General surgery. Cheat sheet: briefly, the most important

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Lecture notes, cheat sheets
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General surgery. Cheat sheet: briefly, the most important

Lecture notes, cheat sheets

Directory / Lecture notes, cheat sheets

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Table of contents

Asepsis. Sterilization
Mechanical antiseptic
Physical, chemical and biological antiseptics
Preoperative stage
postoperative period. Complications in the postoperative period
Surgical operations
Cooperative indications. Operational risk
Local anesthesia
Intravenous anesthesia and pararenal blockade
Spinal anesthesia
Anesthesia. Its components and types
Stages of ether anesthesia
Certain types of anesthesia
Clinic of acute blood loss
Clinical picture of various types of bleeding
Stop bleeding
Blood transfusion. blood group affiliation
Method for determining the blood group according to the ABO system
Rhesus system
Blood substitutes
Complications of blood transfusion
Pathophysiology of the wound process
General principles of wound care
Purulent infection
General principles of therapy for purulent-inflammatory diseases
local treatment. Incisions for purulent diseases
Mastitis
Parotitis
Abscess and gangrene of the lung
Pleural empyema
Purulent mediastinitis
Furuncle, carbuncle
Abscess
Phlegmon
Erysipelas
Osteomyelitis
Purulent-inflammatory diseases of the hand
Clinical forms of felons. General principles of treatment
Tetanus
Peritonitis. Etiology and pathogenesis
Peritonitis. Clinic and treatment
Burns. Degrees of damage to the skin
Determining the area of the burn. The pathogenesis of the lesion
Treatment of burns
Frostbite
Soft tissue injury
Bone fractures
Principles of fracture treatment
Sepsis
The pathogenesis of sepsis
Surgical sepsis
septic complications. Sepsis treatment
Fundamentals of Surgical Oncology
Classification of tumors
Etiology, pathogenesis of tumors. Diagnosis of a tumor disease
Cancer treatment

1. Asepsis. Sterilization

Asepsis is a set of measures aimed at preventing contamination of the surgical wound by microorganisms. The principles of asepsis are carried out using various methods: chemical, physical, biological. The principles of asepsis must be observed carefully and strictly, starting from the first contact of the patient with the doctor in the emergency department, with the emergency doctor. To prevent infection from entering the wound, a sterile gauze bandage is immediately applied to it. The main task of asepsis in a surgical hospital is to prevent microbial agents from entering the wound. All instruments, tissues, materials, and hands of the surgeon in contact with the wound must be sterile. In addition to preventing this route of infection in the wound, it is necessary to prevent the airborne route of infection transmission.

One of the main points is the organization of the work of the hospital. Department of purulent surgery - This department should be isolated from other departments, medical personnel, patients themselves should not come into contact with patients from other departments. If such a department is not provided in the hospital, the department should have separate operating rooms, manipulation rooms, dressing rooms for patients with purulent-inflammatory diseases. In addition, it is known that the content of microorganisms in the air of the operating room during the day increases significantly, therefore it is extremely important to change into sterile clothes when working in the operating room, use sterile gauze masks, caps, completely limiting any possibility of microorganisms entering the wound.

Sterilization is a method aimed at eliminating living microorganisms and their spores from the surface of materials, instruments and other objects that come into contact with the wound surface before, after and during surgery.

Dressings, underwear, suture material, rubber gloves, and instruments should be sterilized. There are the following methods of sterilization.

1. Boiling (its duration depends on the type of pollution).

2. Processing with flowing steam or steam supplied under pressure in a special apparatus - an autoclave (for sterilizing contaminated dressings, linen, gowns, shoe covers). Temperature control is carried out in various ways. One of these methods is to place test tubes containing substances whose melting point corresponds to or is somewhat lower than the required temperature in the sterilization apparatus into a bix. The melting of these substances indicates that the temperature required for sterilization has been reached.

3. Bactericidal effect of ultraviolet radiation (for air disinfection in operating rooms, dressing rooms and manipulation rooms).

Bactericidal lamps are turned on at the end of the working day after cleaning the premises for 3 hours, it is advisable to carry out treatment with lamps during the day.

2. Mechanical antiseptic

Antiseptic is a set of chemical, physical, biological and other measures aimed at the destruction of microorganisms in the patient's body or in the wound.

Mechanical antiseptic. This method is based on mechanical removal of microorganisms from the wound. The main manipulation aimed at achieving this goal is the primary surgical treatment of the wound. First, the skin around the wound is cleaned with an antiseptic, local anesthesia is performed, then all remnants of non-viable tissues are removed from the wound. The wound is dried with a sterile cotton swab and washed with an antiseptic solution. The edges of the wound are economically excised, removing all non-viable tissues. Examining the bottom of the wound, it is established whether there is damage to the vessels, nerve trunks, muscles. If there is damage, its degree is assessed and, if the vessel cannot be restored, the vessel is ligated in the wound. If the damage is not so significant, a vascular suture is performed, restoring its integrity. Similarly, the nerve trunks are restored, the primary suture of the nerve is applied, and the edges of the muscles are sutured. If the initial treatment of the wound was performed in a timely manner (no later than 24 hours after the injury) and the likelihood of complications is negligible, the suture is applied immediately after it. This is the original seam. A primary delayed suture is applied to the wound if more than 24 hours have passed since the wound was received before surgical treatment. In this case, sutures are applied after surgical treatment of the wound, but are tightened only after 5 days, when the likelihood of 2b purulent complications is minimal, but before the appearance of granulations. If there are already signs in the wound that make it possible to suspect the possibility of infection, the wound is left open and a suture is applied only after the first granulations appear. This is a delayed suture.

The method of mechanical antiseptics, called the Mikulich tampon, is widely known. The essence of this method is to create more favorable conditions for the removal of draining tampons from the wound. This improves the outflow of contents and contributes to a more accurate removal of tampons from the wound. To create a Mikulich tampon, it is necessary to sew a thread to a sterile multilayer gauze napkin. The resulting niche is filled with sterile cotton swabs, which must be removed in a timely manner in order to avoid deterioration in the efficiency of the outflow of the contents. The napkin must be replaced in a timely manner.

3. Physical, chemical and biological antiseptics

physical antiseptic. The physical method is the impact on the wound of the ultraviolet spectrum of radiation, which has a bactericidal effect on the wound area.

Physical methods of antisepsis are based on the use of physical methods to reduce microbial contamination of the wound. Such methods include the installation of drainage. It is known that the main condition for curing a purulent infection is the removal of purulent exudate from the focus. The basic rule of purulent surgery is the creation of two incisions - an aperture and a counter-aperture. The first incision is created at the location of the fluctuation, and the other (there may be several) is created in the lower section of the wound - for the best outflow from the bottom of the wound.

In some cases, aseptic gauze dressings are applied to the wound to ensure the outflow of the wound contents. The effectiveness of the method is significantly increased if the gauze bandage is impregnated with a hypertonic sodium chloride solution. Along the concentration gradient, discharge from the wound (together with detritus) enters the dressing, thereby significantly improving wound drainage.

Chemical antiseptic. Chemical antiseptic methods are represented by a variety of chemicals that have a detrimental effect on the growth and reproduction of bacteria. Such substances include, for example, sulfa drugs.

The use of hydrogen peroxide as an antiseptic is widespread in purulent surgery. Its mechanism of action is mixed.

