What does wound healing by secondary intention mean? Characteristics of the types of wound healing
Wound healing by secondary intention occurs with a purulent infection, when its cavity is filled with pus and dead tissues. The healing of such a wound is slow. By secondary intention, unsutured wounds heal with a divergence of their edges and walls. The presence of foreign bodies, necrotic tissues in the wound, as well as beriberi, diabetes, cachexia (cancer intoxication) impede tissues and lead to wound healing by secondary intention. Sometimes, with a purulent wound, its liquid contents spread through the interstitial cracks to any part of the body at a considerable distance from the focus of the process, forming streaks. In the formation of purulent streaks, insufficient emptying of the purulent cavity to the outside matters; most often they form with deep wounds. Symptoms: putrid smell of pus in the wound, fever, pain, swelling below the wound. Treatment of streaks - opening with a wide incision. Prevention - ensuring a free outflow of pus from the wound (drainage), full surgical treatment of the wound.
Usually, there are several stages of wound healing by secondary intention. First, the wound is cleared of necrotic tissue,. The process of rejection is accompanied by abundant purulent discharge and depends on the properties of the microflora, the patient's condition, as well as on the nature and prevalence of necrotic changes. Necrotized muscle tissue is quickly rejected, slowly - cartilage, bone. The terms of wound cleansing are different - from 6-7 days to several months. At subsequent stages, along with the cleansing of the wound, the formation and growth of granulation tissue occurs, in place of which, after epithelialization, scar tissue is formed. With excessive growth of granulation tissue, it is cauterized with a solution of lapis. under secondary tension, it has an irregular shape: multi-beam, retracted. The timing of scar formation depends on the area of the lesion, the nature of the inflammatory process.
Sewn uninfected wounds heal by primary intention (see above), unsewn - by secondary intention.
In an infected wound, infection hampers the healing process. Factors such as exhaustion, cachexia, beriberi, exposure to penetrating radiation, blood loss play a large role in the development of infection, aggravate its course and slow down wound healing. Severely flowing, developed in a contaminated wound, which was mistakenly sutured.
An infection caused by microbial flora that enters the wound at the time of injury and develops before granulation begins is called a primary infection; after the formation of a granulation shaft - a secondary infection. A secondary infection that develops after the elimination of the primary one is called reinfection. A combination of different types of microbes can occur in the wound, i.e., a mixed infection (anaerobic-purulent, purulent-putrefactive, etc.). The causes of secondary infection are gross manipulations in the wound, stagnation of purulent discharge, a decrease in the body's resistance, etc.
Practically important is the fact that during the primary infection, microbes, getting into the wound, begin to multiply and show pathogenic properties not immediately, but after a while. The duration of this period is on average 24 hours (from several hours to 3-6 days).
Then the pathogen spreads outside the wound. Rapidly multiplying, the bacteria penetrate the lymphatic pathways into the tissues surrounding the wound.
In gunshot wounds, infection occurs more often, which is facilitated by the presence of foreign bodies (bullets, shrapnel, pieces of clothing) in the wound channel. The high frequency of infection of gunshot wounds is also associated with a violation of the general condition of the body (shock, blood loss). Changes in tissues during a gunshot wound go far beyond the wound channel: a zone of traumatic necrosis forms around it, and then a zone of molecular concussion. Tissues in the last zone do not completely lose their viability, however, adverse conditions (infection, compression) can lead to their death.
Healing by secondary intention (sanatio per secundam intentionem; synonym: healing through suppuration, healing by granulation, sanatio per suppurationem, per granulationem) occurs if the wound walls are not viable or are far apart from each other, i.e., with wounds with a large area of damage ; with infected wounds, regardless of their nature; with wounds with a small area of damage, but widely gaping or accompanied by loss of substance. A large distance between the edges and walls of such a wound does not allow the formation of primary gluing in them. Fibrinous deposits, covering the surface of the wound, only mask the tissues visible in it, protecting them little from the influence of the external environment. Aeration and drying quickly lead to the death of these surface layers.
During healing by secondary intention, the phenomena of demarcation are pronounced, the cleansing of the wound is carried out with the melting of fibrinous masses, with the rejection of necrotic tissues and their discharge from the wound to the outside. The process is always accompanied by a more or less abundant discharge of purulent exudate. The duration of the inflammation phase depends on the prevalence of necrotic changes and the nature of the tissues to be rejected (quickly dead muscle tissue is rejected, slowly - tendon, cartilage, especially bone), on the nature and influence of the wound microflora, on the general condition of the body of the wounded. In some cases, the biological cleansing of the wound is completed in 6-7 days, in others it drags on for many weeks and even months (for example, with open infected fractures).
The third phase of the wound process (the regeneration phase) is only partially superimposed on the second. In full measure, the phenomena of reparation develop already after the end of the biological cleansing of the wound. They, as in per primam healing, come down to filling the wound with granulation tissue, but with the difference that not a narrow gap between the walls of the wound should be filled, but more. a significant cavity, sometimes with a capacity of several hundred milliliters, or a surface area of tens of square centimeters. The formation of large masses of granulation tissue is clearly visible when examining the wound. As the wound is filled with granulations, and mainly at the end of it, epithelialization occurs, coming from the edges of the skin. The epithelium grows on the surface of the granulations in the form of a bluish-white border. At the same time, in the peripheral parts of the granulation masses, a transformation into scar tissue takes place. The final formation of the scar usually occurs after the complete epithelialization of the granulations, i.e., after the wound has healed. The resulting scar often has an irregular shape, is more massive and extensive than after healing per primam, can sometimes lead to a cosmetic defect or impede function (see Scar).
The duration of the third phase of the wound process, like the second, is different. With extensive defects in the integument and underlying tissues, impaired general condition of the wounded and under the influence of a number of other unfavorable causes, the complete healing of the wound is significantly delayed.
The following circumstance is of utmost importance: the gaping of the wound inevitably leads to the introduction of microbes into it (from the surrounding skin, from the ambient air, during dressings - from the hands and from the nasopharynx of the personnel). Even a surgical, aseptically inflicted wound cannot be protected from this secondary bacterial contamination if its gaping is not eliminated. Accidental and combat wounds are bacterially contaminated from the very moment of application, and then secondary contamination is added to this primary contamination. Thus, wound healing by secondary intention occurs with the participation of microflora. The nature and degree of influence that microbes have on the wound process determines the difference between a bacterially contaminated wound and an infected wound.
bacterial contaminated they call a wound in which the presence and development of microflora does not aggravate the course of the wound process.
