Wound healing by primary and secondary intention. Wound healing by secondary intention. What you need to know

wound healing- this is a normal physiological process, the function of which is to protect the homeostasis of the patient. This process is controlled by general humoral factors and local factors of the affected area.

Violation of integrity, continuity. Primitive animals respond to injury by regenerating through cell mitosis to restore the integrity of their coat. In higher vertebrates, a lower replacement process is noted, allowing the damaged surface to be connected through the formation of a fibrous scar that restores physical continuity.

Regular physical activity, such as walking or cycling, is an additional support. In this way, you can support the wound healing process. In diabetes, blood sugar levels should be checked regularly to optimally manage the condition and prevent wound healing disorders. Wear breathable cotton, wool, or microfiber clothing that doesn't shrink. Avoid socks or stockings with tight cuffs and corsets and corsets as they disrupt or reduce blood circulation. Limit smoking as much as possible, as it contributes to circulatory problems. For the optimal selection and adjustment of shoes, a visit to an orthopedic shoemaker is recommended. Avoid high heels. Be sure to move consciously and enough, for example, to take the stairs instead of using the elevator. Even small exercises, such as circling with the leg or rocking up and down, keep the circulation going. Reduce existing excess weight. . Wound healing occurs in phases that follow each other in time, but sometimes overlap.

The possibility of regeneration in humans is preserved, for example, in liver cells, but even in this case it is limited by damage or lack of liver tissue up to 75%

When required a wider healing process with more extensive damage, a lack of regeneration is found and healing manifests itself in the formation of a fibrous scar, more extensive, leading to cirrhosis.

The exudation phase for hemostasis and wound cleansing is followed by a granulation phase to create granulation tissue and an epithelialization phase to mature, scar and epithelize the wound. This process is completed in acute wounds in about 14-21 days, depending on the size and type of injury.

In chronic wounds, this time is disturbed and greatly increased because the causes of causation are either unknown or insufficiently adequate. Lack of causal therapy leads to impaired wound healing. Chronic wounds can last from several months to several years without the wound actually healing.

Leather, which is a complex organ, is not subject to regeneration. There is a need to distinguish between "epithelization" - a process that occurs during the healing of a burn, superficial damage to the skin. In this case, epithelial cells form a new epidermis and the wound heals.

In addition, in certain cases, such as pregnancy, growth and development of the mammary glands, obesity, subcutaneous tissue expanders (Tissue Expander), at first glance it seems that new skin is being formed, but in reality we are talking about remodeling, manifested in stretching and changing the architectonics of the dermis collagen, which becomes thinner. In these cases, increased mitotic activity of epidermal cells is a normal reaction to stretching, which is not regeneration.

In the exudation phase, also known as the inflammatory phase, inflammatory phase, or clearing phase, the cells and hormones of the immune system are essentially involved in destroying invading bacteria and viruses and stimulating the healing process. First, hemostasis follows a very specific pattern: vessels come into contact and thus lead to a reduction in blood flow. Platelets are activated, releasing their storage materials and thereby attracting more platelets. Parallel plasma coagulation leads to a stable thrombus with the participation of fibrin. Acidosis in the wound area causes edema, which promotes the conversion of fibrocytes to fibroblasts and dilutes toxic waste in the wound area. Decisive for cleaning wounds are.

• Platelets adhere to collagen fibers.
• Fibrinogen binds platelets together, creating a platelet graft.

Cells of the human body are divided into 3 types depending on their ability to regenerate:
1. Mobile cells (Labile).
2. Stable cells (Stable).
3. Permanent cells (Permanent).

mobile cells- various epithelial cells of the body, ranging from the epidermis of the skin to cells that cover internal organs, such as the urinary tract, digestive system, etc. These cells normally multiply throughout life and are able to cover the damaged area if it is small.

Most leukocytes break down, releasing hydrolytic enzymes, which in turn dissolve cellular debris. Immigrant monocytes phagocytize cell debris. Macrophages play a key role here: they cause the wound to be cleaned by phagocytosis, in addition, they produce growth factors that stimulate the subsequent phases of wound healing. Thus, they also stimulate fibroblast proliferation and initiate neovascularization. However, this activity is possible only under moist wound conditions and wound temperature of at least 28 degrees.

stable cells. The rate of reproduction of these cells is low; they react to damage by rapid division and have the ability to quickly restore damage if the base of the connective tissue has retained its integrity. These cells are found in the parenchyma of internal organs such as the liver, spleen, pancreas, and endothelial cells of blood vessels and smooth muscles.