So, the ingress of hydrogen peroxide into the wound and the release of oxygen in the form of abundant foam, consisting of small bubbles, on the one hand, have an adverse effect on microorganisms and cause their death, on the other hand, contribute to the mechanical removal of purulent contents and tissue detritus from the purulent wound.

biological antiseptic. Biological antiseptic methods are currently the most extensive effective group of antiseptic methods. These are antibiotics - chemical preparations that act bactericidal and bacteriostatically, and at present the emphasis is on the development of antibiotics with maximum efficiency and minimal side effects. Broad-spectrum antibiotics can be used in the early stages of the disease until the pathogens are verified. In addition, this group of agents includes bacteriophages, serums and toxoids.

The methods of action of antiseptic drugs are quite diverse. So, ointments with the use of antiseptic drugs, sulfonamides, antibiotics are widespread.

4. Preoperative stage

The preoperative period begins from the moment the patient arrives for inpatient treatment and ends by the time the operation itself begins. The preoperative period itself consists of two blocks, which often (especially in emergency surgery) cannot be divided by time. This is a block of diagnostic and a block of preparatory measures. During the diagnostic stage of the preoperative period, the following goals should be achieved: it is necessary to clarify the diagnosis of the underlying disease, collect information about concomitant diseases in the most complete way, find out the functionality of the patient's organs and systems, decide on the tactics of managing the patient, if necessary, clearly formulate indications for it, decide with the necessary volume of the forthcoming surgical intervention.

The preparatory block includes the following activities: conservative methods of treatment of the underlying disease, correction of impaired body functions aimed at preparing for surgery, direct preparation for surgery.

In order to most fully fulfill all the requirements for examining a patient at the diagnostic stage, it is necessary to adhere to a certain algorithm. Swipe and pass:

1) preliminary examination (subject to a thorough analysis of complaints, the history of life and illness, which in chronic patients is traced from the onset of the disease, and in emergency patients - from the beginning of this attack);

2) a complete physical examination of the patient (palpation, percussion, auscultation according to all requirements);

3) the necessary minimum of special examination methods: biochemical examination of blood and urine, determination of the blood group and Rh factor, blood clotting time and coagulogram, examination by a dentist, ENT doctor, consultation of a therapist, urologist - for men, gynecologist - for women, all patients older than 40 years - ECG. With planned treatment, additional studies are also possible (in order to clarify the presence of concomitant diseases).

The duration of the preoperative period can vary over a very wide range - from several minutes to several months (depending on the urgency of the surgical intervention). In recent years, there has been a trend towards a reduction in preoperative intervention. Due to the high cost of the day of the patient's stay in the hospital, most of the activities of the diagnostic block during elective operations are carried out at the outpatient stage. Even a whole area of outpatient surgery is developing, but more on that below. The result of the preoperative period is the writing of a preoperative epicrisis, which should reflect the following main points: the rationale for the diagnosis, the indications for the proposed surgical intervention and its scope, the proposed anesthesia and the patient's necessarily documented consent to the operation.

5. Postoperative period. Complications in the postoperative period

By time allocate:

1) early postoperative period (from the end of the operation up to 7 days);

2) late postoperative period (after 10 days).

The duration of the postoperative period may vary in different patients, even with the same type of operations.

The first stage of OSA, or the anxiety stage, lasts an average of 1 to 3 days.

The resistance phase, or anabolic phase, lasts up to 15 days. In this phase, anabolism processes begin to predominate.

The anabolic phase smoothly transitions into the convalescence phase, or the phase of body weight recovery.

In the early postoperative period, the patient is usually concerned about pain in the surgical area, general weakness, loss of appetite and often nausea, especially after interventions on the abdominal organs, thirst, bloating and flatulence, body temperature can rise to febrile numbers (up to 38 °C).

After emergency interventions, complications develop more often. Among the complications it should be noted:

1) bleeding. Perform a revision of the wound and ligation of the bleeding vessel;

2) complications from the respiratory system. Manifested by the appearance of shortness of breath, cyanosis, tachycardia;

3) acute cardiovascular failure (pulmonary edema). Manifested by lack of air, pallor, sweating, acrocyanosis, tachycardia, bloody sputum, swelling of the cervical veins. Treatment of this complication is carried out in conditions of resuscitation complication;

4) postoperative paresis of the gastrointestinal tract. Manifested by nausea, vomiting, hiccups. In the treatment, measures such as epidural block, perirenal blockades are used, from pharmacological methods - the introduction of prozerin;

5) development of hepatic-renal insufficiency. Manifested by the development and progression of jaundice, hypotension, tachycardia, drowsiness, lethargy, decreased diuresis, complaints of nausea and vomiting;

6) thromboembolic complications. Most often they develop in patients with a predisposition to the formation of blood clots in the veins of the lower extremities, with atrial fibrillation after operations on the vessels and the heart. To prevent these complications, heparin and its low molecular weight analogues are used according to special schemes.

For the prevention of complications, the following general measures are of great importance:

1) the fight against pain. It is extremely important, because severe pain is a powerful stress factor;

2) improvement of the function of external respiration;

3) fight against hypoxia and hypovolemia;

4) early activation of the patient.

6. Surgical operations

A surgical operation is a complex of measures carried out by means of physiological and mechanical effects on the organs and tissues of the body. Operations are divided into bloody and bloodless. Blood operations are surgical interventions that occur with the dissection of the skin and subcutaneous tissue.

Classification of operations by purpose.

1. Medicinal:

1) radical (with the help of which the pathological focus is completely removed from the body);

2) palliative (as a result of this operation, the patient's life is extended, but the immediate pathological focus (tumor, etc.) remains in the body).

2. Diagnostic (diagnostic laparotomy).

Operations are also divided into primary and repeated (performed on the same organ and for the same reason - reamputation, relaparotomy, resection).

Classification of operations according to the nature of the intervention performed:

1) removal of the pathological focus;

2) restorative and reconstructive;

3) plastic.

Classification of operations depending on the degree of bacterial contamination of the surgical wound:

1) clean (aseptic);

2) non-aseptic;

3) purulent operations.

There is also such a thing as simultaneous operations, i.e. those in which several surgical interventions are performed on several organs simultaneously for several diseases (hernioplasty and prostatectomy).

Combined surgery is the treatment of one disease with the help of operations on different organs.

Surgical intervention can be one-stage, when it is possible to achieve all the goals during the operation, as well as two-stage (for example, surgery for obstruction of the large intestine of a tumor nature) and multi-stage (reconstructive surgery for burn strictures of the esophagus). In the latter case, surgery includes several operations that are separated by time.

Stages of surgical intervention:

1) operational access. Should be forgiving. In a figurative expression, "it should be as big as it needs to be, and as small as possible." Also, operational access should be anatomical and physiological;

2) operational reception. Removal of an organ (ectomy) or its (part) resection;

3) reconstruction (imposition of anastomoses, etc.);

4) suturing the wound.

7. Indications of cooperation. Operational risk

Depending on the timing in which it is necessary to perform surgery, indications for surgery may be as follows:

1) emergency. The operation must be completed without delay. The slightest delay can lead to a worse prognosis, further quality of life, and in some cases even death. Require emergency intervention bleeding, perforation of a hollow organ, peritonitis;

2) urgent. The operation cannot be postponed for a long time due to the progression of the disease. In an emergency, the operation is not performed due to the need to prepare the patient for surgery and compensate for impaired body functions;

3) planned. A planned operation can be performed at any time. It is carried out at the moment most favorable for the patient, since the patient's condition does not cause any particular concern. Indications for a planned operation: malformations, debilitating pain syndrome, loss or decrease in working capacity, preventive surgery.

Emergency surgical interventions are performed in conditions that pose a threat to life.

