage of the method, in addition, is aseptic and atraumatic dissection of tissue, which is of no small importance in case of surgical infection.

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

Use of nitric oxide. The discovery of endogenous nitric oxide (NO), which is produced by cells using NO synthases and functions as a universal messenger regulator, was a major event in biology and medicine. The experiment established the role of endogenous NO in tissue oxygenation and its deficiency in purulent wounds. The combined use of surgical treatment of purulent-necrotic lesions of soft tissues and a complex of physical factors (ultrasound, ozone and NO therapy) helps to accelerate the cleansing of the wound from microflora and necrotic masses, weakening and disappearance of inflammatory manifestations and microcirculatory disorders, activation of the macrophage reaction and proliferation of fibroblasts, growth of granulation tissue and marginal epithelialization.

10. Anaerobic infection.

Anaerobes make up the vast majority of normal human microflora. They live: in the oral cavity (in the gingival pockets, the flora consists of 99% anaerobes), in the stomach (in hypo- and anacid conditions, the microbial landscape of the stomach approaches the intestinal), in the small intestine (anaerobes are contained in smaller quantities than aerobes), in the large intestine (the main habitat of anaerobes). According to etiology, anaerobes are divided into clostridial (spore-forming), non-clostridial (non-spore-forming), bacteroid, peptostreptococcal, and fusobacterial.

One of the common symptoms of anaerobic infection is the absence of microflora in crops using standard methods of their isolation (without the use of anaerostats). Since microbiological identification of anaerobic microflora requires special equipment and a long time, express diagnostic methods, allowing you to confirm the diagnosis within an hour:

Microscopy of a native Gram-stained smear;

Urgent biopsy of affected tissues (characterized by pronounced focal tissue edema, destruction of the dermal stroma, focal necrosis of the basal layer of the epidermis, subcutaneous tissue, fascia, myolysis and destruction of muscle fibers, perivascular hemorrhages, etc.)

Gas-liquid chromatography (volatile fatty acids are determined - acetic, propionic, butyric, isobutyric, valeric, isovaleric, kapronic, phenol and its derivatives produced in the growth medium or in pathologically altered tissues by anaerobes during metabolism).

According to gas-liquid chromatography and mass spectrometry, it is possible to identify not only asporogenous anaerobes, but also clostridial microflora (causative agents of gas gangrene), which are characterized by the presence of 10-hydroxy acids (10-hydroxystearic).

Regardless of the location of the outbreak, the anaerobic process has a number of common and characteristic features:

Unpleasant putrid odor of exudate.

Putrefactive nature of the lesion.

Dirty scanty exudate.

Gas formation (gas bubbles from the wound, crepitus of the subcutaneous tissue, gas above the level of pus in the abscess cavity).

The proximity of the wound to the natural habitats of anaerobes.

Of the anaerobic processes that take place in the surgical clinic, it is necessary to note a special form - epifascial creeping phlegmon of the anterior abdominal wall, which develops as a complication after operations (usually after appendectomy with gangrenous-perforated appendicitis).

Anaerobic clostridial infection– an acute infectious disease caused by the penetration into the wound and the reproduction in it of spore-forming anaerobes of the genus Clostridia ( Clostridium perfringens, Clostridium oedematiens, Clostridium septicum, Clostridium hystolyticum). The disease most often develops in the first 3 days after injury, less often - after a few hours or a week, it is observed with gunshot wounds, in surgical departments - after amputation of the lower extremities due to atherosclerotic gangrene and even after appendectomy, etc. The likelihood of an anaerobic infection increases sharply in the presence of foreign bodies, bone fractures and damaged large arteries in wounds, since such wounds contain a lot of ischemic, necrotic tissue and deep, poorly aerated pockets.

Anaerobic clostridia secrete a number of strong exotoxins (neuro-, necro-, enterotoxin, hemolysin) and enzymes (hyaluronidase, neuraminidase, fibrinolysin, collagenase and elastase, lecithinase, etc.), which cause tissue swelling, severe vascular permeability and hemolysis, necrosis and melting tissues, severe intoxication of the body with damage to internal organs.

Patients first of all feel bursting pain in the wound, and swelling of the tissue around it quickly increases. Foci of a purplish-bluish color appear on the skin, often spreading to a considerable distance from the wound in the proximal direction, and blisters filled with cloudy hemorrhagic contents. When palpating the tissue around the wound, crepitus is determined.

Along with local manifestations, profound general disorders are noted: weakness, depression (less often - excitement and euphoria), increased body temperature to febrile levels, pronounced tachycardia and increased breathing, pallor or yellowness of the skin, progressive anemia and intoxication, and in case of liver damage - yellowness of the sclera .

