Treatment methods for open wounds. f) Physiotherapy treatment

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Treatment Methods

1. Wound drainage: passive, active

2. hypertonic solutions

The most commonly used by surgeons is a 10% sodium chloride solution (the so-called hypertonic solution). In addition to it, there are other hypertonic solutions: 3-5% solution of boric acid, 20% sugar solution, 30% urea solution, etc. Hypertonic solutions are designed to ensure the outflow of wound discharge. However, it has been established that their osmotic activity lasts no more than 4-8 hours, after which they are diluted with wound secretion, and the outflow stops. Therefore, in recent years, surgeons are abandoning hypertensive

3. Ointments

In surgery, various ointments are used on a fatty and vaseline-lanolin basis; Vishnevsky ointment, synthomycin emulsion, ointments with a / b - tetracycline, neomycin, etc. But such ointments are hydrophobic, that is, they do not absorb moisture. As a result, tampons with these ointments do not provide an outflow of wound secretions, they become only a cork. At the same time, antibiotics contained in ointments are not released from ointment compositions and do not have sufficient antimicrobial activity.

The use of new hydrophilic water-soluble ointments - Levosin, levomikol, mafenide-acetate - is pathogenetically justified. Such ointments contain antibiotics that easily pass from the composition of ointments into the wound. The osmotic activity of these ointments exceeds the effect of hypertonic solution by 10-15 times, and lasts for 20-24 hours, so one dressing per day is enough for an effective effect on the wound. treatment wound purulent infection

4. enzyme therapy

For the speedy removal of dead tissue, necrolytic preparations are used. Widely used proteolytic enzymes - trypsin, chymopsin, chymotrypsin, terrilitin. These drugs cause lysis of necrotic tissue and accelerate wound healing. However, these enzymes also have disadvantages: in the wound, the enzymes retain their activity for no more than 4-6 hours. Therefore, for effective treatment of purulent wounds, dressings must be changed 4-5 times a day, which is almost impossible. It is possible to eliminate such a lack of enzymes by including them in ointments. So, the ointment "Iruksol" (Yugoslavia) contains the enzyme pentidase and the antiseptic chloramphenicol. The duration of action of enzymes can be increased by immobilizing them in dressings. So, trypsin immobilized on napkins acts within 24-48 hours. Therefore, one dressing per day fully provides a therapeutic effect.

5. Use of antiseptic solutions

Solutions of furacillin, hydrogen peroxide, boric acid, etc. are widely used. It has been established that these antiseptics do not have sufficient antibacterial activity against the most common pathogens of surgical infection.

Of the new antiseptics, it should be noted: iodopyrone, a preparation containing iodine, is used to treat the hands of surgeons (0.1%) and treat wounds (0.5-1%); dioxidine 0.1-1%, sodium hypochlorite solution.

6. Physical Therapies

In the first phase of the wound process, wound quartzing, ultrasonic cavitation of purulent cavities, UHF, hyperbaric oxygenation are used.

7. Laser application

In the phase of inflammation of the wound process, high-energy, or surgical lasers are used. With a moderately defocused beam of a surgical laser, pus and necrotic tissues are evaporated, thus it is possible to achieve complete sterility of wounds, which in some cases makes it possible to apply a primary suture to the wound.

Treatment of wounds in the second phase of regeneration of the wound process

1. Anti-inflammatory treatment

2. Protection of granulations from damage

3. Stimulation of regeneration

These tasks are:

a) ointments: methyluracil, troxevasin - to stimulate regeneration; fat-based ointments - to protect granulations from damage; water-soluble ointments - anti-inflammatory effect and protection of wounds from secondary infection.

b) herbal preparations - aloe juice, sea buckthorn and rosehip oil, Kalanchoe.

c) the use of a laser - in this phase of the wound process, low-energy (therapeutic) lasers are used, which have a stimulating effect.

Treatment of wounds in the 3rd phase(phase of epithelialization and scarring).

Task: to accelerate the process of epithelialization and scarring of wounds.

For this purpose, sea buckthorn and rosehip oil, aerosols, troxevasin-jelly, low-energy laser irradiation are used.

With extensive defects of the skin, long-term non-healing wounds and ulcers in the 2nd and 3rd phases of the wound process, i.e. after cleansing the wounds from pus and the appearance of granulations, dermoplasty can be performed:

a) faux leather

b) split displaced flap

c) walking stem according to Filatov

d) autodermoplasty with a full thickness flap

e) free autodermoplasty with a thin-layer flap according to Thiersch

Treatment of purulent wounds consists of two directions - local and general treatment. The nature of the treatment, in addition, is determined by the phase of the wound process.

Local treatment of purulent wounds

a) Treatment objectives in the inflammation phase

In the first phase of the wound process (the phase of inflammation), the surgeon faces the following main tasks:

* Fight against microorganisms in the wound.

* Ensuring adequate drainage of exudate.

* Promoting the speedy cleansing of the wound from necrotic tissue.

* Decreased manifestations of the inflammatory response.

