Primary surgical treatment of the wound- This surgery, which must be carried out in a therapeutic setting - preventive institution a doctor qualified as a surgeon. The goal is to prevent suppuration of the damage and create conditions for speedy healing.
Types of wounds
All wounds, except those caused by a sterile instrument under aseptic conditions, are classified as primary - infected wounds and are subject to mandatory treatment with an antiseptic and bandage. Depending on the mechanism of application, wounds are divided into cut, stab, bruised, lacerated and gunshot wounds. If the damage affects the body cavities (abdominal, thoracic), they speak of a penetrating wound. The surgical intervention algorithm is determined based on the type, location of injury and type of damaged tissue. 
Technical equipment and set of tools.
Primary surgical treatment should be carried out under aseptic conditions (operating room, dressing room).
Surgical instruments: Linen picks, scalpel (pointed and belly), Frabeuf hooks, hemostatic forceps (Kocher and Billroth), tweezers (anatomical and surgical), straight and curved forceps, scissors (straight and curved, blunt and pointed), syringes and games , surgical needles, cutting, curved, suture material(lysing and non-lysing), Deschamps ligature needle, Volkmann spoon, probes (buttoned, grooved).
Stages of PHO
Disinfection of damage (using a gauze sponge soaked in ethyl solution or similar means edges of the damage and clean it of dirt, remove foreign bodies, treat the damaged area with an antiseptic and bandage with a sterile bandage). For abrasions and superficial cuts, PST is completed at this stage. In other cases, opening the damaged areas, in compliance with all norms and rules, entails rapid healing under the sutures by primary intention (opening, cutting the edges and the entire depth of the damage within healthy skin, removing dead tissue). Next, the wound cavity is carefully examined for the presence of blind pockets. Before suturing, be sure to stop bleeding, if any. To do this, large vessels are ligated or sutured. Suturing of the bottom and walls of healthy tissue is performed layer by layer to restore the anatomical integrity of the area. Creation of cavities is not allowed.
Opening the damaged area and cutting the tissue creates the possibility of rapid healing by repeated tension; the damage is tightly sutured in several layers in turn. If there is a threat of infection, drainage is installed. The final stage is treatment with an antiseptic and application of a sterile bandage. Regardless of the severity of the damage, an injection of anti-tetanus serum is performed, and in case of animal bites, an anti-rabies vaccine is given.
TECHNIQUE FOR PERFORMING PRIMARY SURGICAL TREATMENT OF THE WOUND 1. Place the patient on the couch or operating table.
2. Wear sterile gloves. 3. Take tweezers and a swab moistened with ether or ammonia, clean the skin around the wound from contamination. 4. Using a dry swab or a swab moistened with hydrogen peroxide (furatsilin), remove foreign bodies and blood clots loose in the wound.
5. A swab moistened with iodonate ( alcohol solution chlorhexidine), treat the surgical field from the center to the periphery.
6. Delimit the surgical field with sterile linen.
7. Use a swab moistened with iodonate (alcohol solution of chlorhexidine) to treat the surgical field. 8. Using a scalpel, cut the wound along its length.
9. If possible, excise the edges, walls and bottom of the wound, remove all damaged, contaminated, blood-soaked tissue.
10. Replace gloves. 11. Demarcate the wound with a sterile sheet. 12. Replace tools. 13. Carefully bandage bleeding vessels, stitch large ones. 14. Decide on the issue of suturing: a) apply primary sutures (stitch the wound with threads, bring the edges of the wound together, tie the threads); b) apply primary delayed sutures (stitch the wound with threads, do not close the edges of the wound, do not tie the threads, bandage with an antiseptic). 15. Treat the surgical field with a swab moistened with iodonate (alcohol solution of chlorhexidine).
16. Apply a dry aseptic dressing. Dress a clean wound.
Execution order
see also
Notes
Links
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See what “Primary surgical treatment of a wound” is in other dictionaries:
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A wound is tissue damage mechanically in the presence of integrity violations skin. The presence of a wound, rather than a bruise or hematoma, can be determined by such signs as pain, gaping, bleeding, dysfunction and integrity. PSO of the wound is performed in the first 72 hours after the injury, if there are no contraindications.
Types of wounds
Each wound has a cavity, walls and a bottom. Depending on the nature of the damage, all wounds are divided into puncture, cut, chopped, bruised, bitten and poisoned. This must be taken into account during PSO of a wound. After all, the specifics of first aid depend on the nature of the injury.
