ZA N I T I E No. 4.

SUBJECT : FIRST AID FOR WOUNDS.

Literature

Textbook by D.V. Marchenko “First medical aid for injuries and accidents”, pages 145-166.

Study questions

1. The concept of injury. Classification and types of injuries.

2. Types of bleeding.

3. General principles of first aid for wounds (stopping bleeding, disinfecting the wound, fixing the limb, pain relief, safe transportation).

4. Basic rules for applying bandages. Individual dressing package (PPI).

5. Procedure for using the syringe tube.

6. Compliance with standard No. 11.

7. Application of a spiral dressing.

TEXT OF THE TEXTBOOK:

1. The concept of injury. Classification and types of injuries.

Blood is a universal liquid that ensures the saturation of every organ and tissue of our body with oxygen. In addition to this main transport function (along with oxygen, nutrients, enzymes, hormones, vitamins, etc. are delivered by the blood), the blood also performs others: it is thermoregulatory (maintaining a constant body temperature due to blood circulation throughout the body), and protective (production antibodies and protection against infection).

That is why any violation of the integrity of the vessel and the vascular system in general as a result of predominantly external influences can lead to serious “breakdowns” within our body and even threaten life.

This situation occurs as a result of injury.

The concept of injury.

So, a wound (or wound) is any violation of the integrity skin and underlying tissues (including blood vessels) as a result of external, mainly mechanical, influence.

Accordingly, signs of injury will be the following:

Bleeding (as a result of a violation of the integrity of the vessel);

Gaping (or divergence of the edges of the wound, approximately following the contour of the wounding object);

Impaired function of the injured (wounded) body part.

In addition, the victim will experience pain, as the nerve trunks are additionally injured. Pain in serious (extensive) wounds can be so intense that it can lead to the development of painful shock.

Characteristic of wounds, in addition to the above signs, is the presence of a wound channel - a cavity formed as a result of the passage of a wounding object into the depths of the body. It is by the location of the wounded channel, its direction, length, etc. that one can judge any properties of the wounding object.

Thus, wounds are characterized by the presence of bleeding, gaping and a wound channel.

Classification and types of injuries.

All injuries are divided into two large groups:

Penetrating (when the integrity of the internal membranes is violated and the wounding object enters one of the cavities of the human body - the skull, chest, abdomen or joints);

Non-penetrating (all other wounds).

According to the mechanism of injury All injuries can be divided into the following types:

Stabbed (with a small diameter of the external hole, a rather large depth of the wounded channel is characteristic);

Cut (quite extensive external damage with a shallow depth of the wounded canal);

Chopped (characterized by widespread crushing of the edges and extensive internal damage);

Bitten (characterized by the presence of an outline/pattern of teeth) - can be combined with the following type

Ragged (extensive external damage with a star-shaped shape);

Scalped (with this type of wound, the skin with the subcutaneous base is completely separated from the underlying tissue);

Firearms (as a result of the impact of a firearm projectile - bullets, shot, buckshot, etc.) (Fig. 2).

In turn, gunshot wounds are divided into:

Blind (when there is only an entrance hole and the wounding projectile is located deep in the body);

Through (there are inlet and outlet openings; as a rule, the outlet is slightly larger than the inlet);

Tangent (superficial damage to the skin).

is tissue damage resulting from mechanical impact. Accompanied by a violation of the integrity of the skin or mucous membrane. They differ in the mechanism of occurrence, method of application, depth, anatomical localization and other parameters. They may or may not penetrate natural closed body cavities (abdominal, thoracic, joint cavities). The main symptoms are gaping, pain and bleeding. The diagnosis is made based on clinical picture, in some cases required additional research: radiography, laparoscopy, etc. Treatment is surgical.

ICD-10

S41 S51 S71 S81

General information

A wound is an extremely common traumatic injury. It is one of the main reasons for visiting emergency rooms and issuing sick leave outpatients. It occupies a significant share in the list of reasons for hospitalization in the traumatology and neurosurgical departments, as well as in the departments of abdominal and thoracic surgery. Extensive damage and trauma with a violation of the integrity of blood vessels often cause the development of shock and acute blood loss and, along with penetrating wounds, can lead to fatal outcome. Possible combination with TBI, fractures of limb bones, chest injury, pelvic fracture, kidney damage and blunt abdominal trauma.

Causes of wounds

Reason traumatic injury most often it is a domestic injury, somewhat less often there are injuries received as a result of accidents during sports, criminal incidents, road accidents, industrial injuries and falls from heights.