Microorganisms vegetating in the wound behave like saprophytes; they inhabit only necrotic tissues and the liquid content of the wound cavity, without penetrating into the depths of living tissues. A few microbes, mechanically introduced into the opened lymphatic tract, can almost always be detected in the next few hours after injury in the regional lymph nodes, where, however, they quickly die. Even short-term bacteremia can occur, which also does not have pathological significance. With all this, microorganisms do not have a noticeable local toxic effect, and the resulting general phenomena are due not to the number and type of microflora, but to the prevalence of necrotic changes in tissues and a greater or lesser mass of absorbed decay products. Moreover, feeding on dead tissues, microbes contribute to their melting and increased release of substances that stimulate demarcation inflammation, which means they can accelerate wound cleansing. Such an influence of the microbial factor is regarded as favorable; the abundant suppuration of the wound caused by it is not a complication, since it is inevitable during healing by secondary intention. Of course, this has nothing to do with a wound that must heal per primam. Thus, suppuration of a tightly sewn-up surgical wound is certainly a serious complication. "Clean" surgical wounds are not subject to suppuration in all cases of their bacterial contamination; it is known that despite strict observance of the rules of asepsis, microorganisms can almost always be found in these wounds before suturing (albeit in a minimal amount), and the wounds still heal without suppuration. Healing per primam is also possible with accidental wounds that obviously contain microflora, if the contamination is small, and the wound has a small area of tissue damage and is localized in an area with abundant blood supply (face, scalp, etc.). Therefore, bacterial contamination of the wound is a mandatory and not even a negative component of healing by secondary intention, and under certain conditions it does not prevent wound healing by primary intention.
In contrast to this, in infected In the wound, the influence of microflora significantly aggravates the course of the wound process during healing per secundam, and healing per primam makes it impossible. Microbes vigorously spread into the depths of viable tissues, multiply in them, and penetrate into the lymphatic and blood tracts. The products of their vital activity have a detrimental effect on living cells, causing a stormy, progressive nature of secondary tissue necrosis, and being absorbed, cause a pronounced intoxication of the body, and the degree of the latter is not adequate to the size of the wound and the area of damage to the surrounding tissues. Demarcation inflammation is delayed, and demarcation that has already begun may be disturbed. All this leads, at best, to a sharp slowdown in wound healing, at worst, to the death of the wounded from severe toxemia or from generalization of infection, i.e., from wound sepsis. The patterns of distribution of the process in tissues and morphological changes in them depend on the type of wound infection (purulent, anaerobic or putrefactive).
The causative agents are usually the same microorganisms that are contained in the wound when it is bacterially contaminated. This is especially true of the germs of putrefaction, which are present in every wound that heals per secundam, but only occasionally acquire the significance of causative agents of putrefactive infection. Pathogenic anaerobes - Clostr. perfringens, oedematiens, etc. - also often vegetate in the wound as saprophytes. Less common is contamination of the wound with pyogenic microbes - staphylococci and streptococci, which does not pass into infection.
The transition of bacterial contamination into wound infection occurs under a number of conditions. These include: 1) violation of the general condition of the body - exhaustion, bleeding, hypovitaminosis, damage by penetrating radiation, sensitization to this pathogen, etc.; 2) severe trauma to the surrounding tissues, which caused extensive primary necrosis, prolonged vasospasm, sharp and prolonged traumatic edema; 3) the complex shape of the wound (winding passages, deep "pockets", tissue stratification) and generally difficulty in outflow from the wound to the outside; 4) especially massive contamination of the wound or contamination by a particularly virulent strain of a pathogenic microbe. The influence of this last point is questioned by some authors.
However, only he explains the fact that "small" violations of asepsis in surgical work often pass without complications if the operating room is not contaminated with pyogenic (coccal) flora. Otherwise, a series of suppuration immediately appears after “clean” and low-traumatic operations (for hernia, dropsy of the testicle), and the same pathogen is found in all festering wounds. With such suppuration, only the immediate removal of sutures and dilution of the edges of the wound can prevent further development and severe course of the resulting wound infection.
With a favorable course of an infected wound, over time, the process is still delimited due to the formation of a zone of leukocyte infiltration, and then a granulation shaft. In tissues that have retained viability, the invading pathogens undergo phagocytosis. Further cleansing and reparation proceed as in a wound healing per secundam intentionem.
A wound infection is called primary if it developed before the onset of demarcation (i.e., in the first or second phase of the wound process), and secondary if it occurs when demarcation has already begun. A secondary infection that flared up after the elimination of the primary one is called reinfection. If an infection caused by another type of pathogen joins an incomplete primary or secondary infection, then they speak of superinfection. The combination of different types of infection is called a mixed infection (anaerobic-purulent, purulent-putrefactive, etc.).
The reasons for the development of a secondary infection can most often be external influences on the wound that violated the created demarcation barrier (rough manipulations in the wound, careless use of antiseptics, etc.), or stagnation of discharge in the wound cavity. In the latter case, the wound walls covered with granulations are likened to a pyogenic abscess membrane (see), which, with continued accumulation of pus, is usurated, allowing the process to spread to the surrounding tissues. Secondary infection and superinfection of the wound can also develop under the influence of a deterioration in the general condition of the wounded. A typical example is putrefactive superinfection of a wound injured by a primary anaerobic infection; the latter causes massive tissue necrosis and a sharp weakening of the organism as a whole, in which the putrefactive microflora, which has abundantly populated dead tissues, acquires pathogenic activity. It is sometimes possible to associate a secondary infection of a wound with additional contamination by some particularly virulent pathogen, but it is usually caused by microbes already present in the wound.
Along with the described local phenomena that characterize the wound and the course of the wound process, each wound (except for the lightest ones) causes a complex set of changes in the general state of the body. Some of them are caused directly by the trauma itself and accompany it, others are associated with the peculiarities of its subsequent course. Of the concomitant disorders, significant, life-threatening hemodynamic disturbances are practically important, arising from severe injuries due to profuse blood loss (see), super-strong pain irritations (see Shock), or both. Subsequent disorders are mainly due to the absorption of products from the wound and surrounding tissues. Their intensity is determined by the characteristics of the wound, the course of the wound process and the state of the body. In case of a wound with a small area of damage, healing by primary intention, general phenomena are limited to a febrile state for 1-3 days (aseptic fever). In adults, the temperature rarely exceeds subfebrile, in children it can be very high. Fever is accompanied by leukocytosis, usually moderate (10-12 thousand), with a shift of the leukocyte formula to the left and an acceleration of ROE; these indicators are aligned shortly after the normalization of temperature. With suppuration of the wound, a more pronounced and prolonged purulent-resorptive fever develops (see).