In the local treatment of a purulent wound, methods of mechanical, physical, chemical, biological and mixed antiseptics are used.

With suppuration of the postoperative wound, it is usually enough to remove the sutures and widely spread its edges. If these measures are not enough, then it is necessary to perform secondary surgical treatment (SDO) of the wound.

b) Secondary surgical treatment of the wound

Indications for VMO wounds are the presence of a purulent focus, the lack of adequate outflow from the wound (pus retention), the formation of extensive areas of necrosis and purulent streaks. The only contraindication is the extremely serious condition of the patient, while they are limited to opening and draining the purulent focus.

Tasks facing the surgeon performing VMO of the wound:

* Opening of the purulent focus and streaks.

* Excision of non-viable tissues.

* Implementation of adequate wound drainage.

Before the start of VMO, it is necessary to determine the visible boundaries of inflammation, the localization of the area of purulent fusion, the shortest access to it, taking into account the location of the wound, as well as possible ways of spreading the infection (along the neurovascular bundles, muscular-fascial sheaths). In addition to pallatation, various types of instrumental diagnostics are used in this case: ultrasound, thermographic, x-ray (for osteomyelitis), and computed tomography.

Like the primary surgical treatment, VMO is an independent surgical intervention. It is performed in the operating room by a team of surgeons using anesthesia. Only adequate anesthesia allows to solve all the problems of the WTO. After opening the purulent focus, a thorough instrumental and digital revision is carried out along the course of the wound itself and the possible presence of streaks, which are subsequently also opened through the main wound or counter-opening and drained. After completing the revision and determining the volume of necrosis, pus is evacuated and excision of non-viable tissues (necrectomy). At the same time, we must not forget that there may be large vessels and nerves near or in the wound itself, which must be preserved. Before the end of the operation, the wound cavity is abundantly washed with antiseptic solutions (hydrogen peroxide, boric acid, etc.), loosely packed with gauze wipes with antiseptics and drained. The most beneficial method of treatment for extensive purulent wounds is flow-flushing drainage. In the case of localization of damage to the limb, immobilization is necessary.

c) Treatment of a purulent wound after surgery

After performing VMO or simple opening (opening) of the wound at each dressing, the doctor examines the wound and assesses its condition, noting the dynamics of the process. The edges are treated with alcohol and an iodine-containing solution. The wound cavity is cleaned with a gauze ball or a napkin from pus and freely lying sequestered areas of necrosis, necrotic tissues are excised in a sharp way. This is followed by washing with antiseptics, drainage (according to indications) and loose plugging.

With pancreatitis, one of the most important organs is affected - the pancreas, in which severe pain occurs. The pancreas helps digest fats, proteins, and carbohydrates in the intestines, while the hormone insulin regulates blood glucose levels. Pancreatitis occurs due to - blockage of the gallbladder or the duct of the gland itself, infection, helminthiasis, trauma, allergies, poisoning, frequent use of alcohol. The main component of treatment pancreas diet, in which the first two or three days you have to starve. And you will have to exclude fatty, fried and spicy foods, alcohol, sour juices, strong broths, spices, smoked foods after treatment. The diet starts from day 4, while you can eat at least 5-6 times a day in small portions. During the diet, it is better to eat some varieties of fish, meat, mild cheese, fresh low-fat cottage cheese. Fats must be reduced to 60 g per day, excluding mutton and pork fat from the diet. Limit sugary and carbohydrate foods. Food should always be warm when consumed. Thanks to all this, the pancreas is restored. And in order to prevent pancreatitis from recurring, follow all the tips that are written above.

In the first phase of healing, when there is abundant exudation, ointment preparations cannot be used, as they create an obstacle to the outflow of the discharge, which contains a large number of bacteria, proteolysis products, and necrotic tissues. During this period, the bandage should be as hygroscopic as possible and contain antiseptics. They can be: 3% solution of boric acid, 10% sodium chloride solution, 1% dioxidine solution, 0.02% chlorhexidine solution, etc. Only for 2-3 days is it possible to use water-soluble ointments: "Levomekol", "Levosin", " Levonorsin", "Sulfamekol" and 5% dioxidine ointment.

Of particular importance in the treatment of purulent wounds is "chemical necrectomy" with the help of proteolytic enzymes that have a necrolytic and anti-inflammatory effect. For this, trypsin, chymotrypsin, chymopsin are used. The preparations are poured into the wound in a dry form or injected in a solution of antiseptics. To actively remove purulent exudate, sorbents are placed directly into the wound, the most common of which is polyphepan.

In order to increase the effectiveness of VMO and further treatment of purulent wounds, various physical methods of influence are used in modern conditions. Ultrasonic cavitation of wounds, vacuum treatment of a purulent cavity, treatment with a pulsating jet, and various methods of using a laser are widely used. All these methods are aimed at accelerating the cleansing of necrotic tissues and the detrimental effect on microbial cells.

d) Treatment in the regeneration phase

In the regeneration phase, when the wound has cleared of non-viable tissues and inflammation subsided, the next stage of treatment is started, the main tasks of which are to suppress infection and stimulate reparative processes.

