Secondary surgical debridement algorithm. Primary and secondary surgical treatment of wounds. Course of the wound process

The interaction of neurons with each other (and with effector organs) occurs through special formations - synapses (Greek - contact). They are formed by the terminal branches of a neuron on the body or processes of another neuron. The more synapses on a nerve cell, the more it perceives various irritations and, therefore, the wider the sphere of influence on its activity and the possibility of participation in various reactions of the body. There are especially many synapses in the higher parts nervous system and precisely in neurons with the most complex functions.

There are three elements in the structure of the synapse (Fig. 2):

1) presynaptic membrane formed by thickening of the membrane of the terminal branch of the axon;

2) synaptic gap between neurons;

3) postsynaptic membrane - thickening of the adjacent surface of the next neuron.

Rice. 2. Synapse diagram

Pre. - presynaptic

membrane, DC - postsynaptic

membrane,

C - synoptic bubbles,

Sh-synoptic gap,

M - mitochondria, ;

Ah - acetylcholine

P - receptors and pores (Pores)

dendrite (D) next

neuron.

Arrow - one-sided conduction of excitation.

In most cases, the transfer of influence from one neuron to another is carried out chemically. In the presynaptic part of the contact there are synoptic vesicles that contain special substances - mediators or intermediaries. They may be acetylcholine (in some cells spinal cord, in the vegetative nodes), norepinephrine (in the endings of the sympathetic nerve fibers, in the hypothalamus), some amino acids, etc. Nerve impulses arriving at the axon endings cause the emptying of synaptic vesicles and the release of the transmitter into the synaptic cleft.

By the nature of the impact on subsequent nerve cell distinguish between excitatory and inhibitory synapses.

At excitatory synapses, mediators (for example, acetylcholine) bind to specific macromolecules of the postsynaptic membrane and cause its depolarization. In this case, a small and short-term (about 1 ms) oscillation of the membrane potential towards delarization and an excitatory postsynaptic potential (EPSP) are recorded. For the neuron to excite, the EPSP must reach a threshold level. For this, the magnitude of the depolarization shift of the membrane potential must be at least 10 mV. The effect of the mediator is very short-lived (1-2 ms), after which it is broken down into ineffective components (for example, acetylcholine is broken down by the enzyme cholinesterase into choline and acetic acid) silt and is reabsorbed back by presynaptic terminals (for example, norepinephrine).

Inhibitory synapses contain inhibitory transmitters (for example, gamma-aminobutyric acid). Their effect on the postsynaptic membrane causes an increase in the release of potassium ions from the cell and an increase in membrane polarization. In this case, a short-term oscillation of the membrane potential towards hyperpolarization is recorded - inhibitory postsynaptic potential (IPSP). As a result, nervous

Surgical intervention aimed at preventing the development of complications and creating favorable conditions for wound healing.

Prevention of the development of complications is achieved by wide dissection of the entrance and exit holes, removal of the contents of the oral canal, removal of clearly non-viable tissues that make up the zone of primary necrosis, and tissues with questionable viability from the zone of secondary necrosis, good hemostasis and complete drainage of the wound.

Creating favorable conditions for wound healing comes down to creating conditions for regression of pathological phenomena in the area of ​​secondary necrosis by influencing general and local links wound process.

Primary debridement wounds, if indicated, is performed in all cases, regardless of the timing of its implementation. In military field conditions, primary surgical treatment of a wound may be forced to be postponed in the absence of urgent and urgent indications for surgical interventions; in such situations, paravulnar and parenteral administration of antibiotics is used to prevent the development of purulent-infectious complications.

Depending on the timing of the initial surgical treatment, it is called early if it is performed on the first day; delayed, if performed within the second day; late, if performed.on..the third day and later. Primary surgical treatment of the wound should be immediate and comprehensive. This principle can be optimally implemented at the stages of specialized surgical care. Therefore, at the stages of qualified surgical care, primary surgical treatment of wounds of the skull and brain is not performed, and primary surgical treatment of gunshot bone fractures is carried out only in cases of injury great vessels, infection of wounds OB, PB, soil contamination and extensive damage to soft tissues - in these cases it should end with fixation of fractures with rod devices.