Operational risk is divided into:

1) insignificant;

2) moderate;

3) relatively moderate;

4) high;

5) emergency (intervention only for health reasons). The following factors are important for assessing operational risk:

1) volume and duration of surgical intervention (operations of the 1st, 2nd, 3rd, 4th categories);

2) type of surgical intervention;

3) the nature of the underlying disease;

4) the presence of concomitant diseases and their severity;

5) gender (for men, all other things being equal, the risk is higher);

6) age;

7) qualifications of the anesthetist and surgical team, operating room equipment.

The most important for determining the risk of concomitant diseases is cardiac pathology: coronary artery disease (including myocardial infarction), hypertension, rheumatic heart disease, cor pulmonale, cardiac arrhythmias.

Regardless of the degree of a certain risk, there is such a thing as anesthetic death, i.e., the unpredictable death of a patient as a result of anesthesia, not directly related to the surgical procedure and its complications. This phenomenon is observed in 1 case per 10 thousand anesthesias.

8. Local anesthesia

Anesthesia is the switching off of any kind of sensitivity, including pain, by using a variety of medicinal substances. Anesthesia can be general The range of medical interventions performed under local anesthesia is quite wide. There is a group of patients who are shown the use of local anesthesia. These are elderly patients, usually with various comorbidities.

Children's age is a contraindication for local anesthesia, since surgery, even a small one, can have a significant impact on the child's psyche. The likelihood of developing an inadequate reaction makes it necessary to refuse the use of local anesthesia in a group of people suffering from mental illness. An important contraindication is the presence of internal bleeding, in which case stopping it is of paramount importance according to vital indications for the patient.

costal nerve block

The use of this anesthesia is indicated for fractures of the ribs to eliminate pain impulses, prevent the development of shock, and ensure adequate respiratory movements of the chest.

The application of this technique is to anesthetize the intercostal nerves corresponding to the affected area. It is necessary to anaesthetize the area of the nerve located closer to the spine. Having determined the place of anesthesia according to it, the skin is anesthetized, and then, prescribing a solution of novocaine, the needle is advanced until it rests on the rib. Then the needle slides along the surface of the rib, first down (half the dose of anesthetic is injected), and then up (the rest of the drug is injected).

Contraindications for this anesthesia, as well as for other types of local anesthesia, are the presence of skin diseases at the injection site, scars that make it difficult for the needle to enter.

Infiltration anesthesia

Method of application. Beforehand, it is necessary to make preoperative preparation according to all the rules, taking into account the general condition of the patient.

The shortest access is determined and, taking it into account, an anesthetic is injected intradermally. Often this is a solution of novocaine in low concentration. Each new portion of the substance is injected into the edge of the nodule formed by the previous injection, thus an anesthetic infiltrate in the form of a lemon peel is created over the entire area of the future incision. Then, moving the needle deeper into the subcutaneous tissue, a new portion of the anesthetic solution is injected.

Subcutaneous tissue is also infiltrated over the entire incision area. Only after this is the dissection of the skin and subcutaneous tissue with a scalpel.

Next, layer-by-layer infiltration of muscle layers is performed, taking into account their anatomical structure. Since the muscles are in fascial cases, the distribution of the solution through the cases to the degree of tight infiltration with the drug provides sufficient anesthesia for all nerve trunks and endings. It is important to administer a sufficient amount of the drug until the desired effect is achieved.

9. Intravenous anesthesia and pararenal blockade

intravenous anesthesia. Most often, this type of anesthesia is used in traumatology, since it ensures that the anesthetic enters the vessels, from which it spreads to the nerve trunks, and anesthesia of the entire limb. As a rule, such anesthesia is necessary for the reposition of bone fragments in fractures, reduction of dislocations, primary and secondary surgical treatment of extensive wounds. A feature of this method is the isolation of blood circulation from the systemic blood flow to exclude the ingress of an anesthetic substance into it and the development of undesirable systemic effects. For the implementation of anesthesia, it is necessary to raise the limb for several minutes in order to empty the vessels of the limb as much as possible. After that, a tourniquet must be applied to the limb to compress the arteries that feed the limb. An alternative to a tourniquet can be a cuff from a pressure measuring device, into which air is injected until a pressure exceeding the pressure in the arterial system is reached, and left for the duration of surgical procedures. The volume of surgical intervention or manipulations on the limb is small, in this regard, intravenous anesthesia is widely used for these purposes. Another limitation is the need for careful, slow removal of the cuff or tourniquet in order for the substance to slowly enter the systemic circulation. The use of this method is contraindicated in the presence of a history of allergic reactions to novocaine or other anesthetics.

Perinephric blockade. With this type of anesthesia, a solution of novocaine or another anesthetic is injected into the perirenal tissue, where it spreads and affects the nerve plexuses - the renal plexus, the solar plexus, and also the celiac nerves. As a result, pain sensitivity is turned off in the region of innervation of these plexuses.

Anesthesia technique. The point to be guided by when introducing a needle with a solution of novocaine or other anesthetic is the top of the angle formed on one side by the longest muscles of the back, and on the other side by the twelfth rib. On the bisector of this angle, stepping back 1 cm, find a point. At this point (on one or both sides) the skin is anesthetized. Then, pre-sending a solution of novocaine, carefully and slowly advance the needle inward at a right angle. The feeling of failure indicates that the needle has entered the perirenal tissue. In order to make sure, you need to pull the syringe plunger towards you. If at the same time blood does not appear in the syringe, then the needle is in the fiber, in this case, a novocaine solution is injected. If blood appears in the syringe, this indicates that the needle has entered the vessel.

Contraindications and precautions, as in previous cases, are associated with the possibility of developing an overdose of the drug and the appearance of an allergic reaction to it.

10. Spinal anesthesia

General issues. This is one of the most effective methods of pain relief. Its mechanism of action is associated with the introduction of an anesthetic solution into the subarachnoid space of the spinal cord. At the same time, the posterior roots of the spinal cord are blocked and the sensory and motor fibers below the site of anesthesia are turned off. This property of subarachnoid anesthesia is associated with the impossibility of using this type of anesthesia during surgical interventions on organs whose innervation centers are located above the centers that innervate the diaphragm. In this case, turning off the motor fibers will lead to paralysis of the diaphragm and respiratory arrest.

To facilitate access, the patient should sit or lie on his side, bending his back as much as possible and pressing his head to his knees. In this position, the distance between the spinous processes of the vertebrae is greatest, this provides correct access. As a rule, the injection of a needle leads to a reflex straightening of the back. In order to keep the patient in a bent back position, an assistant is needed to hold the patient in the desired position (sometimes you have to resort to the help of several people).

Concentration is important, all assistants must strictly obey the instructions of the doctor conducting this type of anesthesia. Since the meaning of anesthesia lies in the penetration of the needle into the subarachnoid space, it is necessary to carefully observe the rules of asepsis and antisepsis to exclude the development of purulent-inflammatory complications. The needle injection zone is located in the middle of the distance between the spinous processes of II and III or III and IV of the lumbar vertebrae. Usually, at the same level with the spinous processes of the IV lumbar vertebra, there is a line connecting the anterior superior iliac spines. The skin at the site of the proposed injection of the needle is carefully treated with alcohol, then it is anesthetized with a solution of novocaine, after which the needle is inserted strictly along the midline of the body between the spinous processes. Produce rotational movements, the needle is injected slowly, pre-sending a solution of novocaine.

The sensation of a needle failure may indicate being in the subarachnoid space. For clarification, the fluid flowing out of the needle is observed after the mandrin is removed from it. If it is a clear yellowish liquid, it is most likely cerebrospinal fluid, then the needle is inserted correctly and is in the subarachnoid space. If blood is released from the needle, it means that the puncture was performed incorrectly, and the needle is removed, after which all manipulations are repeated, inserting the needle between other spinous processes. Before anesthesia, a small amount of cerebrospinal fluid is taken into the needle, it is mixed with a novocaine solution, and then injected into the subarachnoid space. In order to avoid the expiration of the CSF, the puncture site is hermetically sealed with a plaster.

