Primary surgical treatment of wounds. Primary and secondary surgical treatment of wounds What is pho wound

PXO is the first surgical operation performed on a patient with a wound under aseptic conditions, under anesthesia, and consists in the sequential implementation of the following steps:

1) dissection

2) revision

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 options for suturing wounds are possible: 1) layer-by-layer suturing of the wound tightly (for small wounds, slightly contaminated, with localization on the face, neck, torso, with a short period from the moment of injury)

2) suturing the wound with drainage

3) the wound is not sutured (this is done at a high risk of infectious complications: late PST, heavy contamination, massive tissue damage, concomitant diseases, old age, localization on the foot or lower leg)

Types of PHO:

1) Early (up to 24 hours from the moment of infliction of the wound) includes all stages and usually ends with the imposition of primary sutures.

2) Delayed (from 24-48 hours). During this period, inflammation develops, edema and exudate appear. The difference from early PXO is the implementation of the operation against the background of the introduction of antibiotics and the completion of the intervention by leaving it open (not sutured) followed by the imposition of primary delayed sutures.

3) Late (after 48 hours). Inflammation is close to maximum and the development of the infectious process begins. In this situation, the wound is left open and a course of antibiotic therapy is carried out. Perhaps the imposition of early secondary sutures for 7-20 days.

PHO are not subject to the following types of wounds:

1) surface, scratches

2) small wounds with margins less than 1 cm

3) multiple small wounds without damage to deeper tissues

4) stab wounds without organ damage

5) in some cases through bullet wounds of soft tissues

Contraindications to the implementation of PHO:

1) signs of development in the wound of a purulent process

2) the critical condition of the patient

Types of seams:

Primary surgical Apply to the wound before the development of granulations. Impose immediately after the completion of the operation or PST of the wound. It is inappropriate to use in late PST, PST in wartime, PST of a gunshot wound.

primary delayed Impose before the development of granulations. Technique: the wound is not sutured after the operation, the inflammatory process is controlled, and when it subsides, this suture is applied for 1-5 days.

secondary early Impose on granulating wounds, healing by secondary intention. Imposition is made on 6-21 days. By 3 weeks after the operation, scar tissue forms at the edges of the wound, which prevents both the convergence of the edges and the process of fusion. Therefore, when applying early secondary sutures (before scarring of the edges), 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 cicatricial edges of the wound under aseptic conditions, and only then sutured.

13. Toilet wounds. Secondary surgical treatment of wounds.

Wound toilet:

1) removal of purulent exudate

2) removal of clots and hematomas

3) cleansing the wound surface and skin

Indications for VMO are the presence of a purulent focus, the lack of adequate outflow from the wound, the formation of extensive areas of necrosis and purulent streaks.

1) excision of non-viable tissues

2) removal of foreign those and hematomas

3) opening pockets and streaks

4) wound drainage

Differences between PHO and VHO:

14. 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 the 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, impaired vital functions of organs.

Early complications develop in the first days after injury: Infectious complications (suppuration of the wound, pleurisy, peritonitis, sepsis, etc.), traumatic toxicosis.

Late complications are revealed in terms remote from damage: chronic purulent infection; violation of tissue trophism (trophic ulcers, contracture, etc.); anatomical and functional defects of damaged organs and tissues.

4 - Uncomplicated.

Abscess. Concept. Clinic. Tactics of the paramedic FAP in purulent-inflammatory diseases.

Abscess- This is a limited form of purulent inflammation, which is characterized by the formation of a cavity filled with pus in tissues and various organs.

Abscesses by etiology may be nonspecific and anaerobic.

The causative agent of the infection is streptococcus, staphylococcus, purulent bacillus, etc. The causes of formation are both complications of the purulent inflammatory diseases listed above, and various injuries, microtraumas, foreign bodies. Particularly noteworthy are abscesses that occur after injections carried out without observing the rules of asepsis and antisepsis, or when drugs are administered without taking into account anatomical indications, for example, the introduction of metamizole into the subcutaneous tissue, and not in / m, these abscesses - aseptic.