An X-ray of the affected limb reveals gas in the tissues. Diagnosis of anaerobic infection is based mainly on clinical data. Therapeutic tactics are also based on the clinical picture of the disease.

In anaerobic infection, necrotic changes in tissues predominate and inflammatory and proliferative ones are practically absent.

Anaerobic non-clostridial infection(putrefactive infection) is caused by anaerobes that do not form spores: B. coli, B. putrificus, Proteus, bacteroides ( Bacteroides fragilis, Bacteroides melanogenicus), fusobacteria ( Fusobacterium) and others, often in combination with staphylococci and streptococci.

In terms of local tissue changes and the general reaction of the body, putrefactive infection is close to anaerobic clostridial infection. The predominance of necrosis processes over inflammation processes is characteristic.

Clinically, the local process in soft tissues usually occurs in the form of non-clostridial phlegmon, destroying subcutaneous fatty tissue (cellulite), fascia (fasciitis), and muscles (myositis).

The general condition of the patient is accompanied by severe toxemia, quickly leading to bacterial toxic shock with frequent death.

Putrid infection is more often observed in severely infected lacerated wounds or in open fractures with extensive destruction of soft tissue and contamination of the wound.

Surgical intervention for anaerobic clostridial and non-clostridial infection consists of wide dissection and complete excision of dead tissue, primarily muscles. After treatment, the wound is washed abundantly with solutions of oxidizing agents (hydrogen peroxide, potassium permanganate solution, ozonated solutions, sodium hypochlorite), additional “lamps” incisions are made in the area of ​​pathological changes outside the wound, the edges of the “lampas” incisions extend beyond the boundaries of the source of inflammation, necrosis is additionally excised , the wounds are not sutured or tamponed, and their aeration is subsequently ensured. After surgery, hyperbaric oxygen therapy is used.

Antibiotic therapy for anaerobic infections.

For empirical use in anaerobic infections it is recommended clindamycin(delacyl C). But given that most of these infections are mixed, therapy is usually carried out with several drugs, for example: clindamycin with an aminoglycoside. Suppresses many strains of anaerobes rifampin, lincomycin(lincocin). Effective against gram-positive and gram-negative anaerobic cocci benzylpenicillin. However, there is often intolerance to it. Its substitute is erythromycin, but it has a bad effect on Bacteroides fragilis and fusobacteria. An antibiotic effective against anaerobic cocci and bacilli fortum(combined with aminoglycosides), cephobid(cephalosporin).

A special place among drugs used to influence anaerobic microflora is occupied by metronidazole– metabolic poison for many strict anaerobes. Metronidazole has a much weaker effect on gram-positive forms of bacteria than on gram-negative ones, so its use in these cases is not justified. Close in action to metronidazole turned out to be different imidazoles – niridazole(more active than metronidazole), ornidazole, tinidazole.

A 1% solution is also used dioxidine(up to 120 ml IV for adults),
and carbenicillin(12-16 g/day IV in adults).

11. Practical implementation of changing the dressing.

Any dressing change must occur under sterile conditions. It is always necessary to use the so-called “non-touch technique”. The wound or bandage should not be touched without gloves. The doctor performing the dressing must take special measures to protect himself from infection: latex gloves, eye protection, and a mask for the mouth and nose are required. The patient must be positioned comfortably, and the wound area must be easily accessible. A good light source is needed.

If the bandage cannot be removed, it must not be torn off. The bandage is moistened with an aseptic solution (hydrogen peroxide, Ringer's solution) until it comes off.

For infected wounds, the wound area is cleaned from the outside in, and disinfectants are used if necessary. Necrosis in the wound can be removed mechanically using a scalpel, scissors or curette (preference should be given to a scalpel; removal with scissors or a curette carries the risk of tissue crushing and re-traumatization).

Washing with an aseptic solution from a syringe with light piston pressure is quite effective for cleaning a wound. For deep wounds, irrigation is carried out using a button-shaped grooved probe or through a short catheter. The liquid should be collected using a napkin in the tray.

Granulation tissue reacts sensitively to external influences and damaging factors. The best way to promote the formation of granulation tissue is to constantly keep the wound moist and protect it from injury when changing dressings. Excessive granulation is usually removed using a cauterizing pencil (lapis).

If the edges of the wound tend to epithelize and turn inward, then surgical treatment of the edges of the wound is indicated.

A well-developing epithelium does not require any other care other than keeping it moist and protecting it from injury when changing dressings.

The surgeon must ensure that the chosen wound dressing is optimally suited to the surface of the wound - wound secretions can only be absorbed if there is good contact between the dressing and the wound. Insecurely fixed bandages can irritate the wound when moving and slow down its healing.

VII.Scheme of examination of the patient.

When identifying complaints in a patient, identify data on the complicated course of the wound process (signs of inflammation, increased body temperature, etc.).