With it, the intensity and duration of temperature and hematological changes are the greater, the more significant the area of tissue damage, the more extensive the primary and secondary necrotic changes, the more bacterial toxins are absorbed from the wound. Purulent-resorptive fever is especially evident when the wound is infected. But if there are very significant masses of necrotic tissues in the wound, the rejection of which takes a long time, then even without the transition of bacterial contamination of the wound into an infection, a pronounced and prolonged purulent-resorptive fever sharply weakens the wounded and threatens the development of traumatic exhaustion (see). An important feature of purulent-resorptive fever is the adequacy of general disorders to local inflammatory changes in the wound. Violation of this adequacy, the development of severe general phenomena that cannot be explained only by resorption from the wound, indicate a possible generalization of the infection (see Sepsis). At the same time, the insufficiency of the body's defense reactions, which arose as a result of severe intoxication from the wound and blood loss, can distort the picture of general disorders, leading to the absence of a temperature reaction and leukocytosis. The prognosis in cases of such an "areactive" course of wound infection is unfavorable.
According to the method of healing, wounds are divided into wounds that heal by primary intention, secondary intention and heal under the scab (Fig. 1).
Primary Tension aseptic or accidental wounds heal with small sizes, when the edges are separated from each other by no more than 10 mm, with a slight infection. In most cases, wounds heal by primary intention after primary surgical debridement with suturing. This is the best type of wound healing, it occurs quickly, within 5-8 days, does not cause complications and functional disorders. The scar is smooth, inconspicuous. When healing by primary intention, there may be complications
Rice. 1. Types of wound healing (scheme):
a – healing by primary intention;
b - healing by secondary intention.
in the form of suppuration and / or divergence of the edges of the wound. Divergence without suppuration is rare and is the result of defects in surgical technique. The main cause of suppuration is insufficient surgical treatment of the wound, unjustified suturing and / or extensive trauma to the surrounding tissues. Local purulent infection usually develops within the first 3-5 days after injury. If there are signs of suppuration or even a suspicion of the possibility of its development, it is necessary to revise the wound without removing the sutures by spreading the edges of the wound. If at the same time a site of necrosis and / or even a small amount of purulent or serous discharge is detected, then the fact of suppuration becomes certain. In the future, such a wound heals by secondary intention.
Healing secondary tension occurs after severe inflammation through suppuration and the development of granulation tissue, which then transforms into a rough scar. The process of cleansing a purulent wound proceeds in stages. With a good outflow within 4-6 days, a distinct demarcation of the entire wound develops and separate granulations appear. If the boundaries with viable tissues are not defined, wound cleansing cannot be completed on its own. This is an indication for secondary debridement and additional drainage. Sometimes healthy granulation tissue can close sequesters and microabscesses in the depth of the wound, which is clinically manifested by tissue infiltration and subfebrile temperature. In these cases, a wide revision and secondary surgical treatment of the wound is necessary, which is carried out by a specialist surgeon. Objective criteria for assessing the course of the wound process:
Wound healing speed. With normal healing, the wound area decreases by 4% or more per day. If the rate of healing slows down, then this may indicate the development of complications.
bacteriological control. A bacteriological analysis of biopsy specimens is carried out by determining the number of microbes per 1 g of tissue. If the number of microbes rises to 10x5 or more per 1 g of tissue, then this indicates the development of local purulent complications.
Healing under the scab occurs with superficial skin lesions - abrasions, abrasions, burns, etc. The scab is not removed if there are no signs of inflammation. Healing under the scab lasts 3-7 days. If pus has formed under the scab, then surgical treatment of the wound is necessary with the removal of the scab, and further healing occurs according to the type of secondary intention.
Complications of wound healing include the development of infection, bleeding, gaping.
With simultaneous damage to the liver or intestines, a wound complicated by organ damage is indicated.
I.Y. Wounds are also divided according to the damaged part of the body, for example, wounds of the face, head, neck, upper limbs, and the like.
Y. Of great importance is the division of wounds according to the degree of their infection. Only surgical wounds after elective operations or wounds after their primary surgical treatment are considered aseptic. Close to aseptic wounds are incised and chopped wounds, which are caused by a sharp and relatively clean object, for example, a cut with a razor while shaving. All other wounds are regarded as infected, since at the time of injury, the microorganisms were both on the skin and on the objects that caused the wounds.
YI. Wounds are also divided into fresh and late. A wound is considered fresh if the victim asked for help within the first 24 hours after the injury. Wound infection in them can be stopped surgically, excising the edges and bottom of the wound. In this way, an infected wound can be converted into an aseptic wound. If the victim asked for help after 24 hours or later (microorganisms penetrated into the deeper layers of tissues), such wounds are defined as belated.
3.2. Types of wound healing.
Wound healing is a regenerative process that reflects the biological and physiological response to injury. Not all tissues have the same ability to regenerate. The more differentiated tissues are, the slower they recover. The most highly differentiated cells of the central nervous system are practically incapable of regeneration at all. Peripheral nerves can regenerate in the direction from the center to the periphery - 2 axons of the proximal part of the nerve grow into its distal part. The integumentary epithelium, connective tissue derivatives (fascia, tendons, bones), as well as smooth muscles, regenerate well. The striated muscles and parenchymal organs have very low regenerative abilities, their wounds usually heal with a connective tissue scar.
Wound healing can be hindered by local and general factors. Wounds heal worse if large blood vessels and nerves are damaged, if they contain foreign bodies, necrotic tissues, bone sequesters, virulent microorganisms. The general condition of the patient is also negatively affected by concomitant diseases - hypovitaminosis, chronic inflammatory diseases, diabetes mellitus, heart and kidney failure, as well as the inferiority of the immune system.
There are three types of wound healing - primary, secondary and healing under the scab.
The wound heals primarily if its edges are smooth, viable and closely in contact, if there are no cavities and hemorrhages in the wound, there are no foreign bodies, foci of necrosis and infection.
Primary wound healing is observed after aseptic operations, full-fledged primary surgical treatment of wounds, and in some cases with other wounds. It happens quickly - within 5-8 days a smooth and inconspicuous scar is formed.
Secondary healing is observed in cases where one or more of the conditions necessary for primary healing are absent, when the edges of the wound are not viable, do not adjoin each other, there is a large wound cavity and hemorrhages, foci of necrosis, foreign bodies and purulent infection. Healing by secondary intention is also facilitated by general factors: cachexia, hypovitaminosis, metabolic disorders or infectious diseases (tonsillitis, influenza, etc.). Secondary wound healing is characterized by suppuration and the formation of granulations.
The appearance of granulations is due to the fact that during the secondary healing of the wound, an abundant growth of capillaries of blood vessels is revealed. Separate capillaries reach the surface of the wound, but since the edges of the wound are not connected and are located far from each other, the capillaries do not grow together, but form loops.