In the clinic abscess emit local symptoms of inflammation, which are more pronounced when the abscess is localized in superficial tissues.

main feature an abscess is a symptom of fluctuation. When the abscess is located deep in the underlying tissues, these symptoms do not always appear, the signs of intoxication are more pronounced: remitting T, with a range of 1.5-2 C, chills, pain; with careful palpation, limited compaction in the tissues, soreness, and swelling are determined.

For an accurate diagnosis using a diagnostic puncture.

Treatment: an abscess is an absolute indication for surgery: open the abscess, clean it - rinse, drain and carry out further dressings depending on the stage of the inflammatory process. Rational antibiotic therapy, detoxification, symptomatic treatment are shown.

Tactics of the FAP paramedic: Diagnose the process. Cold at the site of inflammation. Symptomatic therapy, for example, the introduction of a lytic mixture in / m (Metamizole 50% -2 ml. + Dimedrol-1 ml.).

Organize qualified transportation of the patient to the surgical department.

PST of wounds, goals, stages, terms.

PHO (primary surgical treatment) is a surgical intervention performed to prevent wound infection and create conditions for the most perfect wound healing in the shortest possible time.

Stages of PHO:

Ø examination of the wound;

Ø toilet wound;

Ø wound dissection;

Ø wound excision;

Ø hemostasis (stop bleeding);

Ø Wound closure or drainage

The timing of the PST is 6-8 hours from the moment of injury, but no later than 12 hours.

When examining the wound, the degree of damage, the type of wound, its contamination are revealed and an action plan is drawn up.

Wound toilet is performed in the usual way, as an independent measure is carried out with minor superficial incised wounds, especially on the face and fingers. The skin around the wound must be cleaned of contamination and treated with iodonate or 5% iodine solution. An aseptic bandage is applied to the wound.

Wound dissection is indicated when a thorough revision is not possible. It is performed under local or general anesthesia depending on the severity of the injury. The wound is washed with a solution of hydrogen peroxide.

Excision of the wound can be complete (within healthy tissues) and partial (excision of non-viable or crushed tissues). Contraindications for excision are wounds of the hand, face and incised wounds.

Then a thorough hemostasis with suturing is performed. According to indications, the wound is drained.

There are wounds that are not subject to PST: multiple, non-penetrating, finely splintered, uncomplicated punctate, through bullet wounds.

Wound - damage of any depth and area, in which the integrity of the mechanical and biological barriers of the human body, delimiting it from the environment, is violated. Patients come to medical institutions with injuries that can be caused by factors of various nature. In response to their impact, local (changes directly in the wounded area), regional (reflex, vascular) and general reactions develop in the body.

Classification

In clinical practice, wounds are classified according to a number of signs:

• origin (, operational, combat);
• localization of damage (wounds of the neck, head, chest, abdomen, limbs);
• the number of injuries (single, multiple);
• morphological features (cut, chopped, chipped, bruised, scalped, bitten, mixed);
• length and relation to body cavities (penetrating and non-penetrating, blind, tangential);
• type of injured tissues (soft tissues, bone, with damage to blood vessels and nerve trunks, internal organs).

In a separate group, gunshot wounds are distinguished, which are distinguished by the particular severity of the course of the wound process as a result of exposure to tissues of significant kinetic energy and a shock wave. They are characterized by:

• the presence of a wound channel (tissue defect of various lengths and directions with or without penetration into the body cavity, with the possible formation of blind "pockets");
• formation of a zone of primary traumatic necrosis (an area of ​​non-viable tissues that are a favorable environment for the development of a wound infection);
• the formation of a zone of secondary necrosis (the tissues in this zone are damaged, but their vital activity can be restored).

