Wound treatment. All about wounds. General ideas about wounds, their varieties and methods
Wound- called tissue damage, accompanied by a violation of the integrity of the skin or mucous membranes.
From deep wound damage can be
superficial
deep -G deeper than subcutaneous tissue, with damage to large vessels, muscles, bones, internal organs.
From penetration into cavities wounds may be
non-penetrating
penetrating(cavity of the skull, chest, abdomen, joints).
From the movement of the wounded subject wounds may be
blind
through,
tangents.
Depending on origin (type of damaging object and method of causing damage) wounds are distinguished:
bruised (torn, bitten) - from the action of blunt solid objects;
Bruised, torn and crushed wounds (stick, stone, building collapse, traffic accident, etc.) have little bleeding with significant soft tissue damage, in which infection easily joins.
bitten wounds are caused by the teeth of an animal or a person. They are often infected, can be poisoned, heal slowly, with complications.
chopped, chopped, chopped, chopped- from the action of sharp objects;
Sliced wounds have smooth edges, they gape, bleed continuously. Healing is going well.
Stab wounds (awl, needle, screwdriver, etc.) are characterized by a small inlet and significant damage to deep-lying tissues and organs (large blood vessels, lungs, heart, liver, etc.). There is little bleeding, but internal bleeding in the depth of the wound canal can be significant.
Chopped wounds (axe, saber, etc.) are characterized by significant damage to the underlying tissues.
scalped wounds are characterized by detachment of the skin and subcutaneous bases from the underlying tissues.
firearms (bullet, shotgun, fragmentation) - from the action of firearms, ammunition and explosives.
firearms wounds inflicted by bullets and shell fragments can be penetrating (a bullet passes through a part of the body, there are inlet and outlet holes) and blind (a bullet remains in the tissues). First aid for injury.
Clear area of clothing
Stop the bleeding
Lubricate the edges of the wound with an antiseptic
Remove foreign bodies from the wound (do not remove deep ones)
Sterile dressing
Painkiller
26. First aid for bleeding
The main ways to temporarily stop bleeding are: elevated position of the injured limb or body part; pressing the bleeding vessel at the site of injury with a pressure bandage; digital pressure of the artery throughout; circular compression of the limb with a tourniquet; stop bleeding by fixing the limb in the position of maximum flexion.
Depending on the nature of the bleeding injury, there are various types:
Arterial(with a deep wound): scarlet blood flows out in a pulsating stream.
Venous(with a superficial wound): dark-colored blood flows from the wound continuously, calmly.
capillary: blood oozes over the entire surface of the wound.
Ways to stop bleeding:
finger pressing of a superficially located arterial vessel slightly above the bleeding wound;
tourniquet 3-5 cm above the wound;
applying a pressure bandage to the site of bleeding;
maximum limb flexion;
giving an elevated (slightly higher than the chest) position of the injured limb.
Lecture #2
Topic “Wounds. Bleeding."
1.1. Definition of a wound.
1.2. Classification of wounds.
1.3. Principles of first aid for wounds.
2. Bleeding.
2.1. Definition of bleeding.
2.3. Providing first aid for bleeding.
3. Blood transfusion.
Wounds.
Wound - mechanical violation of the integrity of the skin, mucous membranes with damage to deep tissues.
The main signs of a wound:
pain - most pronounced in places with the largest number of nerve endings (fingertips, periosteum, pleura).
bleeding is an absolute sign of a wound. Most pronounced in tissues with good blood supply to the head, neck, hand, cavernous bodies.
gaping - the divergence of the edges of the wound. Depends on the size of the wound.
dysfunction of the affected area of the body.
The general reaction of the body to damage depends on the severity of the injury, which is determined by the size of the external wound, its depth, the nature of damage to internal organs and developing complications (bleeding, peritonitis, pneumothorax, etc.)
Injuries can cause a general reaction of the body - fainting shock, a terminal state. The greatest danger in wounds is bleeding and infection, which, getting into the wound, can enter the body.
Classification of wounds.
Origin:
Operating(deliberate) - are applied intentionally under aseptic conditions (with the use of anesthesia, good hemostasis, suturing).
Random- all are considered to be primarily infected, complicated by bleeding, can lead to death.
Depending on the type of injuring object:
cut- applied with a sharp object (knife, glass, razor). The edges of the wound are even, gaping, have great depth, bleeding is profuse. Dangerous due to damage to blood vessels, nerves, hollow organs.
Stab- applied with a sharp and long object (needle, bayonet, awl, nail). Small diameter of external injury and deep wound channel. The wound channel is narrow. There is no external bleeding, but blood accumulates in tissues, cavities, forming hematomas.
Chopped- are applied with a sharp, heavy object (axe, saber, shovel). Extensive damage to superficial and deep-lying tissues with the development of necrosis. Expressed pain syndrome. Often accompanied by bone damage. The edges have a crushed character.
Bruised, torn, crushed- applied with a blunt object (hammer, stone, log). Expressed pain syndrome. The edges of the wounds are uneven, crushed, easily infected. Crushed tissue is a favorable environment for the reproduction of microbes, so these wounds are complicated by the development of infections.
bitten- arise from the bite of an animal or person. Contaminated with the virulent microflora of the oral cavity, the evils of a person. ohms.
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 are therefore complicated by the development of acute surgical infections. Snake saliva contains venom, and dogs have the rabies virus.
firearms- occurs as a result of the impact of gunshot wounds by bullets, shell fragments and other objects that have a high kinetic energy of the injuring projectile, which causes a complex shape of the wound channel, the vastness of the affected area, and a high degree of microbial contamination.
There are three zones of damage:
wound channel,
direct traumatic necrosis,
molecular shaking
The small diameter of the inlet makes it difficult for oxygen to enter, which is favorable for the development of anaerobic infection.
According to the degree of infection:
Aseptic- are applied in the operating room.
Freshly infected- all random, since with a wounding object from the surface of the skin, microbes enter the wound.
Purulent- in which the infectious process develops.
For cavities:
Non-penetrating- the barrier septum of the cavity is not damaged (peritoneum, pleura, dura mater, synovial membrane of the joint).
penetrating- the barrier septum is broken, there may be damage to internal organs.
By difficulty:
Simple- damaged skin, subcutaneous tissue, muscles.
Complex- damaged internal organs, bones.
Principles of first aid for wounds:
First aid algorithm for wounds:
1. Stop bleeding in any way.
2. Applying an aseptic bandage.
3. Anesthesia with the threat of shock (analgesics = analgin + diphenhydramine + novocaine).
4. Transport immobilization (with extensive damage to soft tissues, large vessels, nerves, bones).
5. Transportation to health facilities.
The wound should not be washed with water - this contributes to infection. Cauterizing antiseptic substances should not be allowed to enter the wound surface. The wound should not be covered with powders, ointment should not be applied to it, cotton wool should not be applied directly to the wound surface - all this contributes to the development of infection in the wound.
Asepsis of the wound:
The skin around the wound is treated from the center from the center of the wound to the periphery, with an aqueous solution of an antiseptic (furatsilina, H 2 O 2 , KMnO 4).
Dry the edges of the wound with a sterile cloth.
Treat the edges of the wound with an alcohol solution of an antiseptic (5% solution of iodine, brilliant green).
Close the wound with a sterile dressing.
Secure the napkin with adhesive tape.
Complications of wounds during healing:
gas gangrene - in It occurs when microbes that multiply in the absence of air enter the wound.
Local symptoms: pain in the wound area and the wound itself, a feeling of fullness, tissues of a gray or greenish hue swell out of the wound. When pressed, gas bubbles and a fetid odor are released.
Treatment: Intravenous administration of antigangrenous serum, antibiotics, surgery, limb amputation.
Tetanus - anaerobic infection. The causative agent - a tetanus bacillus, enters the body through the wound surface.
Symptoms: temperature up to 42 0 C appears 4-10 days after injury, involuntary muscle twitching, difficulty in swallowing, spasm of masticatory muscles, convulsions, asthma attacks.
Prevention: the introduction of tetanus toxoid.
Sepsis - spread through the bloodstream and tissues of the microorganism and their toxins.
The reasons: any local purulent process (primary focus) from which the pathogen enters the bloodstream.
Symptoms: fever up to 41 ° C, chills, weakness, sunken eyes, earthy or yellow skin. Tachycardia, shortness of breath, a sharp deterioration in the general condition, up to loss of consciousness.
WOUNDS, WOUNDS(syn. open damage); wound (vulnus) - damage to tissues and organs with a violation of the integrity of their cover (skin, mucous membrane) caused by mechanical action; wound (vulneratio) - mechanical impact (except operational) on tissues and organs, entailing a violation of their integrity with the formation of a wound. In the literature, both terms are sometimes used as synonyms (equivalents). Superficial wounds, in which there is an incomplete (only superficial) violation of the skin or mucous membrane, are sometimes referred to as abrasions if the damage is caused by a flat object over a wide area, or as scratches if they are inflicted in a thin line with a sharp object. Separately, there are thermal, electrical, radiation and chemical damage to the skin and mucous membranes, which differ from wounds in etiology, pathogenesis, wedge, course and treatment (see Radiation injury, Burns, Frostbite, Electrical injury). In these cases, we usually talk about the affected surface (eg, burnt surface) and only after rejection (excision) of charred, coagulated or necrotic tissues can we talk about a special type of wound (eg, burn wound).
Classification
Rice. one. Incised wound of the anterior region of the wrist. Rice. 2. Chopped wound of the anterior region of the forearm. Rice. 3. Bruised wound of the occipital region of the head. Rice. four. Hand after traumatic amputation of I and II fingers. Rice. 5. Multiple wounds to the face (a) and back (b) by grenade fragments.
According to the conditions of occurrence, the following types of wounds are distinguished: operational, inflicted during the operation; random, applied in various conditions of the domestic and industrial environment; received in battle. Surgical wounds are usually applied taking into account the anatomical and physiological characteristics of the tissues to be separated under conditions of anesthesia and the use of measures to prevent microbial contamination. Such wounds are called aseptic (sterile). Accidental wounds, and especially wounds received in battle, arise from the impact of various damaging factors and differ from surgical wounds in bacterial contamination.
According to the mechanism of application, the nature of the injuring object and tissue damage, cut, stab, chopped, bitten, torn, scalped, bruised, crushed, gunshot wounds are distinguished. Their main distinguishing feature is the different volume of destruction of tissue elements at the time of injury.
incised wound applied with a sharp object, characterized by a predominance of length over depth, smooth parallel edges (printing, table, Fig. 1), a minimum amount of dead tissue and reactive changes in the circumference of the wound.
stab wound differs from incised by a significant predominance of depth over width, i.e., a deep, narrow wound channel, often divided into a number of closed spaces (as a result of displacement of layers of damaged tissues). These features cause high danger of emergence inf. complications in the wound healing process.
chopped wound(tsvetn, tabl., Fig. 2), arising from the impact of a heavy sharp object, has great depth; the volume of non-viable tissues at the time of wounding and in the subsequent period may be somewhat larger than in cut wounds.
Wounds inflicted by a circular or band saw are characterized by finely patchy soft tissue edges and frequent bone damage.
Laceration It is formed when a damaging factor acts on soft tissues, exceeding their physical ability to stretch. The edges of its irregular shape, detachment or separation of tissues is noted (Fig. 1) and the destruction of tissue elements over a considerable extent.
In a separate group, the so-called. scalped wounds(see Scalping), characterized by complete or partial detachment of the skin (and on the scalp - almost all soft tissues) from the underlying tissues without significant damage. Such wounds occur when long hair gets into the moving mechanisms (rollers, gears) of machine tools and other machines, limbs into rotating mechanisms, under the wheels of vehicles. These wounds are usually heavily contaminated with earth, lubricating oils, industrial dust, and foreign bodies.
bruised wound(printing, table, Fig. 3), arising from a blow with a blunt object, like a crushed wound, with a cut, crushing and tissue rupture are observed, have an extensive zone of primary and especially secondary traumatic necrosis with abundant microbial contamination. Sometimes, under the action of a large force, causing rupture and crushing of tissues (Fig. 2.3), a complete separation of a limb segment occurs, the so-called. traumatic separation (tsvetn, tab., Fig. 4), an essential feature of which is the separation of the skin above the level of separation of the deeper tissues.
bitten wound arises as a result of a bite by an animal or a person, it is characterized by abundant microbial contamination and frequent inf. complications. When bitten by an animal, infection with the rabies virus can occur (see).
gunshot wounds result from the impact of a projectile. In this case, the damage is characterized by a complex structure, an extensive area of primary and secondary traumatic necrosis, the development of various complications (see below "Features of wartime wounds. Staged treatment"). The variety of systems of firearms and ammunition causes a wide variety of gunshot wounds, in the classification of which, in addition to morphol, signs characteristic of all wounds, the type of injuring projectile is also taken into account. So, there are bullet, shrapnel wounds (printing, table, Fig. 5, 6) and shot wounds (Fig. 4). For gunshot wounds of individual anatomical regions and organs of the body (eg, chest, abdomen, pelvis, joints, etc.), private classifications have been developed.
