Classic types of healing. Types of wound healing (primary intention, secondary intention, under scab) Wound healing by primary intention

Healing by secondary intention (sanatio per secundam intentionem)- healing through suppuration, through the development of granulation tissue. In this case, healing occurs after a pronounced inflammatory process, as a result of which the wound is cleared of necrosis.

Healing conditions by secondary intention

Wound healing by secondary intention requires conditions opposite to those that favor primary intention:

Significant microbial contamination of the wound;

A significant defect in the skin;

The presence in the wound of foreign bodies, hematomas and necrotic tissues;

Unfavorable condition of the patient's body.

In healing by secondary intention, there are also three phases, but they have some differences.

Features of the inflammation phase

In the first phase, the phenomena of inflammation are much more pronounced and the cleansing of the wound takes much longer. Phagocytosis and lysis of cells devitalized as a result of trauma or the action of microorganisms cause a significant concentration of toxins in the surrounding tissues, increasing inflammation and worsening microcirculation. A wound with a developed infection is characterized not only by the presence of a large number of microbes in it, but also by their invasion into the surrounding tissues. On the verge

the penetration of microorganisms forms a pronounced leukocyte shaft. It contributes to the delimitation of infected tissues from healthy ones, demarcation, lysis, sequestration and rejection of non-viable tissues occur. The wound is gradually cleared. As the areas of necrosis melt and the decay products are absorbed, intoxication of the body increases. This is evidenced by all the common manifestations characteristic of the development of wound infection. The duration of the first phase of healing depends on the amount of damage, the characteristics of the microflora, the state of the body and its resistance. At the end of the first phase, after lysis and rejection of necrotic tissues, a wound cavity is formed and the second phase begins - the regeneration phase, the peculiarity of which is the emergence and development of granulation tissue.

The structure and functions of granulation tissue

During healing by secondary intention in the second phase of the wound process, the resulting cavity is filled with granulation tissue.

Granulation tissue (granulum- grain) - a special type of connective tissue formed during wound healing by secondary intention, contributing to the rapid closure of the wound defect. Normally, without damage, there is no granulation tissue in the body.

The formation of granulation tissue. There is usually no clear boundary for the transition of the first phase of the wound process to the second. Vascular growth plays an important role in the formation of granulations. At the same time, the newly formed capillaries, under the pressure of the blood entering them, acquire a direction from the depth to the surface and, not finding the opposite wall of the wound (as a result of the first phase, a wound cavity was formed), make a sharp bend and return back to the bottom or wall of the wound, from which they originally grew. . capillary loops are formed. In the area of these loops, shaped elements migrate from the capillaries, fibroblasts are formed, giving rise to connective tissue. Thus, the wound is filled with small granules of connective tissue, at the base of which are loops of capillaries.

Islets of granulation tissue appear in a wound that has not yet been completely cleansed against the background of necrosis areas already on the 2nd-3rd day. On the 5th day, the growth of granulation tissue becomes very noticeable.

Granulations are delicate, bright pink, fine-grained, shiny formations that can grow rapidly and bleed profusely with minor damage. Granulations develop from the walls and bottom of the wound, tending to quickly fill the entire wound defect.

Granulation tissue can form in the wound without infection. This occurs when the diastasis between the edges of the wound exceeds 1 cm and the capillaries growing from one wall of the wound also do not reach the other and form loops.

The development of granulation tissue is the fundamental difference between healing by secondary intention and healing by primary intention.

The structure of granulation tissue. In granulation tissue, six layers are distinguished, each of which performs a specific function.

1. The superficial leukocyte-necrotic layer consists of leukocytes, detritus and exfoliating cells. It exists during the entire period of wound healing.

2. The layer of vascular loops contains, in addition to vessels, polyblasts. With a long course of the wound process, collagen fibers can form in this layer, which are located parallel to the surface of the wound.

3. The layer of vertical vessels is built of perivascular elements and amorphous interstitial substance. Fibroblasts are formed from the cells of this layer. This layer is most pronounced in the early period of wound healing.

4. The maturing layer is essentially the deeper part of the previous layer. Here, perivascular fibroblasts take a horizontal position and move away from the vessels, collagen and argyrophilic fibers develop between them. This layer, characterized by polymorphism of cell formations, remains the same in thickness throughout the wound healing process.

5. Layer of horizontal fibroblasts - a direct continuation of the previous layer. It consists of more monomorphic cellular elements, is rich in collagen fibers and gradually thickens.

6. The fibrous layer reflects the process of maturation of granulations. Functions of granulation tissue:

Wound defect replacement - granulation tissue is the main plastic material that quickly fills the wound defect;

Protection of the wound from the penetration of microorganisms and the ingress of foreign bodies; achieved by the content in the granulation tissue of a large number of leukocytes, macrophages and the dense structure of the outer layer;

Sequestration and rejection of necrotic tissues occur due to the activity of leukocytes and macrophages, the release of proteolytic enzymes by cellular elements.