All wounds, regardless of origin, are considered to be contaminated with microorganisms. At the same time, it is necessary to distinguish between primary microbial contamination at the time of injury and secondary, occurring during treatment. The following factors contribute to wound infection:

• the presence in it of blood clots, foreign bodies, necrotic tissues;
• tissue trauma during immobilization;
• violation of microcirculation;
• weakening of the immune system;
• multiple damage;
• severe somatic diseases;

If the body's immune defenses are weakened and unable to cope with pathogenic microbes, then the wound becomes infected.

Phases of the wound process

During the wound process, 3 phases are distinguished, systematically replacing one another.

The first phase is based on the inflammatory process. Immediately after the injury, tissue damage and vascular rupture occurs, which is accompanied by:

• platelet activation;
• their degranulation;
• aggregation and formation of a full-fledged thrombus.

First, the vessels react to damage with an instant spasm, which is quickly replaced by their paralytic expansion in the area of ​​damage. At the same time, the permeability of the vascular wall increases and tissue edema increases, reaching a maximum at 3-4 days. Thanks to this, the primary cleansing of the wound occurs, the essence of which is to remove dead tissues and blood clots.

Already in the first hours after exposure to a damaging factor, leukocytes penetrate the wound through the wall of blood vessels, a little later macrophages and lymphocytes join them. They phagocytose microbes and dead tissues. Thus, the process of wound cleansing continues and the so-called demarcation line is formed, which delimits viable tissues from damaged ones.

A few days after the injury, the regeneration phase begins. During this period, granulation tissue is formed. Of particular importance are plasma cells and fibroblasts, which are involved in the synthesis of protein molecules and mucopolysaccharides. They are involved in the formation of connective tissue that ensures wound healing. The latter can be done in two ways.

• Healing by primary intention leads to the formation of a soft connective tissue scar. But it is possible only with a slight microbial contamination of the wound and the absence of foci of necrosis.
• Infected wounds heal by secondary intention, which becomes possible after the wound defect is cleansed of purulent-necrotic masses and filled with granulations. The process is often complicated by the formation.

The identified phases are typical for all types of wounds, despite their significant differences.

Primary surgical treatment of wounds

Timely and radical surgical treatment is considered the key to successful wound treatment. To eliminate the immediate consequences of damage, primary surgical treatment is carried out. It pursues the following goals:

• prevention of complications of a purulent nature;
• creation of optimal conditions for healing processes.

The main stages of primary surgical treatment are:

• visual revision of the wound;
• adequate anesthesia;
• opening of all its departments (should be performed widely enough to obtain full access to the wound);
• removal of foreign bodies and non-viable tissues (skin, muscles, fascia are excised sparingly, and subcutaneous fatty tissue - widely);
• stop bleeding;
• adequate drainage;
• restoration of the integrity of damaged tissues (bones, muscles, tendons, neurovascular bundles).

In a serious condition of the patient, reconstructive operations can be performed delayed after the stabilization of the vital functions of the body.

The final stage of surgical treatment is the suturing of the skin. Moreover, this is not always possible immediately during the operation.

• Primary sutures are necessarily applied for penetrating abdominal wounds, injuries to the face, genitals, and hands. Also, the wound can be sutured on the day of surgery in the absence of microbial contamination, the surgeon's confidence in the radicalness of the intervention and the free convergence of the edges of the wound.
• On the day of the operation, provisional sutures can be applied, which are not tightened immediately, but after a certain time, provided that the course of the wound process is not complicated.
• Often the wound is sutured a few days after the operation (primarily delayed sutures) in the absence of suppuration.
• Secondary early sutures are applied to the granulating wound after it has been cleansed (after 1-2 weeks). If the wound has to be sutured later and its edges are cicatricially changed and rigid, then the granulations are first excised and the scars are dissected, and then they proceed to the actual suturing (secondary-late sutures).

It should be noted that the scar is not as durable as intact skin. It acquires these properties gradually. Therefore, it is advisable to use slowly absorbable suture materials or tighten the edges of the wound with adhesive tape, which helps prevent the divergence of the edges of the wound and changes in the structure of the scar.