In addition, there are wounds tangent, blind and through; penetrating and non-penetrating; with or without damage to internal organs; single, multiple and combined; aseptic, purulent infected; poisoned; combined.
At tangential wound the resulting wound channel is devoid of one wall. At blind wound the wound channel does not have an outlet and ends in the tissues; at penetrating wound There are inlet and outlet openings.
Penetrating is called a wound, when a wounding object enters any cavity of the human body (pleural, abdominal, articular, cranial cavity, eye chambers, paranasal sinuses, etc.), provided that it perforates the entire thickness of the wall of the corresponding cavity, including the parietal leaf pleura, peritoneum, etc.
multiple wound occurs when two or more organs (areas of the body) are damaged by several damaging agents of the same type of weapon (for example, wounding the upper and lower limbs with two bullets).
At combined injury there is damage to two or more adjacent anatomical regions or organs, caused by a single damaging agent (for example, a bullet wound to the stomach and spleen).
At combined wounds a wound occurs as a result of the action of a mechanical factor in various combinations with other damaging factors of modern weapons - thermal, radiation, chemical, bacteriological. Given the defeat by several factors, the term "combined wounds" has fallen into disuse and is replaced by the corresponding term - combined lesions (see).
To aseptic(sterile) include surgical wounds inflicted under conditions of strict observance of the principles of asepsis and antisepsis. The name is conditional, because in reality, truly aseptic wounds are rare. However degree of bacterial pollution of operational wounds, especially pathogenic or conditionally pathogenic microflora, as a rule, is much lower than a critical dose, - that minimum quantity, a cut causes infectious process.
Under bacterial(microbial) contamination of the wound is understood as the entry of microbes into the wound at the time of its occurrence (primary bacterial contamination) or during treatment in violation of the rules of asepsis and antisepsis (secondary bacterial contamination). The concept of "bacterially contaminated wound" is not synonymous with the concept of "infected wound", because under the influence of the autoantiseptic properties of the tissues themselves, cellular elements of blood, tissue fluids and other factors of the body's natural defenses developed in the process of phylogenesis (see), all bacteria or a significant part of them die in the wound. Only bacteria remain in the wound, which are in a state of symbiosis (see) with the macroorganism, which retain the ability to develop and reproduce, but do not cause general disturbances in the body and do not aggravate the course of the wound process. This microflora plays an important role in wound healing by secondary intention. Participating in the destruction and transformation of necrotic tissues into a liquid state (see Pus), i.e., contributing to wound suppuration, they accelerate its cleansing and healing (see Wound infections). A wound that heals by secondary intention, with suppuration being an indispensable component of the wound process, is called purulent.
Symbiosis of bacteria and a macroorganism is possible only under certain conditions, the violation of which can lead to the spread of pathogenic microflora in tissues outside the wound, into the lymphatic and blood vessels. As a result, inf develops. process in the wound (see Abscess, Phlegmon), complicating the course of the wound process and worsening the general condition of the patient. This wound is called infected.
poisoned wound- this is a wound in which poisonous chemicals have penetrated. substances. Substances that have a predominantly local effect (acids, alkalis, etc.) quickly cause tissue necrosis. Such wounds are usually complicated by infection and heal by secondary intention. When substances with a general toxic effect enter the wound, for example. organophosphorus compounds (see), there is a general poisoning of the body.
Pathogenesis
The wound process is a complex set of general and local reactions of the body in response to injury, which ensure wound healing.
In uncomplicated cases, general reactions proceed in two phases. For first phase(1-4th day after injury), excitation of the sympathetic department of the autonomic nervous system is characteristic (see), accompanied by an increased release of adrenaline into the blood (see), under the influence of which the vital activity of the organism, basal metabolism increase, the breakdown of proteins and fats increases and a glycogen, permeability of cellular membranes decreases, mechanisms fiziol are oppressed. regeneration, the aggregation properties of platelets are enhanced (see Aggregation) and the processes of intravascular blood coagulation. The activity of the adrenal cortex also increases (see), which secretes glucocorticoid hormones (see), which have an anti-inflammatory effect, lowering the permeability of the vascular wall and stabilizing cell membranes. Thus, in response to the injury, an adaptive syndrome develops, at the beginning of which the cells, as it were, tune in to the new nature of metabolism and the forces of the body as a whole are mobilized.
For second phase(4-10 days after injury) the predominant influence of the parasympathetic department c. n. N of page, action of mineralocorticoid hormones (see), aldosterone (see) and other hormones and mediators activating regeneration processes. In this phase, metabolism, especially protein metabolism, is normalized, wound healing processes are activated.
Local reactions occurring in damaged tissues (i.e., the actual wound process) were studied by N. I. Pirogov 1861), I. G. Rufanov (1954), S. S. Girgolav (1956), I. V. Davydovsky ( 1958) . Various classifications of these phases have been proposed.
The classification proposed by M. I. Kuzin (1977) distinguishes during the wound process the phase of inflammation (consists of two periods - the period of vascular changes and the period of cleansing the wound from necrotic tissues), the regeneration phase (formation and maturation of granulation tissue) and the phase of scar reorganization and epithelization.
During the wound process, a number of regular cellular and humoral changes are observed, the combination and severity of which determine its dynamics. In addition to morphol, changes, these include changes in microcirculation (see), the action of mediators (see) and other biologically active substances, changes in metabolism, etc.
Microcirculation changes at injury are caused by the reactive phenomena from arterioles, capillaries and venules and their damage, and also changes in limf., capillaries. The first reactive phenomena include vasospasm in the wound area, followed by their paralytic expansion. At the same time, as a result of bleeding (see), the mechanisms of hemostasis are activated, in which the processes of blood coagulation play the main role with the formation of a blood clot inside the damaged vessel (see Thrombus). With the participation of the fibrin-stabilizing factor of blood plasma, fibrin strands are gained on the surface of the wound, which has mechanical, bacteriostatic and sorption properties, and also plays an important role in the antibacterial protection of tissues and subsequent regenerative-reparative processes, the so-called. fibrin barrier.
Rapidly growing traumatic edema is, apparently, the result of a two-phase process.
In the first phase, its development is based mainly on reflex spasm of blood vessels with the occurrence of hypoxia (see) and acidosis (see) tissues, which cause an increase in the permeability of the vessel wall and tissue osmolarity (see Osmotic pressure).
In the second phase, humoral mechanisms are activated. According to I. V. Davydovsky, the development of traumatic edema in this phase is associated with an increase in the permeability of the capillary walls, caused by the release and activation of intracellular enzymes in damaged tissues. Certain importance is attached to the degranulation of mast cells and their release on the surface of the endothelium of substances (histamine, serotonin), which increase its permeability, as well as the formation in damaged tissues of small peptides of endogenous origin, which increase the permeability of the vascular wall and cause vasodilation. The initial vasospasm is replaced by their paretic expansion, and the acceleration of blood flow by its slowdown and the appearance of stasis (see), which further enhances hypoxia and tissue acidosis. Violations of local blood circulation associated with changes in the rheological properties of blood (increased plasma viscosity and hemoconcentration) and intravascular aggregation of its formed elements are of significant importance. Disturbances of a metabolism with accumulation in the damaged fabrics of products patol, a metabolism (see. Metabolites) aggravate progressing of a traumatic hypostasis. Biol, and a wedge, value of a traumatic hypostasis consists that it promotes a spontaneous stop of bleeding from small vessels and clarification of a wound by displacement from the wound channel of the rejected sites of fabrics, blood clots and small foreign bodys, providing it so-called. initial cleansing of the wound. Due to traumatic edema, the edges of the wound come together, which helps their consolidation. At the same time, causing a significant increase in interstitial pressure, traumatic edema enhances microcirculation disorders and tissue hypoxia, which can contribute to the emergence of new foci of necrosis.
Chem. mediators of the wound process carry out the regulation of regenerative-reparative processes in the wound. All substances of this group are sharply activated in damaged tissues, they exhibit pronounced activity even in negligible concentrations. The ratio of mediators determines the nature of the course of the wound process and the rate of wound healing. M. I. Kuzin (1981) et al. The following groups of mediators are distinguished: substances entering the wound from the plasma (included in the kallikrein-kinin system, the complement system, the system of blood coagulation and fibrinolysis); substances of local origin (biogenic amines, acid lipids, leukocyte and lysosomal components, tissue thromboplastins); other substances that can be formed in the lesion and away from it (plasmin, biogenic amines).
The kallikrein-kinin system includes kallikreins - enzymes that break down the inactive kininogen molecule to active kinin, and kinins (see) - small peptides that cause vasodilation, increase vascular permeability and contraction of smooth muscles (are in plasma in the form of inactive kininogen). The main mediator of this system is bradykinin (see Mediators of allergic reactions), To-ry stimulates the contraction of smooth muscle cells, increases the permeability of microvessels and their expansion.
The complement system (see) is a group of substances activated by a number of compounds, especially the antigen-antibody complex (see Antigen-antibody reaction). The system consists of And proteins or 9 groups called complementary components. Functionally, this system is connected with the kinin system and the system of blood coagulation and fibrinolysis. Most complement components are enzymes that circulate in the blood under normal conditions in the form of inactive forms. When wounded, each component is activated by the predecessor and activates the next component. At the same time, biologically active substances are released, causing an increase in the permeability of the vascular wall, leukocyte chemotaxis, phagocytosis and immune responses.
The mediators from the group of acidic lipids (see) include some fatty acids (see), for example, arachidonic, linoleic, etc. and their derivatives - prostaglandins (see), involved in the regulation of the exchange of cyclic nucleotides in cells (see. Nucleic acids ). Mediators of this group affect the inflammatory response in damaged tissues, platelet aggregation and cause a general increase in body temperature (fever). Under the influence of prostaglandins, the sensitivity of pain receptors to mechanical and chemical irritations increases. Interacting with bradykinin, acidic lipids contribute to the development of edema, and accumulating in the wound, have a pronounced effect on microcirculation, the vital activity of leukocytes and other cells.
The blood coagulation system (see) and fibrinolysis (see), providing hemostasis, are included in the wound process at its earliest stage and do not lose their significance until the wound is completely epithelized. Many factors of the coagulation system (fibrinogen, tissue thromboplastin, Hageman factor, fibrin-stabilizing factor, antiplasmins, heparin) are chem. mediators of the wound process involved in its regulation. When blood vessels are damaged, the Hageman factor is activated, which interacts with mediators that cause an increase in vascular permeability. The Hageman factor launches the activity of the blood coagulation system, promotes the activation of the fibrinolytic system and, through the activation of prekallikrein, causes the formation of active kinins, that is, it performs a trigger function (see Trigger mechanisms) in the initial phases of the wound process and inflammation. Activation of plasminogen causes fibrin to melt and thereby promote wound cleansing. In addition, some other proteases (see Peptide hydrolases), for example, contained in neutrophilic leukocytes, can also, like activated plasmogen (plasmin), take part in the breakdown of fibrin clots.
A group of leukocyte and lysosomal enzymes - proteases, phosphatases (see), cathepsins (see), etc. are involved in intracellular cleavage of microstructures phagocytosed by leukocytes and macrophages. Getting into the extracellular environment during the decay of leukocytes, they activate and catalyze the hydrolysis of biopolymers, ensuring the melting of particles of dead cells and bacteria located in the wound, and contribute to its cleansing. In addition, lysosomal hydrolytic enzymes and substances contained in the granules of neutrophilic leukocytes catalyze the transition of inactive forms of other enzymes (plasminogen, Hageman factor, kallikreinogen) into active ones and cause the formation of products that stimulate repair.
Adrenaline and norepinephrine released during tissue damage (see) cause spasm of small vessels, a decrease in the permeability of their walls and contribute to increased formation (under the action of proteolytic enzymes) of histamine, peptides and surfactants. The opposite effect on tissues has histamine (see), which causes hyperemia, exudation, loss of fibrin and migration of leukocytes. The action of histamine is short-lived, it only plays the role of a starting mediator of inflammation, since it is quickly destroyed by histaminase and blocked by heparin.
Serotonin has an action close to histamine (see).