Pathogenesis

There are four zones of the wound: the defect itself, the zone of bruise (contusion), the zone of concussion (commotion) and the zone with a violation physiological mechanisms. The defect may take the form of a surface (for example, with scalped or extensive superficial bruised injuries), a cavity (for example, with cut and deep bruised wounds) or a deep channel (with puncture, through and some blind gunshot injuries). The walls of the defect are formed by necrotic tissue; between the walls there are blood clots, pieces of tissue, foreign bodies, and in the case of open fractures, also bone fragments.

Significant hemorrhages form in the contusion area, bone fractures and ruptures are possible internal organs. In the concussion zone, focal hemorrhages and circulatory disorders are observed - spasm of small vessels, followed by their steady expansion. In the area of ​​impaired physiological mechanisms, passing functional disorders, microscopic hemorrhages and foci of necrosis are detected.

Healing occurs in stages, through the melting of damaged tissue, accompanied by local swelling and fluid secretion, followed by inflammation, especially pronounced during suppuration. Then the wound is completely cleared of necrotic tissue, and granulations are formed in the area of ​​the defect. Then the granulations are covered with a layer of fresh epithelium, and complete healing gradually occurs. Depending on the characteristics and size of the wound, the degree of its contamination and general condition the body may heal by primary intention, heal under a scab, or heal through suppuration (secondary intention).

Classification

Wounds are classified based on a variety of various signs. According to the circumstances of application in traumatology and orthopedics, they distinguish between accidental, combat and surgical wounds, according to the characteristics of the wounding weapon and the mechanism of damage - cut, torn, chopped, stabbed, bruised, gunshot, bitten and crushed. There are also wounds that are mixed in nature, for example, lacerations, bruises and stab wounds. Taking into account the shape, linear, patchy, star-shaped and perforated wounds, as well as damage with loss of substance, are distinguished. Wounds with detachment or loss of significant areas of skin are called scalped. In the case when, as a result of an injury, a part of a limb is lost (lower leg, foot, forearm, finger, etc.), the damage is called traumatic amputation.

Depending on the condition of the tissue, wounds with a large and small area of ​​damage are distinguished. The tissues surrounding a wound with a small area of ​​damage, for the most part, remain viable; only areas that were in direct contact with the traumatic weapon are destroyed. Such injuries include stab and cut wounds. Incised wounds has parallel, smooth edges and a relatively shallow depth with a relatively large length, and with timely adequate treatment, as a rule, they heal with a minimum amount of suppuration.

Blood can be released outside (external bleeding) and into a natural body cavity (internal bleeding). IN the latter case an accumulation of blood is formed with compression of the corresponding organ and disruption of its function. With hemothorax, compression of the lung is observed, with hemopericardium - of the heart, with hemarthrosis - of all joint structures, etc. Minor superficial injuries, as a rule, are not accompanied general symptoms. In case of severe injuries, a decrease in blood pressure, tachycardia, pallor of the skin and mucous membranes, nausea, dizziness, weakness and increased breathing are observed.

Diagnostics

For small superficial wounds that are not accompanied by general symptoms, the diagnosis is made by a traumatologist based on the clinical picture. A detailed study is carried out during the process of PHO. For extensive and deep wounds with a violation of the general condition, additional studies are necessary, the list of which is determined taking into account the location of the damage. For injuries in the chest area, a chest x-ray is prescribed; for injuries to the abdominal area, an abdominal x-ray, ultrasound or laparoscopy, etc. If a violation of the integrity of blood vessels and nerves is suspected, consultation with a neurosurgeon and vascular surgeon is required.

Wound treatment

Minor superficial injuries are treated in an emergency room. For extensive and deep wounds, open fractures, penetrating wounds, suspected violation of the integrity of internal organs, blood vessels and nerves require hospitalization in a traumatology, surgical or neurosurgical department. The need for suturing is determined depending on the duration of the traumatic impact. Primary surgical treatment is carried out only on the first day after injury and in the absence of signs of inflammation.

PHO is carried out under local anesthesia or under anesthesia. The wound is washed, blood clots and foreign bodies are removed. The edges of the wound cavity are excised, the cavity is washed again and sutured in layers, leaving drainage in the form of a rubber outlet, tube or half-tube. If the area of ​​damage is normally supplied with blood, there is no foreign bodies, the surrounding tissues are not crushed or crushed, and the edges are in stable contact throughout (both on the surface and in depth), the wound heals by primary intention. After about a week, signs of inflammation disappear and a gentle skin scar forms.