In the second phase of healing, the process of formation of granulation tissue plays a leading role. Despite the fact that it also has a protective function, the possibility of re-inflammation cannot be completely excluded. In this period, in the absence of complications, exudation is sharply reduced and the need for an absorbent dressing, the use of hypertonic solutions and drainage disappears. Granulations are very delicate and vulnerable, so it becomes necessary to use ointment-based preparations that prevent mechanical trauma. Antibiotics (syntomycin, tetracycline, gentamicin ointments, etc.), stimulants (5% and 10% methyluracil ointment, Solcoseryl, Actovegin) are also introduced into the composition of ointments, emulsions and leniments.

Multicomponent ointments are widely used. They contain anti-inflammatory substances that stimulate regeneration and improve regional blood circulation, antibiotics. These include Levomethoxide, Oksizon, Oxycyclozol, balsamic liniment according to A.V. Vishnevsky.

To accelerate the healing of wounds, the technique of applying secondary sutures (early and late) is used, as well as tightening the edges of the wound with adhesive tape.

e) Treatment of wounds in the phase of formation and reorganization of the scar

In the third phase of healing, the main task is to accelerate the epithelization of the wound and protect it from excessive trauma. For this purpose, dressings with indifferent and stimulating ointments are used, as well as physiotherapy procedures.

f) Physiotherapy treatment

Physiotherapeutic procedures occupy a significant place in the treatment of purulent wounds.

In the first phase, to stop acute inflammation, reduce edema, pain syndrome, accelerate the rejection of necrotic tissues, an UHF electric field and ultraviolet irradiation in an erythemal dose are used, which also stimulates the phagocytic activity of leukocytes and has an antimicrobial effect. For local administration of antibiotics, anti-inflammatory and analgesic drugs, electro- and phonophoresis is used. It should be remembered that with insufficient outflow of purulent contents, physiotherapeutic procedures lead to an aggravation of the purulent-inflammatory process.

In the second and third phases of the wound process, in order to activate reparative processes and epithelialization, UV irradiation and laser irradiation with a defocused beam are used. A magnetic field has a vasodilating and stimulating effect. It was noted that when exposed to a pulsating magnetic field, the growth of the nerve fiber is activated, synaptogenesis increases, and the size of the scar decreases.

During the entire period of the wound process, it is possible to use hyperbaric oxygenation, which improves oxygen saturation of tissues.

g) Treatment in an abacterial environment

With extensive wound defects and burns, treatment in a controlled abacterial environment is successfully used. There are insulators of general and local types. Isolation of the entire patient is necessary in the treatment of patients with reduced resistance to infection: after oncological operations, accompanied by massive chemotherapy or radiation treatment, with organ transplantation associated with the constant intake of immunosuppressants that inhibit the rejection reaction, and various blood diseases that cause disturbance and suppression of lymphatic and leukopoiesis.

Treatment in an abacterial environment is carried out without a bandage, which contributes to the drying of the wound, which adversely affects microorganisms. The following parameters are maintained in the isolator: temperature - 26-32°С, pressure - 5-15 mm Hg. Art., relative humidity 50-65%. They may vary depending on the nature of the course of the wound process.

General treatment

The general treatment of wound infection has several directions:

* Antibacterial therapy.

* Detoxification.

* Immunocorrective therapy.

* Anti-inflammatory therapy.

* Symptomatic therapy.

a) Antibacterial therapy

Antibacterial therapy is one of the components of the complex therapy of purulent diseases, and in particular purulent wounds. It is used mainly in the first, as well as in the second phase of the wound process.

In the absence of signs of intoxication in the patient, the small size of the wound, the preservation of the integrity of the bone structures, the main vessels and the absence of concomitant diseases, it is usually sufficient to implement only the principles of local treatment. Otherwise, antibiotic therapy should be started as early as possible.

One of the main principles of therapy is the use of a drug to which the wound microflora is sensitive. But sometimes more than one day passes from the moment the material is taken to the receipt of the results of the study. Then it is desirable to administer an antibiotic, to which the suspected infection is usually most sensitive. In this case, the determination of the characteristic features of pus inherent in any microorganism can help.

Staphylococci most often form thick yellowish pus, streptococci - liquid yellow-green pus or ichor type, E. coli - brown pus with a characteristic odor. A stick of blue-green pus gives the appropriate staining of the dressings and a sweet smell. Pus formed by Proteus has similar features, but usually does not have a green color. We must not forget that a mixed infection is more common in a purulent wound, therefore it is preferable to prescribe broad-spectrum antibacterial drugs at the initial stages. After determining the sensitivity, a change in the antibiotic or its dosage can be made.