Connective tissue cells, rapidly multiplying, quickly cover the capillary loops - as a result, granulation tissue develops, which is covered with a thin layer of fibrin. As the granulations grow, the foci of necrosis are gradually cleared and the epithelium is formed. Epithelialization starts from the edges of the wound. Young epithelial tissue can also grow in the form of islands on the surface of the wound. After maturation, the granulation tissue becomes harder and turns into scar tissue.
Granulation tissue plays an important role in the wound healing process. It covers deeper tissues and protects them from infection. Wound discharge has bactericidal properties.
If the granulation tissue is damaged, the wound begins to bleed and the infection can penetrate into its deep layers. Therefore, when dressing a granulating wound, it is necessary to avoid mechanical or chemical irritation (damage), and the dressings themselves are made less frequently.
Normal granulation tissue is pink, granular, relatively firm, does not bleed, and has scant discharge. Granulations can be "sick" - plentiful friable or underdeveloped, with a large amount of discharge.
Healing proceeds slowly, a wide and uneven scar is formed. Occasionally, skin tightening scars and contractures of the joints are formed.
Large and superficial wounds (abrasions, scratches, and burns) often heal under a crust (eschar), which is formed by a blood clot and lymph. Approximately within 5 days, epithelization occurs under the crust and the wound heals, after which the scab disappears.
3.3. First aid for wounds.
1. Stop bleeding. To do this, all possible methods are used - finger pressure of the vessel throughout, tight bandaging of the wound, application of a hemostatic arterial tourniquet, etc.
2. The imposition of an aseptic bandage - to prevent bacterial contamination of the wound.
Anesthesia - all available analgesics are used. Is an anti-shock event
Occurs with minor injuries such as superficial abrasions of the skin, damage to the epidermis, abrasions, burns, etc.
The healing process begins with coagulation of the outflow of blood, lymph and tissue fluid on the surface of the injury, which dry up to form a scab.
The scab performs a protective function, is a kind of "biological bandage". Under the scab, rapid regeneration of the epidermis takes place, and the scab is sloughed off. The whole process usually takes 3 -7 days. In healing under the scab, the biological features of the epithelium are mainly manifested - its ability to line living tissue, limiting it from the external environment.
The scab should not be removed if there are no signs of inflammation. If inflammation develops and purulent exudate accumulates under the scab, surgical treatment of the wound with the removal of the scab is indicated.
Healing under the scab occupies an intermediate position and is a special type of healing of superficial wounds.
Wound healing complications
1. Development of infection
The development of nonspecific purulent infection, as well as anaerobic infection, tetanus, rabies, diphtheria, etc.
2. Bleeding
3. Divergence of the edges of the wound (insolvency of the wound) (eventration). Occurs in the early postoperative period (up to 7-10 days), when the strength of the emerging scar is small and tissue tension is observed (intestinal obstruction, flatulence, increased intra-abdominal pressure).
The outcome of the healing of any wound is the formation of a scar.
After healing by primary intention, the scar is even, is on the same level with the entire surface of the skin, linear.
When healing by secondary intention, the scar has an irregular stellate shape, dense. Usually such scars are retracted, located below the surface of the skin.
All scars are divided into normal and hypertrophic.
A normal scar consists of normal connective tissue and is elastic.
Hypertrophic scars consist of dense fibrous tissue and are formed with excessive collagen synthesis.
Keloid - a scar that penetrates into the surrounding normal tissues, not previously involved in the wound process. Its growth usually begins 1-3 months after wound epithelialization. Stabilization of the scar occurs on average through 2 of the year after his appearance.
The morphological structure of a keloid is overgrowing immature connective tissue with many atypical giant fibroblasts. The pathogenesis of keloid formation remains unclear to date. A certain role is played by the mechanisms of autoaggression on one's own immature connective tissue.
Scar complications
Scar contractures.
Scar ulceration.
Scar papillomatosis.
Tumor degeneration scar tissue (malignancy).
Wound treatment
General tasks facing the surgeon in the treatment of any wound:
2. Prevention and treatment of infection in the wound.
3. Achieving healing in the shortest possible time.
4. Complete restoration of the function of damaged organs and tissues.
1. FIRST AID
eliminate early life-threatening wound complications,
prevent further infection of the wound.
The most severe early complications of a wound are bleeding, the development of traumatic shock, and damage to vital internal organs.
Except initial entry of microorganisms possibly in a wound and their further penetration from the skin of the patient, from the surrounding air, from various objects. To prevent additional penetration of bacteria into remove impurities from the surrounding skin.
Then follows lubricate the edges of the wound 5% alcohol tincture of iodine and apply an aseptic bandage, and if necessary - pressing.
Further measures for the treatment of the wound are determined by its type according to the degree of infection. Allocate treatment of operating (aseptic), freshly infected and purulent wounds.
Features of wound healing by secondary intention
Secondary tension differs from primary in that there is a cavity between the edges of the wound, which is filled with newly formed young tissue, called granulation tissue.
Healing by secondary intention occurs with an unsutured surgical wound, in the presence of a foreign body or blood clots, a necrotic focus, and also in the absence of tissue plasticity due to exhaustion, cachexia, beriberi, metabolic disorders, infection in the wound or in the body of the wounded.
All purulent wounds or wounds in which there is a tissue defect heal by secondary intention.
Mechanism of development of granulation tissue. Immediately after the injury, the surface of the wound is covered with a thin layer of clotted blood, which, together with the exudate, forms a fibrous film.
With infection, damage and death of tissues that form the bottom and edges of the wound, symptoms of inflammation develop: the edges of the wound swell, hyperemia appears, local temperature rises, and pain occurs; the bottom of the wound is covered with serous-purulent discharge.
The development of inflammatory phenomena depends on the degree of tissue reaction and the virulence of the infection. After 48-96 hours, small nodules of bright red color (granules) appear on separate parts of the wound; their number gradually increases and the entire surface of the wound, cracks and pockets are filled with a new, young tissue, which is called granulation tissue.
Wound regeneration process
According to N. N. Anichkov et al., 1951, the process of wound regeneration consists of 3 sequentially developing stages:
Filling the wound defect with subcutaneous fatty tissue, which then undergoes inflammatory changes and atrophy;
Replacement of fatty tissue with granulation tissue formed in its place;
Replacement of granulation tissue with fibrous tissue and scar.
If the ability of the epithelium to grow stops, then epithelization of the wound is impossible - a non-healing ulcer remains.
Regeneration of nerve fibers in the skin begins later, from cut skin branches from the edges of the wound; regenerating nerve fibers are sent to the epithelium covering the wound, under which end sensitive apparatuses are formed; regeneration is slow, only after 2 weeks can an increase in nerve fibers be noted at the edges of the wound.
