The time required for pre-briefing and demonstration of the skill on the manikin - 15 minutes
The time it takes to master a skill on your own(in minutes, per student) – 17min
Necessary theoretical knowledge for mastering a clinical skill:
Anatomy and physiology of the skin, serous and mucous membranes.
Types of wounds.
Indications for primary surgical treatment of the wound.
Fundamentals of asepsis and antisepsis.
Surgical instruments.
wound infection.
Tetanus vaccine.
Fundamentals of anesthesiology.
List of mannequins, models, visual aids, interactive computer programs necessary for mastering the clinical skill:
"Hand model for manipulation on the arteries and veins of the upper limb"
Scroll medical devices and equipment:
Tools
forceps - 2 pcs,
clothespins - 4 pcs,
surgical tweezers - 2 pcs,
anatomical tweezers - 2 pcs,
syringe (10 ml) - 2 pcs,
scalpel - 1 piece,
scissors - 2 pcs,
hemostatic clamps - 4-6 pcs,
Farabef hooks - 2 pcs,
sharp-toothed hooks - 2 pcs,
cutting needles - 4 pcs,
stabbing needles - 4 pcs,
grooved probe - 1 piece,
bulbous probe - 1 piece,
suture material,
bix with dressing material,
gloves,
Preparations
skin antiseptics (cutasept, iodonate),
antiseptics for the wound (3% hydrogen peroxide solution, 0.06% sodium hypochlorite solution),
70% ethyl alcohol, disinfectant for instruments (deactin, neochlor),
drug for local anesthesia (lidocaine, novocaine).
Description of the execution algorithm:
Before PHO wounds prophylactic administration of tetanus toxoid and tetanus toxoid is carried out.
To wash hands
Dry your hands with a towel
put on a mask
Wear gloves
Treat hands with antiseptic
Treat with antiseptics the injection sites for local anesthesia.
Perform local anesthesia of the wound.
Excise the wound with surgical instruments.
Stop bleeding.
Remove foreign bodies, necrotic tissue, blood clots, dirt, etc.
Treat the wound with an antiseptic.
If necessary, local administration of antibiotics.
Depending on the nature of the injury, drain the wound.
Apply blind stitch.
Apply an aseptic bandage.
Scheme of primary surgical treatment of the wound: 1 - wound before treatment; 2 - excision; 3 - blind seam.
Criteria for assessing the performance of a skill:
Washed my hands
Dry your hands with a towel
Put on a mask
Wearing gloves
Treated hands with antiseptic
He treated with antiseptics the injection sites for local anesthesia.
Performed local anesthesia of the wound.
He excised the wound with the help of surgical instruments.
Stopped bleeding.
Removed foreign bodies, necrotic tissue, blood clots, dirt, etc.
He treated the wound with an antiseptic.
Topical antibiotics were administered as needed.
Depending on the nature of the injury, the wound was drained.
He put on a blind seam.
He put on an aseptic bandage.
Under primary surgical treatment they understand the first intervention (in a given wounded man) performed according to primary indications, i.e., regarding the tissue damage itself as such. Secondary debridement- this is an intervention undertaken according to secondary indications, i.e., regarding subsequent (secondary) changes in the wound caused by the development of infection.
In some types of gunshot wounds, there are no indications for primary surgical treatment of wounds, so that the wounded are not subjected to this intervention. In the future, in such an untreated wound, significant foci of secondary necrosis may form, an infectious process flares up. A similar picture is observed in cases where the indications for primary surgical treatment were evident, but the wounded man came to the surgeon late and the wound infection had already developed. In such cases, there is a need for an operation according to secondary indications - in the secondary surgical treatment of the wound. In such wounded, the first intervention is secondary surgical treatment.
Often, indications for secondary treatment occur if the primary surgical treatment did not prevent the development of a wound infection; such secondary treatment, carried out after the primary (i.e., the second in a row), is also called re-treatment of the wound. Re-treatment sometimes has to be done before the development of wound complications, that is, according to primary indications. This happens when the first treatment could not be fully carried out, for example, due to the impossibility of X-ray examination of a wounded person with a gunshot fracture. In such cases, in fact, the primary surgical treatment is performed in two steps: during the first operation, the soft tissue wound is mainly treated, and during the second operation, the bone wound is treated, fragments are repositioned, etc. The technique of secondary surgical treatment is often the same as the primary one, but sometimes secondary treatment can be reduced only to ensuring the free outflow of discharge from the wound.