Antibacterial therapy also includes drugs strictly directed against certain bacteria or their groups. Various bacteriophages find their application - streptococcal, staphylococcal, proteus, Pseudomonas aeruginosa, coli-phage, as well as complex phages, such as pyophage, consisting of several types of bacteriophages. For the purpose of passive immunization, anti-staphylococcal y-globulin is administered, various types of plasmas - hyperimmune anti-staphylococcal, anti-escirichia, anti-pseudomonal and anti-lipopolysaccharide (against gram-negative microorganisms). Active immunization with toxoids and vaccines is used for prophylactic purposes in order to prepare the patient to fight the infection on his own. Usually used staphylococcal toxoid, polyvalent Pseudomonas aeruginosa vaccine, etc.

b) Detoxification

A large amount of necrosis and developing infection cause the saturation of the body with toxins. In a patient with a purulent wound in the first phase, all signs of intoxication (chills, fever, sweating, weakness, headache, lack of appetite) appear, inflammatory changes in blood and urine tests increase. All this serves as an indication for detoxification therapy, which involves several methods, presented below in order of increasing complexity and effectiveness:

* Infusion of saline solutions

* Forced diuresis method

* Application of detoxifying solutions

* Extracorporeal methods of detoxification.

The choice of detoxification method depends primarily on the severity of intoxication and the severity of the patient's condition. In the phase of regeneration and scar formation, there is usually no need for detoxification therapy.

c) Immunocorrective therapy

When a purulent process occurs in the wound, the development of intoxication, a decrease in the body's resistance is often observed with a drop in the level of antibody production, phagocytic activity, a deficiency of subpopulations of lymphoid cells and a slowdown in their differentiation. This leads to long-term use of powerful antibacterial drugs.

These changes contribute to the further development of infection, an increase in the zone of secondary necrosis and a progressive deterioration of the patient's condition. In order to correct this temporary deficiency, immunomodulators are used.

The most widely used are interferon, levamisole, thymus preparations (thymalin, thymosin, T-activin). However, with long-term administration and high doses, these drugs suppress the production of their own immune cells. Recently, more and more attention has been paid to cytokines created by genetic engineering, in particular interleukins, which have wide indications for use in immunodeficiency states. Human recombinant interleukin-1 ("Betaleukin") and interleukin-2 ("Roncoleukin") have been created and put into use.

d) Anti-inflammatory therapy

Anti-inflammatory therapy is not the leading method of treating wounds, it is used quite rarely and is reduced to the introduction of drugs from the salicylates group, steroidal and non-steroidal anti-inflammatory drugs. At the same time, manifestations of inflammation and edema decrease, perfusion and oxygenation of the tissues surrounding the wound increase, and their metabolism improves. This leads to the acceleration of the formation of a demarcation line and the speedy clearance of necrosis.

e) Symptomatic therapy

In the phase of inflammation due to tissue edema, pain syndrome develops. It is significantly reduced with adequate wound drainage. If necessary, analgesics (usually non-narcotic) are additionally administered. For fever, antipyretics are used.

In patients with severe disorders of the activity of various organs and systems due to direct trauma or complications of a purulent wound, their correction is necessary. With significant blood loss, a transfusion of blood, its components and blood-substituting solutions is carried out.

With extensive wound defects with loss of fluid, proteins and electrolytes through their surface, infusion replacement therapy includes protein hydrolysates, native plasma, mixtures of amino acids and polyionic solutions. General strengthening therapy includes vitamins of various groups (C, B, E, A) and regeneration stimulants (methyluracil, pentoxyl, potassium orotate, anabolic hormones). At the same time, concomitant diseases are treated that worsen the general condition of the patient and wound healing (correction of diabetes mellitus, normalization of blood circulation, etc.).

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Modern methods of wound treatment

Local treatment of wounds under bandages is one of the main methods of conservative treatment. The modern methodology of such treatment is based on the targeted use of active dressings, taking into account the phase and characteristics of the course of the wound process. The effectiveness of this methodology is largely determined by evidence-based studies of the mechanism of interaction of dressings with wound tissues, the presence of a wide range of required wound dressings, the level of their quality, clearly formulated indications and contraindications for their use.

In dermatosurgical practice, the treatment of wound surfaces after dermabrasion and chemical peeling is usually carried out in dry conditions, treating the wound with a 5% potassium permanganate solution. This method, due to the powerful oxidizing properties of potassium permanganate, is very reliable in terms of disinfection. But, given the pain of removing the scab with the onset of epithelization in the wound area and bright postoperative erythema, this coating has been trying to find a replacement for many years.

In 1962, research by Georg Winter proved that when treating a wound in a humid environment, the healing process is noticeably faster than with dry treatment. For the sake of fairness, it should be noted that historically the priority in the discovery of a method of treating a wound in a humid environment belongs to Joseph Lister and Alexander Vasilyevich Vishnevsky.

Based on this scientific discovery, new dressings, or wound care products, have been created based on the latest achievements of high-tech industries.

In modern medical practice, the principle of wet wound treatment with various types of dressings has become dominant. The positive aspects of this method of treatment are, firstly, the cleaning and reliable protection of the wound from external influences, and secondly, the constant support of the physiological wound environment, which creates optimal conditions for wound healing at all stages of the wound process: cleansing and normalization of microcirculation, formation of granulation tissue (angiogenesis) and epithelialization. In addition, the newly created dressings do not adhere to the wound surface and can be removed when the dressing is changed without harm to the healing tissue and without pain for the patient.