11. Anesthesia. Its components and types

Anesthesia is an artificially induced deep sleep with loss of consciousness, analgesia, inhibition of reflexes and muscle relaxation. Anesthesia is a complex multi-component procedure that includes:

1) narcotic sleep (caused by drugs for anesthesia). Includes:

a) turning off consciousness - complete retrograde amnesia (events that happened to the patient during anesthesia are recorded in the memory);

b) decrease in sensitivity (paresthesia, hypesthesia, anesthesia);

c) proper analgesia;

2) neurovegetative blockade. It is necessary to stabilize the reactions of the autonomic nervous system to surgical intervention, since vegetics is not largely controlled by the central nervous system and is not regulated by anesthetic drugs. Therefore, this component of anesthesia is carried out by using peripheral effectors of the autonomic nervous system - anticholinergics, adrenoblockers, ganglioblockers;

3) muscle relaxation. Its use is applicable only for endotracheal anesthesia with controlled breathing, but it is necessary for operations on the gastrointestinal tract and major traumatic interventions;

4) maintaining an adequate state of vital functions: gas exchange, blood circulation, normal systemic and organ blood flow. You can monitor the state of blood flow by the value of blood pressure, as well as (indirectly) by the amount of urine excreted per hour (urine debit-hour). It should not be lower than 50 ml/h. Maintaining blood flow at an adequate level is achieved by blood dilution - hemodilution - by constant intravenous infusion of saline solutions under the control of central venous pressure; 5) maintaining metabolic processes at the proper level. It is necessary to take into account how much heat the patient loses during the operation, and to conduct adequate warming or, conversely, cooling the patient. Indications for surgical intervention under anesthesia are determined by the severity of the planned intervention and the patient's condition. The more severe the patient's condition and the more extensive the intervention, the more indications for anesthesia. Minor interventions in a relatively satisfactory condition of the patient are carried out under local anesthesia.

Classification of anesthesia according to the route of administration of the narcotic substance into the body.

1. Inhalation (narcotic substance in vapor form is supplied to the patient's respiratory system and diffuses through the alveoli into the blood):

1) mask;

2) endotracheal.

2. Intravenous.

3. Combined (as a rule, induction anesthesia with an intravenously administered drug, followed by the connection of inhalation anesthesia).

12. Stages of ether anesthesia

First stage. Analgesia (hypnotic phase, round anesthesia). Clinically, this stage is manifested by a gradual depression of the patient's consciousness, which, however, does not completely disappear in this phase. The most important change in this stage concerns pain sensitivity, which practically disappears. The remaining types of sensitivity are preserved.

Second stage. Excitation stage. In this stage, the patient loses consciousness, but there is an increase in motor and autonomic activity. The patient is not accountable for his actions.

The duration of this stage during ether anesthesia can reach 12 minutes. With the deepening of anesthesia, the patient gradually calms down, the next stage of anesthesia begins.

Third stage. Anesthesia sleep stage (surgical). It is at this stage that all surgical interventions are carried out. Depending on the depth of anesthesia, there are several levels of anesthesia sleep.

Signs of the first level, or stages of preserved reflexes.

1. Only surface reflections are absent.

2. Breathing is calm.

3. Pulse and blood pressure at the preanesthetic level.

4. The pupils are somewhat narrowed, the reaction to light is lively.

5. Eyeballs move smoothly.

6. Skeletal muscles are in good shape. The second level is characterized by the following manifestations.

1. Weaken and then completely disappear reflexes.

2. Breathing is calm.

3. Pulse and blood pressure at the donor level.

4. Pupils gradually dilate.

5. There is no movement of the eyeballs.

6. Relaxation of skeletal muscles begins. The third level has the following clinical

signs.

1. There are no reflexes.

2. Breathing is carried out only due to movements of the diaphragm, therefore shallow and rapid.

3. Blood pressure decreases, pulse rate increases.

4. Pupils dilate.

5. Skeletal muscles are completely relaxed.

6. The transition of the patient to this level of anesthesia is dangerous for his life.

The fourth level was previously called atonal, since the state of the organism at this level is, in fact, critical. The patient needs a complex of resuscitation measures.

1. All reflexes are absent, there is no pupil reaction to light.

2. The pupils are maximally dilated.

3. Breathing is superficial, sharply accelerated.

4. Tachycardia, thready pulse.

5. There is no muscle tone.

Fourth stage. Occurs after the cessation of the drug supply.

13. Certain types of anesthesia

Mask anesthesia. In this type of anesthesia, the anesthetic in the gaseous state is supplied to the patient's respiratory tract through a mask of a special design. The patient can breathe on his own, or the gas mixture is supplied under pressure. When carrying out inhalation mask anesthesia, it is necessary to take care of the constant airway patency. For this, there are several methods.

1. Throwing the head back and setting it in the retroflexion position.

2. Bringing the lower jaw forward.

3. Establishment of the oropharyngeal or nasopharyngeal duct.

Mask anesthesia is quite difficult to tolerate by patients.

Advantages of endotracheal anesthesia. it

ensuring constant stable ventilation of the lungs and preventing obstruction of the airways by aspirate. The disadvantage is the higher complexity of this procedure.

These qualities of endotracheal anesthesia determine the scope of its application.

1. Operations with an increased risk of aspiration.

2. Operations with the use of muscle relaxants, especially thoracic ones, in which there may often be a need for separate ventilation of the lungs, which is achieved by using double-lumen endotracheal tubes.

3. Operations on the head and neck.

4. Operations with turning the body on its side or stomach (urological, etc.), in which spontaneous breathing becomes very difficult.

5. Long-term surgical interventions.

In modern surgery, it is difficult to do without the use of muscle relaxants.

These drugs are used for anesthesia during intubated trachea, abdominal operations, especially during surgical interventions on the lungs (tracheal intubation with a double-lumen tube allows ventilation of only one lung). They have the ability to potentiate the action of other components of anesthesia, so when they are used together, the concentration of the anesthetic can be reduced. In addition to anesthesia, they are used in the treatment of tetanus, emergency therapy for laryngospasm.

For combined anesthesia, several drugs are used simultaneously. This is either several drugs for inhalation anesthesia, or a combination of intravenous and inhalation anesthesia, or the use of an anesthetic and a muscle relaxant (when reducing dislocations).

In combination with anesthesia, special methods of influencing the body are also used - controlled hypotension and controlled hypothermia. With the help of controlled hypotension, a decrease in tissue perfusion is achieved, including in the area of surgical intervention, which leads to minimization of blood loss.

14. Clinic of acute blood loss

Blood performs a number of important functions in the body, which are mainly reduced to maintaining homeostasis. Thanks to the transport function of blood in the body, a constant exchange of gases, plastic and energy materials becomes possible, hormonal regulation, etc. is carried out. The buffer function of blood is to maintain acid-base balance, electrolyte and osmotic balance.

The bleeding clinic consists of local and general signs of blood loss.