The main task of the primary surgical treatment of the wound- create unfavorable conditions for the development of wound infection. Therefore, this operation is the more effective the earlier it is performed.
According to the timing of the operation, it is customary to distinguish between surgical treatment - early, delayed and late.
Early debridement call the operation performed before the visible development of infection in the wound. Experience shows that surgical treatments performed in the first 24 hours from the moment of injury, in most cases, “ahead” of the development of infection, that is, they are classified as early. Therefore, in various calculations for the planning and organization of surgical care in the war, interventions performed on the first day after the injury are conditionally taken as early surgical treatment. However, the situation in which staged treatment of the wounded is carried out often makes it necessary to postpone the operation. The prophylactic administration of antibiotics can in some cases reduce the risk of such a delay - to delay the development of a wound infection and, thus, extend the period during which surgical treatment of the wound retains its preventive (precautionary) value. Such debridement, albeit with delay, but before the appearance of clinical signs of wound infection (the development of which is delayed by antibiotics), is called delayed debridement. When calculating and planning, interventions performed during the second day from the moment of injury are taken as delayed treatment (provided that antibiotics are systematically administered to the wounded). Both early and delayed wound treatment can, in some cases, prevent wound suppuration and create conditions for its healing by primary intention.
If the wound, by the nature of tissue damage, is subject to primary surgical treatment, then the appearance of clear signs of suppuration does not prevent surgical intervention. In such a case, the operation no longer prevents wound suppuration, but remains a powerful means of preventing more formidable infectious complications and can stop them if they have time to arise. Such treatment, performed with the phenomena of suppuration of the wound, is called late surgical treatment. With appropriate calculations, the category of late includes treatments performed after 48 (and for the wounded who did not receive antibiotics, after 24) hours from the moment of injury.
Late debridement carried out with the same tasks and technically in the same way as early or delayed. The exception is cases when the intervention is undertaken only as a result of a developing infectious complication, and tissue damage by its nature does not require surgical treatment. In these cases, the operation is reduced mainly to ensuring the outflow of the discharge (opening the phlegmon, leakage, imposing counter-opening, etc.). The classification of surgical treatment of wounds depending on the timing of their implementation is largely arbitrary. It is quite possible to develop a severe infection in the wound 6-8 hours after the injury and, conversely, cases of very long incubation of the wound infection (3-4 days); processing, which in terms of execution time seems to be delayed, in some cases turns out to be late. Therefore, the surgeon must first of all proceed from the condition of the wound and from clinical picture in general, and not only from the period that has elapsed since the moment of injury.
Among the means preventing the development of wound infection, an important, albeit auxiliary, role is played by antibiotics. Due to their bacteriostatic and bactericidal properties, they reduce the risk of outbreaks in wounds that have undergone surgical debridement or where debridement is considered unnecessary. Antibiotics play a particularly important role when this operation is forced to be postponed. They should be taken as soon as possible after injury, and by repeated administrations before, during and after surgery, the effective concentration of drugs in the blood should be maintained for several days. For this purpose, injections of penicillin and streptomycin are used. However, under the conditions of [staged treatment, it is more convenient for the affected to administer a prophylactic drug with a prolonged action, streptomycellin (900,000 IU intramuscularly 1-2 times a day, depending on the severity of the injury and the timing of the primary surgical treatment of the wound). If injections of streptomycellin cannot be carried out, biomycin is prescribed orally (200,000 IU 4 times a day.). With extensive muscle destruction and delay in the provision of surgical care, it is desirable to combine streptomycellin with biomycin. With significant damage to the bones, tetracycline is used (in the same dosages as biomycin).
There are no indications for primary surgical treatment of the wound with the following types of injuries: a) penetrating bullet wounds of the extremities with pinpoint inlet and outlet holes, in the absence of tissue tension in the wound area, as well as hematoma and other signs of damage to a large blood vessel; b) bullet or small fragment wounds of the chest and back, if there is no hematoma of the chest wall, signs of crushing of the bone (for example, scapula), as well as open pneumothorax or significant intrapleural bleeding (in the latter case, a thoracotomy becomes necessary); c) superficial (usually not penetrating deeper than the subcutaneous tissue), often multiple, wounds with small fragments.