At the stages of qualified surgical care, primary surgical treatment of wounds is carried out only when performing emergency and urgent surgical interventions. The rest of the wounded receive full first aid with mandatory paravulnar and parenteral administration antibiotics, after which they are evacuated to specialized hospitals. This principle is of great importance, since the waiting period for an operation may be longer than the period of evacuation to a specialized hospital and, in addition, at the stage of specialized care, primary surgical treatment is performed by a specialist and is immediate and comprehensive. The earlier and more effectively the primary surgical treatment of the wound is performed, the better the outcome of the treatment of the wounded.

Primary surgical treatment of a wound as a surgical intervention includes six stages.

The first stage, wound dissection, is performed with a scalpel through the entrance (exit) opening of the wound canal in the form of a linear incision of sufficient length for subsequent work on the damaged area. The skin, subcutaneous tissue and fascia are cut layer by layer with a scalpel; on the extremities, the fascia is incised outside the surgical wound in a proximal and distal direction in a Z-shape (fasciotomy) to decompress the fascial sheaths.

Focusing on the direction of the wound channel, scissors cut the muscles along the course of the muscle fibers. The skin incision, in cases where the extent of muscle damage exceeds its length, expands to the boundaries of the damaged muscles.

The second stage is the removal of foreign bodies: wounding projectiles or their elements, secondary fragments, scraps of clothing, loose bone fragments, as well as blood clots, pieces of dead tissue that make up the contents of the wound canal. At this stage, the wound is washed with a pulsating stream of antiseptic solution. Separate foreign bodies are located deep in the tissues and their removal requires special accesses and methods, which can only be used at stages specialized assistance. Therefore, at the stage of qualified surgical care, only those foreign bodies that are located along the wound canal are removed; foreign bodies located near large main vessels, in the depths of vital important organs, as well as foreign bodies, the removal of which requires additional complex access.

The third stage is excision of non-viable tissues, that is, excision of the zone of primary necrosis and the zone of secondary necrosis where tissues are of doubtful viability. The criteria for tissue viability are: bright color, good bleeding, for muscles - good contractility in response to tweezers. Tissue excision is carried out layer by layer, taking into account different reactions various tissues for damage. The skin is most resistant to damage, so it is excised sparingly with a scalpel, aiming for a linear wound; you should avoid cutting out “nickels” around the entrance (exit) opening of the wound canal. Subcutaneous tissue is less resistant to damage and is excised with scissors until there are clear signs of viability. The fascia is poorly supplied with blood, but is resistant to damage - areas that have lost connection with the underlying tissues are excised. Muscles are precisely the tissue where the wound process fully develops, where secondary necrosis progresses or regresses. Scissors are used to methodically remove clearly non-viable brown muscles that do not bleed or contract. Upon reaching the zone of viable muscles, hemostasis is carried out parallel to the excision. It should be remembered that the zone of viable muscles is mosaic in nature, where clearly viable tissue predominates, but everywhere there are small foci of hemorrhages, foci of reduced viability, which are widespread both on the surface of the wound and in the depths - they are not removed. This zone is called the zone of secondary necrosis. It is the nature of subsequent treatment that determines the course of the wound process in this area: progression or regression of secondary necrosis.

The fourth stage is surgery on damaged organs and tissues: the skull and brain, spine and spinal cord, chest wall and organs of the chest, on the organs of the abdominal cavity, on the bones and pelvic organs, on the great vessels, bones, peripheral nerves, etc. The technique of primary surgical treatment and reconstructive operations on specific organs and tissues is set out in the relevant manuals and manuals.

The fifth stage is wound drainage - creating optimal conditions for the outflow of wound fluid. Drainage is carried out by installing one or several dense polyvinyl chloride tubes with a diameter of at least 10 mm (in case of a complex wound channel, each pocket must be drained with a separate tube) into the wound formed after surgical treatment and removing them through counter-openings in the lowest located relative to the damaged area (segment ) places. Subsequently, three drainage options are possible. The simplest is passive drainage through a single-lumen thick tube. More complex is passive drainage through a double-lumen tube: constant drip irrigation of the tube is carried out through a small channel, which ensures its constant and full operation. Both of these methods are used in the treatment of unsutured wounds at the stages of qualified surgical care. The third method - inflow and outflow drainage - is used when the wound is tightly sutured, that is, at the stages of specialized surgical care. The essence of the method is to install an input polyvinyl chloride tube of a smaller diameter (5-6 mm) and an output (one or more) polyvinyl chloride tube of a larger diameter (10 mm) into the wound. In the wound, the tubes are installed in such a way that the liquid washes the wound cavity through the inlet tube and flows freely through the outlet tube. Best effect is achieved with active supply and drainage drainage, when the outlet tube is connected to an aspirator and a negative pressure of 30-50 cm of water is created in it. Art.