Symptoms of acute blood loss are a unifying clinical sign for all types of bleeding. Fatal blood loss is considered to be such a volume of blood loss when a person loses half of all circulating blood. The second important factor that determines the body's response to blood loss is its rate. With bleeding from a large arterial trunk, death can occur even with smaller volumes of blood loss. This is due to the fact that the compensatory reactions of the body do not have time to work at the proper level, for example, with chronic blood loss in volume. General clinical manifestations of acute blood loss are the same for all bleeding. There are complaints of dizziness, weakness, thirst, flies before the eyes, drowsiness. The skin is pale, with a high rate of bleeding, cold sweat can be observed. Orthostatic collapse, development of syncope are frequent. An objective examination reveals tachycardia, a decrease in blood pressure, and a pulse of small filling. With the development of hemorrhagic shock, diuresis decreases. In the analysis of red blood, there is a decrease in hemoglobin, hematocrit and the number of red blood cells.

There are several degrees of severity of acute blood loss.

1. With a deficit of circulating blood volume (BCC) of 5-10%. The general condition is relatively satisfactory, there is an increase in the pulse, but it is of sufficient filling. Arterial pressure (BP) is normal. When examining blood, hemoglobin is more than 80 g / l. On capillaroscopy, the state of microcirculation is satisfactory: on a pink background, fast blood flow, at least 3-4 loops.

2. With a deficiency of BCC up to 15%. General condition of moderate severity. There is tachycardia up to 110 in 1 min. Systolic blood pressure drops to 80 mm Hg. Art. In the analysis of red blood, a decrease in hemoglobin from 80 to 60 g / l. Capillaroscopy reveals fast blood flow, but on a pale background.

3. With a deficiency of BCC up to 30%. General serious condition of the patient. The pulse is threadlike, with a frequency of 120 beats per minute. Arterial pressure drops to 1 mm Hg. Art. With capillaroscopy, a pale background, slowing of blood flow, 60-1 loops.

4. With a BCC deficit of more than 30%. The patient is in a very serious, often agonal condition. Pulse and blood pressure on the peripheral arteries are absent.

15. Clinical picture of various types of bleeding

It is possible to clearly determine from which vessel the blood is flowing only with external bleeding. When the arteries are damaged, the blood is poured into the external environment in a strong pulsating jet. Scarlet blood. This is a very dangerous condition, since arterial bleeding quickly leads to critical anemia of the patient.

Venous bleeding, as a rule, is characterized by a constant outflow of blood of a dark color. But sometimes (when large venous trunks are injured), there may be diagnostic errors, since transmission pulsation of the blood is possible. Venous bleeding is dangerous with the possible development of an air embolism.

With capillary bleeding, there is a constant outflow of blood from the entire surface of the damaged tissue (like dew). Especially severe are capillary bleedings that occur when traumatizing parenchymal organs (kidneys, liver, spleen, lungs). This is due to the structural features of the capillary network in these organs. Bleeding in this case is very difficult to stop, and during surgery on these organs it becomes a serious problem.

With various types of internal bleeding, the clinic is different and not as obvious as with external bleeding.

Methods for determining the volume of blood loss. Libov's method is used for surgical interventions. The amount of blood lost by patients during the intervention is defined as 57% of the mass of all gauze pads and balls used.

Method for determining blood loss by specific gravity of blood (according to Van Slyke). The specific gravity of blood is determined using a set of test tubes containing a solution of copper sulphate in various dilutions. The analyzed blood is successively dripped into the solutions. The specific gravity of the dilution in which the drop does not sink and lingers for some time is considered equal to the specific gravity of blood. The volume of blood loss is determined by the formula:

Ukr \u37d 1,065 hours (XNUMX - x),

where Ukr - volume of blood loss;

x - a certain specific gravity of blood, as well as according to the Borovsky formula, taking into account the value of hematocrit and blood viscosity. This formula is slightly different for men and women.

DCCm = 1000 × V + 60 × Ht - 6700; DCCzh \u1000d 60 × V + 6060 × Ht - XNUMX,

where DCKm - deficiency of circulating blood for men;

DCKzh - deficiency of circulating blood for women;

V - blood viscosity;

Ht - hematocrit.

The only drawback of this formula can be considered a certain inaccuracy of the values determined with its help in the early period after blood loss, when compensatory blood dilution (hemodilution) has not yet occurred. As a result, there is an underestimation of blood loss.

16. Stop bleeding

Temporary stopping methods

1. Finger pressure. A method to stop bleeding immediately. Places of digital pressure of the arteries:

1) carotid artery. The inner edge of the sternocleidomastoid muscle is at the level of the upper edge of the thyroid cartilage. The artery is pressed against the carotid tubercle on the transverse process of the VI cervical vertebra;

2) subclavian artery. It is possible to achieve blood flow restriction through it by moving the arm as far back as possible in the shoulder joint;

3) axillary artery. It is pressed in the armpit to the humerus. The approximate place of pressing is along the front border of hair growth;

4) brachial artery. Presses against the shoulder bone. The approximate place of pressing is the inner surface of the shoulder;

5) femoral artery. Presses against the pubic bone. The approximate place of pressing is the border between the middle and inner thirds of the inguinal ligament.

2. Maximum flexion of the limb in the joint with the roller (arterial) using:

1) pressure bandage;

2) tourniquet. It is applied proximal to the site of injury for arterial bleeding, distally for venous bleeding. Using a tourniquet for arterial bleeding, it can be applied for a maximum of 1,5 hours. If after this time the need for its use persists, it is dissolved for 15-20 minutes and then applied again, but to another place;

3) clamping on the vessel in the wound;

4) temporary arthroplasty; 5) exposure to cold (with capillary bleeding).

Final stop methods

1. Ligation of the vessel in the wound.

2. Ligation of the vessel throughout.

3. Vascular suture.

4. Vascular transplantation.

5. Vessel embolization.

6. Vessel prosthetics.

7. Laser coagulation.

8. Diathermocoagulation.

Biochemical methods of influencing the hemostasis system.

1. Methods affecting the body as a whole:

1) transfusion of blood components;

2) platelet mass, fibrinogen intravenously;

3) cryoprecipitate intravenously;

4) aminocaproic acid parenterally and enterally.

2. Methods of local influence:

1) tamponade of the wound with a muscle or omentum;

2) hemostatic sponge.

17. Blood transfusion. blood group affiliation

Blood transfusion is one of the frequently and effectively used methods in the treatment of surgical patients. The need for blood transfusion arises in a variety of situations.

The most common of them is acute blood loss, which can occur with traumatic damage to blood vessels during injuries, injuries, fractures. Bleeding can occur not only with direct damage to blood vessels, but also with closed injuries. Bleeding can occur with perforation of internal organs, which is a complication of many diseases.

Indications for blood transfusion are some conditions that occur during bleeding. These are hemorrhagic shock, anemia, surgical interventions associated with blood loss, profuse blood loss during complicated childbirth. Often blood can be transfused for immunological indications.

Both whole blood and its components (plasma, erythrocyte mass) and blood substitutes are subject to transfusion.

Whole blood can be obtained from donors, who must be carefully screened. Blood received from donors is examined for the presence of these diseases, its group affiliation is determined and recorded according to the ABO and Rhesus systems. On the package, the date of blood sampling, the name of the donor, the expiration date, and the group affiliation are recorded.

Blood storage can be carried out only by preventing its clotting, for this, sodium citrate is added to the blood. Blood is stored at a strictly defined temperature in special refrigerators.

The basic rule of blood transfusion must be observed strictly: the blood of the donor and the blood of the recipient must match the groups of the ABO system and Rh, and also have individual compatibility.

Currently, the ABO system is considered generally accepted. It is based on the allocation of individual blood groups according to the content of agglutinins and agglutinogens in them. The dependence of the formation of one or another blood type in a person is determined genetically.