To other chem. mediators of the wound process, still little studied, include tissue breakdown products.
Mediator systems function in close interaction, the leading value of any of them has not yet been determined. Schematically, the action of mediator systems can be represented as follows. As a result of tissue damage, biogenic amines, tissue thromboplastin are released, the Hageman factor is activated, and then kallikreinogen, the plasma precursor of thromboplastin and lysosomal components. Then plasmin, prostaglandins and the complement system are turned on. Tissue thromboplastin triggers the hemostasis system. As a result of the activation of kallikreinogen, active kallikreins are formed, catalyzing the formation of kinins, causing a persistent and prolonged increase in vascular permeability and affecting other factors in the initial stage of the wound process. In the future, due to impaired microcirculation and the development of hypoxia, prostaglandins accumulate, the complement system is activated, and lysosomal enzymes appear that help cleanse the wound and heal it.
Metabolic changes (see Metabolism and energy) in the wound affect all types of metabolism; they are especially clearly manifested in the development of local acidosis, as well as in the accumulation of metabolic products in the tissues.
Acidosis in the wound proceeds in two phases. The first phase (decrease in pH to 6.0) develops within a few seconds after injury as a result of local acid formation - primary acidosis. The second phase (decrease in pH to 5.0 and below) is the result of metabolic shifts, Ch. arr. activation of anaerobic glycolysis - secondary acidosis.
Initially, acidosis is compensated and is manifested only by a decrease in the level of standard bicarbonate and an increase in the excess of bases. With purulent-demarcation inflammation, especially insufficient outflow of wound discharge, buffer systems are depleted, and uncompensated (true) acidosis develops, with Krom, the concentration of hydrogen ions in tissues can increase by 50 or more times. Moderately pronounced local acidosis is a secondary pathogenetic factor in the wound process, since it contributes to the development of infiltrative-exudative phenomena in the wound, increases capillary permeability, enhances the migration of leukocytes and stimulates the activity of fibroblasts. With significant severity, acidosis causes the death of tissue structures and has an inactivating effect on the chemical. mediators of the wound process.
In purulent wounds, the concentration of hydrogen ions varies widely. According to M. I. Kuzin et al. (1981), in 30% of the examined wounded, the reaction of the wound environment was neutral or alkaline. In the cytograms of the wound discharge in an acidic environment, polyblasts and macrophages predominated and young fibroblasts were found, i.e., there were clear signs of repair, while in an alkaline reaction, neutrophilic leukocytes in the decay stage were found in large numbers. From these data, it follows that both acidic and alkaline hydrolases are involved in the wound process, and that by changing the acidity of the wound medium, one can regulate their activity, promoting wound healing.
Simultaneously with a change in the acid-base state of tissues, the concentration and quantitative ratios of electrolytes in them change (for example, the number of potassium ions increases compared to the number of calcium ions), products of incomplete oxidation accumulate (milk and oil acids, etc.), the composition changes. cellular colloids, etc., which leads to an increase in osmotic pressure, edema and swelling of tissues, and in severe cases - to their secondary necrosis.
When purulent-demarcation inflammation occurs in the wound, a large number of enzymes of both endogenous origin (from decaying leukocytes, lymphocytes and other cells) and exogenous ones appear. Among exogenous, enzymes of bacterial origin are of particular importance - hyaluronidase (see), streptokinase, bacterial deoxyribonuclease (see), collagenase (see), etc., which cause proteolysis of dead tissues and contribute to biol, cleaning the wound. According to M. F. Kamaev, V. I. Struchkov and others, the activity of enzymatic systems reaches a maximum at the height of the development of the inflammatory process and decreases as the granulation tissue matures.
According to V. V. Vinogradov (1936), B. S. Kasavina et al. (1959), since the onset of fibroblastic proliferation in the wound, the synthesis and accumulation of sulfate-containing acid mucopolysaccharides (see), as well as hyaluronic acids (see), the concentration of which decreases as collagen fibers mature, increases. The main role in the formation of collagen, which is so necessary for wound healing, is played by the biosynthesis of collagen protein, which is carried out in fibroblasts. The final formation of collagen fibers is completed by the formation of collagen complexes with mucopolysaccharides, hyaluronic acid, chondroitin sulfate (see Chondroitin sulfuric acids) and other components of the intercellular substance.
The level of protein and vitamin supply of the body has a significant impact on the course of the wound process, since proteins and vitamins, in addition to the general effect, contribute to an increase in the functional activity of cells that provide wound cleansing, the development of granulations and collagenogenesis.
When studying the preparations obtained, the phagocytic ability of neutrophils (microphages) and macrophages and the nature of phagocytosis are first evaluated. At normal immunol. resistance of the organism, phagocytosis ends with the lysis of pathogens in the cytoplasm of phagocytes, and the imprints contain phagocytes at different stages of phagocytosis. With insufficient resistance of the organism, neutrophils with incomplete phagocytosis appear in the prints, with Krom the cytoplasm of the phagocyte is destroyed with the release of pathogens contained in it, but not lysed, into the environment. In the complete absence of a phagocytic reaction (eg, with sepsis), neutrophils are surrounded on all sides by microorganisms without signs of their phagocytosis.
Further evaluate the nature of the cells of the reticuloendothelial system located in the imprints (see). Polyblasts and macrophages appear in the wound exudate somewhat later than neutrophils, and their number increases with the development of reactive processes. The appearance of degenerative changes in the cytoplasm of polyblasts or a violation of their maturation (the predominance of young forms for a long time) is a sign of reduced body resistance or high virulence of the pathogenic microflora of the wound. Intensive maturation of polyblasts into Mechnikov's macrophages, which differ from polyblasts in the presence of digestive vacuoles and high phagocytic activity, is an indicator of a good protective reaction of the body and indicates the beginning of biol, wound cleaning; their disappearance in prints in the dehydration stage is associated with the formation of healthy granulation tissue. In the phase of wound healing, polyblasts mature into profibroblasts, and then into fibroblasts, which, multiplying, gradually displace microphages.
The appearance of Unna's plasma cells in the prints, which are distinguished by a characteristic spotted nucleus and a darker color of the cytoplasm, is significant. These cells do not transform into any other elements; they die in the process of wound healing, and their mass appearance in the imprint indicates adverse changes in the regenerative-reparative processes and the failure of the treatment.
Other cells that can be found in the prints, for example, eosinophils and so-called. giant cells of foreign bodies are not essential for assessing the course of the wound process.
At the same time, it is advisable to take into account the number of microorganisms found in wound prints and the dynamics of microbial contamination. I. I. Kolker et al. (1976) believe that such control should be supplemented by counting the number of microbes in 1 g of tissue constituting the wound surface.
MF Kamaev (1970) recommends taking for cytol. research scraping of the surface layer of the wound, which is transferred to a glass slide in the form of a thin uniform layer, fixed and stained. This material contains not only cells of the wound discharge, but also newly formed cells of the surface layer of the wound, the composition and nature of which serve as additional material for assessing the state of regenerative and reparative processes in the wound.
Clinical picture
A fresh accidental wound is characterized by pain (see), the intensity and nature of the cut depend on the location and type of wound, as well as on the condition of the wounded person (in a state of passion or deep alcohol intoxication, pain is less pronounced or absent). There are also violations or limitations of the function of the damaged part of the body, minor with superficial wounds and abrasions and pronounced with damage to the nerve trunks, tendons, blood vessels, muscles, bones, joints. A characteristic feature of the wound is its gaping, i.e., the divergence of the edges associated with the elastic properties of the tissues, more pronounced in the wound located perpendicular to the course of the skin scallops, muscle and fascial fibers. Bleeding is observed (see) from the damaged vessels of the wound wall, usually mixed, of the capillary type, which stops on its own or after applying a bandage. If large blood vessels are damaged, it can be life-threatening. Blood can impregnate tissues (see Hemorrhage) or accumulate in interfascial spaces, subcutaneous, retroperitoneal, perirenal tissue (see Hematoma). In some cases, the hematoma, communicating with the lumen of the damaged artery, forms the so-called. pulsating hematoma. With penetrating wounds, blood can flow into the corresponding cavity and accumulate there (see Hemarthrosis, Hemoperitoneum, Hemothorax). From a penetrating wound, depending on its location, intestinal contents, bile, pancreatic juice, as well as cerebrospinal fluid, urine, etc.
When wounded, the general condition of the body is disturbed to varying degrees. With superficial wounds without significant bleeding, these violations are insignificant. With extensive torn-crushed and gunshot wounds, complicated by significant blood loss (see), there are hemodynamic disturbances, manifested by a decrease in blood pressure, general weakness, dizziness, nausea, pallor of the skin and mucous membranes, tachycardia. In severe cases, a wedge develops, a picture of traumatic shock (see).
The wedge, the course of the wound process depends on the nature, localization and size of the wound, the degree of microbial contamination, the adequacy of the treatment, as well as the immunological characteristics of the body.
In wound healing by primary intention pain in the wound by the end of the second day decreases or disappears, pain on palpation or movement lasts longer. Wedge, signs of reactive inflammation (hyperemia, swelling of the edges of the wound, local temperature increase) are weakly expressed and disappear by the end of the first week. By this time, epithelialization is completed and a delicate skin scar is formed (see). In the deep layers of the wound, the formation of a scar occurs more slowly, which must be taken into account when determining the mode of work and motor activity of the patient. General phenomena are also not very pronounced: subfebrile temperature, slight leukocytosis, acceleration of ESR are noted only in the first 3-4 days, and then disappear without special treatment. The occurrence of these changes is associated with resorption from the wound of the decay products of damaged tissues, physical inactivity and impaired pulmonary ventilation in debilitated patients.
Wound healing under the scab takes longer, but the general phenomena are expressed as slightly as in the case of healing by primary intention.
Wedge, the course of wounds, healing by secondary intention, is largely determined by the development of inf. complications, the severity of purulent-demarcation inflammation and, therefore, largely depends on the emerging relationship between the macroorganism and microorganisms located in the wound. In uncomplicated cases, when the wound microflora is one of the components of the normal course of the wound process, many researchers single out periods of incubation, spread and localization of microbes in the wedge, during the course of the wound process.
The incubation period, which usually coincides with the first period of the first phase of the wound process, during which the wound microflora is formed, can last from several hours to 2-3 days. In this period, the state of the wound is determined by the nature of tissue damage, and the general reactions of the body are determined by the severity of the injury and blood loss.
The period of spread of microflora is clinically manifested by the development of purulent-demarcation inflammation (the second period of the first phase of the wound process), with Krom, microbes penetrate deeper (especially damaged) tissues and multiply in them. There are local symptoms of inflammation and signs of a change in the general condition of the body (deterioration of well-being, fever, the appearance of leukocytosis, etc.), caused by Ch. arr. resorption of waste products of microbes and decay products of dead tissues in the wound. The appearance of the wound changes: its edges are swollen, covered with fibrinous-necrotic plaque, the wound discharge takes the form of serous-purulent exudate. With a favorable course, this period lasts an average of approx. 2 weeks
Then there comes the period of localization of microflora, during to-rogo it is suppressed, and processes of wound healing (the second and third phases of wound process) develop. The wound is gradually cleared of necrotic tissues and is filled with juicy bright red granulations. A wedge, signs of an inflammation decrease, and then completely disappear, the wound discharge becomes more dense and loses purulent character. Body temperature normalizes, appetite and well-being of the wounded person improve.
Despite the fact that during this period, small bone sequesters can depart from the depth of the wound (see Sequestration, sequestration), foreign bodies (ligatures, metal fragments, pieces of clothing, etc.), the process of delimitation of dead tissues and their elimination can be considered mainly finished. The period of localization of the infection can last a long time until the restoration of damaged integuments - skin or mucous membranes; up to this point, the wound or part of it remains filled with granulation tissue.
Complications
During the infection incubation period the complications connected hl are observed. arr. with the nature and location of the wound. The most dangerous of them are shock and acute blood loss. Bleeding into closed spaces (cranial cavity, pleura and pericardium, spinal canal, etc.) can cause compression of vital organs. Penetrating wounds of the skull are often accompanied by liquorrhea (see), chest - by hemopneumothorax (see Hemothorax); a stomach - development of peritonitis (see).