In the normal course of the healing process, epithelialization begins simultaneously with the development of granulations. Through reproduction and migration, epithelial cells “crawl” from the edges of the wound towards the center, gradually covering the granulation tissue. Vyraba-

Fibrous tissue in the lower layers lines the bottom and walls of the wound, as if pulling it together (wound contraction). As a result, the wound cavity is reduced, and the surface is epithelialized.

The granulation tissue that filled the wound cavity is gradually transformed into a mature coarse fibrous connective tissue - a scar is formed.

Pathological granulations. Under the influence of any adverse factors affecting the healing process (deterioration of blood supply or oxygenation, decompensation of the functions of various organs and systems, re-development of the purulent process, etc.), the growth and development of granulations and epithelialization may stop. Granulations become pathological. Clinically, this appears as a lack of wound contraction and a change in the appearance of the granulation tissue. The wound becomes dull, pale, sometimes cyanotic, loses turgor, becomes covered with a coating of fibrin and pus, which requires active therapeutic measures.

Hilly granulations protruding beyond the wound are also considered pathological - hypertrophic granulations (hypergranulations). They, hanging over the edges of the wound, prevent epithelialization. Usually they are cut or cauterized with a concentrated solution of silver nitrate or potassium permanganate and continue to heal the wound, stimulating epithelialization.

Healing under the scab

Wound healing under the scab occurs with small superficial injuries such as abrasions, epidermal damage, abrasions, burns, etc.

The healing process begins with coagulation of the outflow of blood, lymph and tissue fluid on the surface of the injury, which dries up to form a scab.

The scab performs a protective function, is a kind of "biological bandage". Under the scab, rapid regeneration of the epidermis takes place, and the scab is sloughed off. The whole process usually takes 3-7 days. In healing under the scab, the biological features of the epithelium are mainly manifested - its ability to line living tissue, delimiting it from the external environment.

The scab should not be removed if there are no signs of inflammation. If inflammation develops and purulent exudate accumulates under the scab, surgical treatment of the wound with the removal of the scab is indicated.

The question is debatable, what type of healing is the healing under the scab: primary or secondary? It is generally believed that it occupies an intermediate position and is a special type of healing of superficial wounds.

Wound healing complications

Wound healing can be complicated by various processes, the main of which are the following.

development of infection. It is possible to develop a nonspecific purulent infection, as well as anaerobic infection, tetanus, rabies, diphtheria, etc.

Bleeding. There may be both primary and secondary bleeding (see Chapter 5).

Wound dehiscence (wound failure) is considered a serious complication of healing. It is especially dangerous with a penetrating wound of the abdominal cavity, as it can lead to the exit of internal organs (intestines, stomach, omentum) - eventration. Occurs in the early postoperative period (up to 7-10 days), when the strength of the emerging scar is small and there is tissue tension (flatulence, increased intra-abdominal pressure). Eventration requires urgent re-surgical intervention.

Scars and their complications

The outcome of the healing of any wound is the formation of a scar. The nature and properties of the scar primarily depend on the method of healing.

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

Why does the wound not heal for a long time

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

infection

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

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

Diabetes

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

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

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

Elderly age

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

Weak immunity

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

Mechanism of secondary wound healing

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

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

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

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

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

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

Preparations to accelerate wound healing

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

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

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

Levomekol

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

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

Argosulfan

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

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

Solcoseryl

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

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

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

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

Baneocin

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

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

Ambulance

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

Teaching aid

On the topic: "Local surgical pathology and its treatment"

Discipline "Surgery"

By specialty:

0401 "Medicine"

0402 Obstetrics

0406 "Nursing"

The study guide was compiled by the teacher

BU SPO "Surgut Medical School

Devyatkova G.N., in accordance with

requirements of GOS SPO and working

program.

Lecture material

Topic: "Local surgical pathology, its treatment"

Wound - uh This is a mechanical violation of the integrity of the skin and mucous membranes, with the possible destruction of deeper structures, tissues, internal organs.

The elements of any wound are:

Wound cavity (wound defect)

The walls of the wound

The bottom of the wound

If the depth of the wound cavity significantly exceeds its transverse size, then it is called the wound channel.

The main local symptoms of a wound are:

Bleeding

The severity of these symptoms depends on the amount of damage, innervation and blood supply of the wounded area, combined injuries of internal organs.