The sixth stage is wound closure. Taking into account the characteristics of a gunshot wound (the presence of a zone of secondary necrosis), a primary suture is not applied after the initial surgical treatment of the wound. The exception is superficial wounds of the face, scrotum, and penis. Chest wounds with open pneumothorax, when the edges of the wound can be brought together without tension, must be sutured after primary surgical treatment; otherwise, ointment dressings are preferred. During laparotomy from the side abdominal cavity After treating the edges, the peritoneum in the area of ​​the entrance and exit holes of the wound canal is tightly sutured, the laparotomy wound is tightly sutured with a primary suture, and the wounds of the entrance and exit holes treated from the back and abdominal wall are not sutured. The primary suture is also applied to surgical wounds located outside the wound channel and formed after thoracotomy, cystostomy, access to the great vessels throughout, to large foreign bodies, etc.

After the initial surgical treatment, one or several large gaping wounds are formed, which must be filled with materials that have a drainage function. Most in a simple way filling the wound is the introduction into it of gauze napkins moistened with antiseptic solutions in the form of “wicks”. The best way is to fill the wound with carbon sorbents, which speed up the process of wound cleansing. Sorbents are cut into strips of the required length and width, wrapped in one layer of gauze, moistened in any antiseptic solution and are installed in the wound in the form of “wicks”. Since any dressing in a wound loses its hygroscopicity and dries out after 6-8 hours, and dressings at such intervals are sometimes impossible, rubber graduates must be installed in the wound parallel to the napkins or sorbents.

After the initial surgical treatment of the wound, as after any surgical intervention, an inflammatory reaction develops in the wound, manifested by plethora, swelling, and exudation. Having a generally protective and adaptive significance, in conditions where non-viable tissues are removed but tissues with reduced viability are left, inflammatory edema, disrupting blood circulation in these tissues, contributes to the progression of secondary necrosis. In such conditions, the effect on the wound process is to suppress inflammatory reaction. For this purpose, immediately after the initial surgical treatment of the wound and during the first dressing, an anti-inflammatory blockade is performed by paravulnar administration of a solution of the following composition (calculation of ingredients is carried out per 100 ml of novocaine solution, and the total volume of the solution is determined by the size and nature of the wound): 0.25% novocaine solution 100 ml, glucocorticoids (90 mg prednisolone), protease inhibitors (30,000 IU contrical), antibiotics wide range action - either aminoglycosides, cephalosporins, or a combination of the latter in a single or double dose. Indications for subsequent blockades are determined by the severity of the inflammatory process.

Secondary surgical treatment of the wound - surgery, aimed at treating complications that have developed in the wound. The most common complications are progressive tissue necrosis and wound infection. Secondary surgical treatment of a wound can be the first operation on a wounded person, if complications have developed in an untreated wound, or the second, third, etc., in cases where primary surgical treatment has already been performed on the wound.

The volume of secondary surgical treatment depends on the nature and severity of complications that have developed in the wound. Secondary surgical treatment of the wound, if it is performed as the first intervention, is carried out in the same sequence, with the same steps as the primary surgical treatment. The differences lie in the expansion of individual stages of the operation related to the nature and extent of tissue damage. In cases where secondary surgical treatment is performed as a re-intervention, targeted effects are implemented at individual stages of the operation.

With the progression of secondary necrosis in the wound, the essence of the operation comes down to the removal of necrotic tissue, diagnosis and elimination of the cause of its progression. When the main blood flow is disrupted, large muscle masses and muscle groups become necrotic. In these cases, necrectomy is extensive, but measures must be taken to restore or improve the main blood flow.

In cases of development purulent infection The main element of secondary surgical treatment of a wound is the opening of the abscess, phlegmon, swelling and their complete drainage. The surgical technique depends on the location of the purulent infection, and the principle is to preserve natural protective barriers.

The most extensive is secondary surgical treatment of the wound for anaerobic infection. As a rule, the entire limb segment or area of ​​the body is dissected; large volumes affected muscles, fasciotomy of all muscle sheaths is performed - not stripe incisions, but subcutaneous fasciotomy! Then the wounds are well drained and filled with napkins with oxygen-enriched solutions, a system of regional intra-arterial administration of antibiotics and drugs that improve blood circulation is established, and paravulnar anti-inflammatory blockades are performed. In parallel, intensive general and specific therapy is carried out. If secondary surgical treatment is ineffective, it is necessary to promptly set indications for limb amputation. The third task of qualified care is to prepare the wounded for evacuation.