- Puncture wounds are always caused by a sharp object, such as a needle. Distinctive feature The damage is deep, but the damage to the integument is small. In view of this, it is necessary to ensure that there is no damage to blood vessels, organs or nerves. Puncture wounds are dangerous due to mild symptoms. So, if there is a wound on the abdomen, there is a possibility of liver damage. This is not always easy to notice when carrying out PHO.
- An incised wound is caused using a sharp object, so tissue destruction is small. At the same time, the gaping cavity can be easily examined and PSO performed. Such wounds are treated well, and healing occurs quickly, without complications.
- Chopped wounds are caused by a sharp but heavy object, such as an axe. In this case, the damage differs in depth, and is characterized by the presence of a wide gaping and bruising of adjacent tissues. Because of this, the ability to regenerate is reduced.
- Bruised wounds occur when using a blunt object. These injuries are characterized by the presence of many damaged tissues, heavily saturated with blood. When performing PST of a wound, it should be taken into account that there is a possibility of suppuration.
- Bite wounds are dangerous due to the penetration of infection from the saliva of an animal, and sometimes a person. There is a risk of developing acute infection and the emergence of the rabies virus.
- Envenomed wounds usually occur when there is a snake or spider bite.
- differ in the type of weapon used, the characteristics of the damage and the trajectories of penetration. There is a high probability of infection.
When performing PST of a wound, the presence of suppuration plays an important role. Such injuries can be purulent, freshly infected and aseptic.
The purpose of the PHO
Primary surgical treatment is necessary to remove harmful microorganisms that got into the wound. To do this, all damaged dead tissue, as well as blood clots, are cut off. After this, sutures are placed and drainage is performed, if necessary.
The procedure is needed in the presence of tissue damage with uneven edges. Deep and contaminated wounds require the same. Presence of major damage blood vessels and sometimes bones and nerves also require fulfillment surgical work. PHO is carried out simultaneously and exhaustively. The patient needs the help of a surgeon for up to 72 hours after the wound is inflicted. Early PSO is carried out during the first day, carried out on the second day - this is a delayed surgical intervention.
Tools for chemical and chemical treatment
To carry out the procedure primary processing wounds, a minimum of two copies of the set are required. They are changed during the operation, and after the operation dirty stage- dispose of:
- a straight forceps clamp, which is used to process the surgical field;
- pointed scalpel, belly;
- linen pins are used to hold dressings and other materials;
- Kocher, Billroth and “mosquito” clamps are used to stop bleeding; when performing PSO of a wound, they are used in huge quantities;
- scissors, they can be straight, as well as curved along a plane or edge in several copies;
- Kocher probes, grooved and button-shaped;
- set of needles;
- needle holder;
- tweezers;
- hooks (several pairs).
The surgical kit for this procedure also includes injection needles, syringes, bandages, gauze balls, rubber gloves, all kinds of tubes and napkins. All items that will be needed for PSO - suture and dressing kits, tools and medications, intended for treating wounds, are laid out on the surgical table.
Necessary medications
Primary surgical treatment of a wound is not complete without special medications. The most commonly used are:
Stages of PHO
Primary surgical treatment is carried out in several stages:
How is PHO done?
For surgical intervention the patient is placed on the table. Its position depends on the location of the wound. The surgeon should be comfortable. The wound is cleaned and the surgical field is treated, which is delimited by sterile disposable linen. Next is executed primary intention, aimed at healing existing wounds and anesthesia is administered. In most cases, surgeons use the Vishnevsky method - they inject a 0.5% novocaine solution at a distance of two centimeters from the edge of the cut. The same amount of solution is injected on the other side. If the patient reacts correctly, a “lemon peel” is observed on the skin around the wound. Gunshot wounds often require the patient to be put under general anesthesia.
The edges of the damage up to 1 cm are held with a Kochcher clamp and cut off en bloc. When performing the procedure, non-viable tissue is cut off on the face or fingers, after which a tight suture is applied. Gloves and tools used are replaced.
The wound is washed with chlorhexidine and examined. Puncture wounds, which have small but deep cuts, are dissected. If the edges of the muscles are damaged, they are removed. Do the same with bone fragments. Next, hemostasis is performed. Inner part wounds are treated first with a solution and then with antiseptic drugs.
