Wounds – This is one of those injuries that are observed in people especially often. This is not surprising, since each of us can get injured at any time, in any situation and under any circumstances – at work, on the street, in the dacha, at home, at school, etc. According to statistics, this damage is one fifth all diagnosed injuries. Both in terms of the volume of the wound, and in its appearance, the general condition of the edges, and also in terms of the depth of the damage, specialists quite often determine the way it occurs even without the testimony of the victim himself. After reading this article, you will find out exactly what this injury is and what it can be depending on the conditions of its occurrence. In addition, you can familiarize yourself with the rules of care for patients who have this kind of damage.
The wound is a violation of the anatomical integrity of the skin and mucous membranes throughout their thickness, caused by mechanical action. In some cases, internal organs are also damaged. The distinctive signs of such a violation is considered to be pain, gaping (edge mismatch) and bleeding. Note that with deep injuries not only the skin and subcutaneous tissue is damaged, but also the bones, ligaments, muscles, nerves, tendons, and sometimes large blood vessels. There is in medical practice such definition as combined injuries. In this case we are talking about injuries that have been additionally affected by chemical, physical or biological factors. Such factors include microbial contamination, burns, ionizing or hard electromagnetic radiation, frostbite, etc.
Regardless of the nature of the injury, in all cases it consists of the following components:
- wound channel
In the area of the wound itself there are 3 zones:
one. zone of direct action of the wounded object: it is also called the wound channel or wound defect
2 contusion zone (bruise): it occurs due to the lateral action of the injuring object and determines the size of the primary traumatic necrosis (death)
3 shaking zone: in this zone, the development of foci of secondary necrosis as a result of vascular changes and trophic impairment (cell nutrition processes) fabrics. Often, secondary necrosis occurs on the background of foci of hemorrhage.
Features of the course of the wound process
There are only 2 directions in which the wound process can proceed. Each of these areas is determined by the nature of the injury and some other important factors. The first direction involves the healing of a lesion by self-purification or by primary tension. It occurs when the injury is of minor depth and contaminated with a minimum number of bacteria. The same healing is observed with tight contact of the edges of the lesion, as well as with strong immunity. The second direction is characterized by wound healing by secondary tension. In this case, on the face of a clear suppuration.
Periods of the wound process
3 dehydration period: characterized by scarring damage.
The clinical picture of any injury is primarily accompanied by pain. Both the intensity and the nature of the pain are determined by the location and type of injury. Particularly worried about the pain when injured periosteum, nerve trunks, peritoneum or nerve plexuses. If on the 3rd – 4th day the pain increases, it means that the development of those or other complications. In addition, the patient begins to complain about the violation or limitation of the function of the damaged area of the body. Such complaints may not be only if the injury is superficial. If the muscles, joints, nerve trunks, tendons, internal organs, main blood vessels or bones are affected, then the limitations are significant.
Bleeding is another clear sign of injury. With a minor injury, external bleeding is most often capillary or mixed. You should not worry too much about this, since such bleeding in most cases stops on its own. If the lesions were affected by internal organs or large blood vessels, then the bleeding is dangerous. In case of penetrating injuries, in addition to external bleeding, internal bleeding most often also occurs, against which such complications as hemarthrosis (joint cavity hemorrhage), hemopericardium (accumulation of blood in the pericardial cavity), hemoperitoneum (abdominal blood accumulation) and hemothorax (accumulation of blood in the pleural cavity).
In all these cases, not only blood but also the contents of the intestines, bile, urine, or other contents of the damaged organ can be released from the affected area.
If an artery with a diameter of 3 mm was injured, then death from blood loss occurs within 3 to 4 minutes. General signs directly depend on the severity of blood loss and the location of the wound, as well as on the nature of the injury. With extensive wounds, patients may experience nausea, dizziness, vomiting, blanching of the skin, general weakness, low blood pressure, tachycardia (increase in heart rate), tachypnea (rapid shallow breathing) and many other signs. Often in such cases there is a picture of traumatic shock (syndrome characterized by a critical decrease in blood flow in the tissues and severe disorders of the process of respiration and blood circulation).