At the qualified stage medical care only limited soft tissue injuries are treated with total term treatment not exceeding 10 days. The remaining wounded are subject to evacuation to the stage of specialized medical care, where they receive specialized surgical care, treatment and rehabilitation.

Preparing the wounded for evacuation includes a set of measures aimed at restoring and stabilizing vital important functions, creating conditions for damaged organs and tissues that exclude the possibility of complications developing during the evacuation process. These activities boil down to intensive care wounded and treatment of damaged organs and tissues to a level safe for evacuation, and are determined largely by the nature, severity and location of the injury.

When assessing indications for evacuation, one should focus on the general condition of the wounded and the condition of damaged organs and tissues.

When assessing indications for evacuation, a special place is given to those wounded in the head with brain damage. It should be remembered that patients with brain damage tolerate evacuation better without surgery than after surgery. Such wounded people should not be delayed at the stage of qualified care for diagnostic measures and dehydration therapy. Impaired consciousness and focal neurological symptoms are not a contraindication to evacuation.

When preparing wounded people with brain damage for evacuation, the following measures are taken:

restoration of independent external respiration up to tracheal intubation or tracheostomy;

stopping external bleeding from the integumentary tissues of the face and head;

compensation of blood volume until systolic blood pressure stabilizes at levels above 100 mm Hg. Art. and normalization of red blood parameters (erythrocytes - up to 3.0-1012/l, hemoglobin - up to 100 g/l, hematocrit - up to 0.32-0.34 l/l).

For the remaining wounded, safe evacuation is possible with the following indicators of general condition:

state of consciousness is clear or stunned (speech contact is preserved);

external breathing is independent, rhythmic, frequency - less than 20 excursions per minute;

hemodynamics - systolic blood pressure is stable at a level exceeding 100 mm Hg. Art.; pulse rate is stable, less than 100 beats per minute, no rhythm disturbances;

body temperature less than 39°C;

red blood indicators - red blood cells 3.0-1012/l, hemoglobin 100 g/l, hematocrit 0.32-0.34 l/l.

A more objective assessment of the general condition of the wounded is carried out using the “VPH-SG” scale (Table 4 of the Appendix). With a score of 16 to 32 points, the condition is compensated, evacuation is safe by any means of transport; from 33 to 40 points - subcompensated condition, evacuation is acceptable, preferably by air transport with escort medical personnel; if the score is more than 40 points, the condition is decompensated, evacuation is contraindicated.

Depending on the condition of damaged organs and tissues, evacuation by car possible;

for chest wounds - on the 3-4th day after drainage or thoracotomy, before the development of purulent-infectious complications; drainage is removed before evacuation or special collection bags are used; for other damage, the evacuation period is determined general condition and can be shortened;

for abdominal wounds, no earlier than 8-10 days after laparotomy in order to prevent eventration of organs;

for injuries of the extremities with damage to the main vessels and their temporary prosthetics - urgently, taking into account the general condition of the wounded, since the average life of temporary prostheses is 6-12 hours;

for injuries of the spine and spinal cord - immediately after stabilization of the general condition; required before evacuation permanent catheterization Bladder; evacuation is carried out at the shield;

for pelvic injuries - depending on the general condition; on average 3-4 days before the development of purulent-infectious complications; drainage tubes are not removed; for fractures of the pelvic bones, immobilization is carried out by tying lower limbs and bending them into knee joints up to 120-140°;

for injuries to the extremities - based on an assessment of the general condition; on average on the 2nd day; immobilization is carried out with service splints reinforced with plaster rings.

When using air ambulance transport, the indications for evacuation are expanded, and the time frame is reduced to the second day. This is due to comfortable evacuation conditions, relatively short time delivery, but, most importantly, the availability of medical support. Therefore, wounded people with a subcompensated general condition and with functioning drainage systems can be evacuated by air.

When assessing the indications for evacuation by air, it is necessary to take into account the duration and method of transporting the wounded to and from the aircraft, and the length of wait for the aircraft to take off. In such situations, it is necessary to have the strength and means to provide medical care to the wounded at these stages, up to the restoration of external respiration, artificial ventilation lungs, infusion therapy.