The treated wound without signs of sepsis is sutured tightly with primary and covered with an aseptic bandage. The seams are made, uniformly covering all layers in width and depth. It is necessary that they touch each other, but do not pull together. When performing the work, it is necessary to obtain cosmetic healing.
In some cases, primary sutures are not applied. An incised wound may have more serious damage than it seems at first glance. If the surgeon has doubts, a primary delayed suture is used. This method is used if the wound has become infected. The suturing is carried out down to the fatty tissue, and the sutures are not tightened. A few days after observation, until the end.
Bite wounds
PCS of a wound, bitten or poisoned, has its differences. When bitten by non-venomous animals, there is a high risk of contracting rabies. On early stage the disease is suppressed by anti-rabies serum. Such wounds in most cases become purulent, so they try to delay PSO. When performing the procedure, a primary delayed suture is applied and antiseptic medications are used.
A wound caused by a snake bite requires the application of a tight tourniquet or bandage. In addition, the wound is frozen with novocaine or cold is applied. To neutralize the poison, anti-snake serum is injected. Spider bites are blocked with potassium permanganate. Before this, the poison is squeezed out and the wound is treated with an antiseptic.
Complications
Failure to thoroughly treat the wound with antiseptics leads to suppuration of the wound. The use of the wrong pain reliever, as well as the infliction of additional injuries, causes anxiety in the patient due to the presence of pain.
Rough treatment of tissues and poor knowledge of anatomy lead to damage to large vessels, internal organs and nerve endings. Insufficient hemostasis causes the appearance of inflammatory processes.
It is very important that the primary surgical treatment of the wound is carried out by a specialist in accordance with all the rules.
PSO is the first surgical operation performed on a patient with a wound under aseptic conditions, with anesthesia and consisting of the sequential implementation of the following steps:
1) dissection;
2) audit;
3) excision of the edges of the wound within apparently healthy tissues, walls and bottom of the wound;
4) removal of hematomas and foreign bodies;
5) restoration of damaged structures;
6) if possible, suturing.
The following wound suturing options are possible:
1) layer-by-layer suturing of the wound tightly (for small wounds, lightly contaminated, when localized on the face, neck, torso, with a short period from the moment of injury);
2) suturing the wound leaving drainage;
3) the wound is not sutured (this is what they do when high risk infectious complications: late postoperative surgery, heavy contamination, massive tissue damage, accompanying illnesses, elderly age, localization on the foot or lower leg).
Types of PHO:
1) Early (up to 24 hours from the moment the wound is inflicted) includes all stages and usually ends with the application of primary sutures.
2) Delayed (from 24-48 hours). During this period, inflammation develops, swelling and exudate appear. The difference from early PSO is that the operation is performed while antibiotics are administered and the intervention is completed by leaving it open (not sutured) with the subsequent application of primary delayed sutures.
3) Late (later than 48 hours). Inflammation is close to maximum and development begins infectious process. In this situation, the wound is left open and a course of antibiotic therapy is given. It is possible to apply early secondary sutures on days 7-20.
PHO are not subject to the following types wound:
1) superficial, scratches;
2) small wounds with a discrepancy of the edges of less than 1 cm;
3) multiple small wounds without damage to deeper tissues;
4) puncture wounds without damage to organs;
5) in some cases, through bullet wounds of soft tissues.
Contraindications to performing PSO:
1) signs of development of a purulent process in the wound;
2) critical condition of the patient.
Types of seams:
Primary surgical. Apply to the wound before granulation begins to develop. Apply immediately after completion of the operation or postsurgical treatment of the wound. It is not advisable to use in late PHO, PHO in war time, PCS of a gunshot wound.
Primary deferred. Apply until granulation develops. Technique: the wound is not sutured after surgery, monitored inflammatory process and when it subsides, this suture is applied for 1-5 days.
Secondary early. Applied to granulating wounds that are healing secondary intention. The application is carried out for 6-21 days. By 3 weeks after surgery, scar tissue forms at the edges of the wound, preventing both the approximation of the edges and the process of fusion. Therefore, when applying early secondary sutures (before the edges become scarred), it is enough to simply stitch the edges of the wound and bring them together by tying the threads.
Secondary late. Apply after 21 days. When applying, it is necessary to excise the scarred edges of the wound under aseptic conditions, and only then apply sutures.
Toilet wound. Secondary surgical treatment of wounds.
1) removal of purulent exudate;
2) removal of clots and hematomas;
3) cleansing the wound surface and skin.