During the period of infection observed inf. complications of the wound process. In an infected wound, unlike a purulent wound, suppuration is a complication, and not a natural component of the wound process. Occurrence inf. complications are facilitated by massive seeding of the wound with pathogenic microflora, accumulation of wound discharge due to insufficient drainage, the presence of foreign bodies, impaired blood supply to tissues in the damaged area (segment), a decrease and perversion of the general reactivity of the body (alimentary dystrophy, hypovitaminosis, exposure to ionizing radiation, etc.). Depending on the type of pathogens, the wound process can be complicated by purulent, anaerobic and putrefactive infection (see Anaerobic infection, Putrid infection, Purulent infection). With a purulent infection in the wound area, purulent inflammation can develop in the form of an abscess (see), phlegmon (see), purulent streaks (see), erysipelas (see Erysipelas), lymphangiitis (see), lymphadenitis (see) , thrombophlebitis (see), etc. As a result of purulent processes, arrosive bleeding is possible. Receipt in an organism of products of disintegration of fabrics, toxic substances of a microbial origin causes a feverish state, a cut I. V. Davydovsky defined as purulent and resorptive fever (see). Long-term suppuration and delayed wound healing, disorders of local and general immune processes can lead to traumatic exhaustion (see) of the body or generalization of infection - sepsis (see).
During the healing period secondary infection is possible, which is usually provoked by trauma or superinfection. Complications in this period are connected by hl. arr. with violation of regenerative-reparative processes in the wound. Such complications include divergence of the edges of the wound after removal of sutures in the absence of suppuration, prolonged non-healing of the wound, the formation of ulcers (see Ulcer), fistulas (see), keloid scars (see Keloid), various deformities. General complications of this period are often due to prolonged intoxication, immunological and metabolic disorders (protein depletion, amyloidosis). In long-term non-healing wounds (ulcers), purulent fistulas, massive ulcerative scars, a malignant tumor may develop (see Tumors).
A special group of complications are therapeutic diseases, often arising or passing into the active phase due to injury: pneumonitis (see), pneumonia (see), gastritis (see), exacerbation of peptic ulcer (see), hepatitis (see). According to N. S. Molchanov, E. V. Gembitsky and others, the course of these diseases has features associated with the localization of the wound and the phase of the wound process.
Disorders of the cardiovascular system in the early period after injury, they are predominantly functional in nature and are expressed in an increase in heart rate and respiration, a decrease in blood pressure, pallor or cyanosis of the mucous membranes and skin, pain in the heart, and general weakness. They are usually easy to treat. However, with injuries, for example, to the brain and spinal cord, chest, accompanied by hypoxia that is difficult to eliminate, such disorders are persistent and require long-term treatment.
With massive damage to soft tissues, acute renal failure often develops (see Traumatic toxicosis), with injuries of large tubular bones - nephrolithiasis, with acute blood loss - hypochromic iron deficiency anemia (see), with infected wounds - infectious toxic nephrosis (see Nephrotic syndrome), focal and diffuse glomerulonephritis (see), wound psychoses, etc.
Wound psychoses
Wound psychoses are a kind of symptomatic psychoses (see). Most often they develop at wounds of the lower and top extremities, a thorax and maxillofacial area complicated by acute or hron, a wound infection, especially osteomyelitis. Like other symptomatic psychoses, they can be acute and protracted (protracted).
Acute wound psychoses develop in the first 2-3 weeks. after injury in the presence of an acute wound infection with a suppurative process in soft tissues and bones. In the etiology and pathogenesis of such acute psychoses, an important role belongs to the infectious-toxic factor. With suppuration of soft tissues, the wedge, the picture is limited mainly to reactions of an exogenous type (see Vongeffer exogenous types of reactions). Psychosis is preceded by asthenia (see Asthenic syndrome), a feature of the cut are pronounced sleep disturbances and sometimes hypnagogic hallucinations (see). Of the syndromes of clouded consciousness, delirium is most common (see Delirious syndrome). The characteristic content of delirium in the wounded in a combat situation is a military theme. In more severe cases, amentia develops (see Amentative syndrome), more often with motor excitation, less often with stupor. The amental syndrome often begins with a delirium of ordinary content, reflecting the real situation. It is also possible to develop twilight stupefaction in the form of epileptiform excitation. Acute wound psychoses last several days and usually end with superficial asthenia. A more complex wedge, a picture of psychosis acquires when the wound process is complicated by osteomyelitis.
In this case, after amentia, transient Wick syndromes can develop (see Symptomatic psychosis) in the form of hallucinatory paranoid and depressive paranoid symptom complexes, and the psychosis ends with asthenia of a more complex nature with hypochondriacal and hysterical disorders. This variant of wound psychoses occupies an intermediate position between acute and protracted psychoses.
Protracted wound psychoses develop with chronic wound infection after 2-4 months. after injury. In their etiology and pathogenesis, the phenomena of hypoxia, prolonged intoxication, anemia, pronounced electrolyte imbalance, in severe cases, dystrophic changes, and unresponsiveness of the body occupy a significant place. The psychogenic factor also takes part in the formation of prolonged wound psychoses. Repeated injuries contribute to the development of wound psychoses. intoxication, infection. The wedge, the picture of protracted wound psychoses is characterized by transitional Wick's syndromes more often in the form of depression, depressive-paranoid and hallucinatory-paranoid syndromes with delusions of self-accusation, hypochondriacal statements. An apathetic stupor and a paralysis-like state with euphoria and foolishness are also possible. The states of clouded consciousness occur much less frequently. With wound exhaustion, a prognostically unfavorable apathetic stupor, a paralysis-like and anxious-dreary state with unconscious anxiety, melancholy, fear, agitation and suicidal attempts, as well as states of consciousness obnubilation (see Stunning) with body schema disorders develop. Protracted wound psychoses end with deep asthenia; development of a psychoorganic syndrome is possible (see).
Treatment of acute wound psychoses perhaps in a surgical hospital, because it provides primarily for the treatment of the underlying disease. Antipsychotics (chlorpromazine, tizercin, haloperidol, triftazin) are used to relieve arousal. Protracted wound psychoses require treatment in a psychiatric hospital. Along with general strengthening, detoxification and anti-infective therapy, psychopharmacol is used carefully, taking into account the characteristics of the somatic condition. means - neuroleptics (see. Antipsychotics) and tranquilizers (see).
Treatment
Wound treatment is a system of measures, including first aid, surgical treatment of the wound, a set of measures aimed at increasing the body's immune forces, preventing infections and fighting against it and other complications, the use of physiotherapy methods, to lay down. physical education, etc. The degree of use of these activities. their sequence, execution time are determined by the nature and localization of the wound and the condition of the wounded, and in wartime - by the combat and medical situation at the stages of honey. evacuation.
When providing first aid, edges are usually carried out at the site of injury, first of all, external bleeding is stopped (see) by finger pressure of a blood vessel outside the wound, giving an elevated position or forced flexion of the limb, applying a pressure bandage, a tourniquet (see Hemostatic tourniquet ) or twists from improvised material. The circumference of the wound is freed from clothing (shoes) and, if conditions permit, the skin around the wound is treated with 5% alcohol solution of iodine, after which an aseptic dressing is applied to the wound.
With small superficial skin wounds (abrasions and scratches), the role of the primary dressing can be performed by a protective film of film-forming preparations applied to the wound (see) such as plastubol and others, which have antiseptic properties.
At fractures of bones, injuries of joints, large blood vessels and extensive damage to soft tissues, transport immobilization is performed (see) using tires (see Tires, splinting) or improvised material, after which the victim should be urgently taken to the hospital. institution.
In a hospital setting, the wounded person is taken out of shock, tetanus toxoid and tetanus toxoid are administered to him (see Tetanus) and measures are taken to prepare for the operation (see Preoperative period). In especially hard cases use of hyperbaric oxygenation is shown (see), edges promotes normalization of indicators of a hemodynamics and positively influences a condition of a wound.
Surgical treatment is the main method of wound treatment. It provides for surgical treatment - primary and secondary (repeated) and operational methods for closing a wound defect - the imposition of primary, primary delayed, secondary early and late sutures and plastic surgery (see Primary suture, Secondary suture, Plastic surgery, Surgical treatment of wounds).
Primary surgical treatment of wounds it is made before emergence a wedge, signs of a wound infection. Its goal is to prevent wound infection and create the most favorable conditions for wound healing. It is achieved by radical excision of all dead and non-viable tissues. Hemostasis is performed, the wound is drained. The walls of the wound channel should be living, well-vascularized tissues. Primary surgical treatment, performed at the most optimal time (up to 24 hours after injury), is called early. Modern means of antibacterial therapy make it possible to delay the development of wound infection and, if necessary, delay surgical treatment up to 48 hours. (delayed primary debridement). The primary surgical treatment performed after 48 hours is called late. In the practice of modern surgery, there has been a tendency to carry out primary surgical treatment of the wound as a one-stage primary recovery operation, widely using primary and early delayed skin plasty (see), metal osteosynthesis (see), restorative operations on tendons, peripheral nerves (see Nerve suture ) and blood vessels.
Secondary (repeated) surgical treatment of wounds it is made in the presence a wedge, displays of a wound infection for the purpose of its elimination. This goal is achieved by excision of the walls of a purulent wound within healthy tissues (complete surgical treatment of a purulent wound), if it is impossible to-rogo, they are limited to dissection of the wound, opening pockets and streaks, and excising only large necrotic, non-viable and purulent tissues (partial surgical treatment of a purulent wound). Secondary surgical treatment of wounds, if indicated, can be performed at any phase of the wound process; it is especially appropriate in the inflammation phase, since it provides the most rapid removal of dead tissue and transfer of the process to the regeneration phase.
In the practice of surgical treatment of wounds, secondary surgical treatment can be for the wounded both the first operation, if for some reason the primary surgical treatment was not performed, and the second, if the goal of the primary treatment performed - the prevention of wound infection - is not achieved.
Primary surgical suture used as the final stage of primary surgical treatment in order to restore the anatomical continuity of tissues, prevent secondary microbial contamination of the wound and create conditions for its healing by primary intention. The wound can be sutured tightly only if it is possible to perform a radical primary surgical treatment. The imposition of primary sutures is permissible only under such conditions as the absence of abundant contamination of the wound, excision of all non-viable tissues and removal of foreign bodies, the preservation of the blood supply to the wound area, the possibility of approaching the edges of the wound without rough tension, and if the condition of the wounded person is not aggravated by blood loss, starvation, inf. disease. The wounded should be under the supervision of a surgeon after initial treatment until the sutures are removed. Failure to comply with any of these requirements leads to severe complications. Therefore, primary sutures are most often applied to shallow musculoskeletal wounds. These include, in particular, incised, chopped, sawn, some bullet wounds, etc. Deep blind wounds, especially those accompanied by a bone fracture, are temporarily left open after surgical treatment and tamponed. In the surgical treatment of extensive crushed, bruised, especially gunshot wounds, it is practically impossible to guarantee compliance with the above conditions (primarily the radicalness of the surgical treatment). For this reason, the so-called delayed primary suture, which is applied 5-7 days after the operation (until granulations appear) in the absence of signs of wound suppuration. It can be applied in the form of provisional sutures, which are applied during the operation, but tightened after a few days, making sure that there is no danger of suppuration of the wound.
In the practice of peacetime surgery, the possibility of applying a primary suture in the surgical treatment of abscesses, phlegmon, after secondary surgical treatment of festering wounds is being studied. The success of such operations is achieved only under the condition of complete excision of necrotic tissues, adequate drainage of the wound, followed by prolonged washing with antiseptics, proteolytic enzymes, and rational antimicrobial therapy.
Early secondary sutures impose on a granulating, cleansed of pus and necrotic tissue wound (2nd week after surgical treatment). If scar tissues have formed in the wound, preventing the edges of the wound from approaching, they are excised and late secondary sutures are applied (3-4 weeks after surgical treatment).
A prerequisite for the success of the operation is the creation of an unhindered outflow of wound discharge using various drainage methods (see). The most effective methods of active aspiration of wound discharge using various vacuum systems (see Aspiration drainage).
For prevention of a wound infection primary surgical treatment of a wound is combined with use of antibiotics (see) which enter in the form of solutions directly into a wound or surrounding fabrics by intramuscular injections; the most effective is the combined administration of prolonged-acting antibiotics. Sulfonamides and other antibacterial agents are also used.
If, after the primary surgical treatment, completed with the primary suture, healing proceeds by primary intention, the bandage is changed on the 2-3rd day and the wound is not bandaged again until the sutures are removed (usually on the 7-10th day). At suppuration of a wound seams remove partially or completely and apply necessary to lay down. Events; in the presence of a seroma, it is opened and festering ligatures are removed. Such wounds heal by secondary intention.