Collect medical history in detail, paying special attention
on the etiological and pathogenetic moments of wound formation, background conditions (stress, alcohol, medication, drug intoxication, violent actions, etc.).

In the long-term anamnesis, identify past diseases or existing suffering that affect the reparative process and immune status, establish the possible significance in the development of pathology of the patient’s lifestyle and working conditions.

Carry out an external examination and interpret the information received (nature of tissue damage, size of the wound, number of injuries, their location, presence of inflammatory changes, risk of bleeding, condition of regional lymph nodes).

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

Take material from the wound for microbiological examination or interpret existing results (microbial landscape of the wound, degree of microbial contamination, sensitivity of microflora to antibiotics).

Dress the patient, perform necrectomy if necessary, wash the wound, drainage, and physiotherapeutic treatment.

When re-dressing, evaluate the dynamics of the wound process.

Prescribe antibacterial, immunocorrective, detoxification treatment, physiotherapeutic methods of treatment.

VIII.Situational tasks.

1. A 46-year-old patient received a non-penetrating stab wound to the chest from unknown assailants. He sought medical help early, underwent primary surgical treatment of the wound, followed by drainage and suturing, and tetanus prophylaxis with antitoxic tetanus serum and tetanus toxoid. When viewed through
5 days marked hyperemia of the skin, tissue edema, local increase in temperature, painful infiltration in the wound area. There is purulent discharge from the drainage.

Indicate the phase of the wound process, determine medical tactics.

Sample answer: A clinical example describes the phase of purulent inflammation in a sutured and drained wound after surgical treatment of a non-penetrating stab wound to the chest. It is necessary to remove the sutures, inspect the wound, examine it for purulent leaks, remove material from the wound using a sterile syringe with a needle or a cotton swab for microbiological examination (direct microscopy of native material, bacterial culture and determination of the sensitivity of microflora to antibiotics), perform sanitation with a 3% solution of hydrogen peroxide , install drainage and apply an antiseptic bandage with antibacterial water-soluble ointment (for example: Levosin or Levomekol ointment). Schedule re-dressing in 24 hours.

2. A 33-year-old patient received an accidental laceration and bruise of the left leg with damage to the skin, subcutaneous fat and muscles. In the surgical department, primary surgical treatment of the wound was performed, with the application of rare sutures, and tetanus prophylaxis was carried out with antitoxic anti-tetanus serum and tetanus toxoid. Due to the development of purulent inflammation during the wound healing stages, the sutures were removed. At the time of examination, the wound defect is of irregular size, is formed by granulation, and there are areas of sloughing tissue necrosis in the area of ​​the wound edges.

Indicate the type of wound healing, the stage of the wound process, the scope of assistance with dressing and the method of its implementation.

Sample answer: The wound heals by secondary intention, the exudation stage ends (rejection of necrotic tissue), there are signs of the repair stage (formation of granulation tissue). It is necessary to perform dressing sanitation of the wound with antiseptics, necrectomy, apply a bandage that has antimicrobial, analgesic, osmotic, anti-edematous, wound-healing, necrolytic effects (for example: hydrophilic wound dressing or antibacterial water-soluble ointments “Levosin”, “Levomekol”). Under sterile conditions, remove the bandage; clean the wound from the outside in, using one of the antiseptic solutions; remove necrosis with a scalpel, rinse the wound with a syringe using light piston pressure, apply a bandage and secure well.

3. After an appendectomy for acute gangrenous appendicitis, the patient began to complain of bursting pain in the wound. Upon examination, pronounced swelling of the tissues around the wound was revealed, on the skin there were foci of purplish-bluish coloration, spreading from the wound in different directions, more so to the side wall of the abdomen, as well as individual blisters filled with cloudy hemorrhagic contents. When palpating the tissue around the wound, crepitus is determined. The patient is somewhat euphoric, febrile temperature and tachycardia are noted.

What is your presumptive diagnosis? How can you clarify the diagnosis? What will be the priority actions?

Sample answer: The postoperative period was complicated by the development of anaerobic infection in the surgical wound after appendectomy. The diagnosis is established by characteristic clinical signs and can be clarified by microscopy of a native Gram-stained smear, urgent biopsy of affected tissue, gas-liquid chromatography and mass spectrometry. Stitches should be removed; spread the edges of the wound; provide wide access through additional dissection and complete excision of dead tissue; make additional “lamps” incisions in the area of ​​pathological changes in the abdominal wall outside the wound; after excision of necrosis, rinse the wounds generously with oxidizing solutions (hydrogen peroxide, potassium permanganate solution, ozonated solutions, sodium hypochlorite); do not stitch wounds or pack them; provide wound aeration. Antibacterial and detoxification therapy must be corrected and, if possible, hyperbaric oxygen therapy must be prescribed.

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