To ensure that dressings have an optimal healing effect on wound healing, the treatment and care process must be accurately documented. Only thanks to standardized records of the course of treatment, it is possible to carefully analyze the course of the rehabilitation process and adjust therapy. In addition, complete documentation of the course of treatment and care is a necessary requirement of modern insurance medicine.

Treatment and care documentation must include:

The underlying disease

The nutrition of the patient

The patient's mobility

taking medications;

localization of the wound;

The size of the wound

degree of severity of the wound process;

infection of the wound

morphology of the wound;

time of wound epithelialization;

· complications.

In addition, the fastest healing is also influenced by how simple the technique of applying modern wound treatment products is to perform by junior medical personnel. Therefore, at the initial stage, a single, standardized use of materials in a certain set is preferable. An additional factor in rehabilitation treatment is the preparation of the patient, taking into account his psychological status: he must be informed about the features of modern wound treatment, trained in proper wound care.

Strict requirements are imposed on modern wound care products. Their quality is assessed according to the following criteria:

maintaining a moist environment in the wound area;

Standards for the treatment of wounds of various localization
Protocols for the treatment of wounds of various localization

Wounds of various localization

Profile: surgical.
Stage: hospital.
Purpose of the stage: timely diagnosis of wounds, taking into account their localization, determination of therapeutic tactics (conservative, operative), prevention of possible complications.
Duration of treatment (days): 12.

ICD codes:
T01 Open wounds involving multiple areas of the body
S21 Open wound of chest
S31 Open wound of abdomen, lower back and pelvis
S41 Open wound of shoulder girdle and upper arm
S51 Open wound of forearm
S61 Open wound of wrist and hand
S71 Open wound of hip and thigh
S81 Open wound of lower leg
S91 Open wound of ankle and foot
S16 Injury of muscles and tendons at neck level
S19 Other and unspecified injuries of neck
S19.7 Multiple injuries of neck
S19.8 Other specified injuries of neck
S19.9 Injury of neck, unspecified
T01.0 Open wounds of head and neck
T01.1 Open wounds of chest, abdomen, lower back and pelvis
T01.2 Open wounds of multiple regions of upper limb(s)
T01.3 Open wounds of several regions of lower limb(s)
T01.6 Open wounds of several regions of upper and lower limbs
T01.8 Other combinations of open wounds involving more than one area of the body
T01.9 Multiple open sores, unspecified

Definition: Wound - damage to body tissues due to mechanical impact, accompanied by a violation of the integrity of the skin and mucous membranes.

Wound classification:
1. Stab - as a result of exposure to a sharp object;
2. Cut - as a result of exposure to a sharp long object, no less than 0.5 cm in size;
3. Bruised - as a result of the impact of an object of large mass or high speed;
4. Bitten - as a result of a bite of an animal, less often, a person;
5. Scalped - there is a detachment of the skin and subcutaneous tissue from the subject
fabrics;
6. Gunshots - as a result of the action of firearms.

Delivery: emergency.

Diagnostic criteria:
Pain in the injured limb;
Forced position of the injured limb;
Limitation or lack of mobility of the limb;
Soft tissue changes over the fracture site (edema, hematoma, deformity, etc.);
Crepitus on palpation of the alleged injured area of the lower leg;
Concomitant neurological symptoms (lack of sensitivity, coldness, etc.);
Damage to the skin according to the classification given;
X-ray signs of trauma to the underlying tissues.

List of main diagnostic measures:
1. Determining the type of injury in accordance with the above classification;
2. Determination of the degree of dysfunction of the injured organ (range of motion);
3. Clinical examination of the patient (see diagnostic criteria);
4. X-ray examination of the injured leg in 2 projections.
5. Complete blood count;
6. General analysis of urine;
7. Coagulogram;
8. Biochemistry;
9. HIV, HbsAg, Anti-HCV.

Treatment tactics
The need for anesthesia depends on the type of wound according to the classification.
Taking into account the violation of the integrity of the skin, the introduction of tetanus toxoid is mandatory.

Conservative treatment:
1. Primary surgical treatment of the wound;
2. In the absence of wound infection, antibiotic prophylaxis is not carried out.

Surgical treatment:
1. The imposition of primary sutures in the absence of signs of infection of the wound;
2. Antibiotic prophylaxis is carried out for 3-5 days for wounds received more than 8 hours ago with a high risk of infection:
Moderate and severe wounds;
Wounds reaching the bone or joint;
Hand wounds;
immunodeficiency state;
Wounds of the external genital organs;
Bite wounds.

3. Surgical treatment of wounds is indicated when damage to the nerve or vascular bundle is confirmed.

The results of multicenter studies have established that the use of antibiotic prophylaxis in patients with wounds reduces the risk of developing pyoinflammatory complications.