In chronic wounds, this phase is often significantly prolonged because bacterial inflammatory responses delay wound healing. The granulation phase begins approximately 24 hours after the formation of the wound and reaches a maximum within 72 hours.

During this phase, new tissue is formed that fills the wound. It is characterized by the migration of accompanying vascular cells to the edges of the wound. These cells have the ability to form vessels, phagocytic bacteria and form fibrin fibers. Fibroblasts also form mucopolysaccharides and other substances important for wound healing.

permanent cells. These are cells that do not divide after birth. These include striated muscle cells, heart muscles, and nerve cells. Damage to these cells leads to replacement with connective tissue and scar formation.

Flaw healing through the formation of connective tissue is reduced mainly to the unaesthetic scar, as well as dysfunction. Healing processes with the formation of excess fibrous tissue can lead to severe complications in the healing of internal organs: narrowing of the esophagus, cirrhosis of the liver, scarring in the cornea, damage to the heart valves.

Fibroblasts can feed mainly on amino acids, which are produced by the breakdown of blood clots by macrophages. As a rule, fibrin is destroyed during the injection of collagen. It is at this point that the wound disorder often occurs in chronic wounds: fibrin persistence. Fibrin is not destroyed, but is deposited on the wound surface.

Up to one third exclusively by shrinkage and two thirds by new formation. . Epithelialization begins in an acute wound after 3-4 days and may take several weeks. This leads to an increase in the formation of new collagen fibers, which are stitched together in the form of a bundle. The strength of normal tissue is no longer achieved. Pressure ulcers on scar tissue are about 5 to 10 times faster than on normal skin. Epidermal cells usually start unevenly from the edge to spread over the wound surface.

Similar processes in the skin lead to the formation of hypertrophic scars, keloids and contractures. There are conditions in which healing processes are disturbed due to lack of vitamin C, excess of vitamin A, depression of the immune system, local infection, etc. An understanding of the wound healing process and a clinical attitude to its various stages is necessary in order to achieve the desired direction for obtaining ideal healing.

However, epithelial islands can also be placed in the middle of individual areas of the wound. It also allows migration, which ultimately serves to close the wound. Aggressive agents often suffer from our body. A more or less severe injury, caused in different ways, destroys areas of the body that need to be repaired from now on.

The skin, which is the most peripheral and superficial area, is most often affected. As a sheath of internal structures, it is more stable than the organs involved. If we consider a muscle, or part of the intestines, or any other organ, the skin is stronger, except, of course, the bones, which have great resistance and may be considered the most energetic of the body.

following a statement Ambroise Pare(1510-1590) - "I bandaged the wound, and God will heal it" does not always contribute to successful healing, but serves to hide failure and to let nature and God do their work away from the searching eyes.

If it is in our interest to intervene and speed up the wound healing process, it is important to become familiar with the mechanism of healing.

Healing is called the phenomenon by which the body tends to repair the damaged part. If an attacking agent inflicts damage in one place, a series of phenomena immediately arise that are aimed at reorganizing this zone and develop in the same order in order to repair.

Healing by primary intention (sanatio per primam intentionem) is the most economical and functionally beneficial, it occurs in a shorter time with the formation of a thin, relatively strong scar.

Rice. 2. Wound healing by primary intention

Surgical wounds heal by primary intention when the edges and walls of the wound are in contact with each other (for example, incised wounds), or if they are connected by sutures, as is observed after the primary surgical treatment of the wound, or suturing of surgical wounds. In these cases, the edges and walls of the wound stick together, stick together due to a thin fibrin film. Reparative regeneration in this case goes through the same phases as the course of the wound process: inflammation, proliferation and formation of connective tissue, epithelialization. The amount of necrotic tissue in the wound is small, the inflammation is not pronounced.