Damage that is more than 24 hours old is considered stale and cannot be sutured. The wound heals either under a scab, which takes a little longer, or through suppuration. In the latter case, pus appears and a demarcation shaft forms around the damaged area. Suppuration is accompanied general reaction body - intoxication, increased temperature, increased ESR and leukocytosis are observed. During this period, dressings and active drainage are performed. If necessary, purulent leaks are opened.

If the course is favorable, after about 2 weeks the wound is cleaned and the healing process begins. At this time, both local and general symptoms inflammation, the patient’s condition returns to normal. The outcome is a rougher scar than with primary intention. If there is a significant tissue defect, spontaneous healing may not occur. In such cases, plastic surgery with a free skin flap or a displaced skin flap is required.

Wound is damage to tissues and organs that occurs simultaneously with a violation of the integrity of the skin and mucous membranes due to a number of reasons.

Classic signs on the basis of which the presence of a wound can be immediately established are:

2) gaping;

3) bleeding.

Classification of wounds

By etiology (depending on the type of traumatic agent).

1. Surgical (applied in an operating room, are aseptic).

2. Random.

Depending on the type of traumatic agent.

1. Cut.

2. Chipped.

3. Chopped.

4. Bitten.

5. Bruised.

6. Crushed.

7. Torn.

8. Firearms.

9. Burns.

10. Mixed.

Depending on the presence of microflora in the wound and its quantity.

1. Aseptic.

2. Microbially contaminated.

3. Purulent.

In relation to body cavities.

1. Penetrating.

2. Non-penetrating.

Depending on the presence of complications.

1. Complicated.

2. Uncomplicated.

Factors for the development of complications

Factors contributing to the occurrence of complications are the nature and degree of tissue damage, the presence in the wound of blood clots, areas of necrotic tissue, foreign bodies, microflora, its quantity and virulence.

Types of wound healing:

1) primary intention (without suppuration);

2) secondary intention (with the obligatory phase of wound suppuration and the development of granulations);

3) under the scab.

The type of wound healing is extremely important because it determines clinical course wound process and all medical tactics. Any wound can heal without or with suppuration. Everything depends on the fulfillment of a number of conditions.

Conditions for healing by primary intention

1. No high microbial contamination of the wound.

2. The absence of foreign bodies, blood clots and non-viable tissues in the wound.

3. Sufficient blood supply.

4. Accurate alignment of wound edges, no tension or pockets.

5. Preservation of innervation of the wound edges.

6. Absence metabolic disorders(with decompensated diabetes mellitus).

Any wound should be brought into compliance with these conditions, since in this case the treatment will take much less time.

The course of the wound process has a phase character, and surgeons have long noticed this. Various attempts have been made to classify the phases of the wound process. According to Pirogov, the wound goes through three stages - swelling, wound cleansing, granulation.

According to Kaliev they distinguish early period, degenerative-inflammatory period, recovery phase.

Modern classification wounds proposed by M.I. Kuzin. He identifies the phases:

1) inflammation;

2) proliferation;

3) regeneration (scarring).

Inflammation phase. The first stage on the path to wound healing.

How do wounds heal?

The wound healing process begins from the moment when bleeding in the wound stops under the influence of plasma coagulation factors and the platelet component of hemostasis. Acidosis forms in the wound and surrounding tissues due to impaired blood supply to the damaged areas and the accumulation of organic acids. If normal value pH internal environment body 7.3, in the wound the pH can drop to 5 or even lower. With excessive acidification in the wound, processes are disrupted immune defense, but in general, acidosis in wound healing is protective in nature, since it prevents the active proliferation of microorganisms. An increase in tissue acidity leads to their hydrophilicity and a parallel increase in capillary permeability. In parallel with the development of acidosis, hyperkalemia also occurs. Active exudation into the wound occurs, which contributes to its cleansing. Simultaneous edema and swelling of the edges of the wound lead to their approach and combination, due to which the inflammation zone is delimited from environment. At the same time, the edges of the wound are glued together with their exact alignment due to the loss of fibrin on the walls of the wound. Metabolism changes in the wound, metabolic processes shift towards catabolism. At the same time, migration of inflammatory cells (macrophages, polymorphonuclear leukocytes, lymphocytes) into the wound is observed. These cells, under the influence of inflammatory mediators, release enzymes into the wound and biologically active substances. Proteases promote the lysis of non-viable tissue. Oxidase prevents excessive accumulation of toxins. Superoxide dismutase leads to the accumulation active forms oxygen, which have toxic effect to microorganisms. Lipase destroys the protective membranes of microbial cells and makes them accessible to the action of other protective factors. In parallel, an increase in serum protective factors is observed in the wound. At the end of the inflammation phase, the wound is cleared of decay products (if any) and a smooth transition to the next phase is observed. When the wound is healed by primary intention, this phase is short and takes 2–3 days, but when the wound is healed by secondary intention and it suppurates, this phase can last more than a week.