In persons with I (O) blood group, there are no agglutinogens in erythrocytes, but there are agglutinins in serum (a and b). Owners of II (A) blood group have agglutinogen A and agglutinin b in the blood serum. People with III (B) blood group contain agglutinogen B in erythrocytes and have agglutinins (a) in serum. And, finally, the rarest blood group - IV (AB) - contains both agglutinogens in erythrocytes, but does not have agglutinins in serum. When the agglutinins of the same name interact with agglutinogens (for example, A and a), which is possible, say, when transfusing a donor with group II blood of a recipient with group III, an agglutination (gluing) reaction of erythrocytes will occur. These blood groups are incompatible.

18. Method for determining the blood group according to the ABO system

To conduct the study, standard hemagglutinating sera I (O), II (A), III (B), IV (AB) are required, and the first three variants of the serum should be presented in two series.

The serum must be suitable for use, for this it is imperative to check its compliance with the expiration date indicated on the serum label, and visually determine its condition. Serum should not be used if it is cloudy, contains impurities, flakes, suspension, has changed color.

The serum is considered suitable for use if it is transparent, the ampoule has a label indicating its main properties (series, expiration date, group affiliation, color marking according to the group affiliation), the ampoule is not damaged, not opened.

A clean plate is needed, which must be divided into four parts, noting the correspondence to each specific blood group, a scarifier needle, sterile cotton swabs, a clean, dry, fat-free glass slide, and alcohol. On a plate, in accordance with the marking, apply a drop of each serum. Then the skin of the pad of the fourth finger of the left hand is treated with a sterile cotton swab with alcohol. With the help of a scarifier, the skin is pierced, removing the first drop of blood that has come out (an admixture of alcohol and tissue fluid to it can distort the results of the study). The next drop of blood is taken with a corner of a glass slide, for each drop of serum - with a clean corner of the glass.

For research, a drop of blood is added to a drop of hemagglutinating serum in a ratio of 10: 1. Then, gently turning and shaking the plate, the blood is mixed. Agglutination usually comes to light in the form of loss of flakes which are well visualized. To clarify the result, an isotonic sodium chloride solution is added to the drop, after which the result is evaluated with sufficient reliability.

One of the prerequisites for the study is compliance with the temperature regime.

If hemagglutination occurs in a drop with serum I (O), III (B), but does not occur with serum II

(A), and the result is similar with the sera of two sera, which means that the studied blood belongs to group III (B) according to the ABO system.

If hemagglutination occurs in a drop with sera I (O), II (A), but does not occur with serum III

(B), this means that the analyzed blood belongs to the II (A) group according to the ABO system.

But such a situation is also possible when hemagglutination does not occur with any of the studied sera, and both series. This means that the studied blood does not contain agglutinogens and belongs to group I (O) according to the ABO system.

If agglutination occurs with all sera, and both series, this means that the test serum contains both agglutinogens (A and B) and belongs to group IV (AB) according to the ABO system.

19. Rh system

Conducting a biological test

The presence of angigens of the Rhesus system makes it possible to classify such persons as Rh-positive, the absence of it - as Rh-negative. Currently, when transfusing blood, they adhere to the rule of transfusing blood only of the same group according to the Rh system in order to avoid the occurrence of post-transfusion complications.

Express method for determining blood grouping according to the Rh system. For the study, it is necessary to have a standard anti-Rhesus serum belonging to the IV (AB) group according to the ABO system, a Petri dish, an isotonic sodium chloride solution, a 30% solution of rheopolyglucin, a clean, dry, fat-free glass slide. First, it is necessary to dilute the standard anti-Rhesus serum with a solution of rheopolyglucin and put a drop of it on a Petri dish. In addition, a drop of IV (AB) group serum, which does not contain antibodies, is applied to the Petri dish. A drop of blood is taken using the angle of a glass slide, added to a drop of serum and gently mixed. A drop is taken from another angle to be added to another serum and also mixed. The preliminary result is evaluated after 4 minutes, then a drop of isotonic sodium chloride solution must be added to each drop, and the final result is evaluated after 2 minutes. If no flakes of agglutination are observed in both drops, this indicates that the blood under test is Rh-negative. If agglutination occurred with both sera, the result of the study cannot be considered reliable. Finally, if agglutination occurs with anti-Rh serum, but does not occur with another, control, the blood is considered Rh-positive.

Finally, if it is found that the donor's blood and the recipient's blood match in ABO and Rhesus systems, a biological compatibility test must be performed for transfusion. Having connected the blood transfusion system, open the clamp and inject approximately 20 ml of the donor's blood in a jet, then close the clamp and carefully observe the patient's reaction for 3 minutes. If facial flushing, psychomotor agitation are observed, the patient tends to stand up, inappropriate behavior, tachycardia and tachypnea, and a decrease in blood pressure may be noted. Increased breathing may be combined with a feeling of lack of air. Such a reaction is an absolute contraindication for transfusion of this donor's blood to this recipient. If the biological test is not accompanied by the appearance of a similar reaction when repeated twice, it is considered suitable for transfusion. The transfusion is continued, however, during the entire time it is necessary to carefully monitor the recipient's condition, his blood pressure, body temperature, general condition, respiratory rate and rhythm, evaluate the frequency and quality of the pulse, pay attention to the subjective sensations of the patient: a feeling of heat, a feeling of lack of air, skin itching, pain in the lumbar region, chills, etc. Such monitoring of the patient's condition is carried out within 4 hours after blood transfusion.

20. Blood substitutes

In addition to blood products, transfusion of blood-substituting fluids may be necessary for adequate therapy. Different conditions require different composition and mechanism of action of transfusion media. The transfusion of transfusion media is carried out to meet a number of objectives.

1. Replenishment of the BCC. If, as a result of extensive blood loss or dehydration of another origin, such as profuse vomiting, there was a sharp decrease in the volume of circulating blood, then severe hypovolemia can lead to the development of such a formidable complication as shock. In addition, even with minor blood loss and a favorable response to blood transfusion, it is not recommended to transfuse more than 500 ml, since this significantly increases the risk of post-transfusion complications. To correct hypovolemia and microcirculation disorders, transfusion of hemodynamic colloidal solutions is performed. The most commonly used 10% solution of low molecular weight dextrans - rheopolyglucin. This substance has a variety of properties, the main of which are the replacement of BCC deficiency, an increase in rheological properties, the ability to improve microcirculation by reducing the aggregation of blood cells, and reducing its viscosity. The drug is used for shocks of various origins, severe intoxication, poisoning, with severe purulent-inflammatory diseases (peritonitis), in the treatment of burn disease. The drug is excreted by the kidneys, so severe chronic kidney disease is a contraindication for its use.

2. Removal of toxins from the body. Such a problem arises in various conditions, such as acute and chronic poisoning, prolonged compression syndrome, burn disease, sepsis, severe purulent-inflammatory and infectious diseases, and other conditions accompanied by the entry of a significant amount of toxic substances into the blood. In such situations, the introduced transfusion media are intended to relieve severe intoxication. Hemodez is a water-salt solution of a low molecular weight polymer compound. Due to its chemical structure, it is able to bind toxic substances, dilute the concentration and remove them through the kidneys. Similar to rheopolyglucin, the drug is not recommended for use in patients with severe chronic kidney disease, especially those accompanied by the formation of renal failure and bronchial asthma.

3. Nutritional function. A number of drugs are used with the main function - parenteral nutrition.

It must be remembered that the effective effect of transfusion media is possible only if forced diuresis is provided, adequate to the volume of incoming fluid, carried out by introducing a solution of diuretics at the end of the system, for example, lasix (furosemide).

21. Complications of blood transfusion

The most severe and still occurring complications of hemotransfusion should be considered hemolytic complications (primarily hemotransfusion shock). This complication develops during transfusion of other group blood. At the same time, massive hemolysis of erythrocytes develops in the vascular bed, the released hemoglobin enters the renal tubules and clogs them, as it settles in acidic urine. Acute renal failure develops.