Classification

1. Wounds by origin:

Deliberate (operational)

Accidental (domestic, traumatic)

2. Wounds by the presence of microflora:

Aseptic (operating)

Bacterially contaminated (there is a microflora in the wound that does not cause inflammation)

Infected (an infectious process develops in the wound)

3. Wounds according to the mechanism of damage:

- stab wound, applied with a narrow long object (awl, needle, knitting needle). It is characterized by great depth, but little damage to the integument. They present difficulties in diagnosis. They are accompanied by damage to deep tissues and organs and there is a high risk of developing infectious complications due to impaired outflow of wound discharge.

- incised wound- applied with a sharp cutting object (knife, blade, glass). It is characterized by minimal destruction along the wound channel, strong gaping, and good drainage of the wound discharge (self-cleaning of the wound).

- chopped wounds- applied with a heavy, sharp object (axe, saber). It is characterized by concomitant concussion of deeper tissues.

- bruised wounds, crushed- are applied with a hard, heavy, blunt object. It is characterized by a violation of tissue trophism, small bleeding.

- lacerated wound occur as a result of tissue overstretching. It is characterized by a large amount of damage, tissue detachment, irregular shape.

If such a wound was formed with a detachment of a skin flap, then it is called scalped.

- bite wound- applied when bitten by animals, insects, humans. It is characterized by the ingress of animal saliva, insect venom into the wound.

- gunshot wound- applied by a projectile, set in motion by the energy of the combustion of gunpowder. Has a number of features:

a). the wound channel consists of 3 zones (defect zone, primary traumatic necrosis, molecular concussion).

b). specific mechanism of formation (direct or side impact)

in). extensive tissue destruction.

G). complex shapes and structure of the wound channel

e). microbial contamination.

4. Wounds by the nature of the wound channel:

-through- The wound has an inlet and outlet.

-blind- the wound has only an inlet.

- tangents- a long superficial passage is formed, covered with necrotic tissue.

5. Wounds in relation to body cavities:

- penetrating - a wounding projectile damages the parietal sheet of the serous membrane, and penetrates into the cavity. Signs of a penetrating injury are eventration of the internal organs, the outflow of the contents of the cavity (urine, bile, cerebrospinal fluid, feces). Signs of fluid accumulation in the cavity (hemothorax, hemoperitoneum, hemarthrosis).

- non-penetrating

6. Number of wounds:

Singles

Multiple

Wound process

Wound process- This is a complex set of local and general body reactions aimed at cleansing, restoring damaged tissues, and fighting infection.

The wound process is divided into 3 phases:

1 phase Inflammation, uniting the processes of alteration, exudation, necrolysis - cleansing the wound from necrotic tissues.

2nd phase of proliferation– formation and maturation of granulation tissue

3 phase healing- scar organization and epithelialization.

Phase 1 Inflammation. Within 2-3 days after the injury, vasospasm occurs in the wound area, which is replaced by a strong expansion, an increase in the permeability of the vascular wall, which leads to a rapid increase in tissue edema. As a result of impaired microcirculation, tissue hypoxia and acidosis develop. These phenomena lead to the breakdown of collagen and the concentration of formed elements in the wound. The wound is flooding hyperhydration. Leukocytes die, as a result of which proteolytic enzymes are released and pus is formed.

Signs of inflammation: appears

Hyperemia,

Pain on palpation

Necrotic tissues are visible on the bottom and wall,

Fibrinous films, pus.

Phase 2 Proliferation . It starts on about 3-5 days, the inflammation subsides as the wound is cleansed. Proliferation (increased growth) of fibroblasts and capillary endothelium comes to the fore. In separate foci and zones, granulation tissue (accumulation of fibroblasts, capillaries, mast cells) begins to appear.

Functions of granulation tissue:

A) Completes the process of rejection of necrotic tissues.

B) A protective barrier to the penetration of microbes and their toxins, environmental influences.

C) A substrate filling a wound defect.

Signs of the 2nd phase of proliferation are characterized by:

increased hyperemia,

purulent discharge,

The formation of a scab underneath is juicy, easily bleeding tissue.

3 phase Healing. As the granulation matures, they become depleted in capillaries and fibroblasts and enriched in collagen fibers. This intensifies the flooding of tissue dehydration. In parallel with the formation of collagen fibers, their partial destruction occurs, as a result of which a delicate balance is ensured in the formed scar. In this case, the edges of the wound converge, due to which the size of the wound is significantly reduced.

Epithelialization - the growth of the epithelium, begins simultaneously with the growth of granulation, it occurs due to the growth of the basal layer of the epithelium from the healthy ends of the wound, as a result of cell migration.

Clinically, phase 3 manifests itself:

Reducing the size of the wound

The absence of separable

The epithelium looks like a white-blue border, which gradually covers the entire surface of the wound.

Types of wound healing

Wound healing is possible in various ways, depending on a number of reasons:

The amount of damage

Presence of necrotic tissue

Trophic disorders

infectious infection

General condition of the victim

1. Healing by primary intention. The edges of the wound stick together, which is facilitated by the loss of the fibrin film. The fibrin layer quickly grows into fibroblasts and granulation tissue with the formation of a narrow linear scar after 6-7 days.