Treatment of wounds that heal by secondary intention is much more difficult. In a phase of hydration and biol, cleanings of such wound to lay down. measures should contribute to the rapid rejection of non-viable tissues and the suppression of pathogenic microflora. To improve the rejection of necrotic tissues, reduce the resorption of toxic components of wound exudate in this phase, suction dressings are widely used (see) with a hypertonic solution of sodium chloride and certain antiseptics, as well as powdered substances (for example, Zhitnyuk's powder) and sorbents ( e.g. activated charcoal). Effective for the purposes of biol, wound cleaning proteolytic enzymes (see Peptide hydrolases) pancreatic, for example, chymotrypsin (see), and bacterial origin, which along with necrolytic action have anti-inflammatory and anti-edematous properties, significantly reduce the duration of the wound hydration period. Enzyme preparations in some cases enhance the effect of antibiotics, making their combined use expedient.
Antibacterial wound therapy is carried out taking into account immunol. the state of the body, the nature of the microflora of the wound, the individualization of chemotherapeutic agents. In the presence of staphylococci in the wound, usually resistant to the most widely used antibiotics (penicillin, streptomycin, tetracycline, etc.), antibiotics with a higher antistaphylococcal activity (erythromycin, novobiocin, ristomycin, oleandomycin, polymyxin, etc.), as well as drugs nitrofuran series (furatsilin, furazolin, furazolidone, solafur). To improve the effectiveness of antibiotic therapy and reduce the drug resistance of microflora V. I. Struchkov et al. (1975) recommend the combined use of antibacterial drugs with different mechanisms and spectrum of action. Antibacterial drugs are used topically in the form of solutions and ointments, as well as intramuscularly and intravenously.
For activation of nonspecific factors immunol. body resistance (opsonins, phagocytosis, bactericidal activity of leukocytes and serum), the most important is the normalization and stimulation of protein metabolism (high-calorie nutrition, intravenous infusion of plasma, protein hydrolysates, protein, albumin, etc.), saturation of the body with all vitamins (see) , the appointment of pyrimidine and purine derivatives (see Pyrimidine bases, Purine bases), etc. To stimulate anabolic processes, anabolic hormones are prescribed - retabolil, nerobol (see Anabolic steroids). In order to detoxify and fight anemia, a transfusion of freshly citrated blood (250-500 ml with an interval of 1-2 days) is indicated. Prodigiosan (see) and other polysaccharides of bacterial origin increase the bactericidal properties of blood, activate the complement system and enhance the effect of antibiotics. At low values of chemotaxis and complement, a decrease in the phagocytic-bactericidal activity of leukocytes and the bactericidal activity of serum, fresh plasma is transfused. The low content of T- and B-lymphocytes in the blood is replenished by transfusion of fresh leukocyte suspension.
Mineralocorticoid hormones (see), thyroxine (see), growth hormone (see), sex hormones (see), etc. are used to stimulate the processes of regeneration and wound healing.
Specific immunoprophylaxis is aimed at creating passive (using hyperimmune serum and plasma, gamma globulin) or active (using vaccines) immunity against a specific pathogen of wound infection. For the purpose of active immunization, staphylococcal toxoid is most widely used (see Anatoxins). At the developed infection of a wound carry out an immunotherapy (see).
In connection with the widespread and often incorrect use of antibiotics, the ecology of the causative agents of wound infection and the reactivity of the human body to it have changed - antibiotic-resistant and antibiotic-dependent strains of microbes have been formed that are not sensitive to existing antibacterial agents. In this regard, the possibilities of treating wounds in a controlled abacterial environment are being studied, for which they use general isolator chambers with a laminar flow of sterile air (see. Sterile chamber) and local isolators to create abacterial conditions around damaged areas of the body, mainly on the extremities (see Controlled antibacterial environment). In general isolation wards, an optimal microclimate is created, the patient is isolated from the environment, communication with a cut is carried out through special gateways. The attendants work in sterile underwear and shoes.
Local isolators are plastic bags that are glued to the wound area. There are three options for treatment using local isolators: in a controlled environment, in conditions of local gnotobiological isolation (biolysis) and in a controlled abacterial environment.
A method of treatment in a controlled environment has been proposed for the treatment of sutured wounds after amputation of limbs. A stump without a bandage is placed for 10-15 days in a plastic isolation chamber, into which sterile air is supplied; temperature and air pressure are controlled. Carrying out to lay down. manipulations in the chamber are not provided. According to the creators of the method, its use helps prevent nosocomial infection, helps reduce edema and improve blood and lymph circulation in the wound area.
The method of local gnotobiological isolation was proposed by Yu. F. Isakov et al. (1976). Its essence lies in the fact that the wounded limb without prior surgical treatment and without a bandage is placed for the entire duration of treatment (10-20 days) in a special chamber with an abacterial air environment. The chamber has special sleeves with gloves and a gateway for supplying instruments and material, which allows for manipulations and surgical interventions. During the entire treatment period, sterile air is blown through the isolator; The camera does not have devices that regulate the microclimate. The main goal of treatment is to suppress the microflora in the wound and prepare it for plastic closure. According to S. S. Belokrysenko et al. (1978), a sharp or complete disappearance of pathogenic microbes in the wound during this treatment occurs mainly due to the drying effect of the blown air.
The method of treatment in a controlled abacterial environment, developed in Ying-those surgery. A. V. Vishnevsky of the USSR Academy of Medical Sciences (1976), allows you to combine an operational manual with local gnotobiological isolation of the wound. Sterile air is supplied to the chamber, it is possible to regulate many environmental parameters (temperature, humidity) and create optimal conditions for wound healing. The limb without a bandage is placed in a sterile plastic isolator immediately after surgical treatment for the entire duration of treatment. The improvement of the general condition of the wounded and the condition of the wound itself occurs already in the first 2-3 days after the start of treatment.
In the phase of dehydration of the wound, characterized by a gradual decrease in the inflammatory response and the development of regenerative and reparative processes, the goal of treatment is preservation of granulation tissue and elimination of obstacles to wound epithelialization. This is achieved by proper care of the wound and the surrounding skin, the sparing nature of dressings and other manipulations. Instead of dressings with antiseptic substances and hypertonic solutions that damage granulation tissue, dressings with ointments and emulsions that have antibacterial properties and positively affect tissue trophism (for example, solcoseryl, sea buckthorn oil, Shostakovsky's balm, colanchoe, etc.) are used. In this phase, operations are often performed that can dramatically reduce the time of wound healing (delayed skin grafting, secondary sutures, etc.).
Physiotherapy It is used in the treatment of wounds in all phases of the wound process in order to combat infection and intoxication, as well as to improve local blood circulation and stimulate regenerative and reparative processes.
During the surgical treatment of extensive and complex wounds, the wound is treated with a pulsating jet of an antiseptic solution or a sterile isotonic solution of sodium chloride, which are supplied with oxygen pressure. Apply also vacuum processing of wounds in the conditions of constant irrigation by antiseptic solution. Both methods contribute to the removal of microflora, blood clots, wound detritus from the wound and provide the possibility of deeper penetration of drugs into the lesion. The effectiveness of ultrasound is being studied (printing, table, fig. 9), which helps to suppress wound microflora (by increasing its sensitivity to antibiotics) and accelerate reparative processes in tissues (see Ultrasound, Ultrasound therapy).
Sanitation of the wound is facilitated by its irradiation with short UV rays (2-3 biodoses). In the first days after surgical treatment, the wound surface and the surrounding skin are irradiated with UV rays (1-2 biodoses); in the presence of inflammation in the wound circumference and damage to deep-seated tissues, an UHF electric field is used (10-15 minutes each up to 10-12 procedures). When necrotic tissues or sluggish granulations appear, UV irradiation is adjusted to 6-8 biodoses and iodine electrophoresis, darsonvalization or air ionization (for 10-20 minutes) of the wound area are added during dressing change. To suppress the microflora of the wound, electrophoresis of antibacterial drugs (antibiotics, sulfonamides, nitrofuran derivatives, etc.) is used * During the biological cleaning of the wound, electrophoresis of proteolytic enzymes (trypsin) can be used.
With delayed wound healing, electrophoresis of iodine-zinc and peloidin (see) is prescribed for 20-30 minutes. daily for 10-12 days, pulsed ultrasound, microwave therapy. In the later stages of delayed wound healing, in the presence of dystrophic changes in granulations or signs of ulcer formation, mud and paraffin applications can be applied to the wound surface, spark darsonvalization around the wound circumference, sinusoidal modulated and diadynamic currents, general UV irradiation, local exposure to infrared radiation. To stimulate reparative-regenerative processes, an alternating low-frequency magnetic field and laser radiation are also used (see Laser).
Physiotherapy during injuries, it helps to mobilize the vital forces of the body and create optimal conditions for blood circulation and reparative processes in the tissues of the damaged area.
Indications for exercise therapy for injuries are very wide. Moderately pronounced suppuration and subfebrile body temperature with a good outflow of pus and the absence of infection spread to the veins, tendon sheaths and joints are not contraindications to the appointment of exercise therapy. Exercise therapy is especially important for sluggishly healing wounds. Contraindications to such activities are the general serious condition of the wounded, high body temperature, severe pain in the wound and the risk of bleeding.
In the hydration phase of the wound, physical therapy exercises are mainly limited to breathing exercises, changing the position of the body in bed, movements of intact limbs, etc.
Purposeful exercises begin from the beginning of wound regeneration (I period of exercise therapy). In this period, general tonic exercises are used. Stimulation of wound healing is facilitated by exercises for the distal segments of the injured limb and exercises for symmetrically located muscles.
When the formation of scar tissue begins (II period of exercise therapy), active muscle contractions in the area of damage are used to influence locally occurring processes. Improving blood supply and stimulating healing, they slow down the development and reduce the severity of contractures (see), contribute to the preservation of the interchangeability of the skin, muscles and tendons. A variety of movements should be repeated many times during the day. To avoid injury to the granulations during exercise, the dressings are loosened or removed. After suturing the damaged tendon, active movements begin from the 3rd-4th day in order to cause small displacements of the tendon in relation to the surrounding tissues and especially to the tendon sheath. After applying delayed or secondary sutures, movements in the damaged segment are resumed after 3-4 days, however, their amplitude is limited, given the risk of suture divergence.
After wound healing, but in the presence of residual effects - scars, contractures, muscle weakness (III period of exercise therapy) to lay down. gymnastics should help restore the function of the damaged organ. During this period, active movements are performed along all axes of the joints with a gradually increasing amplitude. As the scar matures, exercises are included to lightly stretch it; slight pain during movement is not a contraindication. Clubs, gymnastic sticks, stuffed balls, etc. can be used. Great attention must be paid to restoring the strength and endurance of the muscles of the damaged segment (see also Gymnastics, Therapeutic exercise).
Features of the treatment of wounds in children
Treatment of wounds in children is carried out mainly according to the generally established rules of surgery.
During the primary surgical treatment of the wound, tissue excision is performed more economically than in adults; preference is given to complete excision of the edges of the wound, followed by a blind suture. Contaminated wounds are pre-washed with a stream of antiseptic solution or hydrogen peroxide. Uncontaminated wounds of the soft tissues of the face and head are sutured with sparse sutures without excision of the edges after skin treatment with alcohol and 3% alcohol solution of iodine; small wounds are pulled together with a sticky plaster. With extensive scalped and patchwork wounds with detachment of the skin and subcutaneous tissue, surgical treatment is performed according to the Krasovitov method (see Skin plasty). The bandage is applied to the wound with special care, because due to the high mobility of children, it can slip and there is a danger of infection of the wound. When the wound is located in the joint area, a fixing plaster splint is applied. According to indications, antibiotic therapy is carried out. With a smooth course of the postoperative period, the sutures are removed on the 7th day, and in places where the skin is subjected to constant mechanical stress, immobilization and sutures remain for another 3-4 days.
For any injuries, unvaccinated children are given a prophylactic dose of tetanus toxoid, and vaccinated children are given tetanus toxoid in accordance with the instructions.
For the treatment of extensive infected, long-term non-healing wounds and open fractures in pediatric practice, the method of local gnotobiological isolation is used, as well as the treatment of wounds with ultrasound and helium-neon laser, the combined use of which accelerates skin regeneration and the elimination of marginal lysis in transplanted skin autografts and reduces the time treatment of long-term non-healing wounds.
Hyperbaric oxygen therapy in children is especially effective in the first hours and days after injury. As a result of its application, the wound heals 1.5-2 times faster than under normal conditions.
Features of wartime wounds. Staged treatment
The nature and severity of injuries depend on the weapon used. In the wars of the 19th - early 20th century. bullet wounds prevailed, there were relatively many wounds from edged weapons, the proportion of the most severe - shrapnel - wounds was small. With the improvement of military equipment and weapons, the proportion of gunshot (especially shrapnel) wounds increased and the number of wounds with cold steel decreased. During the Great Patriotic War of 1941-1945. 99.98% of all injuries were caused by bullets or fragments of mines, aerial bombs, artillery shells, etc.; cold steel injuries averaged 0.02%. In this regard, the severity of injuries increased compared to previous wars.