In these cases, the wounds usually do not contain a significant amount of dead tissue and their healing most often proceeds without complications. This, in particular, can be facilitated by the use of antibiotics. If, in the future, suppuration develops in such a wound, then the indication for secondary surgical treatment will be mainly the retention of pus in the wound channel or in the surrounding tissues. With a free outflow of discharge, a festering wound is usually treated conservatively.
Primary surgical treatment is contraindicated in the wounded, who are in a state of shock (temporary contraindication), and in those who are agonizing. According to data obtained during the Great Patriotic War, the total number of those not subject to primary surgical treatment is about 20-25% of all those affected by firearms (S. S. Girgolav).
Military field surgery, A.A. Vishnevsky, M.I. Schreiber, 1968
Surgical debridement may be primary or secondary.
The purpose of the primary surgical treatment of the wound is to prevent the development of suppuration, create favorable conditions for wound healing and restoration of the function of the damaged part of the body in the shortest possible time.
Secondary surgical treatment of the wound is performed in order to treat infectious complications that have developed in it.
Primary surgical treatment of the wound
In the primary surgical treatment of the wound, a total of five or more surgical techniques are performed.
Dissection of the wound.
Excision of dead tissues and tissues of doubtful viability.
Detection and removal from the wound of small bone fragments devoid of periosteum, foreign bodies, blood clots.
The final stop of bleeding, i.e. ligation of bleeding vessels, vascular suture or prosthetics of large wounded vessels.
In the presence of conditions - various options for osteosynthesis, suture of tendons and nerve trunks.
Primary skin suture or wound tamponade.
Detection in the course of surgical treatment of a wound of its penetration into the pleural, abdominal or other natural cavity of the body serves as an indication for changing the plan of surgical intervention. Depending on the specific clinical situation, suturing of an open pneumothorax, closed drainage of the pleural cavity, wide, suture of the joint capsule and other surgical interventions are performed.
The provisions outlined above convince us that surgical debridement is largely diagnostic. Complete and accurate diagnosis of injuries, foreign bodies is one of the most important conditions for the successful operation and uncomplicated course of the postoperative period.
The dissection of the fascia is necessary for full-fledged manipulations in the depth of the wound. Undissected fascia prevent the spreading of the edges and inspection of the bottom of the wound channel.
If a wound is suspected to have penetrated into the serous cavity, the lumen of a hollow organ and it is impossible to reliably establish this by examination, vulneography is indicated. A catheter is inserted into the wound channel without effort. The patient on the operating table is given a position in which the area to be contrasted is below the wound. From 10 to 40 ml of a water-soluble contrast agent is injected through the catheter and radiography is performed in one or two projections. Vulneography greatly facilitates the diagnosis of deep, tortuous wound channels penetrating into the cavity.
In the case of multiple, especially shot wounds in the projection of large vessels, there is an indication for performing intraoperative angiography. Failure to follow this rule can have dire consequences. We present a clinical observation.
F., aged 26, wounded from a distance of 30 meters by a buckshot charge. Delivered to the Central District Hospital after 4 hours in a state of hemorrhagic shock III Art. There were 30 shot wounds on the front wall of the abdomen, on the anterointernal surface of the left thigh. There was no pulse in the arteries of the left leg. There were symptoms of widespread peritonitis and intra-abdominal bleeding. After anti-shock measures, an emergency laparotomy was performed, 6 shot wounds of the ileum were sutured. Removed blood clots from the retroperitoneal space, sutured marginal defect in the wall of the left external iliac artery. There was a pulsation of the femoral artery. However, on the arteries of the left foot, the pulse was not determined. not carried out. The absence of a pulse in the arteries of the foot was explained by a spasm of the arteries. The patient was transferred to hospital 3 days after the operation in an extremely serious condition with ischemia of the left leg 3A st. and anuria. During the operation, a wound of the left femoral artery 1.5 × 0.5 cm in size, thrombosis femoral arteries and veins. It was not possible to restore the main blood flow in the limb. Made at the level of the upper third of the thigh. The patient died of acute renal failure.