The clinical picture is dominated by manifestations of cardiovascular insufficiency, systolic blood pressure may drop to 50 mm Hg. Art. and below. Along with this, tachycardia is observed, the pulse is so weak filling and tension that it is determined only on the central arteries. The patient's skin is pale, cold, covered with sticky cold sweat. In the lungs, dry rales are determined on auscultation. The leading symptom is renal failure, which is manifested by a decrease in the debit-hour of urine, less than 10 ml. Urine cloudy, pink. In laboratory parameters - azotemia.

Treatment of transfusion shock should be two-stage.

1. At the first stage, it is necessary to stop blood transfusion at the first signs of shock, leave the needle in the vein: massive infusion therapy will be carried out through it:

1) for infusion, both crystalloid solutions (5-10% glucose solution, Ringer-Locke solution, saline) and drugs that affect the rheological properties of blood (rheopolyglucin, solutions of hydroxylated starch) are used. The goal of infusion therapy is to stabilize systolic blood pressure at least at the level of 90-100 mm Hg. Art.;

2) it is also necessary to administer prednisone intravenously in an amount of 60-90 mg, which will lead to an increase in vascular tone, maintenance of blood pressure, and correction of immune disorders;

3) a bilateral pararenal blockade is performed with a 0,25% solution of novocaine in order to maintain intrarenal blood flow, as well as pain relief;

4) when blood pressure stabilizes, it is necessary to resort to diuretics - lasix in high doses (240-360 mg) intravenously - in order to reduce the severity of acute renal failure and prevent its progression.

2. At the second stage of assistance to a patient with hemotransfusion shock, measures from the group of symptomatic therapy are carried out. This group includes:

1) the appointment of antihistamines;

2) the use of cardiovascular drugs and analeptics;

3) the appointment of euffilin intravenously;

4) correction of violations of the acid-base state;

5) carrying out hemodialysis if indicated.

22. Pathophysiology of the wound process

phase of inflammation. The first stage on the way to wound healing. The process of wound healing begins from the moment when the bleeding stops in the wound under the action of plasma coagulation factors and platelet hemostasis. Acidosis is formed in the wound and surrounding tissues due to impaired blood supply to the damaged areas and the accumulation of organic acids. If the normal pH value of the internal environment of the body is 7,3, the pH in the wound can drop to 5 or even lower.

With excessive acidification in the wound, the processes of immune defense are disrupted, but in general, acidosis in the wound is protective in nature, since it prevents the active reproduction 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. There is an active exudation into the wound, which contributes to its cleansing. Simultaneous edema and swelling of the wound edges lead to their convergence and alignment, due to which the inflammation zone is delimited from the environment. At the same time, the edges of the wound are glued together with their exact comparison due to the loss of fibrin on the walls of the wound. In the wound, there is a change in metabolism, metabolic processes are shifted towards catabolism. Simultaneously, migration of inflammatory cells into the wound is observed. These cells, under the action of inflammatory mediators, release enzymes and biologically active substances into the wound.

Proteases promote the lysis of non-viable tissues. Oxidase prevents excessive accumulation of toxins. Superoxide dismutase leads to the accumulation of reactive oxygen species, which have a toxic effect on microorganisms.

Lipase destroys the protective membranes of microbial cells and makes them available for the action of other protective factors. At the end of the inflammation phase, the wound is cleared of decay products (if any), a smooth transition to the next phase. When the wound heals by primary intention, this phase is short and takes 2-3 days, but when the wound heals by secondary intention and suppurates, this phase can last more than a week.

proliferation phase. Lasts up to 14-28 days from the moment of injury. It is characterized by the predominance of granulation processes.

Granulation is a young connective tissue that contains a large number of cellular elements capable of proliferation. Tissue trophism improves, new capillaries grow into newly formed tissues, microcirculation processes improve, and tissue edema decreases. Metabolic processes again shift towards anabolism.

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

23. General principles of wound care

In the treatment of accidental wounds, care should be taken to ensure that wound healing occurs by primary intention. This is provided by the primary surgical treatment of the wound.

At the stage of first aid, it is necessary to stop bleeding, the wound is closed with an aseptic bandage. If there is damage to the bone apparatus, splinting is performed. Surgical treatment of the wound includes:

1) stop bleeding;

2) revision of the wound cavity, removal of foreign bodies and non-viable tissues;

3) excision of the edges of the wound, treatment with antiseptics;

4) comparison of the edges of the wound (suturing). Allocate:

1) primary surgical treatment (up to 6 hours from the moment of injury);

2) delayed surgical treatment (6-24 hours from the moment of injury);

3) late surgical treatment (after 24 hours after injury).

During the primary surgical treatment, the conditions are achieved under which the wound will heal by primary intention. In some cases, it is more appropriate to leave the wound to heal by first intention. When excising the edges of the wound, it is necessary to remove only those that are not viable, in order to then carry out an adequate comparison of the edges of the wound without strong tension (because with strong tension, ischemia of the wound edges occurs, which makes healing difficult).

The final stage of the first surgical treatment is the suturing of the wound. Depending on the time and conditions of application, the seams are distinguished:

1) primary. They are applied and tightened immediately after the initial surgical treatment. The wound is sutured tightly. The condition for applying primary sutures is that no more than 6 hours should pass from the moment of injury;

2) primary delayed sutures. After the primary surgical treatment of the wound, a thread is passed through all layers, but it is not tied. An aseptic dressing is applied to the wound;

3) secondary early sutures. Superimposed on a purulent wound after its cleansing and the beginning of granulation;

4) secondary late sutures. Superimposed after the formation of a scar, which is excised. The edges of the wound are compared.

Principles of active surgical treatment of purulent wounds and acute purulent surgical diseases.

1. Surgical treatment of a wound or purulent focus.

2. Drainage of the wound with PVC drainage and long-term washing with antiseptic solutions.

3. Early wound closure with primary delayed, early secondary sutures and skin grafting.

4. General and local antibiotic therapy.

5. Increasing the specific and nonspecific reactivity of the body.

24. Purulent infection

Violation of the rules of asepsis and antisepsis in surgery, both during and after surgery, can lead to a purulent infection. As a rule, a purulent-inflammatory process occurs at the site of the introduction of pathogen microbes into the wound. The onset and progression of inflammation is facilitated by a decrease in the overall resistance of the organism. Like any other disease, purulent inflammation of any localization occurs with a combination of an etiological factor, a susceptible organism, and environmental conditions in which they interact.

The etiological factor of purulent infection can be various microorganisms. These are staphylococci, Pseudomonas aeruginosa, streptococci, Escherichia coli and some others, which also cause purulent aerobic tissue inflammation. This type of infection is non-specific. Contamination of wounds with earth, deep closed wounds contribute to the occurrence of anaerobic infection, i.e. infection, a prerequisite for the occurrence of which is the almost complete impossibility of oxygen access to the wound. An example of such an infection is gas gangrene.

A specific surgical infection occurs when pathogens of diphtheria, tetanus, anthrax and some others enter the wound. In addition, putrefactive infection is isolated.

The entry of an etiological agent into the cellular spaces or cavities of the body leads to typical changes in cells and biologically active substances.

Any purulent inflammation is accompanied by the appearance of general and local symptoms of infection. Local symptoms include the following five: redness, pain, fever, swelling, and impaired function.

Some general symptoms of purulent intoxication are revealed. These include fever, often taking on a hectic character, weakness, lethargy, irritability, decreased performance, drowsiness, headache, lack of appetite, and some others.