Healing by secondary intention.

Occurs when there are unfavorable conditions in the wound (large wound size, uneven edges, complex wound channel, the presence of clots and infectious necrotic tissues in the wound, impaired tissue trophism). All this leads to prolonged inflammation in the wound, the 2nd phase of the wound process comes much later. Infection affects the growth of granulation. It becomes lethargic, pale, grows poorly, as a result, the wound defect is filled much later. The healing time in this case can vary from 2 weeks to several months. The result of this is the formation of a scar.

3. Healing under the scab. An intermediate variant close to healing by primary intention. In this case, the edges of the wound do not touch, a crust forms on its surface - a scab, dried blood, lymph, fibrin. The scab protects the wound from infection and environmental influences.

All phases of the wound process proceed under the scab and after epithelialization it is rejected.

Wound treatment

Purpose of treatment: Restoring the integrity and function of damaged tissues and organs in the shortest possible time.

Objectives of wound care:

1. Cleansing the wound from necrotic tissues, creating optimal conditions for the outflow of wound discharge.

2. Destruction of microorganisms.

3. Elimination of factors that adversely affect the wound process.

First aid for injury

1. Stop external bleeding.

2. Applying a protective aseptic bandage.

3. Introduction of analgesics (pain relief)

4. Immobilization of the wounded area

5. Hospitalization, in order to diagnose damage to internal organs,

6. The introduction of tetanus toxoid for the prevention of tetanus.

7. Provision of qualified medical care in a surgical hospital.

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In medicine, there are three main types of wound healing: healing under the scab, as well as the method of secondary and primary intention. A certain method of healing is always chosen by the doctor, based on the patient's condition and the characteristics of his immune system, the nature of the wound received, and the presence of infection in the affected area. The stages of wound healing, or rather their duration, depends directly on the type of injury and its scale, as well as on the type of healing itself.

In this article, you will learn everything about the type of wound healing and their characteristics, what are the features and how to properly care for an injury after the healing process.

Healing by first intention

This type of regeneration is the most perfect, since the whole process takes place over a short period of time, and a rather thin, but very strong scar is formed.

As a rule, wounds after operations and suturing heal by primary intention, as well as minor injuries after cuts, if the edges of the wound do not have strong discrepancies.

Wound healing in this way is possible in the absence of an inflammatory process accompanied by suppuration. The edges of the wound are tightly connected and fixed, resulting in normal and rapid healing of the wound without the formation of a large amount of coarse scar tissue.

In place of the wound, only a thin scar remains, which at first after formation has a red or pink color, but later gradually brightens and acquires an almost general tone with the skin.

The wound heals by primary intention if its edges are completely close to each other, while between them there are no areas of necrosis, any foreign bodies, there are no signs of inflammation, and the damaged tissues have fully retained their viability.

secondary tension

Secondary intention mainly heals wounds that cannot be sewn up and those that were not sewn up in time due to the fact that the person turned to the doctors late. By secondary intention, wounds also heal, in which the process of inflammation and the formation of pus is actively developing. With this method of healing, granulation tissue first develops in the wound cavity, gradually filling all the available space, while forming a sufficiently large and dense connective tissue scar. Subsequently, this tissue is covered with epithelium from the outside.

The processes of secondary healing usually proceed against the background of a fairly intense inflammation that has arisen due to primary, as well as secondary infection, and is accompanied by the release of pus.

The type of secondary tension can be used for healing wounds with a strong divergence of edges and a significant wound cavity, as well as for those injuries in the cavity of which there are necrotic tissues or foreign bodies, blood clots.

Also, this technique is resorted to in cases where the patient has hypovitaminosis, general exhaustion of the body, metabolic processes are disturbed, due to which not only the body's defenses decrease, but also the intensity of natural tissue regeneration processes.

The granulation tissue that develops in the wound cavity has a very important biological significance for the general healing process and the organism as a whole. It is a kind of physiological as well as a mechanical barrier that creates an obstacle to the absorption of toxins, microbes from the wound cavity and decay products of the inflammatory process into the tissues of the body, which are toxic to the body.

In addition, the granulation tissue secretes a special wound secret, which contributes to faster wound cleansing in mechanical terms, and also has a natural bactericidal effect, which creates an obstacle to the spread of bacteria and other pathogenic microorganisms from the damaged area to the skin and healthy tissues.

It is with the help of the process of granulation in the wound cavity that the dead tissues are separated from the living ones while filling the damaged space.

Of course, only granulation tissue, which is not subject to damage, has all the protective properties, therefore, when changing dressings, it is very important to be extremely careful and careful so as not to cause additional damage to the wound.