Proliferation phase. Lasts up to 14–28 days from the moment of injury. Characterized by the predominance of granulation processes. Granulation is young connective tissue, which contains a large number of cellular elements capable of proliferation. Tissue trophism improves, new capillaries grow in again formed tissues, microcirculation processes improve, tissue swelling decreases. Metabolic processes again shift towards anabolism.

Regeneration phase. Depending on how the wound healed (by primary or secondary intention), either epithelization of the wound is observed by creeping of the epithelium from the edges of the wound (healing occurs under a scab or by primary intention), or a rough connective tissue scar is formed (healing occurs by secondary intention).

Wounds are classified according to various criteria.
1. According to the nature of tissue damage:
Puncture wounds are inflicted with a piercing weapon (bayonet, needle, etc.). Anatomical feature their is a significant depth at minor damage covers. With these wounds, there is always a danger of damage to vital structures located deep in the tissues, in cavities (vessels, nerves, hollow and parenchymal organs). Appearance puncture wounds and secretions from them do not always provide enough data to make a diagnosis. Thus, with a puncture wound to the abdomen, injury to the intestine or Liver is possible, but discharge of intestinal contents or blood from the wound usually cannot be detected. With a puncture wound, in an area with a large array of muscles, a large artery may be damaged, but there may be no connection with muscle contraction and displacement of the wound channel. An interstitial hematoma is formed with the subsequent development of a false aneurysm.

Puncture wounds They are dangerous because due to the small number of symptoms, damage to deep-lying tissues and organs can be seen, so a particularly thorough examination of the patient is necessary. Puncture wounds are also dangerous because microorganisms are introduced deep into the tissues with the wounding weapon, and the wound discharge, not finding a way out, serves as a good source for them. nutrient medium, which creates especially favorable conditions for the development of purulent complications.

Incised wounds applied with a sharp object. They are characterized by a small number of destroyed cells; surrounding Pishi are not damaged. Gaping the wound allows for inspection of damaged tissue and creates good conditions for the outflow of discharge. With an incised wound, there are the most favorable conditions for healing, therefore, when treating any fresh wounds, they strive to turn them into incised wounds.

Chopped wounds applied with a heavy sharp object (checker, ax, etc.). Such wounds are characterized by deep tissue damage, wide gaping, bruising and concussion of surrounding tissues, reducing their resistance and regenerative abilities.

Bruised and lacerations are the result of exposure to a blunt object. They are characterized by a large number of crushed, bruised, blood-soaked tissues with a violation of their viability. Bruised blood vessels often diamond-shaped. Bruised wounds create favorable conditions for the development of infection.

Bite wounds are characterized not so much by extensive and deep damage, but by severe infection by the virulent flora of the mouth of a person or animal. The course of these wounds is more often than others complicated by the development acute infection. Bite wounds can become infected with the rabies virus.

Poisoned wounds- these are wounds into which poison enters (from the bite of a snake, scorpion, penetration of toxic substances), etc.

Gunshot wounds differ from all others in the nature of the wounding weapon (bullet, fragment); complexity of anatomical characteristics; feature of tissue damage with areas complete destruction, necrosis and molecular concussion; high degree infected™; variety of characteristics (through, blind, tangent, etc.).

2. Based on the damage, wounds are divided into surgical (intentional) and accidental.

3. According to infection, wounds are classified as aseptic, freshly infected and purulent.

4. In relation to body cavities (cavities of the skull, chest, abdomen, joints, etc.), penetrating and non-penetrating wounds are distinguished. Penetrating wounds pose a great danger due to the possibility of damage or involvement in the inflammatory process of the membranes, cavities and organs located in them.

5. There are simple and complicated wounds in which there is any additional tissue damage (poisoning, burn) or a combination of soft tissue injuries with damage to bone, hollow organs, etc.

General concept of surgical infection.