The budding epithelium of the capillaries of the wound walls and fibroblasts pass through the fibrin gluing to the opposite side (as if piercing the granulations that fill small cavities between the walls), are organized with the formation of collagen, elastic fibers, a thin linear scar is formed with rapid epithelialization along the line of connection of the edges of the wound. Incidental, superficial wounds of small size with dehiscence up to 1 cm can 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”.

With this method of healing, there is no cavity between the edges and walls of the wound, the resulting tissue serves only to fix and strengthen the fused surfaces. Only wounds that do not have an infectious process heal by primary intention: aseptic surgical or accidental wounds with minor infection, if microorganisms die within the first hours after injury.

Thus, in order for the 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;

2. Describe the phases of the wound process. What phase does the patient have?

3. What complication of the pathological process has developed in the patient K.?

Task 3.

Patient A., 29 years old, two days after the traumatic removal of the 6th tooth of the upper jaw on the right, the body temperature in the armpit increased to 39.9°C.

Objectively: in the area of ​​the extracted tooth, the edges of the wound are swollen, painful, opening the mouth is also painful; the patient's skin is pale, dry and cold to the touch. The patient's condition is not satisfactory.

1. What pathological process has developed in the patient? List the local and general signs of this process.

2. What phase of the wound process does the patient have?

3. What elements make up a wound?

4. List the complications of the wound process.

Task 4.

Patient P., aged 15, is hospitalized in a clinical hospital for acute lymphadenitis of the right submandibular region, which arose after acute hypothermia. The patient has a history of chronic tonsillitis, surgical treatment is recommended. The patient's condition is unsatisfactory. The head is tilted to the right. On the right in the submandibular region, a dense infiltrate is palpated, painful on palpation. Body temperature in the armpit - 38.3ºС. Compliment C-3 of blood plasma - 2.3 g / l (norm 1.3-1.7 g / l), NBT - test 40% (norm 15%), (the nitrosine tetrazole reduction test reflects the degree of activation of oxygen-dependent mechanisms of bactericidal activity phagocytic cells). C - reactive protein in blood plasma (++), ESR - 35 mm/hour.

1. What pathological process is characterized by the identified changes?

2. What symptoms of the body's general reactions to inflammation did you identify when analyzing the problem?

3. What local symptoms of an inflammatory reaction are given in the problem?

4. What outcomes of the inflammatory response do you know?

5. Give an example of a complete blood count:

a) with acute inflammation;

b) chronic.

Task 5.

Patient B., aged 46, was admitted to the dental department of the clinical hospital with complaints of fever (temperature up to 39°C), throbbing pain in the submandibular region on the right. The disease began after a sharp hypothermia four days ago. Objectively: in the submandibular region on the right there is a red-bluish infiltrate with a softening area in the center. With emergency care, an abscess was opened. A laboratory study revealed a high content of neutrophilic leukocytes in the exudate. The hemogram revealed: nuclear shift to the left, acceleration of ESR. "Acute phase proteins" were detected in the blood plasma.

1. For which inflammation, acute or chronic, is this situation more typical?

2. What is meant by the term "acute phase proteins" in inflammation? What changes in the body are evidenced by the presence of "acute phase proteins" in the blood and the dynamics of their changes in different stages of the disease, the significance for the prognosis.

3. How are wounds subdivided by origin and by the degree of contamination with microflora?

4. What factors worsen and slow down the course of the wound process?

5. Causes of a chronic process in the tooth-jaw area.

Main:

1. Pathophysiology (scholar for medical universities) / ed., M.: GEOTAR-MED -200s.

2. Atlas of Pathophysiology / edited by MIA: Moscow

Additional:

1. Guide to the practical course of pathophysiologists: textbook / etc. // R-on-Don: Phoenix

2.Badger physiology. Lecture notes. - M.: EKSMO - 2007

3. Hormonal regulation of the main physiological functions of the body and the mechanisms of its violation: textbook / ed. . - M.: VUNMTs

4. Long pathophysiology: textbook.- R-on-Don: Phoenix

5. Pathological physiology: Interactive lecture course /,. - M .: news agency ", 2007. - 672 p.

6. Robbins S. L., Kumor V., Abbas A. K. et al. Robbins and Cotran pathological basis of disease / Saunders/Elsevier, 2010. - 1450P.