Which doctor to contact

For any wound, even at first glance, a small one, you need to go to the emergency room. The doctor must assess the degree of tissue contamination, prescribe antibiotics, and treat the wound.

Conclusion

Despite the different types of wounds in origin, depth, localization, the principles of their treatment are similar. At the same time, it is important to carry out the primary surgical treatment of the damaged area on time and in full, which will help to avoid complications in the future.

Pediatrician E. O. Komarovsky tells how to properly treat a wound to a child.

The time required for pre-briefing and demonstration of the skill on the manikin - 15 minutes

The time it takes to master a skill on your own(in minutes, per student) – 17min

Necessary theoretical knowledge for mastering a clinical skill:

Anatomy and physiology of the skin, serous and mucous membranes.

Types of wounds.

Indications for primary surgical treatment of the wound.

Fundamentals of asepsis and antisepsis.

Surgical instruments.

wound infection.

Tetanus vaccine.

Fundamentals of anesthesiology.

List of mannequins, models, visual aids, interactive computer programs necessary for mastering the clinical skill:

"Hand model for manipulation on the arteries and veins of the upper limb"

List of medical products and equipment:

Instruments

forceps - 2 pcs,

clothespins - 4 pcs,

surgical tweezers - 2 pcs,

anatomical tweezers - 2 pcs,

syringe (10 ml) - 2 pcs,

scalpel - 1 piece,

scissors - 2 pcs,

hemostatic clamps - 4-6 pcs,

Farabef hooks - 2 pcs,

sharp-toothed hooks - 2 pcs,

cutting needles - 4 pcs,

stabbing needles - 4 pcs,

grooved probe - 1 piece,

bulbous probe - 1 piece,

suture material,

bix with dressing material,

gloves,

Preparations

skin antiseptics (cutasept, iodonate),

wound antiseptics (3% hydrogen peroxide solution, 0.06% sodium hypochlorite solution),

70% ethyl alcohol, disinfectant for instruments (deactin, neochlor),

drug for local anesthesia (lidocaine, novocaine).

Description of the execution algorithm:

Before carrying out PST of the wound, prophylactic administration of tetanus toxoid and tetanus toxoid is carried out.

To wash hands

Dry your hands with a towel

put on a mask

Wear gloves

Treat hands with antiseptic

Treat with antiseptics the injection sites for local anesthesia.

Perform local anesthesia of the wound.

Excise the wound with surgical instruments.

Stop bleeding.

Remove foreign bodies, necrotic tissue, blood clots, dirt, etc.

Treat the wound with an antiseptic.

If necessary, local administration of antibiotics.

Depending on the nature of the injury, drain the wound.

Apply blind stitch.

Apply an aseptic bandage.

Scheme of primary surgical treatment of the wound: 1 - wound before treatment; 2 - excision; 3 - blind seam.

Criteria for assessing the performance of a skill:

Washed my hands

Dry your hands with a towel

Put on a mask

Wearing gloves

Treated hands with antiseptic

He treated with antiseptics the injection sites for local anesthesia.

Performed local anesthesia of the wound.

He excised the wound with the help of surgical instruments.

Stopped bleeding.

Removed foreign bodies, necrotic tissue, blood clots, dirt, etc.

He treated the wound with an antiseptic.

Topical antibiotics were administered as needed.

Depending on the nature of the injury, the wound was drained.

He put on a blind seam.

He put on an aseptic bandage.

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The primary surgical treatment of a wound in medicine is a certain surgical intervention, the purpose of which is to remove various foreign bodies, debris, dirt, areas of dead tissue, blood clots and other elements from the wound cavity, which can lead to complications in the treatment process and increase the recovery time and repair of damaged tissues.

In this article, you will learn the varieties and algorithm for performing primary surgical treatment of a wound, as well as the principles of PST, features and types of sutures.