Indications for VCO are the presence of a purulent focus, lack of adequate outflow from the wound, the formation of large areas of necrosis and purulent leaks.
1) excision of non-viable tissue;
2) removal of foreign bodies and hematomas;
3) opening pockets and leaks;
4) drainage of the wound.
Differences between PHO and VHO:
| Signs | PHO | VHO |
| Deadlines | In the first 48-74 hours | After 3 days or more |
| Main purpose of the operation | Prevention of suppuration | Treatment of infection |
| Condition of the wound | Does not granulate and does not contain pus | Granulates and contains pus |
| Condition of excised tissues | WITH indirect signs necrosis | WITH obvious signs necrosis |
| Cause of bleeding | The wound itself and tissue dissection during surgery | Arrosion of a vessel in conditions of a purulent process and damage during tissue dissection |
| Character of the seam | Closure with primary suture | Subsequently, secondary sutures may be applied. |
| Drainage | According to indications | Necessarily |
Classification by type of damaging agent: mechanical, chemical, thermal, radiation, gunshot, combined.
Types of mechanical injuries:
1 - Closed (skin and mucous membranes are not damaged),
2 - Open (damage to mucous membranes and skin; risk of infection).
3 - Complicated; Immediate complications that occur at the time of injury or in the first hours after it: Bleeding, traumatic shock, violation of vital important functions organs.
Early complications develop in the first days after injury: Infectious complications(wound suppuration, pleurisy, peritonitis, sepsis, etc.), traumatic toxicosis.
Late complications, detected at a time distant from the injury: chronic purulent infection; disruption of tissue trophism ( trophic ulcers, contracture, etc.); anatomical and functional defects of damaged organs and tissues.
4 - Uncomplicated.
Surgical treatment of wounds- surgical intervention consisting of a wide dissection of the wound, stopping bleeding, excision of non-viable tissue, removal of foreign bodies, free bone fragments, blood clots in order to prevent wound infection and create favorable conditions for wound healing. There are two types surgical treatment of wounds primary and secondary.
Primary surgical treatment of the wound- first surgery regarding tissue damage. Primary surgical treatment of wounds must be immediate and comprehensive. Performed on the 1st day after injury, it is called early; on the 2nd day - delayed; after 48 h from the moment of injury - late. Delayed and late surgical treatment of wounds are a necessary measure in case of mass influx of wounded, when it is impossible to perform surgical treatment in early dates to everyone in need. Proper organization is important medical triage, in which the wounded are identified with ongoing bleeding, tourniquets applied, avulsions and extensive destruction of the limbs, signs of purulent and anaerobic infection in need of immediate surgical treatment of wounds. For the remaining wounded, surgical debridement may be delayed. When transferring primary C. o. at a later date, they provide measures that reduce the risk of infectious complications, prescribe antibacterial agents. With the help of antibiotics, it is only possible to temporarily suppress the vital activity of wound microflora, which makes it possible to delay, rather than prevent, the development of infectious complications. The wounded are able to traumatic shock before surgical treatment of wounds carry out a set of anti-shock measures. Only if bleeding continues is it permissible to perform immediate surgical treatment while simultaneously carrying out anti-shock therapy.
The extent of surgical intervention depends on the nature of the injury. Stabbed and cut wounds with minor tissue damage, but with the formation of hematomas or bleeding, they should only be dissected in order to stop the bleeding and decompress the tissue. Wounds large sizes, the treatment of which can be done without additional tissue dissection (for example, extensive tangential wounds) are subject only to excision; through and blind wounds, especially with comminuted bone fractures, are subject to dissection and excision. Wounds with complex architecture wound channel, extensive damage to soft tissue and bones is dissected and excised; Additional incisions and counter-openings are also made to provide better access to the wound canal and drainage of the wound.
Surgical treatment is carried out strictly observing the rules of asepsis and antiseptics. The method of anesthesia is chosen taking into account the severity and location of the wound, the duration and traumatic nature of the operation, the severity general condition wounded.
Excision of the skin edges of the wound should be done very sparingly; Only non-viable, crushed areas of skin are removed. Then the aponeurosis is widely dissected and an additional incision is made in the area of the wound corners in the transverse direction so that the aponeurosis incision is Z-shaped. This is necessary so that the aponeurotic sheath does not compress the swollen muscles after injury and surgery. Next, the edges of the wound are pulled apart with hooks and damaged non-viable muscles are excised, which are determined by the absence of bleeding, contractility and characteristic resistance (elasticity) of muscle tissue. When carrying out primary treatment in the early stages after injury, it is often difficult to establish the boundaries of non-viable tissue; in addition, late tissue necrosis is possible, which may subsequently require re-treatment of the wound.