Granulation tissue is a good barrier, mechanically protecting the wound from external harmful influences, absorption of bacteria, toxins.
The secret released from the wound, having bactericidal properties, mechanically and biologically washes and cleans it.
Granulation tissue is delicate and easily vulnerable. Mechanical and chemical effects, rubbing with a gauze ball, cauterization with lapis, the use of a hypertonic solution can damage the granulations and open the gate for the absorption of infection and its toxins.
Wound (inflammatory) purulent exudate
Pus (Pus) is an inflammatory exudate rich in protein and containing cellular elements, mainly neutrophils, and a large number of bacteria (streptococci, staphylococci, less often anaerobes), enzymes. It differs in color, smell, morphological and chemical content. The reaction is alkaline, sometimes (with a high content of fatty acids) it can be acidic. Under the influence of enzymes, which are rich in pus, there is a resorption of dead tissues, decay products, which undergo further splitting. The source of enzymes are both destroyed cells and bacteria.
Under the influence of glycolytic enzymes, lactic acid is formed, which is one of the acidity factors.
The products of proteolysis are absorbed into the general blood stream and cause intoxication (resorption fever).
Basic Principles of Wound Treatment
Modern methods of wound treatment
Modern methods of wound treatment are based on:
Prevention and control of wound infection and intoxication;
Accounting for the local and general reaction of the body to injury and infection of the wound;
Dynamic data (period or phase of the wound process);
Individualization of the patient, his age-related typological features.
Wound infection is associated with the fact that all accidental wounds are primarily microbially contaminated. In the first 6-12 hours, microbes are in a static state, that is, they adapt to a new environment, do not multiply and do not show pathogenic properties. Therefore, the primary surgical treatment of the wound in the first 6-12 hours after the injury allows you to remove microbes mechanically, that is, to perform the primary surgical treatment of the wound - the main method of treating wounds and preventing wound infection.
Of the numerous microbes that have entered the wound, only those types of them can be a source of wound complications that have pathogenic activity (fulminant sepsis) or the development of which is favored by the conditions of the wound environment (blood clots, dead tissues, foreign bodies, etc.). One of the conditions that increase the pathological activity of microbes is the synergistic effect of their individual groups.
Therefore, chain breaking in the microbial association (dehydration, drying, antiseptics, antibiotics) can prevent the development of infection in the wound or reduce its degree.
The local reaction of tissues is a manifestation of the general reaction of the body. With an infected wound, the local tissue reaction is expressed in neurovascular disorders, edema, mobilization of cellular elements and strengthening of the wound barrier. With a fresh infected wound, prevention of the development of infection (specific and nonspecific) is of great importance. In the presence of an infection in the wound, conditions are created for the outflow of pus from it, the immunobiological state of the body increases.
Treatment of wounds taking into account the dynamics of the wound (inflammatory) process
Wound treatment is based on taking into account the 2-phase course of the inflammatory process, morphological, pathophysiological and biophysical-chemical changes in the wound in its 1st and 2nd phases (periods). The clinical picture of the wound will be different at the height of inflammation and during its regeneration, granulation. Treatments will also be different.
In the 1st period, or phase, of the wound process, rest, physical and chemical antiseptics, increased exudation, promotion of active hyperemia, swelling of colloids, enzymatic breakdown of dead tissues, increased phagocytosis and a decrease in the virulence of microbes are recommended. Traumatic dressings, vasoconstrictors and agents that reduce hydration and dry out the wound (frequent dressings, ice, calcium, dry dressings, etc.) are not recommended.
The most acceptable means in this period will be osmotic agents, bactericidal, antiseptic drugs (penicillin, sulfonamides, gramicidin, chloramine, chloracid, Vishnevsky ointment), bacteriophages, enzymes, etc.
In the 2nd period, when the wound is almost cleared of decay products, when there is a strong wound barrier, when most of the bacteria are phagocytosed or have lost their activity, when morphologically we have a mononuclear reaction and a partial transition of macrophages to the fibroblast stage, the agents used in 1- th period of the inflammatory process, it is impossible to use in the 2nd period: hypertonic solutions, wet dressings, antiseptics, etc. are contraindicated. In the 2nd period of the wound process, it is necessary to protect granulations from damage and secondary infection, promote granulation, scarring and epithelialization. Dressings with fish oil, petroleum jelly, sterile indifferent powder, talc, or open treatment are recommended. Physiotherapeutic procedures and tissue grafting according to Filatov are used.
The general reaction of the body is manifested in a change in the neurovascular and reticulo-endothelial apparatus, metabolism and the endocrine system. Depending on the severity of the clinical manifestation of the infection, this reaction will be different, ranging from imperceptible changes to significant changes in the subjective and objective nature, severe intoxication or septic conditions.
Assessment of the general condition of the patient, his reactivity, the degree of damage to individual organs and systems, metabolic disorders is a necessary condition for choosing therapeutic measures to reduce intoxication, protect the nervous, vascular and endothelial systems from damage by toxins. Depending on this, appropriate measures are taken to reduce reactivity in acute course and a sharp severity of reactive processes and, conversely, to increase it, with a decrease in the intensity of reactive processes, indicating a lack of protective forces of the body.
These fundamental provisions determine the methods of wound treatment.
Anti-tetanus serum is always administered, and, according to indications, anti-gangrenous serum (for anaerobic infection).
With a possible variety in the course of the wound process, depending on the nature of the injury, the degree of development of the microflora, and the characteristics of the impaired immune response, they cannot always be reduced to three classical types of healing:
· healing by primary intention;
· healing by secondary intention
· healing under the scab.
1. Healing by primary intention (sanatio per priman intentionem) occurs in a shorter time with the formation of a thin, relatively durable scar. Surgical wounds heal by primary intention when the edges of the wound come into contact with each other. (connected with seams). The amount of necrotic tissue in the wound is small, the inflammation is not pronounced.
Occasional superficial wounds of small size with margins of up to one centimeter may also heal by primary intention without suturing. This is due to the convergence of the edges under the influence of edema of the surrounding tissues, and in the future they are held by the resulting “primary fibrin adhesion”. Thus, with this method of healing, there is no cavity between the edges and walls of the wound, and the resulting tissue serves only to fix and strengthen the fused surfaces.
In order for a wound to heal by primary intention, the following conditions must be met:
· absence of infection in the wound;
· tight contact of the edges of the wound;
· absence of hematomas and foreign bodies in the wound;
· Absence of necrotic tissue in the wound;
· satisfactory general condition of the patient.