Varieties of primary wound treatment

Conducting primary surgical treatment of wounds, if there are indications for such a procedure, is carried out in any case, regardless of when the victim entered the department. If for some reason it was not possible to carry out the treatment immediately after the injury, then the patient is given antibiotics, most optimally intravenously.

Primary surgical treatment of the wound, depending onThe timing of the procedure is divided into:

Of course, the ideal option is the situation when PST of the wound is performed immediately immediately after the injury and at the same time is an exhaustive treatment, but this is not always possible.

Types and features of seams

Sutures during wound treatment can be applied in various ways, with each type having its own characteristics:

How is PHO carried out

Primary wound treatment is carried out in several main stages. Wound PST algorithm:

• The first stage is the dissection of the wound cavity with a linear incision. The length of such an incision should be sufficient so that the doctor can carry out all the work on the injury. The incision is made taking into account the topographic and anatomical features of the structure of the human body, that is, in the direction along the nerve fibers, blood vessels, as well as Langer's skin lines. Layers of skin and tissues, fascia and subcutaneous tissue are dissected in layers so that the doctor can accurately determine the depth of damage. Muscle dissection is always carried out along the fibers.
• The second stage of treatment can be considered the removal of foreign bodies from the wound cavity.. In the case of gunshot wounds, such an object is a bullet, with fragmentation - fragments of a projectile, with a knife and cut - a cutting object. In addition, when receiving any injury, various small objects, debris, which also need to be removed, can get into it. Simultaneously with the elimination of all kinds of foreign bodies, doctors also remove dead tissue, formed blood clots, particles of clothing, bone fragments, if any. The entire contents of the existing wound channel is also removed, for which the method of washing the wound with a special apparatus with a pulsating solution jet is usually used.
• At the third stage, the tissues that have lost their viability are excised.. This removes the entire area of ​​primary necrosis, as well as areas of necrosis of the secondary type, that is, those tissues whose viability is in doubt. As a rule, the doctor evaluates tissues according to certain criteria. Viable tissue is characterized by a bright color, as well as bleeding. Living muscles should respond with a contraction of the fibers when irritated with tweezers.

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• The fourth stage is the operation on damaged tissues and internal organs., for example, on the spinal cord and spine, on the brain and skull, on the main vessels, organs of the abdomen, chest cavity or small pelvis, on bones and tendons, on peripheral nerves.
• The fifth step is called wound drainage., while the doctor creates the maximum possible optimal conditions for the normal outflow of the produced wound discharge. The drainage tube can be installed alone, but in some cases it is required to place several tubes in the damaged area at once. If the injury is complex and has several pockets, then each of them will be drained by a separate tube.
• The sixth stage is the closure of the wound, depending on its type.. The type of suture is chosen individually in each individual case, since some of the wounds are subject to mandatory suturing immediately after the treatment, and the other part is closed only a few days after the PST.

Secondary debridement

VHO (secondary treatment) is required in cases where a purulent focus and serious inflammation form in the wound. At the same time, the secreted ichor does not go away on its own, and purulent streaks and areas of necrosis begin to appear in the wound.

During the secondary treatment, accumulations of purulent exudate are first removed from the wound cavity, and then hematomas and blood clots. After that, the surface of the damaged area and the surrounding skin integuments are cleaned.

The WTO is carried out in several stages:

• Tissues that do not have signs of viability are excised.
• Blood clots, hematomas and other elements are removed, as well as foreign bodies, if any.
• An opening of wound pockets and formed streaks is carried out in order to cleanse them.
• Drainage of the secondarily cleaned wounds is carried out.

The difference between primary and secondary treatment is that primary treatment is carried out when any wound is received, as well as during operations.

Secondary treatment is carried out only in cases where the primary was not enough and a purulent-inflammatory process began in the wound. In this case, secondary treatment of the wound is necessary to prevent the development of serious complications.