In case of forced delayed or late surgical treatment of wounds the boundaries of non-viable tissues are determined more accurately, which makes it possible to excise tissue within the outlined demarcations. As tissue is excised, foreign bodies and loose small bone fragments are removed from the wound. If at surgical treatment of wounds large vessels or nerve trunks are detected, they are carefully pushed aside with blunt hooks. Fragments of damaged bone, as a rule, are not treated, with the exception of sharp ends that can cause secondary trauma to soft tissues. Sparse sutures are placed on the adjacent layer of intact muscle to cover the exposed bone to prevent acute traumatic osteomyelitis. Muscles also cover naked great vessels and nerves to avoid vascular thrombosis and nerve death. In case of injuries to the hand, foot, face, genital organs, distal parts of the forearm and lower leg, the tissue is excised especially sparingly, because Wide excision in these areas can lead to permanent dysfunction or the formation of contractures and deformities. In combat conditions surgical treatment of wounds complemented by reconstructive operations: suturing of blood vessels and nerves, fixation of bone fractures metal structures and so on. In peacetime conditions, reconstructive operations are usually an integral part of the primary surgical treatment wound The operation is completed by infiltrating the wound walls with antibiotic solutions, drainage Active aspiration of wound discharge using silicone perforated tubes connected to vacuum devices is advisable. Active aspiration can be supplemented with wound irrigation antiseptic solution and applying a primary suture to the wound, which is only possible with constant monitoring and treatment in a hospital.
The most significant mistakes when surgical treatment of wounds: excessive excision of unchanged skin in the wound area, insufficient dissection of the wound, making it impossible to perform a reliable revision of the wound channel and complete excision of non-viable tissue, insufficient persistence in searching for the source of bleeding, tight wound tamponade for the purpose of hemostasis, the use of gauze tampons for drainage of wounds.
Secondary surgical treatment of the wound carried out in cases where primary treatment has not given an effect. Indications for secondary surgical treatment of wounds are the development of wound infection (anaerobic, purulent, putrefactive), purulent-resorptive fever or sepsis caused by retention of tissue discharge, purulent leaks, peri-wound abscess or phlegmon. The volume of secondary surgical treatment of the wound may vary. Complete surgical debridement purulent wound involves excision within healthy tissue. Often, however, anatomical and surgical conditions (danger of damage to blood vessels, nerves, tendons, joint capsules) allow only partial surgical treatment of such a wound. When the inflammatory process is localized along the wound canal, the latter is widely opened (sometimes with additional dissection of the wound), the accumulation of pus is removed, and foci of necrosis are excised. With the aim of additional rehabilitation wounds are treated with a pulsating jet of antiseptic, laser beams, low-frequency ultrasound, as well as vacuuming. Subsequently, proteolytic enzymes and carbon sorbents are used in combination with parenteral administration antibiotics. After complete cleansing of the wound, good development granulations, overlapping is acceptable secondary seams. When an anaerobic infection develops, secondary surgical treatment is carried out most radically, and the wound is not sutured. Treatment of the wound is completed by draining it with one or more silicone drainage tubes and suturing the wound.
The drainage system allows you to wash the wound cavity with antiseptics in the postoperative period and actively drain the wound when vacuum aspiration is connected (see. Drainage). Active aspiration-washing drainage of the wound can significantly reduce its healing time.
Treatment of wounds after their primary and secondary surgical treatment is carried out using antibacterial agents, immunotherapy, restorative therapy, proteolytic enzymes, antioxidants, ultrasound, etc. Treatment of the wounded under conditions of gnotobiological isolation is effective (see. Abacterial controlled environment), and for anaerobic infection - with the use hyperbaric oxygenation.
Bibliography: Davydovsky I.V. Gunshot wound of a person, vol. 1-2, M., 1950-1954; Deryabin I.I. and Alekseev A.V. Surgical treatment of wounds, BME, vol. 26, p. 522; Dolinin V.A. and Bisenkov N.P. Operations for wounds and injuries, L., 1982; Kuzin M.I. and others. Wounds and wound infection, M., 1989.
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