In local wars of recent years, there has been a further increase in the severity of gunshot wounds. Ammunition specially designed for the destruction of manpower appeared in the arsenal of foreign armies - ball bombs, artillery shells stuffed with arrow-shaped and ball elements, and others. When these munitions explode, a large number of submunitions scatter at a high initial flight speed, causing multiple severe injuries.
According to wound ballistics (the study of the movement of a wounding projectile in organs and tissues and the processes of transferring its energy to tissues), a gunshot wound is formed as a result of the impact on the tissues of the most injuring projectile, head shock wave, side impact energy and vortex wake.
The destructive force of a wounding projectile depends on its mass, shape, size and speed of movement at the moment of contact with the tissues. Thus, fragments that have an irregular shape and a large area of contact with tissues quickly transfer their kinetic energy to them and cause extensive destruction. The same is observed when wounded by ricocheted, deformed or changing stability in flight (tumbling) bullets.
The nature of the destruction also depends on the anatomical and physiological characteristics of the tissues and their physical properties (elasticity, density, resilience, etc.), which determine the deceleration effect of the injuring projectile, i.e., the rate of transfer of kinetic energy to it. For example, when a wounding projectile comes into contact with a bone, the braking effect, and, consequently, the rate of energy transfer and the degree of tissue destruction, is much higher than when it comes into contact with muscular-elastic structures.
Due to the characteristics of the wounding projectile and the difference in the physical properties of the affected tissues, the wound channel may have different shapes, sizes and directions in certain areas. Often there is a curvature of the wound channel (deviation), a cut due to a change in the direction of movement of the injuring projectile (primary deviation) or subsequent displacement, mutual movement of damaged tissues (secondary deviation).
Rice. 6, c. Scheme of the distribution of zones of mechanical stress that occurs in the bone tissue of the thigh during the destructive effect of a bullet depending on its flight speed: a - at a bullet flight speed of 871.5 m/s, most of the bone diaphysis is damaged; b - at a bullet speed of 367 m / s, only the central part of the diaphysis is damaged (arrows indicate the places where the bullet hit); c - conventional color designations indicate the dimensions of the zones of mechanical stress in kg / cm 2. The vertical scale is given to determine the size of the mechanical impact zones in cm.
The study of the action of the head shock wave, the energy of the side impact and the vortex wake became possible using pulsed high-speed X-ray photography, which makes it possible to record the movement of the projectile within one millionth of a second. For the first time in our country, this method was applied by S. S. Girgolav (1954). It turned out that at high projectile flight speeds (close to 1000 m/s), the main role in the formation of the structure of a gunshot wound, including in bone tissue, belongs to the speed, and not to the mass of the projectile (printing, table, Fig. 6c ). This provision is decisive in the improvement of small arms, it led to the creation of combat small-caliber systems (caliber 5.6 mm or less), providing a high initial speed of the bullet and the resulting increase in the size of the destructive effect.
The head shock wave is a layer of compressed air. It has a destructive effect on tissues in the process of penetration of a wounding projectile into them, a cut has the character of an interstitial explosion; it is also involved in the formation of the effect of ejection of wound detritus through the inlet and outlet of the wound.
The integrated action of a shock wave, side impact energy and vortex movements causes the formation of a temporary pulsating cavity along the wound channel (the so-called cavitation effect), the pressure in a cut can reach 100 atm or more. According to L. N. Aleksandrov, E. A. Dyskin and others, the diameter of this cavity can exceed the diameter of the injuring projectile by 10-25 times or more, and the duration of the pulsation can exceed the time it takes the projectile to pass through the tissues by 2000 times or more. As a result of the pulsating nature of cavitation, extensive and severe tissue damage occurs at a considerable distance from the wound channel (bruises, ruptures of muscles, fascia, hollow organs, vessels, nerve trunks, etc.) and conditions are created for the penetration of microflora into the wound channel already at the time of wound formation. , which is equally intense both from the side of the inlet and the outlet.
Extent of a zone morfol, changes outside the wound channel can exceed diameter of the injuring projectile by 30-40 times. As the distance from the wound channel increases, these changes are increasingly determined by circulatory disorders (hemorrhages, thrombosis, microcirculation disorders), which are the main cause of subsequent focal necrosis. The physical phenomena arising outside the wound channel are caused by hl. arr. hydrodynamic effect, the severity of which largely depends on the water content in the tissues and the mass of the organ.
Rice. 6. Multi-fragmentation wounds: on the right foot with crushed tissues (a) and on the soles of both feet (b). Rice. 7. View of the inlet (a) on the skin of the lower leg when wounded by a small-caliber bullet with a high flight speed, which is accompanied by extensive tissue destruction in the area of the bullet channel; on the radiograph (b) of the same wound, multi-fragmented bone fractures are visible. Rice. eight. Multiple wounds on the skin of the thigh when injured by sagittal elements. Rice. 9. Processing the edges of the wound with ultrasound using the apparatus UZUM-1.
The wounds inflicted by modern types of small arms differ from the wounds observed in previous wars by the extent and depth of damage to tissues and organs, the presence of multiple and combined wounds, and the mass destruction of personnel. Of particular concern should be wounds with arrow-shaped elements and small-caliber bullets, in which the inlet can be barely noticeable (printing, table, Fig. 7, 8), and damage to deep-lying tissues is extensive and severe. Under the conditions of modern warfare, nuclear and chemical weapons can be used, which will lead to the occurrence of combined injuries (injury and burns, injury and damage by penetrating radiation, wounding and damage to explosive agents, etc.), the course and outcomes of which are determined by the strength of the impact of each damaging factor and the phenomenon their mutual burdening (see. Combined lesions). Significantly aggravate the course of the wound process such inevitable factors during the war as overwork, hypothermia or overheating, starvation, hypovitaminosis, water and electrolyte imbalance, etc. Wartime wounds are accompanied by a more severe general reaction of the body (shock, collapse and etc.), are more often complicated by infection, have longer healing periods and more often end in death.
The massive nature of combat wounds requires a clear and well-coordinated system of medical care and treatment of the wounded.
Main task first aid(see First aid), which is a complex of the simplest measures using individual standard-issue and improvised means, is to save the life of the wounded (for example, with bleeding from a wound, open pneumothorax, asphyxia, etc.) and the prevention of life-threatening complications. First aid is provided on the battlefield in the order of self-help and mutual assistance (see), as well as a sanitary instructor (see) and a nurse (see). First of all, a temporary stop of external bleeding is carried out. To apply the primary dressing, use an individual dressing package (see Individual dressing package). Immobilization in case of bone fractures, injuries of joints, large blood vessels and extensive wounds of soft tissues is carried out using a scarf, improvised materials or service equipment (tires). In order to prevent wound infection, the victims are given tableted antibiotics. For injuries accompanied by shock, analgesics are administered subcutaneously (see Analgesics).
After providing first aid, the wounded are evacuated to the battalion medical center (see) or enlarged nests of the wounded, where the paramedic provides them with first aid (see First aid). The main tasks of pre-hospital medical care are the fight against asphyxia (see), the introduction of respiratory and cardiovascular analeptics, the control and correction of primary dressings, hemostatic tourniquets, immobilization with transport tires, the introduction of analgesics for severe wounds.
To provide first aid(see) the wounded are sent to the regimental medical center (see), and first of all, the wounded are subject to evacuation with applied hemostatic tourniquets, in a state of shock, sudden bleeding, with respiratory disorders, as well as with penetrating wounds, closed abdominal injuries and wounds, infected with OV or RV. Here, the primary medical card is filled in for the wounded (see). All the wounded are injected with tetanus toxoid (3000 IU) and tetanus toxoid (0.5-1 ml) with a separate syringe. First of all, the wounded with suspected internal bleeding, with penetrating wounds of the abdomen, skull, chest and with applied hemostatic tourniquets are evacuated to the stage of providing qualified medical care.
Qualified medical care(see) wounded in wartime is in the MB, OMO and in military field surgical hospitals. In these institutions, after medical sorting (see. Medical sorting), surgical treatment of wounds, the final stop of bleeding, treatment of shock, operations for penetrating wounds of the abdomen, open pneumothorax, decompressive trepanation of the skull in case of cerebral compression syndrome, and suprapubic fistula for injuries of the spinal cord are performed and urethra, as well as surgery for anaerobic infection of wounds. The operated patients are sent to the hospital department, where their treatment continues until transportability is restored, after which they are evacuated to specialized or general surgical hospitals of the hospital base of the front.
In specialized (cf. Specialized medical care) and general surgical hospitals, treatment is carried out until the wound heals and the outcome of the injury is determined. The wounded, requiring long-term (up to several months) treatment, and also having no prospect of returning to duty after treatment, are evacuated to the hospital. home front institutions.
Determination of the degree of loss by the wounded of combat capability (capacity for work) or a change in the category of fitness for military service is carried out at the end of treatment on the basis of current legislation.
In the GO system, the first medical aid to the wounded is provided by the personnel of the sandruzhin (see Sanitary squad) and in the order of self-help and mutual assistance, first medical aid - in the first aid squad (see), specialized medical aid - in the lay down. institutions of hospital base (see).
Wounds and wounds in the forensic relation
At court.-med. examination of wounds, they carefully study and describe their localization, shape, size, features of the edges and ends, extraneous overlays and intrusions, the state of the surrounding tissues and other features that reflect one or another specificity of this injury. This often allows you to determine the type of weapon, the wound was inflicted, the mechanism of its formation, the prescription of occurrence, the severity of bodily injuries, etc.
Wounds caused by a blunt object arise both from direct blows with solid objects of various configurations, and when hitting them, and occur with domestic injuries, falls from a height, with transport injuries, etc. As a rule, bleeding from these wounds is insignificant. Bruised wounds have raw, often uneven edges with bruises; when the edges of the wound are pulled apart in the corners and at the bottom, connective tissue bridges are observed, in its walls one can see twisted hair follicles. The appearance of the wound depends on the shape and area of the striking surface of the tool, for example, when struck with a cylindrical object (metal rod), linear wounds are more often formed, with an object with a flat surface (board) - stellate wounds. When struck with a blunt solid object applied with great force (for example, with a transport injury), wounds are often combined with damage to internal organs. With lacerations and bite wounds close to them, extensive damage to soft tissues is noted; the edges of the wound are uneven patchwork.
Wounds caused by a sharp instrument are often characterized by profuse bleeding, relatively little damage to the edges, gaping. Incised wounds tend to have sharp ends and smooth edges. The length of the wound always prevails over the width; at the end of the wound, additional superficial incisions-notches are sometimes observed that occur when the blade is removed. Stab wounds are small, more or less deep wound channel. The edges of the wound are often even, smooth, and around them a belt of sedimentation usually forms. The shape of the wound depends on the configuration of the cross section of the weapon and is determined by the number of faces on it. In most cases, the wound is slit-like or oval in shape. Penetrating stab wounds are often accompanied by damage to internal organs and bones, which can display the cross-sectional shape of the weapon. Stab-cut wounds have even, smooth edges. When exposed to a double-edged weapon (dagger), the wound in shape approaches an oval with pointed ends. When exposed to a weapon with a one-sided sharpening of the blade (Finnish knife), one end of the wound is sharp, the other (from the butt side) is sharp or rounded (with a butt thickness of less than 1 mm), rectangular or with additional tears in the corners (with a butt thickness of more than 1 mm) . Chopped wounds are caused by heavy chopping tools (axe, hoe, saber, etc.). They have a rectilinear or fusiform shape, even and smooth edges, often sharp ends; at the edges of the wounds, signs of sedimentation can often be seen. Unlike cut wounds, chopped wounds, as a rule, are accompanied by bone damage.
On the planes of bone cuts, one can almost always find individual signs of the blade of a chopping tool - traces of irregularities, notches, which is used in the forensic identification of the tool. Sawn wounds are characterized by uneven, serrated, finely patchwork edges. When they are often observed damage to the bones, the cut surface of which is usually relatively flat, with arcuate marks from the action of the saw teeth.
Cut, stab, stab-cut wounds are more often household, chopped and sawing are found both in everyday life and in industrial accidents.
Gunshot wounds result from the impact of a bullet (combat and sporting weapons), shot (hunting rifles) and fragments of grenades, bombs, shells, etc. Occasionally, there are household wounds inflicted by defective (sawed-off) and home-made (self-made) weapons.