Electronic resources:

1. Frolov pathophysiology: Electronic course on pathophysiology: textbook.- M.: MIA, 2006.

2.Electronic catalog of KrasSMU

3.Electronic library Absotheue

5.DB Medicine

6.BD Medical Geniuses

7.Internet resources

Occurs through the development of granulation tissue, which gradually fills the wound cavity, and then turns into scar connective tissue. Occurs in the following cases:

When the wound becomes infected;

When the wound contains blood clots, foreign bodies, there is a divergence of its edges;

If there is a tissue defect that cannot be closed with sutures;

When the tissues of the body have lost the ability to heal - when the body is depleted, a complete metabolic disorder.

In the first minutes after injury, loose blood clots are found in the wound, as well as a large amount of blood plasma. By the end of the first hour, a wound secret appears - a serous bloody fluid. The strongest infectious inflammation develops. Already on the second day, the edges of the wound swell, the pain increases, the local temperature is elevated, the surface of the wound is covered with a yellowish coating, a small amount of purulent exudate begins to stand out. Two days later, pink-red nodules the size of a millet grain can be found in the marginal areas of the wound. On the third day, the number of granules increases by 2 times, on the fifth day the entire surface of the wound is covered with granulation - young connective tissue. Healthy granulations do not bleed, have a delicate pink-red color, and a rather dense texture. Granulation tissue always occurs at the border between dead and living tissue. Normally, granulation tissue never becomes healthy. Having reached the level of the skin, the granulations decrease in volume, turn pale, become covered with skin epithelium, and slightly protrude above the skin surface. As the vessels in the granulations become empty, the scar becomes even paler and narrower.

27. Wound healing by primary intention

The fusion of the edges of the wound without the formation of intermediate tissue and clinical symptoms of inflammation. Healing by primary intention is possible:

If there is no infection;

With full contact of the edges of the wound;

If tissue viability is preserved;

When there are no foreign objects in the wound.

According to the primary intention, both surgical wounds and contaminated ones subject to surgical treatment can heal. A wound that heals by primary intention is a slit-like cavity filled with lymph, fibrin, and tissue fragments. Healing begins in the first hours after injury. Hyperemia develops, the pH shifts to the acid side, fibrin, which has fallen on the wound walls, begins to stick it together, and a primary adhesion develops. During the first day, the wound is filled with lymphocytes, macrophages, fibroblasts. Vascular endothelial cells swell and form angioblasts (processes), then they move towards each other from opposite edges and anastomose with each other. Thus, blood flow is restored between the walls of the wound. On the fourth day, the wound already has its own formed network of capillaries. On the sixth day, connective tissue is formed around the vessels, which firmly fixes the edges of the wound.

28. Foreign bodies in the body

Foreign bodies are objects of organic and inorganic origin that have entered the body of an animal when injured, with food, or introduced into it for therapeutic purposes.

Pathogenesis

Small fragments, needles, bullets, if they are aseptic, can be encapsulated. Around the foreign body, a network of fibrin first forms, an infiltrate of leukocytes, and then scar connective tissue. Most often, foreign bodies are not encapsulated, which leads to a dormant infection, sluggish wound healing, and long non-healing of fistulas. Swallowed blunt and rounded objects do not cause pathology in animals (large).

If foreign bodies threaten life, they are immediately removed. If the foreign body is located very deep, does not cause pain, suppuration, any inflammatory reactions, then it is better not to touch it.

29. Carbuncle

Acute purulent inflammation of the hair follicle and sebaceous gland with a predominance of skin necrosis.

Etiology

Poor skin care, hypovitaminosis A, B, C, intestinal intoxication, metabolic disorders.

Clinical signs

The carbuncle is characterized by the formation of a large number of niches and pockets.

Open with a cruciform incision, intramuscularly, intravenously with antibiotic solutions, locally washed with a solution of potassium permanganate, peroxide, apply Vishnevsky ointment.

30. Classification and clinical and morphological characteristics of wounds

Wound - vulnus - open mechanical damage to tissues and organs. Minor skin damage (only the epidermis is damaged) - abrasions.

In the wound, the edges, walls, cavity, bottom of the wound are distinguished.

Penetrating wounds - when they are perforated by a wounding object before penetrating into any cavity.