Patients can be divided into 3 risk groups:
1. Injuries with damage to the skin and soft tissues less than 1 cm long, the wound is clean.
2. Injuries with damage to the skin longer than 1 cm in the absence of severe damage to the underlying tissues or significant displacements.
3. Any injury with severe damage to underlying tissues or traumatic amputation.
Patients in risk groups 1-2 need a dose of antibiotics (as soon as possible after injury), mainly with an effect on gram-positive microorganisms. For patients at risk group 3, additional antibiotics are prescribed that act on gram-negative microorganisms.

Antibiotic prophylaxis regimens:
Patients of 1-2 risk groups - amoxicillin 500 thousand after 6 hours 5-10 days per os;
Patients of the 3rd risk group - amoxicillin 500 thousand after 6 hours 5-10 days per os + clavulonic acid 1 tablet 2 times.

List of essential medicines:
1. Amoxicillin tablet 500 mg, 1000 mg; capsule 250 mg; 500 mg
2. Hydrogen peroxide solution 3% in a bottle of 25 ml, 40 ml
3. Nitrofural 20 mg tab.

Criteria for moving to the next stage: wound healing, restoration of functions of damaged organs.

Treatment of purulent wounds consists of local and general treatment. The nature of the treatment, in addition, is determined by the phase of the wound process.

Local treatment

Treatment goals in the inflammation phase

In the first phase of the wound process (the phase of inflammation), the surgeon faces the following main tasks:

Fight against microorganisms in the wound;

Ensuring adequate drainage of exudate;

Promoting the speedy cleansing of the wound from necrotic tissues;

Decreased manifestations of the inflammatory response.

In the local treatment of a purulent wound, methods of mechanical, physical, chemical, biological and mixed antiseptics are used.

With suppuration of the postoperative wound, it is usually enough to remove the sutures and widely spread its edges. With severe inflammation and extensive necrosis in a purulent wound, it is necessary to perform secondary surgical treatment (SDO) of the wound.

Secondary debridement

An indication for WMO of a wound is the presence of a purulent wound in the absence of adequate outflow from it (pus retention) or the formation of extensive zones of necrosis and purulent streaks. The only contraindication is the extremely serious condition of the patient, while they are limited to opening and draining the purulent focus.

Tasks facing the surgeon performing VMO of the wound:

Opening of a purulent focus and streaks;

Excision of non-viable tissues;

Implementation of adequate wound drainage.

Before the start of VMO, it is necessary to determine the visible boundaries of inflammation, the localization of purulent fusion, the shortest access to it, taking into account the location of the wound, as well as possible ways of spreading the infection (along the neurovascular bundles, muscular-fascial sheaths). In addition to palpation examination, various types of instrumental diagnostics are used: ultrasound, thermographic, x-ray (for osteomyelitis) methods, CT.

Like the primary surgical treatment, VMO is an independent surgical intervention. It is performed in the operating room by a team of surgeons using anesthesia. Only adequate anesthesia allows to solve all the problems of the WTO. After opening the purulent focus, a thorough instrumental and digital revision is carried out along the course of the wound itself and the possible presence of streaks, which are subsequently also opened through the main wound or counter-opening and drained. After completing the revision and determining the volume of necrosis, pus is evacuated and non-viable tissues are excised (necrectomy). At the same time, we must not forget that there may be large vessels and nerves near or in the wound itself, which must be preserved. Before the end of the operation, the wound cavity is abundantly washed with antiseptic solutions (hydrogen peroxide, boric acid, etc.), loosely packed with gauze swabs with antiseptics and drained. The most beneficial method of treatment for extensive purulent wounds is flow-flushing drainage. In the case of localization of damage to the limb, immobilization is necessary. Most often, a plaster cast is used.

In table. 4-2 shows the main differences between PST and WTO wounds.

Treatment of a purulent wound after surgery

After performing the VMO or simple opening (opening) of the wound at each dressing, the doctor examines the wound and assesses its condition, noting the dynamics of the process. The edges are treated with alcohol and an iodine-containing solution. The wound cavity is cleaned with a gauze ball or a napkin from pus and free-lying sequesters, necrotic tissues are excised in a sharp way. This is followed by washing with antiseptics (3% hydrogen peroxide solution, 3% boric acid solution, nitrofural, etc.), drainage (according to indications) and loose plugging using various antiseptic agents.

Table 4-2. Differences between primary and secondary surgical treatment of the wound

The main measures for the treatment of a purulent wound in the inflammation phase are associated with the need for exudate outflow and infection control. Therefore, hygroscopic dressings are used, it is possible to use a hypertonic solution (10% sodium chloride solution). The main antiseptics are a 3% solution of boric acid, 0.02% aqueous solution of chlorhexidine, 1% solution of hydroxymethylquinoxylindioxide, nitrofural (solution 1:5000).