2. Healing by secondary intention (sanatio per secundam intentionem) - healing through suppuration, through the development of granulation tissue. In this case, when healing occurs after a pronounced inflammatory process, as a result of which the wound is cleared of necrosis. Wound healing by secondary intention requires conditions opposite to those that favor primary intention:
· significant microbial contamination of the wound;
· a significant defect in the skin;
· the presence of necrotic tissue;
· unfavorable condition of the patient.
With secondary intention, there are two phases of healing, each of which has certain differences.
In the first period, inflammation is much more pronounced, and the cleansing of the wound takes much longer. At the border of inflammation, a pronounced leukocyte shaft is formed. It helps to separate healthy tissues from infected ones. Gradually, demarcation, lysis occurs. As a result, at the end of the first phase, a wound cavity is formed and the second phase begins - the regeneration phase.
6. Rules for carrying out PST in case of injuries.
Treatment of fresh wounds begins with the prevention of wound infection, i.e. with the implementation of all measures to prevent the development of infection. Any accidental wound is primarily infected, because. microorganisms in it multiply rapidly and cause suppuration.
1. An accidental wound must be surgically treated. Currently, for the treatment of accidental wounds, an operative method of treatment is used, i.e. primary surgical treatment of wounds. Any wound must be subjected to PST of the wound.
By means of PST wounds, one of the following 2 tasks can be solved:
1) The transformation of a bacterially contaminated accidental or combat wound into a practically aseptic surgical wound (“sterilization of the wound with a knife”).
2) Transformation of a wound with a larger area of damage to surrounding tissues into a wound with a small area of damage, simpler in shape and less contaminated with bacteria.
We distinguish the following types of surgical treatment of wounds:
1) Wound toilet.
2) Complete excision of the wound within aseptic tissues, allowing, if successful, healing of the wound under the sutures by primary intention.
3) Dissection of the wound with excision of non-viable tissues, which creates conditions for uncomplicated wound healing by secondary intention.
1. Wound toilet
is performed for any wound, but as an independent measure, it is carried out with minor superficial incised wounds, especially on the face, on the fingers, where other methods are not usually used. The toilet of the wound means cleaning, by means of a gauze ball moistened with gasoline, or ether, alcohol, or alcohol, ( or other antiseptic) the edges of the wound and its circumference from dirt, removing adhering foreign particles, lubricating the edges of the wound with iodonate and applying an aseptic bandage. It should be noted that when cleaning the circumference of the wound, movements should be made from the wound outward, and not vice versa, in order to avoid introducing a secondary infection into the wound. Complete excision of the wound with the imposition of a primary or primary delayed suture on the wound (i.e., an operation is performed - the primary surgical treatment of the wound). Wound excision is based on the doctrine of the primary infection of an accidental wound.
1 - Stage excision
and dissection of the edges and bottom of the wound within healthy tissues. It should be noted that we do not always cut the wound, but almost always cut it. We dissect in those cases when it is necessary to revise the wound. If the wound is located in the area of large muscle masses, for example: on the thigh, then all non-viable tissues are excised, especially muscles within healthy tissues along with the bottom of the wound, up to 2 cm wide. This is not always possible to complete and strictly enough. This is sometimes prevented by the tortuous course of the wound or functionally important organs and tissues located along the wound channel. The wound after excision is washed with antiseptic solutions, thorough hemostasis is carried out and should not be washed with antibiotics - allergization.
2 - Stage wound
sutured tightly in layers. Sometimes PXO of a wound turns into a rather complicated operation, and one must be prepared for this. A few words about the features of PST wounds localized on the face and hand. On the face and hand, a wide PST of wounds is not performed, because. these areas have little tissue, and we are interested in cosmetic considerations after surgery. On the face and hand, it is enough to minimally refresh the edges of the wound, toilet it and apply the primary suture. Features of the blood supply to these areas allow this to be done. Indication for PST of wounds: In principle, all fresh wounds should be subjected to PST. But a lot also depends on the general condition of the patient, if the patient is very heavy, in a state of shock, then PST is delayed. But if the patient has profuse bleeding from the wound, then, despite the severity of his condition, PST is carried out.
Timing of PST wounds.
The most optimal time for PST is the first 6-12 hours after injury. The earlier the patient arrives and the earlier the PST of the wound is performed, the more favorable the outcome. This is an early PST wound. Time factor. At present, they have somewhat departed from the views of Friedrich, who limited the period of PST to 6 hours from the moment of injury. PST, carried out after 12-14 hours, is usually a forced treatment due to the late arrival of the patient. Thanks to the use of antibiotics, we can extend these periods, even up to several days. This is a late PST wound. In those cases when PST of the wound is performed late, or not all non-viable tissues are excised, then primary sutures can not be applied to such a wound, or such a wound can not be tightly sutured, but the patient can be left under observation in the hospital for several days, and if the condition allows in the future wounds, then take it in tightly.
Therefore, we distinguish:
1) Primary seam
when the suture is applied immediately after injury and PST wounds.
2) Primary
o - delayed suture, when the suture is applied 3-5-6 days after the injury. The suture is applied to the pre-treated wound until granulations appear, if the wound is good, without clinical signs of infection, with the general good condition of the patient.
3) Secondary seams
, which are superimposed not to prevent infection, but to accelerate the healing of an infected wound. Among the secondary seams we distinguish:
a) Early secondary suture
superimposed 8-15 days after injury. This suture is applied to a granulating wound with movable, non-fixed edges without scarring. Granulations are not excised, the edges of the wound are not immobilized.
b) Late secondary suture
in 20-30 days and later after injury. This suture is applied to a granulating wound with the development of scar tissue after excision of the scar edges, walls and bottom of the wound and mobilization of the wound edges.
PST wounds are not performed:
a) with penetrating wounds (for example, bullet wounds)
b) for small, superficial wounds
c) in case of wounds on the hand, fingers, face, skull, the wound is not excised, but a toilet is made and sutures are applied
d) purulent wounds are not subject to PHO
e) complete excision is not feasible if the wound walls include anatomical formations, the integrity of which must be spared (large vessels, nerve trunks, etc.)
e) shock.
3. Wound dissection
. Where, due to anatomical difficulties, it is not possible to completely excise the edges and bottom of the wound, a wound dissection should be performed. Dissection with its modern technique is usually combined with excision of non-viable and obviously contaminated tissues. After dissection of the wound, it becomes possible to revise and mechanically clean it, ensure free outflow of discharge, improve blood and lymph circulation; the wound becomes available for aeration and therapeutic effects of antibacterial agents, both introduced into the wound cavity and especially circulating in the blood. In principle, the dissection of the wound should ensure its successful healing by secondary intention.