Healing under the scab

This type of healing usually restores scratches, small wounds, abrasions, burns, small and shallow wounds, as well as bedsores, ulcers and other skin lesions.

In the process of healing, a crust forms on the surface of the wound or other damage, having at first red, and, then, dark brown color, which is called a scab. Such a formation consists of lymph, clotted blood and wound exudate, mixed together and covering the surface of the injury with the formed substance.

The scab is a fairly dense formation that perfectly protects the wound. from pollution, penetration of harmful microorganisms, mechanical damage, while holding the edges of the injury together, ensuring their relative immobility.

Treatment of minor abrasions and cuts

Abrasions and various small wounds can be treated and treated at home, on their own, but be sure to follow all the rules of care and use the right tools.

First of all, when receiving any wound, it must be washed with soap and water to clean it of dirt and microorganisms that have got inside.

After that, the wound should be dried with a napkin and, using a gauze swab, treat the damage with a pharmacy solution of hydrogen peroxide, gently wetting the surface.

It is not necessary to pour hydrogen peroxide directly from the vial onto the wound. This tool allows not only to effectively disinfect the surface of the injury and the skin around it, while eliminating almost all types of harmful microorganisms, but also helps to stop bleeding.

Then it is best to apply a sterile bandage. If the wound is very small or the damage is a scratch or a minor abrasion, you can fold a piece of bandage according to the size of the injury or take a cotton pad, soak them with a solution, for example, apply to the wound and secure with a plaster or bandage. If the bandage becomes saturated with blood, it must be changed to a fresh one, repeating the treatment of the wound.

It is necessary to change the bandage soaked in blood so that later, when changing the dressing, you do not accidentally tear off the blood clot that has formed on the surface of the wound, which will later become a scab.

Once a crust has formed, the dressing should be removed and the lesion left open. Wounds under the scab heal best and much faster in the air.

Care after healing

After the formation of a scab on the surface of the damage, which indicates the beginning of the normal healing process, it is very important to ensure that the crust is not injured by any careless movement.

In no case should you try to rip off the scab before the time when new tissues under it have not yet formed. Such actions can lead not only to the penetration of infection and an increase in the recovery time of damaged tissues, but also to the formation of a scar, which in the future will require treatment and adjustment. After the formation of a full-fledged tissue, the scab will fall off on its own.

It is important that the surface of the scab always remains dry. If the crust is wet with water, for example, when washing hands or body, it should be dried immediately with a paper towel.

After the scab falls off, various ointments, creams or folk remedies can be used to accelerate the formation of epithelium at the site of the former injury, as well as to soften and moisturize young tissues and prevent the formation of a serious scar.

Damage recovery

The recovery time for any injury largely depends on its characteristics, location, location, depth, size, healing method used, medications, proper care, timeliness of treatments and dressing changes.

The healing method plays a significant role in the healing process and recovery time.

If the wound heals by the method of primary intention, is clean, there is no inflammatory process in it, then healing occurs in about 7-10 days, and tissue restoration and strengthening occurs within about a month.

If an infection has got into the wound and an inflammatory process develops with severe suppuration, then healing occurs according to the secondary tension method and the recovery time is delayed. In this case, the timing of complete healing will be individual, since much depends on the condition and correct functioning of the patient's immune system, the presence of diseases of the endocrine system and any ailments in a chronic form.

If the human body is weakened and there are disturbances in metabolic processes, then the recovery time in the presence of an inflammatory process can be very delayed and amount to several months.

The rate of wound healing under the scab primarily depends on the state of the immune system and on the correct care of the wound site. It is very important not to tear off the formed crust, but to wait until it falls off on its own at the end of the process of regeneration of new tissues.

With the help of special preparations, such as various antiseptic solutions, therapeutic powders in powder form, as well as gels, creams and ointments, in many cases it is possible not only to significantly speed up the recovery time, but also to make the scar after healing much smaller, softer, lighter or not formed at all. For the same purpose, traditional medicine can also be used, but it is important that only a qualified doctor make any appointments in the treatment of wounds.

What to do with suppuration and microbial infection of the wound

If an infection has entered the wound cavity, an inflammatory process will certainly begin in it, the intensity of which primarily depends on the general state of human health, as well as on the type of microorganisms that have penetrated the wound cavity.

When suppuration begins, wounds should be dressed frequently, changing dressings at least twice a day, but if the dressing becomes contaminated more rapidly, dressings should be changed more frequently, as needed, each time the wound is treated.

When changing dressings, the surface of the wound and the skin around it must be treated with an antiseptic solution, after which, if necessary, special ointments are applied to help not only fight microorganisms, but also eliminate inflammation, swelling, accelerate the cleansing of the wound cavity, and also maintain the necessary moisture balance in the wound, without letting it dry out.