The clinical picture of infected lesions is characterized by pronounced purulent inflammation and the development of a wound infection. Wound infection is a pathological process caused by the penetration of pathogenic microorganisms into the wound. Other common signs include fever, fainting, collapse (life-threatening condition, accompanied by a drop in blood pressure and a deterioration in the blood supply to vital organs) and shock (a set of metabolic disorders, respiratory and cardiac processes, as well as neuro-endocrine regulation in response to super-strong irritation).
Initially, complications can directly tell about themselves that are directly related to blood loss, brain damage or internal organs, or the development of traumatic shock. During the spread of the infectious process may appear abscesses (limited purulent inflammation of tissues with their melting and the formation of a purulent cavitygangrene (massive tissue death), purulent flow (accumulation of pus in the tissues), lymphadenitis (lymph node inflammation), thrombophlebitis (inflammation of the vein wall with its blockage by a blood clot) phlegmon (acute purulent inflammation of cellular spaces).
Erysipelas (acute infection of skin and fatty tissues) – Another possible complication that occurs in this period. Note that gangrene in such cases is the result of putrid or anaerobic infection. In addition to local complications, it is quite possible that common, starting with purulent-resorptive fever and ending with sepsis (severe infectious disease in which pyogenic microorganisms and their metabolic products in the face of toxins get into human blood and tissues). Due to purulent fusion of the vascular walls may develop and secondary bleeding. During the healing of a wound, its secondary suppuration often occurs due to repeated injury or penetration into the damaged area of the pathogenic flora. Against the background of a disruption of the regeneration processes, the following phenomena may be noted: the formation of non-healing ulcers, deformation of the tissue in the form of rather coarse scars, the divergence of the edges of damage after the removal of sutures.
Quite often, patients have common complications. So, for example, with massive crush of tissue, the development of renal failure is quite possible. A long purulent process can cause the development of amyloidosis (violations of protein metabolism, accompanied by the formation and deposition in the tissues of amyloid-specific protein-polysaccharide complex). Occurs in such cases and such a complication as pneumonia. Quite possible exacerbation and existing chronic pathologies of the gastrointestinal tract.
Owing to the injury of a person, various mental disorders can also begin to disturb. In medicine, these disorders are called wound psychosis. All wound psychoses are divided into acute and protracted. Their acute forms occur on the background of infectious intoxication factors 1 to 3 weeks after the development of infection due to asthenia (chronic fatigue syndrome). Such psychosis does not last long and is characterized by stupefaction. As for the protracted forms, they most often occur on the background of avitaminosis and metabolic disorders. Weak immunity can also cause their development. Such psychosis occurs only after 2 to 4 months after injury and is characterized by depressive states, accompanied by hallucinations, anxiety and delirium. In severe cases, patients have an apathetic stupor (total indifference in what is happening).
When examining injuries, it is important to submit the following information:
- specify the location of damage according to the anatomical segment of the body (neck, limb, face, chest, abdomen, head, etc.)
- specify the exact location of the lesion according to the anatomical orientation (for example, in the thigh, 6 cm above the elbow joint, in the midclavicular line, etc.)
- specify the exact size of the gaping wound (3 by 5 cm or 1 by 4 cm). If the bottom of the wound is visible, then it is important to record its depth (2 cm, 3 cm, 5 cm)
- indicate the direction of the lesion along the longitudinal axis of the body: longitudinal, oblique or transverse
- describe the form of injury: round, sickle, stellate, linear, triangular or other
- describe the edges of the injury: uneven or even, indistinct or clear, their dimensions
- to characterize hemorrhages: their shape, color, size
- describe the bottom of the lesion.