7. Principles of local and general treatment of clean and purulent wounds.
Despite many specific features of various wounds, the main stages of their healing are fundamentally the same. It is possible to single out the general tasks facing the surgeon in the treatment of any wound:
· the fight against early complications;
· prevention and treatment of infection in the wound;
· achievement of healing in the shortest possible time;
· complete restoration of the function of damaged organs and tissues.
Granulation tissue - a special type of connective tissue, which is formed only during wound healing by the type of secondary intention, contributing to the rapid closure of the wound defect. Normally, without damage, there is no granulation tissue in the body. Islets of granulation tissue appear in the still not completely cleansed wound, against the background of areas of necrosis as early as 2-3 days. Granulations are delicate, bright pink, fine-grained, shiny formations that can grow rapidly and bleed profusely, with little damage.
The role of the entire granulation is as follows:
· wound substitution defect, is the main plastic material;
· wound protection from the penetration of microorganisms and the ingress of foreign bodies: it is achieved by the content of a large number of leukocytes and microphages in it and the dense structure of the outer layer;
· sequestration and rejection of necrotic tissues, which is facilitated by the activity of leukocytes, microphages and the release of proteolytic enzymes by cellular elements;
With the normal course of regeneration processes, epithelialization begins simultaneously with the development of granulations. As a result, the wound cavity is reduced, and the surface is epithelialized. The granulation tissue that filled the wound cavity is gradually transported into the mature, coarse fibrous connective tissue - a scar is formed.
Healing under the scab.
Occurs with minor injuries such as superficial abrasions of the skin, damage to the epidermis, abrasions, burns, etc. Rapid regeneration of the epidermis occurs under the scab, the scab is a "biological bandage" and the scab is torn off. The whole process usually takes 3-7 days. The scab should not be removed if there are no signs of inflammation.
If inflammation develops and purulent exudate accumulates under the scab, surgical treatment of the wound with the removal of the scab is indicated.
Complications of wound healing.
Wound healing can be complicated by various processes, the main of which are:
1. infection development - non-specific purulent, anaerobic infection, as well as the development of tetanus, rabies, diphtheria, etc.
2. bleeding. Both primary and secondary bleeding may occur.
3. discrepancy edges of the wound (wound failure). Considered as a severe complication of healing. It is especially dangerous with a penetrating wound of the abdominal cavity, as it can lead to the exit of internal organs (intestine, stomach, omentum, etc.) - eventration. It occurs in the early postoperative period (from 7 to 10 days), when the strength of the forming node is low and tissue tension is observed (intestinal obstruction, flatulence, increased intra-abdominal pressure). The divergence of all layers of the surgical wound requires urgent re-surgical intervention.
Scars and their complications .
The outcome of the healing of any wound is the formation of a scar. The nature and properties of the scar, first of all, depend on the method of healing.
Differences of scars during healing by primary and secondary intention.
After healing by primary tension, the scar is even, is on the same level with the entire surface of the skin, linear, indistinguishable in consistency from the surrounding tissues, mobile.
When healing by secondary intention, the scar has an irregular shape, dense, often pigmented, and inactive. Typically, such scars are retracted, located below the skin surface, since the granulation tissue is replaced by scar connective tissue, which has a higher density and a smaller volume, which leads to retraction of the surface layers of the epithelium.
The process of wound healing is a reaction of the whole organism to injury, and the state of nervous trophism is of great importance in wound healing.
Depending on the reaction of the body, the state of nervous trophism, infection and other conditions, the process of wound healing is different. There are two types of healing. In some cases, the adjacent edges of the wound stick together with the subsequent formation of a linear scar and without the release of pus, and the entire healing process ends in a few days. Such a wound is called clean, and its healing is called healing by primary intention. If the edges of the wound gape or parted due to the presence of an infection, its cavity is gradually filled with a special newly formed tissue and pus is released, then such a wound is called purulent, and its healing is called healing by secondary intention; Wounds by secondary intention heal longer.
Cream "ARGOSULFAN®" helps to accelerate the healing of abrasions and small wounds. The combination of the antibacterial component of silver sulfathiazole and silver ions provides a wide range of antibacterial action of the cream. You can apply the drug not only on wounds located in open areas of the body, but also under bandages. The agent has not only a wound healing, but also an antimicrobial effect, and in addition, it promotes wound healing without a rough scar (1). It is necessary to read the instructions or consult with a specialist.
All surgical patients, depending on the course of the wound process, are divided into two large groups. Patients who undergo operations under aseptic conditions, who do not have purulent processes and wound healing occurs by primary intention, make up the first group - the group of clean surgical patients. The same group includes patients with accidental wounds, in whom wound healing after primary surgical treatment occurs without suppuration. A huge number of patients in modern surgical departments belong to this group. Patients with purulent processes, with accidental wounds, usually infected and healing by secondary intention, as well as those postoperative patients who heal with wound suppuration, belong to the second group - the group of patients with purulent surgical diseases.
Healing by primary intention. Wound healing is a very complex process in which a general and local reaction of the body and tissues to damage is manifested. Healing by primary intention is possible only when the edges of the wound are adjacent to each other, being brought together by sutures, or simply touching. Infection of the wound prevents healing by primary intention in the same way that necrosis of the wound edges (contusion wounds) also prevents it.
Wound healing by primary intention begins almost immediately after the wound, at least from the moment the bleeding stops. No matter how exactly the edges of the wound touch, there is always a gap between them, filled with blood and lymph, which soon coagulate. In the tissues of the edges of the wound there is a greater or lesser number of damaged and dead tissue cells, they also include red blood globules that have left the vessels and blood clots in the cut vessels. In the future, healing follows the path of dissolution and resorption of dead cells and restoration of tissues at the incision site. It occurs mainly by the reproduction of local connective tissue cells and the release of white blood cells from the vessels. Due to this, already during the first day, the primary gluing of the wound occurs, so that some effort is already needed to separate its edges. Along with the formation of new cells, there is a resorption and dissolution of damaged blood cells, fibrin clots and bacteria that have entered the wound.
Following the formation of cells, a new formation of connective tissue fibers also occurs, which ultimately leads to the construction of a new tissue of a connective tissue nature at the site of the wound, and there is also a new formation of vessels (capillaries) connecting the edges of the wound. As a result, a young cicatricial connective tissue is formed at the site of the wound; at the same time, epithelial cells (skin, mucosa) are growing, and after 3-5-7 days the epithelial cover is restored. In general, within 5-8 days, the healing process by primary intention basically ends, and then there is a decrease in cellular elements, the development of connective tissue fibers and partial desolation of blood vessels, due to which the scar turns from pink to white. In general, any tissue, be it muscles, skin, internal organ, etc., heals almost exclusively through the formation of a connective tissue scar.
Wound healing certainly affects the general condition of the body. Exhaustion, chronic diseases clearly affect the course of the healing process, creating conditions that slow it down or do not favor it at all.