In the first phase of healing, when there is abundant exudation, ointment preparations cannot be used, as they create an obstacle to the outflow of the discharge, which contains a large number of bacteria, proteolysis products, and necrotic tissues. Only on the 2-3rd day is it possible to use water-soluble ointments based on polyethylene oxide. They contain various antimicrobial agents: chloramphenicol, hydroxymethylquinoxylindioxide, metronidazole + chloramphenicol, nitrofural, diethylaminopentylnitrofuryl vinylquinoline carboxamide, mafenide (10% mafenide ointment). In addition, the composition of ointments includes drugs such as trimecaine, for the purpose of an analgesic effect, and methyluracil, which has anabolic and anti-catabolic activity, in order to stimulate cell regeneration processes.

Of particular importance in the treatment of purulent wounds is "chemical necrectomy" with the help of proteolytic enzymes that have necrolytic and anti-inflammatory effects. For this, trypsin, chymotrypsin are used. The preparations are poured into the wound in a dry form or injected in a solution of antiseptics. For active removal of purulent exudate, sorbents are placed directly into the wound, the most common of which is hydrolytic lignin.

In order to increase the effectiveness of VMO and further treatment of purulent wounds, various physical methods of influence are used in modern conditions. Widely used are ultrasonic cavitation of wounds, vacuum treatment of a purulent cavity, treatment with a pulsating jet, and various methods of using a laser. All these methods are aimed at accelerating the cleansing of necrotic tissues and the detrimental effect on microbial cells.

Treatment in the regeneration phase

In the regeneration phase, when the wound has cleared of non-viable tissues and inflammation has subsided, the next stage of treatment is started, the main tasks of which are to stimulate reparative processes and suppress infection.

In the second phase of healing, the process of formation of granulation tissue plays a leading role. In this period, in the absence of complications, exudation is sharply reduced and the need for an absorbent dressing, the use of hypertonic solutions and drainage disappears. Granulations are very delicate and vulnerable, so it becomes necessary to use ointment-based preparations that prevent mechanical trauma. The most effective are ointments containing stimulants (5% and 10% methyluracil ointment). However, despite the fact that the granulation tissue also performs a protective function, it is impossible to completely exclude the possibility of the re-development of the infectious process. Therefore, during dressings, the wounds continue to be washed with antiseptic solutions, ointments, emulsions and liniments are used, including antibiotics (chloramphenicol, tetracycline, gentamicin ointments, etc.). Multicomponent ointments containing anti-inflammatory, antiseptic, stimulating regeneration and improving regional blood circulation substances (hydrocortisone + oxytetracycline, balsamic liniment according to A.V. Vishnevsky) are widely used.

To accelerate the healing of wounds, the technique of applying secondary sutures (early and late) is used, as well as tightening the edges of the wound with adhesive tape.

Treatment of wounds in the phase of formation and reorganization of the scar

In the third phase of healing, the main tasks are to accelerate the epithelization of the wound and protect it from excessive trauma. For this purpose, dressings with indifferent and stimulating ointments are used, as well as physiotherapy procedures.

Physiotherapy

Physiotherapeutic procedures occupies a significant place in the treatment of purulent wounds. In the first phase, to stop acute inflammation, reduce edema, pain syndrome, accelerate the rejection of necrotic tissues, an electric field of UHF and UVR in an erythemal dose is used, which also stimulates the phagocytic activity of leukocytes and has an antimicrobial effect. For local administration of antibiotics, enzymes, anti-inflammatory and analgesic drugs, electro- and phonophoresis are used. It should be remembered that with insufficient outflow of purulent contents, physiotherapeutic procedures lead to an aggravation of the purulent-inflammatory process.

In the second and third phases of the wound process, in order to activate reparative processes and epithelialization, ultraviolet radiation and laser irradiation with a defocused beam are used. A magnetic field has a vasodilating and stimulating effect: when exposed to a pulsating magnetic field, the size of the scar decreases.

During the entire period of the wound process, it is possible to use hyperbaric oxygenation, which improves oxygen saturation of tissues.

Treatment in an abacterial environment

With extensive wound defects and burns, treatment in a controlled abacterial environment is successfully used. There are isolators of general and local types, isolation of the entire patient is necessary in the treatment of patients with reduced resistance to infection: after oncological operations accompanied by massive chemotherapy or radiation treatment; with organ transplantation associated with the constant intake of immunosuppressants that inhibit the rejection reaction; various blood diseases that cause disruption and inhibition of lymphopoiesis.

Treatment in an abacterial environment is carried out without a bandage, which contributes to the drying of the wound, which adversely affects microorganisms. The following parameters are maintained in the insulator: temperature 26-32°C, overpressure 10-15 mm Hg. st, relative humidity 50-65%. The parameters may vary depending on the nature of the course of the wound process.

Treatment with special dressings

In modern practice of local treatment of both clean and purulent wounds, a technique using ready-made dressings of domestic and foreign production containing multicomponent fillers is increasingly being used. Dressings for use in phase I include preparations that can absorb wound exudate, adsorb bacterial cells and toxins, and promote the lysis of necrotic masses. Dressings for phases II and III contain fillers that protect granulations and the "young" scar, stimulate reparative processes. This technique is also used for temporary closure of extensive wound surfaces in order to reduce the loss of protein, electrolytes, and fluid. The most common dressings at present are Vaskopran, Algipor, Sorbalgon, Suspurderm, Hydrocoll, etc.