It is important to carry out dressings correctly and in a timely manner, using sterile instruments, sterile materials, the right means to eliminate inflammation and accelerate healing, and also by following the rules for changing dressings.

Wound healing by secondary intention occurs with a purulent infection, when its cavity is filled with pus and dead tissues. The healing of such a wound is slow. By secondary intention, unsutured wounds heal with a divergence of their edges and walls. The presence of foreign bodies, necrotic tissues in the wound, as well as beriberi, diabetes, cachexia (cancer intoxication) impede tissues and lead to wound healing by secondary intention. Sometimes, with a purulent wound, its liquid contents spread through the interstitial cracks to any part of the body at a considerable distance from the focus of the process, forming streaks. In the formation of purulent streaks, insufficient emptying of the purulent cavity to the outside matters; most often they form with deep wounds. Symptoms: putrid smell of pus in the wound, fever, pain, swelling below the wound. Treatment of streaks - opening with a wide incision. Prevention - ensuring a free outflow of pus from the wound (drainage), full surgical treatment of the wound.

Usually, there are several stages of wound healing by secondary intention. First, the wound is cleared of necrotic tissue,. The process of rejection is accompanied by abundant purulent discharge and depends on the properties of the microflora, the patient's condition, as well as on the nature and prevalence of necrotic changes. Necrotized muscle tissue is quickly rejected, slowly - cartilage, bone. The terms of wound cleansing are different - from 6-7 days to several months. At subsequent stages, along with the cleansing of the wound, the formation and growth of granulation tissue occurs, in place of which, after epithelialization, scar tissue is formed. With excessive growth of granulation tissue, it is cauterized with a solution of lapis. under secondary tension, it has an irregular shape: multi-beam, retracted. The timing of scar formation depends on the area of the lesion, the nature of the inflammatory process.

Sewn uninfected wounds heal by primary intention (see above), unsewn - by secondary intention.

In an infected wound, infection hampers the healing process. Factors such as exhaustion, cachexia, beriberi, exposure to penetrating radiation, blood loss play a large role in the development of infection, aggravate its course and slow down wound healing. Severely flowing, developed in a contaminated wound, which was mistakenly sutured.

An infection caused by microbial flora that enters the wound at the time of injury and develops before granulation begins is called a primary infection; after the formation of a granulation shaft - a secondary infection. A secondary infection that develops after the elimination of the primary one is called reinfection. A combination of different types of microbes can occur in the wound, i.e., a mixed infection (anaerobic-purulent, purulent-putrefactive, etc.). The causes of secondary infection are gross manipulations in the wound, stagnation of purulent discharge, a decrease in the body's resistance, etc.

Practically important is the fact that during the primary infection, microbes, getting into the wound, begin to multiply and show pathogenic properties not immediately, but after a while. The duration of this period is on average 24 hours (from several hours to 3-6 days).

Then the pathogen spreads outside the wound. Rapidly multiplying, the bacteria penetrate the lymphatic pathways into the tissues surrounding the wound.

In gunshot wounds, infection occurs more often, which is facilitated by the presence of foreign bodies (bullets, shrapnel, pieces of clothing) in the wound channel. The high frequency of infection of gunshot wounds is also associated with a violation of the general condition of the body (shock, blood loss). Changes in tissues during a gunshot wound go far beyond the wound channel: a zone of traumatic necrosis forms around it, and then a zone of molecular concussion. Tissues in the last zone do not completely lose their viability, however, adverse conditions (infection, compression) can lead to their death.

Healing by secondary intention (sanatio per secundam intentionem; synonym: healing through suppuration, healing by granulation, sanatio per suppurationem, per granulationem) occurs if the wound walls are not viable or are far apart from each other, i.e., with wounds with a large area of damage ; with infected wounds, regardless of their nature; with wounds with a small area of damage, but widely gaping or accompanied by loss of substance. A large distance between the edges and walls of such a wound does not allow the formation of primary gluing in them. Fibrinous deposits, covering the surface of the wound, only mask the tissues visible in it, protecting them little from the influence of the external environment. Aeration and drying quickly lead to the death of these surface layers.

During healing by secondary intention, the phenomena of demarcation are pronounced, the wound is cleansed with the melting of fibrinous masses, with the rejection of necrotic tissues and their discharge from the wound to the outside. The process is always accompanied by a more or less abundant discharge of purulent exudate. The duration of the inflammation phase depends on the prevalence of necrotic changes and the nature of the tissues to be rejected (quickly dead muscle tissue is rejected, slowly - tendon, cartilage, especially bone), on the nature and influence of the wound microflora, on the general condition of the body of the wounded. In some cases, the biological cleansing of the wound is completed in 6-7 days, in others it drags on for many weeks and even months (for example, with open infected fractures).