The bottom of the wound requires increased attention from a specialist. In some cases, it is dissected specifically, so that the specialist has the opportunity to carefully examine and accurately describe it. With penetrating wounds, endoscopic examination or abdominal surgery is performed. They are necessary to describe the wound canal, the general condition of the bottom and the damage of various internal organs. When diagnosing it is important to pay attention to the contents of the wound. In the wound can be as bone fragments, and fragments, decomposition products of tissues, bullet, earth, etc. In the case of the presence of complications, the specialist should indicate them. So, for example, he can note the fact of damage to the tendons, internal organs, brain, muscles or neurovascular bundles.
Long-lasting wounds – how dangerous are they?
Long-term unhealed or chronic wounds are actually very dangerous. They are damages whose reparation is disturbed against the background of unfavorable basic pathological conditions. These can be both skin ulcers, which are most often observed in diabetes mellitus, and ulcers due to impaired outflow of blood through the veins or as a result of the constant pressure of the prosthesis. Such injuries do not heal until the unfavorable background condition can be corrected. Experts note the fact that all such lesions tend to be delayed until a certain time, after which the process of their healing for unknown reasons stops. The most terrible complication of such lesions is considered to be the development of squamous cell carcinoma – a malignant tumor, which in most cases occurs in areas of old injuries.
Types of healing
There are 3 types of wound closure, namely:
one. primary wound closure: is based on the approach of the severed tissues using clips, adhesive tape or stitches. Over time, collagen fibers intertwine, thereby providing the fabric with the necessary strength.
2 delayed primary closure: usually occurs several days after the damage has already formed. Such a delay is most often necessary for the prevention of infection of the wound, which was susceptible to contamination by numerous pathogens or was accompanied by extensive tissue destruction.
3 secondary closure: observed when the damage is left open, after which its edges converge on their own due to a biological process characterized by tightening the edges of the wound. If the biological capabilities of the organism are insufficient, then the process begins to be chronic.
The whole process of healing injuries is carried out by 3 biological mechanisms.
You can add to their list:
one. epithelialization is a process accompanied by the movement of cells of a stratified squamous epithelium, as a result of which the defects of the skin or mucous membrane are closed
2 congestion or convergence: a process characterized by the spontaneous closure of the affected area or a reduction after damage to the lumen of the tubular organs. It can be either the esophagus or the bile duct.
3 collagen deposition: the process by which fibroblasts (basic cellular forms of connective tissue) move to the site of the lesion and synthesize a new connective tissue matrix (extracellular tissue structure).
In no case can not
- rinse the wound with alcohol, iodine tincture or water
- apply cotton directly on the wound
- fill the damaged area with powders or lubricate it with ointment
- remove any foreign objects from the affected area
- inward protruding tissue such as the intestines or the brain.
Local treatment is determined by the stage of injury. If we are talking about the stage of hydration, then on the face, as a rule, pain and dysfunction of this or that damaged area. In such cases, the patient must be forced and immobilized for 2–3 days. In addition, the course of therapy involves the administration of special pain medication. Possible treatment of the affected area with a solution of magnesium sulfate, sodium chloride or glucose solution. During this period, dressings are recommended as often as possible. During the dehydration stage, granulation or eschar forms at the site of injury.crust covering the injured surface). In this case, the site of the lesion is recommended to be treated with tanning solutions such as alcohol or brilliant green. Dressings in this period are made much less frequently. It is also necessary to use ointment dressings with the imposition of any ointment on a lanolin basis with an antibiotic preparation. Older people such dressings should be done no more than 1 time per week with the use of ointments, which tend to enhance the growth of granulations. The list of such ointments can be put sea buckthorn oil, rosehip oil, Vishnevsky ointment, lavender oil, solcoseryl ointment and others. In the case of increased granulation, cauterizing solutions such as a strong solution of silver nitrate are used.
Surgical therapies are needed first and foremost to close an existing wound defect. Surgical treatment of a wound is not carried out only if the patient has multiple small broken wounds of the back and chest or pin holes in the lower or upper extremities. There are other contraindications for such procedures, namely, traumatic shock and agonal condition (condition which is the precursor of human death). There are the following types of surgical treatment of wounds.