Skvoznyakova- if the wound has an inlet and outlet.

blind- if there is only an inlet, and there is no outlet.

stabbed- deep narrow wound channel. Pitchfork, awl, trocar.

cut wound - smooth edges, significant gaping, severe bleeding.

Chopped wound - it is applied with blunt cutting objects. Axe. Such wounds show signs of bruising and concussion. They bleed less. Very often damaged bones and periosteum.

bruised wound. Contusion - contusion. Damage to tissues with a blunt object (stick, rod, hooves; when animals fall from great heights). The edges of the wound are uneven, swollen, crushed. Such a wound is always contaminated (dirt, dust, skin areas).

Ragged- claws of animals, horns, knots of trees.

smashed the wound is the most severe. Occurs under the influence of maximum force and enormous pressure. Wheels of railway transport, cars, falling from heights above the fifth floor.

bitten wound - bruise, crush, tissue rupture. When bitten by a horse, deep cyanotic imprints of the incisors are formed.

gunshot wound: 3 zones:

Wound channel zone - blood clots with crushed tissues;

Traumatic necrosis - directly adjacent to the wound channel;

Molecular shaking.

The inlet for a gunshot wound is concave inward, the edges are burned, the outlet is larger and turned outward.

Poisoned wound - mixed. When bitten by snakes - poisoned + bitten wound.

Combined wounds (stab-cut, torn-bruised).

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 are glued 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, 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 new formation of vessels (capillaries) connecting the edges of the wound also occurs. 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 further 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 characteristic of the inflammatory process is felt in depth.

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 second 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 come out, 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 forming separate 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, cicatricial wrinkling of the tissue occurs in the deeper layers, 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, clothes, 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, all measures must be taken 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

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.

neniya 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 during 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 with which the victim sought help within the first 24 hours after the injury is considered fresh. 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 conditions necessary for primary healing are absent, when the edges of the wound are not viable, do not adhere to 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 loose 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.

Secondary wound healing is a complex anatomical process that involves the formation of new connective tissue through prior suppuration. The result of the healing of such a wound will be an ugly scar of a contrasting color. But little depends on doctors: if a person is damaged in a certain way, secondary tension cannot be avoided.

Why does the wound not heal for a long time

The same wounds in all people can heal in different ways: both the duration of healing and the process itself differ. And if a person has problems with this (the wound fester, bleeds, itches), there are several explanations for this.

infection

Problems with the healing of wound surfaces can be explained by their infection, which occurs either immediately after injury or after some time. For example, if hygiene rules are not followed at the stage of dressing or cleansing the wound, harmful microorganisms can penetrate into it.

Whether a wound is infected or not can be understood by elevated body temperature, reddening of the skin and swelling around the damaged area. When you press on the tumor, severe pain occurs. This indicates the presence of pus, which provokes intoxication of the body, causing general symptoms.

Diabetes

Diabetics have trouble healing even light scratches, and any injury easily leads to a festering infection. This is due to the fact that in diabetes mellitus, blood clotting is usually increased, i.e. she's too thick.

Because of this, blood circulation is disturbed, and certain blood cells and elements that we could contribute to the healing of the wound simply do not reach it.

Damage to the legs heals especially badly in diabetics. A small scratch often turns into a trophic ulcer and gangrene. This is due to the swelling of the legs, because due to the large amount of blood water, it is even more difficult to “get close” to the damaged areas.

Elderly age

Problematic wound healing is also observed in the elderly. They often suffer from diseases of the heart and blood vessels, which also provokes a violation of the functions of the blood. But even if an elderly person is relatively healthy, all the same, all organs are worn out, so the blood circulation process slows down, and wounds heal for a long time.

Weak immunity

Wounds heal poorly even in weakened patients. Weakened immunity can be caused by a lack of vitamins or concomitant diseases. Often these two factors are combined. Of the diseases that affect the deterioration of wound healing, HIV, oncology, obesity, anorexia, and various blood diseases are distinguished.

Mechanism of secondary wound healing

Primary healing, in simple terms, is the connection of the ends of the wound and their fusion. This is possible with cuts or simple surgical penetrations, when there is no free space inside the wound. Primary healing goes faster and leaves no traces. This is a natural anatomical process associated with the resorption of dead cells and the formation of new ones.