Removal of stitches. When healing by primary intention, it is believed that the tissues grow together quite firmly already on the 7-8th day, which makes it possible to remove skin sutures these days. Only in very weakened and emaciated persons with cancer, in which the healing processes are slowed down, or in cases where the sutures were applied with great tension, they are removed on the 10-15th day. The removal of sutures must be carried out in compliance with all asepsis rules. Carefully remove the dressing, avoiding pulling on the sutures if they are stuck to the dressing. When healing by primary intention, there is no swelling and redness of the edges, soreness with pressure is insignificant, no compaction is felt in depth, which is characteristic of the inflammatory process.
After removing the bandage and lubricating the sutures with iodine tincture, gently pull the free tip of the suture near the knot with anatomical tweezers, lift it up and, pulling the knot to the other side of the incision line, remove the thread from a depth of several millimeters, which is noticeable by the color of the thread, dry and dark outside, white and moist, deep in the skin. Then this whitened section of the thread, which was in the skin, is cut with scissors, and the thread is easily removed by pulling. So the seam is removed so as not to pull through the entire channel its dirty outer part, which has a dark color. After removing the stitches, the injection sites are smeared with iodine tincture and the wound is covered with a bandage for several days.
Healing by secondary intention. Where there is a wound cavity, where its edges are not brought together (for example, after tissue excision), where there is dead tissue or a voluminous blood clot in the wound, or foreign bodies (for example, tampons and drains), healing will go by secondary intention. In addition, any wound complicated by an inflammatory purulent process also heals by secondary intention, and it should be noted that this complication of a purulent infection does not occur in all wounds that heal by secondary intention.
During healing by secondary intention, a complex process occurs, the most characteristic feature of which is the filling of the wound cavity with a special newly formed granulation tissue, so named because of its granular appearance (granula - grain).
Soon after the injury, the vessels of the edges of the wound expand, causing their redness; the edges of the wound become swollen, wet, there is a smoothing of the boundaries between the tissues, and by the end of the second day, the newly formed tissue is noticed. In this case, there is an energetic release of white blood cells, the appearance of young connective tissue cells, the formation of offspring of capillary vessels. Small ramifications of capillaries with surrounding connective tissue cells, white blood cells and other cells make up individual grains of connective tissue. Usually, during the 3rd and 4th days, granulation tissue lines the entire wound cavity, forming a red granular mass that makes individual wound tissues and borders indistinguishable between them.
Granulation tissue, therefore, forms a temporary cover that somewhat protects the tissues from any external damage: it delays the absorption of toxins and other toxic substances from the wound. Therefore, a careful attitude to granulations and careful handling of them is necessary, since any mechanical (when dressing) or chemical (antiseptic substances) damage to easily vulnerable granulation tissue opens an unprotected surface of deeper tissues and contributes to the spread of infection.
On the outer surface of the granulation tissue, fluid is exuded, cells are released, new vascular offspring appear and, thus, the tissue layer grows and enlarges and fills the wound cavity with it.
Simultaneously with the filling of the wound cavity, its surface is covered with epithelium (epithelization). From the edges, from neighboring areas, from the remains of the excretory ducts of the glands, from randomly preserved groups of epithelial cells, they multiply, not only by growing from the edges of continuous layers of the epithelium, but also by the formation of individual islands on the granulation tissue, which then merge with the epithelium that goes from the edges of the wound. The healing process generally ends when the epithelium covers the surface of the wound. Only with very large surfaces of the wounds, their epithelium may not be closed, and it becomes necessary to transplant the skin from another part of the body.
At the same time, in the deeper layers, cicatricial wrinkling of the tissue occurs, the release of white blood cells decreases, capillaries become empty, connective tissue fibers are formed, which leads to a decrease in tissue in volume and contraction of the entire wound cavity, accelerating the healing process. Any lack of tissue is compensated for by a scar, which is first pink, then - when the vessels are empty - white.
The duration of wound healing depends on a number of conditions, especially on its size, and sometimes reaches many months. Also, the subsequent wrinkling of the scar continues for weeks and even months, and it can lead to disfigurement and restriction of movement.
Healing under the scab. With superficial skin lesions, especially with small abrasions, blood and lymph appear on the surface; they curl up, dry up and look like a dark brown crust - a scab. When the scab falls off, a surface lined with fresh epithelium is visible. This healing is called healing under the scab.
Wound infection. All accidental wounds, no matter how they are caused, are infected, and the primary is the infection that is introduced into the tissues by the injuring body. In case of wounds, pieces of clothing and dirty skin get into the depth of the wound, which cause the primary infection of the wound. Secondary is an infection that enters the wound not at the time of injury, but after that - for the second time - from the surrounding areas of the skin and mucous membranes, from bandages, clothing, from infected body cavities (esophagus, intestines), during dressings, etc. Even with infected wound and in the presence of suppuration, this secondary infection is dangerous, since the body's response to a new infection is usually weakened.
In addition to infection with purulent cocci, infection of wounds with bacteria that develop in the absence of air (anaerobes) can occur. This infection greatly complicates the course of the wound.
The question of whether an infection will develop or not is usually clarified within a few hours or days. As already mentioned, in addition to the virulence of microbes, the nature of the wound and the reaction of the body are of great importance. The clinical manifestation of the infection, the course of the inflammatory process, its spread, the transition to a general infection of the body, depends not only on the nature of the infection and the type of wound, but also on the state of the body of the wounded.
Initially, there are only a small number of microbes in the wound. During the first 6-8 hours, microbes, finding favorable conditions in the wound, multiply rapidly, but do not yet spread through the interstitial spaces. In the following hours, the rapid spread of microbes through the lymphatic crevices, into the lymphatic vessels and nodes begins. In the period before the spread of infection, it is necessary to take all measures to limit the development of microbes by eliminating the conditions conducive to their reproduction.
Suppuration of the wound. With the development of an infection in the wound, an inflammatory process usually occurs, expressed locally in redness and swelling around the wound, pain, inability to move the diseased part of the body, local (in the wound area) and a general increase in temperature. Soon, pus begins to stand out from the wound and the walls of the wound become covered with granulation tissue. The entry of bacteria into a sewn, for example, postoperative, wound causes a characteristic picture of the disease. The patient has a fever and is febrile. The patient feels pain in the area of the wound, its edges swell, redness appears and sometimes pus accumulates in depth. The fusion of the edges of the wound usually does not occur, and pus is either released spontaneously between the seams, or such a wound has to be opened.
(1) - E.I. Tretyakova. Complex treatment of long-term non-healing wounds of various etiologies. Clinical dermatology and venereology. - 2013.- №3