These may include:
- early processing: up to 24 hours
- delayed processing: from 24 to 48 hours
- late processing: more than 48 hours.
There are also so-called primary, as well as secondary surgical treatment of wounds. Primary surgical treatment or abbreviated PHO is a surgical procedure involving the excision of the edges, walls and bottom of the wound with the subsequent removal of all contaminated, damaged and blood-soaked tissues. Such treatment can be carried out only in the first 12 hours after injury. In all cases in the course of its implementation stitches are applied. Such an operative intervention is impossible if the excision requires damage in the area of the hand, feet or face. PHO can be either complete or incomplete. In the first case, all non-viable tissues are removed, but in the second, some of them have to be left intact. Before such treatment, the injury is first washed with hydrogen peroxide, dioxidine, or furacilin. PEC stages include wound revision and removal of non-viable tissues. In case of incomplete treatment, the wound is drained, after which the patient is stitched. If the wound is located on the scrotum or on the scalp, then it is closed tightly. If it is impossible to sew up a lesion site, then a special bandage is applied with sorbents. Secondary surgical treatment is a surgical intervention, carried out according to secondary indications in order to get rid of the complications that have appeared.
There are 4 types of stitches that can be applied for injuries, namely:
one. Primary suture – applied to a fresh wound, and immediately after the end of the surgical intervention, i.e. before the development of granulation
2 Delayed primary suture – applied after 24 to 48 hours until granulation tissue appears
3 Early secondary suture – superimposed on the granulating wound after the phase of purulent inflammatory process and cleaning the affected area from dead tissue
four. Late secondary suture – superimposed after excision of the bottom and walls of the wound, since the patient already has scar tissue.
Bandages. What can they be?
Bandages are applied to secure the dressing on the damaged area or to establish the necessary pressure on a specific area in order to stop the bleeding. Often, dressings are applied to keep one or another part of the body in a stationary state. Depending on which material is used for dressing, they can be both soft and hard.
There are other types of dressings, namely:
- firming bandage: used with minor superficial damage and involves the imposition of several strips parallel to each other or crosswise
- scarf bandage: it is applied mainly in the provision of first aid, as well as in order to create the rest of the upper limb
- adhesive bandage: used for injuries of small size to strengthen the dressing on the skin
- bandage bandage: it is used especially often as it is the most convenient. Such a bandage as firmly holds, and exerts a uniform pressure on body tissue.
- sling bandage: consists of a strip of cloth or a piece of bandage, both ends of which are notched longitudinally, but the cuts do not reach the middle. Without such a bandage can not do if the wound of the nose and lower jaw.
Properly applied bandage must completely close the affected area, at the same time, without disturbing the blood circulation and not restricting the movements of the patient. When applying it is very important that the patient is in a comfortable position for him.
General therapy in all cases is based on the use of painkillers and detoxification drugs. In addition, the efforts of specialists are aimed at restoring the circulating blood volume and stimulating hematopoiesis (blood formation process). Equally important is anti-shock therapy. A special role is assigned to strengthening the body’s defenses. Very often, specialists use physiotherapy treatment, namely, ultraviolet radiation, UHF-therapy, electrophoresis with antiseptic preparations, etc.
Suture wound care
Such damage experts recommend to keep open and daily 2 – 3 times to process them with a solution of brilliant green. This treatment should be carried out until the seams are removed. To wet such injuries is strictly prohibited.