The tasks of the examination of gunshot injuries include establishing the inlet and outlet openings of wounds, the direction of the wound channels, the distance from which the shot was fired, the type and type of weapon with which the injury was made, as well as the resolution of other issues related to the specifics of a particular case. .
The inlet of a gunshot wound, depending on the type of weapon, the injuring projectile and the distance from which the shot was fired, can be cruciform, star-shaped, round or oval. Common signs of the wound inlet are the presence of a tissue defect at the site of bullet penetration, a belt of deposition on the skin (1-2 mm wide) due to the epidermis being torn off by the side surfaces of the projectile, a wiping belt (up to 2-2.5 mm wide), which is a consequence of wiping the bullet about the edges of the wound, traces of components associated with the shot (gases, soot, unburned powders, flame burns) detected when wounded at close range. The entrance bullet hole is clearly defined when flat bones are damaged: it has the form of a cone with its base facing the direction of the bullet flight. The diameter of the entrance hole, as a rule, almost corresponds to the diameter of the bullet, which allows you to make a conclusion about the caliber of the weapon used.
The exit hole of a gunshot wound has a slit-like or irregular shape, its edges are often turned outward, there are no tissue defects and traces of components associated with a shot. When bones are damaged, especially tubular ones, their fragments can cause additional damage in the area of the wound outlet, the edge becomes torn.
The direction of the wound channel is determined by the location of the inlet and outlet of the wound or the inlet of the wound and the location of the bullet in a blind wound.
Of essential importance is the question of the distance from which the shot was fired. There are three main firing distances: point-blank range, close range (within the detection range of the components accompanying the shot), and close range (outside the detection range of these components). A point-blank shot is characterized by a cruciform shape of the wound inlet, the presence of a muzzle imprint in its area, a tissue defect and traces of components accompanying the shot along the wound channel. When fired at close range at an angle, deposits of soot and powders in the form of an oval are visible on the skin from the side of the open angle. When fired at close range, singing of vellus hair and sedimentation of the epidermis (parchmentation) are observed at a shot distance of 1-3 cm, soot deposition - up to 35-40 cm, grains of unburned powders - up to 1 m and more. Soot particles also settle on the outer surface of clothing and occupy a significant area. When fired from a hunting rifle, the components accompanying the shot spread over a longer distance. When fired from a short distance, the inlet of the wound has a rounded or slit-like shape; there are no traces of the components of the shot. Since the bullet loses its kinetic energy at the end, it acquires a contusion effect and leaves bruises and deposits on the skin. Sometimes when fired from a short distance, when the speed of the bullet exceeds 500 m / s, soot particles are transported over considerable distances and settle around the bullet hole on the second and subsequent layers of clothing (more often under conditions when the wet layers of clothing do not fit tightly to each other), and also on the skin in the form of a radiant corolla up to 11/2 cm wide, sometimes with the formation of a peripheral ring separated from it by 1-11/2 cm (Vinogradov's phenomenon). This circumstance should be taken into account when differentiating a shot at point-blank range or at close range from a shot at a distance that is an extremely difficult expert task.
Damage caused by the impact of an exploding projectile, grenade, etc., is characterized by multiple wounds inflicted by fragments of the projectile and objects caught in the explosion zone. Wound channels of such wounds are usually blind.
When examining wounds to establish the lifetime of their occurrence, a gistol and a histochemical are performed. research, to study the features of the edges and ends of the wound - stereoscopy, to detect metal particles in the wound area - the study of color prints, radiography and spectrography; to detect soot and powders on fleecy tissues and hair covered in blood, photographs are taken in infrared rays (see Infrared radiation); using UV rays, they detect the presence of gun grease, etc.
When examining and hospitalizing the wounded, the doctor must carefully describe the wounds, indicating their features. Tissue sections excised during surgical treatment of the wound are subject to fixation in 10% formalin solution and subsequent transfer to the investigating authorities for laboratory research.
Bibliography
Avtsyn A.P. Essays on military pathology, M., 1946; Ageev A.K. Features of wound healing in the treatment of antibiotics, Voyen.-med. journal, no. 3, p. 47, 1960; And to about N about in V. I. Forensic examination of injuries by blunt objects, M., 1978; Anichkov H. H., In about l to about in and K. G. and G and r-sh and V. G N. Morphology of wound healing, M., 1951, bibliogr.; Arutyunov D. N. On the influence of the summation of exogenous factors on the clinic and the structure of psychoses in extracerebral injuries, in the book: Psychopathol. combat injury, ed. E. M. Zalkinda, p. 35, Molotov, 1946; Berkutov A. N. Features of modern gunshot wounds, Vestn. USSR Academy of Medical Sciences, No. 1, p. 40, 1975; B e r k u t o v A.N. and D ys to and E. A N. The modern doctrine about a gunshot wound, in the same place, No. 3, page. 11, 1979; In and y l S. S. Materials on pathological anatomy of a combat injury, Kirov, 1943; Vishnevsky A. A. and Shraiber M. I. Military field surgery, M., 1975; Military field surgery, ed. K. M. Lisitsyna. Moscow, 1982. Gorovoy-Shaltan V. A. About psychosis in wound infections, Neuropath, and psychiat., t. 14, No. 4, p. 11, 1945; Davydovsky I. V. The process of wound healing, M., 1950; he, Gunshot wound of a person, vol. 1-2, M., 1950 - 1954; Deryabin I. I. and Lytkin M. I. Basic principles of treatment of modern gunshot wounds, Vestn. USSR Academy of Medical Sciences, No. 3, p. 52, 1979; Dmitriev M. L., Pugachev A. G. and Kushch N. L. Essays on purulent surgery in children, M., 1973; Zagr yadskaya A. P. Determination of the instrument of injury in a forensic medical examination of a stab wound, M., 1968; Zagryadskaya A. P., Edelev N. S. and Furman M. V. Forensic medical examination in case of injuries with saws and scissors, Gorky, 1976; Isakov Yu. F. and D about l e c-ky S. Ya. Children's surgery, M., 1978; Isakov Yu.F. etc. Operative surgery with topographic anatomy of childhood, M., 1977; And with and to about in Yu. F., etc. The abacterial principle in surgery, Vestn. hir., t. 122, No. 5, p. 3, 1979; Laboratory and special research methods in forensic medicine, ed. V. I. Pashkova and V. V. Tomilin. Moscow, 1975. Lytkin M. I. and To about l about m and-e c V. P. Acute trauma of the main blood vessels, L., 1973; Lytkin M. I., D yskin E. A. and Peregudov I. G. About the mechanism of gunshot wounds of blood vessels and their treatment at the stages of medical evacuation, Voyen.-med. journal, no. 12, p. 27, 1975; Malkin P. F. Mental illnesses in connection with extracerebral wounds, Zhurn. neuropath, and psychiat., t. 14, no. 4, p. 14, 1945; Multivolume guide to surgery, ed. B. V. Petrovsky, t. 1, p. 647, M., 1962; Naumenko V. G. and Mityaeva N. A. Histological and cytological methods of research in forensic medicine, M., 1980; Nemsadze V. P. et al. The method of local gnotobiological isolation in the treatment of open fractures of long bones in children, Ortop. and traumat., No. 3, p. 9, 1980; Essays on military field surgery, ed. Yu. G. Shaposhnikova. Moscow, 1977. R and in to and GI N. Mental disorders in wound sepsis and traumatic exhaustion, Neuropathy, and psychiat., t. 13, No. 3, p. 30, 1944; Wounds and wound infection, ed. M. I. Kuzina and B. M. Kostyuchenko, M., 1981, bibliogr.; Ratner Ya. A. and Mirskaya M. M. Materials for the treatment of exogenous psychoses in the wounded, in the book: Nervous and mental. diseases in wartime conditions, ed. R. Ya. Golant and V. N. Myasishchev, p. 98, L., 1948; Remezova A.S. On neuropsychiatric disorders in severe wounds that occur with prolonged wound healing, in the book: Somato-psychic. disorders, ed. V. A. Gilyarovsky, p. 33, M., 1946; With a case of the issue to and y I. F. and G and and and N and M. N. About intoxication-wound psychosis, Neuropath. and psychiat., vol. 13, no. 3, p. 36, 1944; Struchkov V. I., Grigoryan A. V. iGostishchev V. K. Purulent wound, M., 1975, bibliogr.; Forensic traumatology, ed. A. P. Gromova and V. G. Naumenko. Moscow, 1977. Chaplinsky V. V. et al. Ultrasonic treatment of purulent wounds, Surgery, No. 6, p. 64, 1976, bibliogr.; Chernukh A. M. and Kaufman O. Ya. Some features of the pathogenesis of inflammation and wound healing, Vestn. USSR Academy of Medical Sciences, No. 3, p. 17, 1979, bibliogr.; Shemetylo I. G. and Vorobyov M. G. Modern methods of electro- and phototherapy, L., 1980; Eid-l and N L. M. Gunshot injuries, Tashkent, 1963; Biologic basis of wound healing, ed. by L. Menaker, Hagerstown, 1975; Douglas D.M. Wound healing and management, Edinburgh-L., 1963, bibliogr.; E n g i n A. Hyperactivation of fibroplasia by the transferable sulphur in wound healing, Res. Exp. Med., v. 164, p. 169, 1974; Fundamentals of wound management, ed. by T. K. Hunt a. J. E. Dunphy, N. Y., 1979; Hernandez-Richter H.J.u. Struck H. Die Wundheilung, Stuttgart, 1970, Bibliogr.; Maximow A. A., Bloom W. a. Fawcett D. W. A textbook of histology, Philadelphia a. o., 1968; M e n k i n V. Biochemical mechanisms in inflammation, Springfield, 1956; M b r 1 F. Lehrbuch der Unfallchirurgie, B., 1968; Peacock E. E. a. van Wink1 e W. Wound repair, Philadelphia, 1976; Raekallio J. Enzyme histochemistry of wound healing, Jena, 1970, bibliogr.; Ross R. a. BenditE. P. WTound healing and collagen formation, 1 Note, J. Biophys. biochem. Cytol., v. 11, p. 677, 1961; aka, WTound healing and collagen formation, 5 Note, J. Cell Biol., v. 27, p. 83, 1965.
M. I. Lytkin; V. P. Illarionov (to lay down. physical.), Yu. L. Melnikov (court.), V. P. Nem-sadze (det. hir.), D. S. Sarkisov (stalemate. An.), M. A. Tsivilno (psychiat.), V. A. Romanov (tsvetn, fig. 1-4).
- this is tissue damage as a result of mechanical action. Accompanied by a violation of the integrity of the skin or mucous membrane. They differ in the mechanism of occurrence, method of application, depth, anatomical localization and other parameters. May or may not penetrate into natural closed body cavities (abdominal, thoracic, joint cavities). The main symptoms are gaping, pain and bleeding. The diagnosis is made on the basis of the clinical picture, in some cases additional studies are required: radiography, laparoscopy, etc. The treatment is surgical.
Causes of wounds
The cause of traumatic injury is most often a domestic injury, injuries resulting from accidents during sports, criminal incidents, road accidents, industrial injuries and falls from a height are somewhat less common.
Pathogenesis
There are four zones of the wound: the actual defect, the zone of injury (contusion), the zone of concussion (commotion) and the zone with a violation of physiological mechanisms. The defect may take the form of a surface (for example, with scalped or extensive superficial bruised injuries), a cavity (for example, with incised and deep bruised wounds) or a deep channel (with stab, through and some blind gunshot injuries). The walls of the defect are formed by necrotic tissues, between the walls there are blood clots, pieces of tissue, foreign bodies, and in the case of open fractures, there are also bone fragments.
Significant hemorrhages are formed in the contusion zone, bone fractures and ruptures of internal organs are possible. In the concussion zone, focal hemorrhages and circulatory disorders are observed - a spasm of small vessels, followed by their steady expansion. In the zone of disturbed physiological mechanisms, passing functional disorders, microscopic hemorrhages and foci of necrosis are detected.
Healing occurs in stages, through the melting of damaged tissues, accompanied by local edema and fluid release, followed by inflammation, especially pronounced with suppuration. Then the wound is completely cleared of necrotic tissues, granulations are formed in the area of the defect. Then the granulations are covered with a layer of fresh epithelium, and complete healing gradually occurs. Depending on the characteristics and size of the wound, the degree of its contamination and the general condition of the body, healing by primary intention, healing under the scab, or healing through suppuration (secondary intention) is possible.