The third phase of the wound process (the regeneration phase) is only partially superimposed on the second. In full measure, the phenomena of reparation develop already after the end of the biological cleansing of the wound. They, as in per primam healing, come down to filling the wound with granulation tissue, but with the difference that not a narrow gap between the walls of the wound should be filled, but more. a significant cavity, sometimes with a capacity of several hundred milliliters, or a surface area of tens of square centimeters. The formation of large masses of granulation tissue is clearly visible when examining the wound. As the wound is filled with granulations, and mainly at the end of it, epithelialization occurs, coming from the edges of the skin. The epithelium grows on the surface of the granulations in the form of a bluish-white border. At the same time, in the peripheral parts of the granulation masses, a transformation into scar tissue takes place. The final formation of the scar usually occurs after the complete epithelialization of the granulations, i.e., after the wound has healed. The resulting scar often has an irregular shape, is more massive and extensive than after healing per primam, can sometimes lead to a cosmetic defect or impede function (see Scar).

The duration of the third phase of the wound process, like the second, is different. With extensive defects in the integument and underlying tissues, impaired general condition of the wounded and under the influence of a number of other unfavorable causes, the complete healing of the wound is significantly delayed.

The following circumstance is of utmost importance: the gaping of the wound inevitably leads to the introduction of microbes into it (from the surrounding skin, from the surrounding air, during dressings - from the hands and from the nasopharynx of the personnel). Even a surgical, aseptically inflicted wound cannot be protected from this secondary bacterial contamination if its gaping is not eliminated. Accidental and combat wounds are bacterially contaminated from the very moment of application, and then secondary contamination is added to this primary contamination. Thus, wound healing by secondary intention occurs with the participation of microflora. The nature and degree of influence that microbes have on the wound process determines the difference between a bacterially contaminated wound and an infected wound.

bacterial contaminated they call a wound in which the presence and development of microflora does not aggravate the course of the wound process.

Microorganisms vegetating in the wound behave like saprophytes; they inhabit only necrotic tissues and the liquid content of the wound cavity, without penetrating into the depths of living tissues. A few microbes, mechanically introduced into the opened lymphatic tract, can almost always be detected in the next few hours after injury in the regional lymph nodes, where, however, they quickly die. Even short-term bacteremia can occur, which also does not have pathological significance. With all this, microorganisms do not have a noticeable local toxic effect, and the resulting general phenomena are due not to the number and type of microflora, but to the prevalence of necrotic changes in tissues and a greater or lesser mass of absorbed decay products. Moreover, feeding on dead tissues, microbes contribute to their melting and increased release of substances that stimulate demarcation inflammation, which means they can accelerate wound cleansing. Such an influence of the microbial factor is regarded as favorable; the abundant suppuration of the wound caused by it is not a complication, since it is inevitable during healing by secondary intention. Of course, this has nothing to do with a wound that must heal per primam. Thus, suppuration of a tightly sewn-up surgical wound is certainly a serious complication. "Clean" surgical wounds are not subject to suppuration in all cases of their bacterial contamination; it is known that despite strict observance of asepsis rules, microorganisms can almost always be found in these wounds before suturing (albeit in a minimal amount), and the wounds still heal without suppuration. Healing per primam is also possible with accidental wounds that obviously contain microflora, if the contamination is small, and the wound has a small zone of tissue damage and is localized in an area with abundant blood supply (face, scalp, etc.). Therefore, bacterial contamination of the wound is a mandatory and not even a negative component of healing by secondary intention, and under certain conditions it does not prevent wound healing by primary intention.

In contrast to this, in infected In the wound, the influence of microflora significantly aggravates the course of the wound process during healing per secundam, and healing per primam makes it impossible. Microbes vigorously spread into the depths of viable tissues, multiply in them, and penetrate into the lymphatic and blood tracts. The products of their vital activity have a detrimental effect on living cells, causing a stormy, progressive nature of secondary tissue necrosis, and being absorbed, cause a pronounced intoxication of the body, and the degree of the latter is not adequate to the size of the wound and the area of damage to the surrounding tissues. Demarcation inflammation is delayed, and demarcation that has already begun may be disturbed. All this leads, at best, to a sharp slowdown in wound healing, at worst, to the death of the wounded from severe toxemia or from generalization of infection, i.e., from wound sepsis. The patterns of distribution of the process in tissues and morphological changes in them depend on the type of wound infection (purulent, anaerobic or putrefactive).

The causative agents are usually the same microorganisms that are contained in the wound when it is bacterially contaminated. This is especially true of the microbes of putrefaction, which are present in every wound that heals per secundam, but only occasionally acquire the significance of causative agents of putrefactive infection. Pathogenic anaerobes - Clostr. perfringens, oedematiens, etc. - also often vegetate in the wound as saprophytes. Less common is contamination of the wound with pyogenic microbes - staphylococci and streptococci, which does not pass into infection.

