SURGICAL DISEASES, TRAUMATOLOGY, ORTHOPEDICS, UROLOGY : WOUNDS (VULNERA) - etiology, pathogenesis, symptoms and course of, recognition, prediction and prevention
In the result of the interaction of mechanical forces and elastic tissue resistance is a violation of the integrity of the outer integument of the body, skin and mucous membranes. Depending on the nature of the wound body (tools, guns, firearms, projectile) distinguish wounds chipped, sliced, chopped, bruised, torn, crushed, poisoned, fire (the latter are divided into gunshot and shrapnel). Depending on the extent and nature of tissue damage, wounds can be simple in case of damage to the outer integument, complicated - while damage to internal organs, bones, joints, major vessels, nerves and tendons Wounds that communicate with the cavities (skull, chest and abdomen, joints, are penetrating, all other non - penetrating. Gunshot wounds are divided into blind when a foreign body (bullet or projectile) is delayed in the depth of the tissue, and through, when a foreign body penetrates all tissues through, and wound channel has two holes: input and output.
Symptoms Dehiscence of the wound depends on its depth and direction, localization, different from the elasticity and contractility of the damaged tissues. Bleeding depends on the size and type of the damaged vessel (artery, vein, capillary) or organ (lung hemorrhage). Has the importance of localization and nature of injury: sliced, chopped wounds give large bleeding than wounds hurt and crushed: the latter, due to compression and twisting of the ends of the vessels, often not bleed. The General condition of the body (shock drop in blood pressure) also affects the strength of bleeding, sometimes causing a temporary cessation. Diseases such as hemophilia, zynga, causing reduced blood clotting, maintain prolonged bleeding. Pain in the wound depends on the damage and irritation of sensitive nerve endings.
For. Since the wound begins the complex process of wound healing. This process splits into phase hydration, swelling, accompanied by a self-cleaning wounds, actor feared dead, non-viable tissue, and the phase of dehydration, development of connective tissue, scarring and epithelization of the wound. Wound healing can occur: 1) the primary tension in the absence of tissue necrosis and in aseptic condition of the wound, the edges of which are contiguous and in a short period of time (6 - 7 days) heal, giving a narrow linear scar (for example, sewn postoperative wounds), or 2) the secondary tension - in the presence of necrotic slowly attachaudio tissues and the development of infection, complicating the course of the wound and is often accompanied by General intoxication of the organism. Healing by second intention simultaneously with the rejection of necrotic tissue on the bottom and around the edges of the wound develops young, rich vascular granulation tissue.
When any accidental wound is its colonization by microbes, among which are found as saprophytes and pathogens of different virulence. Among the latter are important causative agents of purulent infections (staphylococci and streptococci). Healing of infected wounds not only depends on the pathogenicity and virulence introduced into the wound microbes, but also from local and General reactions to established infection.
Recognition does not present any difficulties. In each case, you must determine the possibility and extent of damage lying in the depths of organs and tissues. As the study of the wound with a finger or a probe is not (the possibility of introducing a secondary infection!), you have to judge the damage to nearby organs, by:
1) check their function, for example, when the wounds of the extremities (damage to bones, joints, tendons, nerves),
2) determine changes in the internal organs using conventional diagnostic methods: percussion, auscultation, and palpation studies (recognition of the damage to the organs of the chest and abdomen),
3) thorough neurological research (for suspected damage to the Central nervous system - brain and spinal cord, also damage nerve roots, plexuses and large nerve trunks).
In all such studies pay particular attention to the General condition of the wounded and, without losing time, in appropriate circumstances, proceed to primary surgical treatment of wounds.
First aid - lubrication circumference of the wound 5% iodine tincture and applying an antiseptic bandage, with extensive and complicated wounds - transport immobilization. Unacceptable study of a fresh wound with a finger or a probe, washing the wounds of different solutions.
Primary debridement (mechanical removal of contaminated, crushed, injured tissues, which is a good breeding ground for bacteria, by excision of the edges, sides and bottom of the wound with simultaneous removal of hematomas and foreign bodies) is required curative activity in fresh wounds. When carefully and promptly made perdiccas treatment (up to 6 - 8 hours after injury) operation should be complete by the imposition of the primary seams, with extensive superficial wounds - primary plastics. In field conditions the imposition of the primary seams contraindicated. Instead impose their primary delayed and secondary seams after complete cleansing wounds from disintegrating, necrotic tissue.
In the processing of wounds after 12 - 18 - 24 hours, when already inflammatory disease, surgical intervention: dissection wounds wide open all of the detachments and pockets, destruction of skin bridges and bridges and removal of obviously non-viable tissue.
In all cases, extensive soft tissue lesions after surgery - immobilization plaster langenau bandage to provide injured body rest. In the future, steadily watching the wounded, do not produce dressings without special indications (fever, local pain, an increase in associated lymph nodes). When local or General symptoms of infection are urgently needed ligation, suture removal, partial or full disclosure of the wound.
In the treatment of festering wounds are applied: in the first phase 1) create a correct and complete outflow of wound well suction dressings (aseptic dressing of sterile gauze with absorbent cotton or lignin); 2) the open method of treatment, based on the strength of evaporation, drying and healing of wounds under a scab (used primarily in extensive but more superficial wounds where the primary excision and primary closure is not possible or has not been timely made); a wide incision, dissection of the wound and prodiversity to ensure drainage of pus, subsequent betampona treatment. To speed up the cleansing of wounds, rejection damaged, necrotic tissue and reduction of germs apply zulfigarova emulsion (when the wounds of joints, brain wounds, and others), bandage with ointment Vishnevskogo, changed after 7 to 9 days.
In the process of epithelialization granulating wounds - dressings with fatty substances that promote epithelialization (vaseline oil, fish oil). With extensive granulating surfaces early plastic surgery (skin grafts). In order to accelerate the healing process applied electric field UHF, ultraviolet irradiation, tissue therapy (injections of aloe, tissue grafting, canned by the cold method Filatova). In acute blood loss or wound depletion and weak healing wounds - blood transfusion. In the first case, and simultaneously the drip method is introduced to 500,0 - 1 000.0; in other cases - 100,0 - 150,0 after 3 - 5 days 5 - 6 times. Enhanced fortification.
When not exclude the possibility of contamination of the wound by the bacilli of tetanus or anaerobes, prevention introduction tetanus, antigangrenous serum.