Purulent wound care
Purulent weeping wounds should be tied every day. In severe cases, the dressing should be carried out even several times a day as the dressing becomes dirty and wet. Dressings are best wetted in a solution of furatsillin and hypertonic solution in a 1: 1 ratio. This solution can be replaced with water-soluble ointments such as levomicol or levocin. It is also recommended to wash the same wounds 2 – 3 times a day. To wash them you can use a weak solution of potassium permanganate. After the procedure we dry the wound with a sterile napkin, and then apply a bandage. Do not put a bandage with Vishnevsky ointment on the open area of damage. As soon as such a wound begins to heal, do not soak it any more and continue to do the dressings 1 time in 2 – 3 days. In this period, fat-soluble ointments should be used to apply dressings. In any doubtful situations, without fail, consult a surgeon or dermatologist.
Superficial wound care
Initially, this wound should be washed with 3% hydrogen peroxide solution, then dry it thoroughly with a sterile cloth, and then treat the edges with green paint or iodine and try to bring them together as best as possible with narrow strips of adhesive plaster. Spacing between the strips 2 – 3 times a day grease with brilliant green. If a wound is observed on the face, then such a bandage should be kept for 5-7 days. On other parts of the body, it should be 7 – 8 days. All this time it is not recommended to wet the affected area, after removing the bandage it should be kept open.
Burn wound care
In case of burn wounds, the patient must apply a so-called three-layer bandage. Take 3 pieces of gauze or a bandage of the same size and put them one on top of the other. After that, prepare a solution of furatsilina – 1 tablet for 0.5 glass of water and moisten all 3 pieces of gauze in it. This bandage should be pinned. It will help the affected area to dry faster and, consequently, heal. Most often, such a bandage “dries” to the damaged area. The most important thing is not to tear it. As soon as the wound begins to heal, the dressing will gradually disappear. If you notice that she began to get wet, then replace it with another one with the same dressing.
Care of postoperative wounds
Postoperative lesions are considered to be the entrance gate for various kinds of pathogenic microorganisms. Given this fact, special attention should be paid to the prevention of infection and acceleration of tissue regeneration. In the first place should pay attention to the bandage. In no case do not let it slide off and open the postoperative suture. A wet dressing should be replaced with another made exclusively from sterile dressing.
Particular attention should be paid to the nature, as well as the amount of discharge, which flows through the drainage tubes. Immediately after surgery, a rubber bladder with ice or a bag of sand should be placed on the surgical wound area. Keep the bubble or bag should be 4 – 5 hours. Both the severity and the cold will help to squeeze and narrow the small blood vessels, preventing the accumulation of large amounts of blood in a given area. Plus, the cold will help reduce the strength of the manifestation of pain. In the case of suppuration of such injuries, the patient has an increase in body temperature, redness of the skin, the appearance of swelling in the affected area and other unpleasant symptoms.
Care of wounds in diabetes
It is especially difficult to care for patients with injuries that occur in diabetes, as these wounds heal very slowly and hard. Even minor cuts in such patients are delayed for a very long time. In the fight against damage in such cases, you should fight first and foremost with the main pathology. Folk healers for treating skin damage in diabetes mellitus are suggested to use the help of this tool: we take sunflower root, preferably with a large number of hairs, wash and chop the hairs, then 1 tbsp. l raw materials are placed in a 3-liter jar and pour boiling water. Water should be poured in such a way that 4–5 cm is left to the edges of the can. We wrap the can and leave it for 40 minutes. The resulting infusion should be drunk during the day instead of water, compote, tea and other liquids. Every day we prepare fresh infusion. Damage will begin to tighten, as this infusion tends to lower blood sugar levels.
Features of the treatment of wounds in children
Accidental injuries of soft tissues in children are treated using the general principles of surgery for open injuries. In this case, tissue excision in the case of primary surgical treatment is carried out more economically. Children, as a rule, imposed a primary seam. Uncontaminated wounds are initially treated with 3-5% alcohol solution of iodine and 70% ethyl alcohol, after which the damaged area is sewn up with rare seams without excision of the edges. If a child was injured and was not vaccinated against tetanus, then the first dose of tetanus toxoid should be given to him. Children with vaccinations are given tetanus toxoid. In order to prevent any complications, anti-bacterial medications are administered.