Thus, during the first operation, the injury of a large artery that was outside the intervention zone was not recognized. Arteriography after suturing the wound of the external iliac artery would make it possible to diagnose the wound of the femoral artery.
The stab wounds of the chest wall, located on the anterior surface below the 4th rib, on the side below the 6th rib and on the back below the 7th rib, are subject to pedantic research. In these cases, the diaphragm is more likely to be injured. If the penetration of the wound into the pleural cavity is established during PST, the defect in the intercostal space should be expanded by dissecting the tissues up to 8-10 cm to examine the adjacent part of the diaphragm. The elastic diaphragm is easily displaced by tupfers in different directions and inspected over a large area. Rare doubts about the integrity of the diaphragm can be resolved using diagnostic laparoscopy.
Excision of non-viable tissues is the most important step in the surgical treatment of the wound. Unremoved necrotic tissues cause a prolonged course of suppuration in the wound with a possible outcome in wound depletion and sepsis. During treatment in the first hours after injury, devitalized tissues are less noticeable, which makes it difficult to perform a full necrectomy. Unreasonable radicalism leads to the loss of viable tissues. Necrosis is recognized by the loss of anatomical connection with the body, macroscopic destruction of the structure, and the absence of bleeding from the incision. Primary skin necrosis in bruised, gunshot wounds usually does not extend further than 0.5-1.5 cm from the edge of the defect. Subcutaneous fatty tissue, imbibed with blood, contaminated with foreign particles, deprived of a reliable blood supply, is subject to excision. Non-viable fascias lose their color and luster, becoming dull. A non-viable muscle loses its natural bright pink color and elasticity, does not respond to intersection. The incision line does not bleed. Small, free-lying, often numerous bone fragments are subject to removal. A sparing version of the primary operation often entails the need to re-treat the gunshot, crushed wound after 2-3 days in conditions of more clearly defined boundaries between living and dead structures.
Secondary debridement
With the development of suppuration, except common symptoms purulent infection, skin hyperemia, local fever, swelling and tissue infiltration, purulent discharge, lymphangitis and regional lymphadenitis are observed. In the wound, areas of tissue necrosis and fibrin overlay are determined.
Anaerobic non-spore-forming infection complicates the course of the wound of the neck, abdominal walls, pelvis when contaminated with contents oral cavity, pharynx, esophagus, colon. This infectious process usually proceeds in the form of phlegmon: cellulitis, fasciitis, myositis. Fields of necrosis of subcutaneous adipose tissue and fascia have a gray-dirty color. The fabrics are saturated with brown exudate with a sharp unpleasant odor. Due to thrombosis of blood vessels, the affected tissues almost do not bleed during excision.
With clostridial infection, a significant growing tissue draws attention. The fabrics look lifeless. Swollen skeletal muscles are dull in color, devoid of elasticity, elasticity and natural pattern. When captured by instruments, the muscle bundles are torn and do not bleed. An unpleasant odor, unlike a non-spore-forming infection, is absent.
The operation to remove the substrate of suppuration and ensure complete outflow of purulent exudate from the wound is a secondary surgical treatment, regardless of whether the primary surgical treatment of the wound was preceded or not. The direction of the incision is determined by inspection and palpation of the damaged area. Diagnostic information about the localization and size of purulent streaks is provided by radiography, fistulography, CT and.
The article was prepared and edited by: surgeonPXO is the first surgical operation performed on a patient with a wound under aseptic conditions, under anesthesia, and consists in the sequential implementation of the following steps:
1) dissection
2) revision
3) excision of the edges of the wound within apparently healthy tissues, walls and bottom of the wound
4) removal of hematomas and foreign bodies
5) restoration of damaged structures
6) if possible, suturing.
The following options for suturing wounds are possible: 1) layer-by-layer suturing of the wound tightly (for small wounds, slightly contaminated, with localization on the face, neck, torso, with a short period from the moment of injury)
2) suturing the wound with drainage
3) the wound is not sutured (this is done when high risk infectious complications: late PST, heavy pollution, massive tissue damage, concomitant diseases, old age, localization on the foot or lower leg)
Types of PHO:
1) Early (up to 24 hours from the moment of infliction of the wound) includes all stages and usually ends with the imposition of primary sutures.