General treatment

The general treatment of wound infection has several directions:

Antibacterial therapy;

detoxification;

Immunocorrective therapy;

Anti-inflammatory therapy;

Symptomatic therapy.

Antibacterial therapy

Antibacterial therapy is one of the components of the complex therapy of purulent diseases and, in particular, purulent wounds. It is used mainly in I, as well as in II and III phases of the wound process.

In the absence of signs of intoxication in the patient, the small size of the wound, the preservation of the integrity of the bone structures, the main vessels and the absence of concomitant diseases, only local treatment is usually sufficient. Otherwise, antibiotic therapy should be started as early as possible.

Staphylococci most often form thick yellowish pus, streptococci - yellow-green liquid pus or an ichor type, Escherichia coli - brown pus with a characteristic odor, Pseudomonas aeruginosa gives the appropriate coloration of the dressings and a sweet smell (pus formed by Proteus has similar features, but usually not green). We must not forget that a mixed infection is more common in a purulent wound, therefore it is preferable to prescribe broad-spectrum antibacterial drugs at the initial stages. After determining the sensitivity, you can change the antibiotic.

Antibacterial therapy also includes drugs strictly directed against certain bacteria or their groups. Various bacteriophages find their application - streptococcal, staphylococcal, proteus, aeruginosa, coliphage, as well as complex phages, for example, pyophage, consisting of several types of bacteriophages. For the purpose of passive immunization, anti-staphylococcal γ-globulin, various types of plasmas are administered [hyperimmune anti-staphylococcal, anti-escirichia, anti-pseudomonal and anti-lipopolysaccharide (against gram-negative microorganisms).

Detoxification

A large amount of necrosis and developing infection cause the saturation of the body with toxins. A patient with a purulent wound in the first phase of the wound process shows all signs of intoxication (chills, fever, sweating, weakness, headache, lack of appetite), inflammatory changes in blood and urine tests increase. All this serves as an indication for detoxification therapy, which includes the following methods (in order of increasing complexity and effectiveness):

Infusion of saline solutions;

Forced diuresis method;

The use of detoxifying blood-substituting solutions;

Extracorporeal methods of detoxification.

The choice of method depends primarily on the severity of intoxication and the severity of the patient's condition.

In the phase of regeneration and scar formation, there is usually no need for detoxification therapy.

Immunocorrective therapy

When a purulent process occurs in the wound, the development of intoxication often causes a decrease in the body's resistance with a drop in the level of antibody production, phagocytic activity, a deficiency of subpopulations of lymphoid cells and a slowdown in their differentiation. This leads to long-term use of powerful antibacterial drugs. These changes contribute to the further development of infection, an increase in the zone of secondary necrosis and a progressive deterioration of the patient's condition.

In order to correct this temporary deficiency, immunomodulators are used. The most widely used interferons, levamisole, thymus preparations. However, with long-term administration and high doses, these drugs suppress the production of their own immune cells. Recently, more and more attention has been paid to cytokines created by genetic engineering, in particular interleukins, which have wide indications for use in immunodeficiency states. Human recombinant interleukin-1 and interleukin-2 have been created and are being used in treatment.

Active immunization with toxoids and vaccines is used for prophylactic purposes in order to prepare the patient to fight the infection on his own. Usually used staphylococcal toxoid, polyvalent Pseudomonas aeruginosa vaccine, etc.

Anti-inflammatory therapy

Anti-inflammatory therapy is not the leading way to treat wounds, it is used quite rarely and is reduced to the introduction of glucocorticoids and non-steroidal anti-inflammatory drugs. In addition to the analgesic effect, these drugs help reduce the manifestation of inflammation, reduce edema, increase perfusion and oxygenation of the tissues surrounding the wound, and improve their metabolism. This leads to the acceleration of the formation of a demarcation line and the speedy clearance of necrosis.

Symptomatic therapy

In the phase of inflammation, due to tissue edema, pain syndrome develops. Therefore, if necessary, analgesics (usually non-narcotic) are administered. For fever, antipyretics are used. With significant blood loss, transfusion of blood components and blood-substituting solutions is carried out.

With extensive wound defects with loss of fluid, proteins and electrolytes through their surface, infusion replacement therapy includes protein hydrolysates, native plasma, mixtures of amino acids and polyionic solutions. General strengthening therapy includes vitamins of various groups (C, B, E, A) and regeneration stimulants (methyluracil, orotic acid, anabolic hormones). In patients with severe disorders of the activity of various organs and systems due to trauma or complications of a purulent wound, their correction is necessary.

At the same time, concomitant diseases are treated that worsen the general condition of the patient and wound healing (correction of diabetes mellitus, normalization of blood circulation, etc.).

Treatment methods for open wounds. f) Physiotherapy treatment

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