The transition of bacterial contamination into wound infection occurs under a number of conditions. These include: 1) violation of the general condition of the body - exhaustion, bleeding, hypovitaminosis, damage by penetrating radiation, sensitization to this pathogen, etc.; 2) severe trauma to the surrounding tissues, which caused extensive primary necrosis, prolonged vasospasm, sharp and prolonged traumatic edema; 3) the complex shape of the wound (winding passages, deep "pockets", tissue stratification) and generally difficulty in outflow from the wound to the outside; 4) especially massive contamination of the wound or contamination by a particularly virulent strain of a pathogenic microbe. The influence of this last point is questioned by some authors.

However, only he explains the fact that "small" violations of asepsis in surgical work often pass without complications if the operating room is not contaminated with pyogenic (coccal) flora. Otherwise, a series of suppuration immediately appears after “clean” and low-traumatic operations (for hernia, dropsy of the testicle), and the same pathogen is found in all festering wounds. With such suppuration, only the immediate removal of sutures and dilution of the edges of the wound can prevent further development and severe course of the resulting wound infection.

With a favorable course of an infected wound, over time, the process is still delimited due to the formation of a zone of leukocyte infiltration, and then a granulation shaft. In tissues that have retained viability, the invading pathogens undergo phagocytosis. Further cleansing and reparation proceed as in a wound healing per secundam intentionem.

A wound infection is called primary if it developed before the onset of demarcation (i.e., in the first or second phase of the wound process), and secondary if it occurs when demarcation has already begun. A secondary infection that flared up after the elimination of the primary one is called reinfection. If an infection caused by another type of pathogen joins an unfinished primary or secondary infection, then they speak of superinfection. The combination of different types of infection is called a mixed infection (anaerobic-purulent, purulent-putrefactive, etc.).

The reasons for the development of a secondary infection can most often be external influences on the wound that violated the created demarcation barrier (rough manipulations in the wound, careless use of antiseptics, etc.), or stagnation of discharge in the wound cavity. In the latter case, the wound walls covered with granulations are likened to a pyogenic abscess membrane (see), which, with continued accumulation of pus, is usurated, allowing the process to spread to the surrounding tissues. Secondary infection and superinfection of the wound can also develop under the influence of a deterioration in the general condition of the wounded. A typical example is putrefactive superinfection of a wound injured by a primary anaerobic infection; the latter causes massive tissue necrosis and a sharp weakening of the organism as a whole, in which the putrefactive microflora, which has abundantly populated dead tissues, acquires pathogenic activity. It is sometimes possible to associate a secondary infection of a wound with additional contamination by some particularly virulent pathogen, but it is usually caused by microbes already present in the wound.

Along with the described local phenomena that characterize the wound and the course of the wound process, each wound (except for the lightest ones) causes a complex set of changes in the general state of the body. Some of them are caused directly by the trauma itself and accompany it, others are associated with the peculiarities of its subsequent course. Of the concomitant disorders, significant, life-threatening hemodynamic disturbances are practically important, arising from severe injuries due to profuse blood loss (see), super-strong pain irritations (see Shock), or both. Subsequent disorders are mainly due to the absorption of products from the wound and surrounding tissues. Their intensity is determined by the characteristics of the wound, the course of the wound process and the state of the body. In case of a wound with a small area of damage, healing by primary intention, general phenomena are limited to a febrile state for 1-3 days (aseptic fever). In adults, the temperature rarely exceeds subfebrile, in children it can be very high. Fever is accompanied by leukocytosis, usually moderate (10-12 thousand), with a shift of the leukocyte formula to the left and an acceleration of ROE; these indicators are aligned shortly after the normalization of temperature. With suppuration of the wound, a more pronounced and prolonged purulent-resorptive fever develops (see).

With it, the intensity and duration of temperature and hematological changes are the greater, the more significant the area of tissue damage, the more extensive the primary and secondary necrotic changes, the more bacterial toxins are absorbed from the wound. Purulent-resorptive fever is especially evident when the wound is infected. But if there are very significant masses of necrotic tissues in the wound, the rejection of which takes a long time, then even without the transition of bacterial contamination of the wound into an infection, a pronounced and prolonged purulent-resorptive fever sharply weakens the wounded and threatens the development of traumatic exhaustion (see). An important feature of purulent-resorptive fever is the adequacy of general disorders to local inflammatory changes in the wound. Violation of this adequacy, the development of severe general phenomena that cannot be explained only by resorption from the wound, indicate a possible generalization of the infection (see Sepsis). At the same time, the insufficiency of the body's defense reactions, which arose as a result of severe intoxication from the wound and blood loss, can distort the picture of general disorders, leading to the absence of a temperature reaction and leukocytosis. The prognosis in cases of such an "areactive" course of wound infection is unfavorable.