2) Delayed (from 24-48 hours). During this period, inflammation develops, edema and exudate appear. The difference from early PXO is the implementation of the operation against the background of the introduction of antibiotics and the completion of the intervention by leaving it open (not sutured) followed by the imposition of primary delayed sutures.
3) Late (after 48 hours). Inflammation is close to maximum and the development of the infectious process begins. In this situation, the wound is left open and a course of antibiotic therapy is carried out. Perhaps the imposition of early secondary sutures for 7-20 days.
PHO are not subject to the following types of wounds:
1) surface, scratches
2) small wounds with margins less than 1 cm
3) multiple small wounds without damage to deeper tissues
4) stab wounds without organ damage
5) in some cases through bullet wounds of soft tissues
Contraindications to the implementation of PHO:
1) signs of development in the wound of a purulent process
2) the critical condition of the patient
Types of seams:
Primary surgical Apply to the wound before the development of granulations. Impose immediately after the completion of the operation or PST of the wound. It is inappropriate to use in late PST, PST in wartime, PST of a gunshot wound.
primary delayed Impose before the development of granulations. Technique: the wound is not sutured after the operation, the inflammatory process is controlled, and when it subsides, this suture is applied for 1-5 days.
secondary early Impose on granulating wounds, healing by secondary intention. Imposition is made on 6-21 days. By 3 weeks after the operation, scar tissue forms at the edges of the wound, which prevents both the convergence of the edges and the process of fusion. Therefore, when applying early secondary sutures (before scarring of the edges), it is enough to simply stitch the edges of the wound and bring them together by tying the threads.
secondary late Apply after 21 days. When applying, it is necessary to excise the cicatricial edges of the wound under aseptic conditions, and only then sutured.
13. Toilet wounds. Secondary surgical treatment of wounds.
Wound toilet:
1) removal of purulent exudate
2) removal of clots and hematomas
3) cleansing the wound surface and skin
Indications for VMO are the presence of a purulent focus, the lack of adequate outflow from the wound, the formation of extensive areas of necrosis and purulent streaks.
1) excision of non-viable tissues
2) removal of foreign those and hematomas
3) opening pockets and streaks
4) wound drainage
Differences between PHO and VHO:
|
signs | ||
|
Deadlines |
In the first 48-74 hours |
After 3 days or more |
|
The main purpose of the operation |
Suppuration warning |
Infection treatment |
|
Wound condition |
Does not granulate and does not contain pus |
Granulates and contains pus |
|
Condition of excised tissues |
With indirect signs of necrosis |
With obvious signs of necrosis |
|
Cause of bleeding |
The wound itself and the dissection of tissues during surgery |
Arrosion of the vessel in the conditions of a purulent process and damage during tissue dissection |
|
The nature of the seam |
Closure with primary seam |
In the future, the imposition of secondary sutures is possible |
|
Drainage |
According to indications |
Necessarily |
14. Classification by type of damaging agent : mechanical, chemical, thermal, radiation, gunshot, combined. Types of mechanical injuries:
1 - Closed (skin and mucous membranes are not damaged),
2 - Open (damage to the mucous membranes and skin; risk of infection).
3 - Complicated; Immediate complications that occur at the time of injury or in the first hours after it: Bleeding, traumatic shock, impaired vital functions of organs.
Early complications develop in the first days after injury: Infectious complications (suppuration of the wound, pleurisy, peritonitis, sepsis, etc.), traumatic toxicosis.
Late complications are revealed in terms remote from damage: chronic purulent infection; violation of tissue trophism (trophic ulcers, contracture, etc.); anatomical and functional defects of damaged organs and tissues.
4 - Uncomplicated.
PXO is the first surgical operation performed on a patient with a wound under aseptic conditions, under anesthesia, and consists in the sequential implementation of the following steps:
1) dissection;
2) revision;
3) excision of the edges of the wound within apparently healthy tissues, walls and bottom of the wound;
4) removal of hematomas and foreign bodies;
5) restoration of damaged structures;
6) if possible, suturing.