Surgical infection refers to complications of wounds or diseases that are caused by pathogenic microorganisms and require primarily surgical methods treatment. A surgical infection is a process of interaction between a microorganism and a macroorganism. The nature of the pathological (inflammatory) process that occurs in the wound depends on the type of microorganisms that have entered the wound.
Depending on this, purulent, putrefactive, specific, anaerobic and mixed wound infections are distinguished.
Purulent infection is the most common, caused by representatives of a group of pyogenic microbes (most often staphylococci, streptococci, Pseudomonas aeruginosa, etc.). Most staphylococci are found on the surface of the human body, clothing, in the air and on surrounding objects. This creates certain conditions for microbial contamination of the wound.
Putrefactive infection occurs in combination with purulent infection. Called mainly coli, as well as sarcins, representatives of the Salmonella group.
Anaerobic infection is caused by microorganisms - anaerobes, which develop without access to oxygen, especially in the presence of injured and dead muscles.
Specific infection caused by microorganisms that, when they enter a wound, lead to the development of a specific process (tuberculosis, tetanus, diphtheria, etc.).
A mixed infection occurs as a result of the simultaneous entry of several types of microorganisms into the wound.

There are two ways of penetration of microorganisms into the wound: exogenous - penetration of microorganisms into the wound from external environment(mainly contact, droplet, airborne dust, implantation) and endogenous - penetration of microorganisms into the wound through lymphatic (lymphogenous) or blood (hematogenous) vessels from the source of infection located inside the sick person (abscess, carious teeth, sore throat, pustular skin diseases etc.).

Asepsis and antiseptics

Asepsis- a system of measures aimed at preventing the introduction of infectious agents into the wound, tissues, organs, body cavities of the patient during surgical operations, dressings and diagnostic procedures.

It is achieved by destroying microbes and their spores through disinfection and sterilization using physical factors and chemicals.

Antiseptics- a set of therapeutic and preventive measures aimed at destroying microbes in a wound, other pathological education or the body as a whole.

There are:

• Preventive antiseptics - carried out in order to prevent microorganisms from entering the wound or the patient’s body (treating the hands of medical staff, treating the injection site with an antiseptic, etc.).
• Therapeutic antiseptics, which includes: mechanical (removal of infected and non-viable tissues, removal of foreign bodies, primary debridement wounds, opening leaks and pockets, etc.), physical (hygroscopic dressings, solutions with high osmotic pressure, the action of dry heat, ultrasound, etc.); chemical (use of various bactericidal and bacteriostatic substances); biological (antibiotics, antitoxins, bacteriophages, proteolytic enzymes, etc.) methods and their combination.

There are 2 types of surgical infection: endogenous and exogenous. The endogenous source is located in the patient’s body, the exogenous source is in the environment.

In warning endogenous infection The main role belongs to antiseptics, exogenous - asepsis.

Classification, signs and complications of wounds

Wound– mechanical damage tissues or organs, accompanied by a violation of the integrity of their integument or mucous membrane. It is the violation of the integrity of the integumentary tissues (skin, mucous membrane) that distinguishes wounds from other types of damage (bruise, rupture, sprain).

The main classic signs of wounds are pain, bleeding and gaping (characteristics of the extent of the wound, its depth, etc.). The severity of each sign is determined by the nature of the wound, the volume of damaged tissue, the characteristics of the innervation and blood supply to the wound canal area, and the possibility of life-threatening injury. important organs

Exists whole line classifications of wounds depending on the type of symptom under consideration.

By origin, wounds are divided into:

• intentional (operational)
• and random.

According to the nature of the damage, depending on the type of traumatic agent, wounds are divided into:

• cut (occur as a result of the impact of a sharp object on the surface of the skin (knife, razor, shards of glass, metal, etc.));
• punctured (occur as a result of deep penetration of a sharp long thin instrument (awl, bayonet, knife, knitting needle, sharpening, etc.). A feature of puncture wounds is a significant depth with little damage to the skin.),
• chopped (occur as a result of the impact of a sharp object (axe, sword, saber) with greater force perpendicularly or at an angle to the tissues. They are characterized by deep damage, wide gaping, bruising and concussion of surrounding tissues.);
• bruised (occur when a blunt, hard object with a wide damaging surface impacts tissue in areas where there is solid support in the form of bones.),

crushed, crushed (formed by the impact of a blunt object with a wide surface in opposition to a solid support (bones, other objects). Crushing and extensive tissue necrosis are characteristic.);