Classification
Wounds are classified according to many different signs. According to the circumstances of application in traumatology and orthopedics, accidental, combat and operational wounds are distinguished, according to the characteristics of the injuring weapon and the mechanism of damage - cut, torn, chopped, stab, bruised, gunshot, bitten and crushed. There are also wounds that are of a mixed nature, for example, lacerations and stab wounds. Depending on the shape, linear, patchwork, star-shaped and perforated wounds, as well as damage with loss of substance, are distinguished. Wounds with detachment or loss of significant areas of skin are called scalped. In the case when, as a result of an injury, a part of a limb is lost (shin, foot, forearm, finger, etc.), the damage is called traumatic amputation.
Depending on the state of the tissues, wounds with a large and small area of damage are distinguished. The tissues surrounding the wound with a small area of damage, for the most part, remain viable, only the areas that were in direct contact with the traumatic instrument are destroyed. These injuries include stab and cut wounds. Incised wounds have parallel even edges and a relatively shallow depth with a relatively large length, and with timely adequate treatment, as a rule, they heal with a minimum amount of suppuration.
Blood can leak out (external bleeding) and into a natural body cavity (internal bleeding). In the latter case, an accumulation of blood is formed with compression of the corresponding organ and a violation of its function. With hemothorax, compression of the lung is observed, with hemopericardium - the heart, with hemarthrosis - all structures of the joint, etc. Minor superficial injuries, as a rule, are not accompanied by general symptoms. In severe injuries, there is a decrease in blood pressure, tachycardia, pallor of the skin and mucous membranes, nausea, dizziness, weakness and increased respiration.
Diagnostics
With small superficial wounds that are not accompanied by general symptoms, the diagnosis is made by a traumatologist based on the clinical picture. A detailed study is carried out in the process of PST. With extensive and deep wounds with a violation of the general condition, additional studies are needed, the list of which is determined taking into account the location of the damage. For injuries in the chest area, a chest x-ray is prescribed, for damage to the abdomen, an abdominal x-ray, ultrasound or laparoscopy, etc. If a violation of the integrity of blood vessels and nerves is suspected, consultation with a neurosurgeon and a vascular surgeon is required.
Wound treatment
Small superficial injuries are treated in a trauma center. With extensive and deep wounds, open fractures, penetrating wounds, suspected violation of the integrity of internal organs, blood vessels and nerves, hospitalization in the trauma, surgical or neurosurgical department is required. The need for suturing is determined depending on the duration of the traumatic impact. Primary surgical treatment is carried out only on the first day after the injury and in the absence of signs of inflammation.
PHO is performed under local anesthesia or anesthesia. The wound is washed, blood clots and foreign bodies are removed. The edges of the wound cavity are excised, the cavity is washed again and sutured in layers, leaving drainage in the form of a rubber outlet, tube or half-tube. If the area of damage is normally supplied with blood, there are no foreign bodies left, the surrounding tissues are not crushed or crushed, and the edges are firmly in contact throughout (both on the surface and in depth), the wound heals by primary intention. After about a week, signs of inflammation disappear and a tender skin scar forms.
Injuries older than a day are considered as stale and are not subject to suturing. The wound heals either under the scab, which takes a little longer, or through suppuration. In the latter case, pus appears, a demarcation shaft forms around the damage zone. Suppuration is accompanied by a general reaction of the body - intoxication, fever, an increase in ESR and leukocytosis are observed. In this period, dressings and active drainage are carried out. If necessary, purulent streaks are opened.
With a favorable course, after about 2 weeks, the wound is cleared, the healing process begins. At this time, both local and general symptoms of inflammation decrease, the patient's condition returns to normal. The outcome is a rougher scar than with primary tension. With a significant tissue defect, self-healing may not occur. In such cases, plasty with a free skin flap or a displaced skin flap is required.
Wounds can cause great harm to the human body, even if they are not dangerous at first glance. In the field of medicine, there is their classification, which helps to provide adequate assistance to the victims. This article is devoted to such a problem as types of wounds and first aid for various types of injuries.
What is a wound: definition
Everyone must have experienced various injuries and know what they look like. Let's first understand what wounds are from a medical point of view. We will discuss the types of wounds a little later. First of all, this concept implies mechanical damage to the skin and mucous membranes and adjacent soft tissues, nerves, muscles, tendons, blood vessels, ligaments, and bones.
The main sign of injury is the presence of a divergence of the edges of the skin and muscles, that is, gaping, bleeding and soreness. Multiple or single injuries can cause shock due to blood loss and severe pain, as well as become infected with a variety of microbes that can harm the entire body.
What are wounds: types of wounds
In the classification of wounds and injuries, there are several characteristics that combine different features: the depth of penetration into soft tissues and organs, the number of wounds, the nature of the wound channel, its localization, the presence or absence of pathogenic microflora in the wound cavity, and much more. So, let's figure out what types of wounds exist today.
Firstly, without exception, all wounds are initially divided into accidental and gunshot. Random wounds include lacerations, bruised, crushed, scalped, stab and chopped. Firearms include those that are usually called bullet and fragmentation. Secondly, depending on what form of the wound channel is typical for a particular case, they are divided into tangent, through and blind. This classification of wounds applies to all, both accidental and gunshot wounds.
The third characteristic that allows organizing adequate assistance in case of injury is localization relative to the internal organs of a person. In the presence of damage, we are talking about a penetrating wound. In the opposite case - about non-penetrating. An important role is played by such a characteristic as their number on the body. Based on this indicator, they are single and multiple.
In addition, the types of wounds are divided according to the presence or absence of infection in their cavity. So, there are wounds bacterially contaminated and aseptic (sterile), infected and purulent. Aseptic ones are formed only under the conditions of their application in the operating room. In other cases, depending on the type of microbes that have entered the wound cavity, we are talking about infected wounds. Consider the main types of injuries that are most common in medical practice.
Ragged, crushed wounds and bruises: characteristic
This group of wounds most often occurs as a result of transport, industrial and domestic injuries. Characteristic signs for them are a significant area of tissue damage, especially the skin. Crushed and lacerated wounds heal very poorly and very often cause shock due to large blood loss and general intoxication of the body. As a rule, experts call their distinguishing feature a high degree of infection, which may require increased measures taken by doctors. Bruised wounds carry the risk of injury to internal organs and fracture of bones. Wounds from this group look very impressive, since the gaping appears on a large surface, soft tissue damage is extensive.
stab wounds
Stab wounds are inflicted with the use of sharp long objects: needles, knives, bayonets and others. The shape of the wound channel is narrow and deep. Often, with this type of damage, not only the skin and muscles are affected, but also nerve fibers, blood vessels, and internal organs. Bleeding from this type of injury is usually scanty, leaving puncture wounds prone to suppuration and infection with tetanus.
Chopped and cut wounds
Wounds caused by sharp objects of a long pointed shape are cut and chopped. They differ from others in the presence of profuse venous or arterial bleeding, but at the same time they heal quite quickly and easily. This group is also distinguished by the fact that the edges of the damaged tissues are even. The main difference between a chopped wound and an incised one is the depth and force of the impact of a sharp object on the tissue. So, incised wounds are usually shallow, that is, superficial. Others are characterized by deep damage to muscles and even bones. Chopped wounds are treated somewhat longer than incised ones due to the fact that, in addition to soft tissues, it is necessary to restore the bones of the skeleton.
Bites and poison wounds
Experts call large-scale and deep tissue damage the main feature of bites. They are also distinguished by a high degree of contamination of the wound surface with biological products that are unusual for humans: saliva or poisons. As a result, very often they are complicated by putrefactive processes and acute infection of adjacent tissues or the whole organism. Poison wounds inflicted by reptiles, arthropods and many insects are often accompanied by the following symptoms: intense and prolonged pain, swelling and discoloration of the skin, the appearance of vesicles on the skin at the site of the bite, as well as a deterioration in the general condition of the victim.
gunshot wounds
Gunshot wounds unite under one concept all wounds received by penetration into the body of bullets, fragments of grenades, mines, capsules or other damaging particles. This group of injuries is subdivided, in turn, into penetrating and non-penetrating, through, blind and tangential. Depending on how far a bullet or a fragment penetrated into the body, there is a possibility of bone fracture, rupture of blood vessels and muscle ligaments. The inlet of a gunshot wound is always much smaller than the outlet. Around him there is always a trace of gunpowder or other explosives in the form of a small halo.
What are the dangers of wounds and wounds
Almost all types of wounds are dangerous to human life and health. First of all, this is due to the penetration of pathogenic microflora into their cavity. Even with a low level of infection in the wound, microorganisms can multiply, as it contains a nutrient medium - completely or partially dead tissue. It is the development of infection in the wound cavity that poses the main threat to human health.
Cut, chopped and stab wounds are at the lowest risk of developing a secondary infection, since the destruction and necrosis of tissues in them occurs in areas with which the object that caused the injury was in direct contact. In addition, with these types of injuries, blood flows freely from the wound cavity, which contributes to its spontaneous cleansing. Stab wounds are less likely to become infected for other reasons: as a rule, their edges are quite tightly closed, which means that the wound does not gape, and the infection cannot freely penetrate into its cavity from the outside.
The greatest danger regarding the development of infection is torn, crushed, gunshot and bitten wounds. Due to the large area of damage characteristic of them, as well as the fact that the tissues in their cavity are practically non-viable, the risk of developing anaerobic and other infections is very high. Numerous blind pockets filled with fragments of muscle tissue and blood clots can become an excellent breeding ground for bacteria trapped in them. This can cause suppuration even outside the wound and lead to sepsis. Lacerations, accompanied by a detachment of a flap of skin (so-called scalped wounds), are considered one of the longest healing wounds, however, due to the shallow depth of the lesion, the risk of infection in them is somewhat reduced.
General rules for first aid for injuries
The further treatment and restoration of the patient's health depends on how correct the actions will be when any type and nature of a wound appears on the body. There are a number of general rules for first aid for such injuries. First of all, it is worth understanding that immediate treatment with antiseptics is a guarantee that there will be fewer microorganisms in the wound. A completely different question is how to do it right. So, let's understand the basics of first aid:
- As a means to clean the wound surface, it is best to use hydrogen peroxide or another aseptic liquid that does not contain alcohol, since its entry into tissues can cause burns and irritation.
- Tincture of iodine, brilliant green and other alcohol-based products can only be used to treat the skin surrounding the wound.
- If there is bleeding from the wound, it is important to stop it by applying a tourniquet or tight bandage, and only then treat the wound with antiseptics.
- Cotton wool cannot be used as an insulating material for application directly to the wound, since its fibers can cause additional infection. It is best to use a bandage or pieces of cloth for this.
- Even a small bite of an animal without obvious damage to the skin requires treating the skin with an antiseptic and contacting a specialist as soon as possible, as there is a risk of infection with rabies.
- If there are fragments of soil or other foreign bodies in the wound, do not try to remove them yourself, it is better in this case to take the victim to the nearest hospital.
- The movement of victims with a wound in the abdomen and chest must be very careful, it is best to do this with a stretcher.
Otherwise, in the issue of first aid, it is necessary to rely on the type of injury.
First aid for wounds caused by cuts, punctures and bruises
Bruised, chopped and cut wounds, it is important first of all to isolate and stop the bleeding, for which a tourniquet or tight bandage is applied just above the location of the wound. An important point in this process is the duration of tissue clamping - a maximum of 20 minutes. Too long an exposure of this kind can lead to necrosis of a part of the body. After applying a tourniquet and stopping bleeding, you can clean the wound from visible contamination with asepsis and apply a bandage.
First aid for gunshot wounds
A gunshot wound in itself is very dangerous, as it often leads to large-scale destruction of tissues inside the body. When the limbs are injured, it is important to immobilize them as much as possible by applying a splint, since there is a risk of bone fracture. In case of a wound in the stomach or chest, the victim must also be kept calm. Gunshot wounds should not be freed from fragments of ammunition, it is enough to cover them with a clean cloth and, if there is bleeding, apply a tourniquet or a tight bandage.
First aid for poisoned wounds
Wounds inflicted by poisonous reptiles and insects are dangerous both in themselves and in relation to the state of the organism as a whole. First aid for this type of wound should be provided as quickly as possible. If there is a sting in the wound (bees, for example), it is important to carefully remove it, while trying not to squeeze the poison sac. After that, you can treat the wound with alcohol-containing antiseptics. If there is a large swelling, severe burning or pain, a rash at the site of the bite, you should consult a doctor.
Snake bites are treated with antiseptics and covered with a clean bandage. Some experts recommend applying cold to such wounds and using a tourniquet to avoid the rapid spread of poison through the bloodstream.
Any type of injury requires going to the clinic even after providing first aid to the victim, as this will help to avoid various risks, as well as speed up a full recovery.