The following wound closure options are available:
1) layer-by-layer suturing of the wound tightly (for small wounds, slightly contaminated, with localization on the face, neck, torso, with a short period from the moment of injury);
2) suturing the wound leaving drainage;
3) the wound is not sutured (this is done at a high risk of infectious complications: late PST, heavy contamination, massive tissue damage, concomitant diseases, old age, localization on the foot or lower leg).
Types of PHO:
1) Early (up to 24 hours from the moment of infliction of the wound) includes all stages and usually ends with the imposition of primary sutures.
2) Delayed (from 24-48 hours). During this period, inflammation develops, edema and exudate appear. The difference from early PXO is the implementation of the operation against the background of the introduction of antibiotics and the completion of the intervention by leaving it open (not sutured) followed by the imposition of primary delayed sutures.
3) Late (after 48 hours). Inflammation is close to maximum and the development of the infectious process begins. In this situation, the wound is left open and a course of antibiotic therapy is carried out. Perhaps the imposition of early secondary sutures for 7-20 days.
PHO are not subject to the following types of wounds:
1) surface, scratches;
2) small wounds with divergence of edges less than 1 cm;
3) multiple small wounds without damage to deeper tissues;
4) stab wounds without organ damage;
5) in some cases through bullet wounds of soft tissues.
Contraindications to the implementation of PHO:
1) signs of development of a purulent process in the wound;
2) critical condition of the patient.
Types of seams:
Primary surgical. Apply to the wound before the development of granulations. Impose immediately after the completion of the operation or PST of the wound. It is inappropriate to use in late PST, PST in wartime, PST of a gunshot wound.
Primary delayed. Impose before the development of granulations. Technique: the wound is not sutured after the operation, the inflammatory process is controlled, and when it subsides, this suture is applied for 1-5 days.
Secondary early. Impose on granulating wounds, healing by secondary intention. Imposition is made on 6-21 days. By 3 weeks after the operation, scar tissue forms at the edges of the wound, which prevents both the convergence of the edges and the process of fusion. Therefore, when applying early secondary sutures (before scarring of the edges), it is enough to simply stitch the edges of the wound and bring them together by tying the threads.
Secondary late. Apply after 21 days. When applying, it is necessary to excise the cicatricial edges of the wound under aseptic conditions, and only then sutured.
Wound toilet. Secondary surgical treatment of wounds.
1) removal of purulent exudate;
2) removal of clots and hematomas;
3) cleansing of the wound surface and skin.
Indications for VMO are the presence of a purulent focus, the lack of adequate outflow from the wound, the formation of extensive areas of necrosis and purulent streaks.
1) excision of non-viable tissues;
2) removal of foreign those and hematomas;
3) opening pockets and streaks;
4) wound drainage.
Differences between PHO and VHO:
| signs | PHO | WMO |
| Deadlines | In the first 48-74 hours | After 3 days or more |
| The main purpose of the operation | Suppuration warning | Infection treatment |
| Wound condition | Does not granulate and does not contain pus | Granulates and contains pus |
| Condition of excised tissues | With indirect signs of necrosis | With obvious signs of necrosis |
| Cause of bleeding | The wound itself and the dissection of tissues during surgery | Arrosion of the vessel in the conditions of a purulent process and damage during tissue dissection |
| The nature of the seam | Closure with primary seam | In the future, the imposition of secondary sutures is possible |
| Drainage | According to indications | Necessarily |
Classification by type of damaging agent: mechanical, chemical, thermal, radiation, gunshot, combined.
Types of mechanical injuries:
1 - Closed (skin and mucous membranes are not damaged),
2 - Open (damage to mucous membranes and skin; danger of infection).
3 - Complicated; Immediate complications that occur at the time of injury or in the first hours after it: Bleeding, traumatic shock, impaired vital functions of organs.
Early complications develop in the first days after injury: Infectious complications (suppuration of the wound, pleurisy, peritonitis, sepsis, etc.), traumatic toxicosis.
Late complications are revealed in terms remote from damage: chronic purulent infection; violation of tissue trophism ( trophic ulcers, contracture, etc.); anatomical and functional defects of damaged organs and tissues.
4 - Uncomplicated.