If the damage is more serious (a piece of flesh is torn out), then the edges of the wound cannot simply be sewn together. It’s easier to explain this with the example of clothes: if you cut out a piece of fabric on the sleeve of a shirt, and then bring the edges together and sew them together, the sleeve will become shorter. Yes, and wearing such a shirt will be uncomfortable, because the fabric will constantly stretch and strive to tear again.

The same with the flesh: if the ends of the wound are distant, they cannot be sewn together. Therefore, healing will be secondary: first, granulation tissue will begin to form in the cavity, which will fill all the free space.

It temporarily protects the mucosa, so it cannot be removed during dressings. While the wound is covered with granulation tissue, a connective tissue is gradually formed under it: the process of epithelization takes place.

If the wound is extensive, and the patient's immunity is weakened, then the formation of the epithelium will occur slowly. In this case, the granulation tissue will not dissolve completely, but will partially fill the cavity, forming a scar. At first it is pink, but over time, the vessels become empty, and the scar becomes whitish or beige.

By the way! The appearance of granulation tissue depends on the nature and depth of the wound. But more often it is quite thin, has a red-pink color and a granular surface (from lat. granum- grain). Due to the large number of blood vessels, it bleeds easily.

Preparations to accelerate wound healing

External means for wound healing by secondary intention should have several properties:

• anti-inflammatory (do not allow inflammation to develop);
• disinfectant (destroy microbes);
• analgesic (to relieve the patient's condition);
• regenerating (to promote the speedy process of the formation of new cells).

Today in pharmacies you can find a lot of different ointments and gels that have the above properties. Before buying a certain remedy, you should consult your doctor, because each drug has its own characteristics.

Levomekol

Universal ointment, which is a must-have in the dressing rooms of hospitals. In fact, it is an antibiotic that prevents the development of a purulent infection. It is also used for frostbite and burns, but only at first. When the wound becomes covered with a crust (scab) or begins to heal, Levomekol should be canceled and something else should be used.

Overdose (long-term use or frequent use) can lead to accumulation of the antibiotic in the body and provoke changes in the structure of the protein. Side effects include mild redness, swelling of the skin, itching. Levomekol is inexpensive: about 120 rubles for 40 g.

Argosulfan

The basis of this drug for secondary wound healing is colloidal silver. It perfectly disinfects, and the ointment can be used for 1.5 months. The regenerative properties are somewhat lower than those of other drugs, so Argosulfan is usually prescribed at the beginning or middle of the treatment of complex wounds in order to kill all microbes for sure.

The drug is quite expensive: 400-420 rubles per pack of 40 g.

Solcoseryl

A unique preparation containing blood components of young calves. They favorably affect the healing of secondary wounds, contributing to the saturation of cells with oxygen, accelerating the synthesis of granulation tissue and early scarring.

Another distinctive point of Solcoseryl: it is also produced in the form of a gel, which is good to use on weeping wounds, such as trophic ulcers. It is also suitable for burns and already healing wounds. Average price: 320 rubles for 20 g.

A popular remedy for pregnant women and young mothers, because in its composition there is nothing that could harm the fetus or baby. The active substance of the drug - dexpanthenol - when it enters the wound surface turns into pantothenic acid. She is a catalyst for regeneration processes.

Mostly, Panthenol is used for burns. But it is also suitable for extensive and deep wounds of a different nature. Secondary healing of the suture after surgery can also be accelerated with this drug. It applies easily and evenly without needing to be washed off before the next application. Cost: 250-270 rubles for 130 g.

Baneocin

Antibacterial agent in the form of ointment (for dry wounds) and powder (for weeping). It has an excellent penetrating effect, therefore it promotes rapid healing. But it is impossible to use it often and for a long time, because the antibiotic accumulates in the body. A side effect may be partial hearing loss or kidney problems.

Baneocin ointment can be bought for 340 rubles (20 g). The powder will cost a little more: 380 rubles for 10 g.

Ambulance

It is a powder based on medicinal plants and salicylic acid. It can be used after a course of Baneocin as an adjuvant. It has anti-inflammatory, analgesic and antiseptic properties. Dries the wound, thereby preventing suppuration. Ambulance - an inexpensive powder: only 120 rubles per 10 g.