The inflammatory process, localized in the organs and cavities of the body, inaccessible to direct examination, can be suspected if there are general symptoms of an infectious disease.

The general principles of treatment of purulent-inflammatory diseases include surgical and conservative methods of treatment.

Surgical, as a rule, include opening a purulent focus, cleansing it, washing it with disinfectants, an antibiotic solution, and draining the wound.

Conservative methods of treatment at the very beginning of the disease may include the use of some physiotherapeutic methods of treatment, such as exposing the infiltrate to high-frequency or infrared radiation, the use of anti-inflammatory ointments, the use of antibiotics orally and parenterally, the use of agents that increase the general nonspecific resistance of the organism, vitamins, parenteral detoxification -cation therapy in case of a serious condition of the patient.

25. General principles of therapy for purulent-inflammatory diseases

Conservative treatment is carried out at the infiltrative stage of the inflammatory process before the appearance of fluctuation, with slightly pronounced general phenomena, small purulent foci, which tend to be limited. Conservative treatment is largely represented by general measures. Three essential components are involved in the inflammatory process: the microbe-causative agent, the susceptible organism with reduced immunity, and the environment in which they interact. Therefore, the impact aimed at stimulating the body's defenses is no less important than the fight against an infectious agent. Such measures include adherence to bed rest with severe general symptoms of the disease, immobilization of the limb, if the inflammatory focus is on the limbs. Among the general measures of influence, the organization of proper nutrition of the patient is singled out. General principles of nutrition at the height of the disease, with high fever: nutrition is multiple, fractional, in small portions, an increased amount of protein in all purulent-inflammatory diseases, since it is lost with exudate. Abundant consumption of liquid is shown, especially compotes, fruit drinks from fresh fruits, rosehip broth. Apply biogenic stimulants, such as Chinese magnolia vine, ginseng. Activation of immune capabilities is carried out with the help of transfusion of hyperimmune plasma. Sometimes, for the purpose of detoxification, intravenous infusions of gemodez, dextrans (polyglucin, reopolylyukin), glucose with ascorbic acid, and salt solutions are performed. Polyglucin and reopoliglyukin belong to dextrans (glucose polymers). The mechanism of their action is associated with an improvement in the rheological properties of blood, a decrease in its viscosity, normalization of blood flow, and the removal of toxic substances from the body. To stimulate the immune system, autohemotransfusion is possible. Depending on the severity of the condition, it is possible to use various symptomatic drugs, since in severe forms of purulent-inflammatory diseases, numerous changes affect many organs and organ systems.

Etiological treatment includes antibiotic therapy. Before it is carried out, it is necessary to conduct a study of purulent discharge from the focus (inoculation on nutrient media) to verify the pathogen, to identify its sensitivity to antibiotics. Preference is given to intramuscular or intravenous administration. In the absence of data on the etiology of the process, broad-spectrum drugs (cephalosporins, tetracyclines, penicillins may be used) are immediately used or, based on the clinical picture, an assumption is made about the pathogen. In case of specific surgical diseases, specific treatment is carried out - the introduction of vaccines, sera, gamma globulins, in contact with a sick person or in the presence of a contaminated wound in the anamnesis, it is possible to carry out prophylactic vaccinations.

26. Local treatment. Incisions for purulent diseases

conservative methods of treatment. Local treatment of the disease in the infiltrate stage includes exposure to it using physiotherapeutic techniques, such as UHF, exposure to cold or heat (compresses, heating pads). Be sure to need local application of ointments, which include antibiotics, sulfa drugs.

Surgical treatment is the main method of treatment of purulent-inflammatory diseases. With small limited abscesses, panaritiums, mild general phenomena, treatment can be carried out on an outpatient basis. Diseases of moderate severity, abscesses and phlegmons of considerable size, purulent-inflammatory diseases of cavities, internal organs, boils located on the face are an indication for hospitalization and treatment in a hospital.

Depending on the size of the purulent focus, it is possible to use local or general anesthesia. The incision must be made at the site of the greatest fluctuation, always taking into account the location of anatomical formations: fascio-muscular sheaths, neurovascular bundles. The incisions must be made in parallel and stepping back from these formations. If there are deep streaks that do not allow cleansing the focus through the first incision, it is necessary to make another incision, determining its location along the finger located in the area of the streak. After opening the focus, it is cleansed of purulent exudate, tissue detritus, the focus is examined with a stupid finger to detect streaks. Then it is washed with an antiseptic substance, antibiotic solutions. After the end of the operation, the wound is never sutured tightly; for the best drainage, it is necessary to have an aperture and counter-opening, through which rubber drains are removed, through which the contents are drained. It is desirable to make an incision along the lowest level of the purulent focus. Dressings consist in removing the drains and replacing them with new ones, washing the wound with an antiseptic solution, filling the wound with an ointment containing an antibiotic, and applying an aseptic dressing. It is possible to use proteolytic enzymes, hypertonic sodium chloride solution - to reduce the effects of exudation and improve the outflow of pus.

Carbuncles should be dissected with a cruciform incision.

With subarareolar mastitis, when pus is located around the nipple, it is necessary to make a para-areolar incision, that is, an incision around the nipple of the mammary gland, if there is an abscess in the thickness of the mammary gland tissue, a radial incision is made parallel to the course of the milk ducts to prevent their damage. Intramammary: the abscess is located in the fiber located between the muscles of the chest wall and the breast tissue. In this case, the incision is made along the transitional fold of the breast.

With purulent parotitis, incisions are made parallel to the branches of the lower jaw.

In purulent-inflammatory diseases of the hand, incisions are made parallel to the location of the nerve fibers.

27. Mastitis

Mastitis is a purulent-inflammatory disease of the breast tissue. The most common microorganisms (causative agents of this process) are staphylococci, streptococci, Pseudomonas aeruginosa.

Penetration of the infectious agent occurs through cracks in the nipple (most often) or milk ducts. The hematogenous route of infection is extremely rare.

Invading, microorganisms receive a favorable environment for growth and reproduction, serous inflammation occurs. It is the initial stage of the process and can be reversible even with conservative treatment.

Subsequently, leukocytes begin to migrate to the focus, an increase in vascular permeability leads to the release of the liquid part of the blood into the tissue - exudate. These changes indicate successive infiltrative and suppurative stages of purulent inflammation of the mammary gland.

By localization, suareolar mastitis is distinguished, while the focus of inflammation is located around the areola, retromammary - inflammation is localized in the retromammary space, intramammary - the focus of inflammation is located directly in the breast tissue.

The disease develops rapidly. The first symptoms are associated with galactostasis and include intense pain of a bursting nature, mainly in one mammary gland. There is a violation of the secretion of milk from this gland, it increases in size, thickens.

The general health of the woman is deteriorating.

There are complaints of a general nature, including the appearance of fever, chills, most often aggravated in the evening, decreased performance, appetite, and sleep disturbance.

In the general blood test, an increase in the erythrocyte sedimentation rate (ESR), the appearance of leukocytosis with a shift of the leukocyte formula to the left are noted. When examining the patient, an increase in one mammary gland in volume, local redness and hyperemia are noted. When a focus of suppuration appears in the mammary gland, the general condition of patients worsens significantly, fever can take on a hectic character, and general complaints are expressed. When viewed in the mammary gland, there is a focus of redness, over which softening (fluctuation) is determined.

Surgical treatment includes opening and drainage of the focus. Depending on the localization of the inflammation, paraareolar, radial incisions and an incision along the transitional fold of the mammary gland are isolated. The abscess is washed, exudate is removed, all streaks are cleaned, its cavity is sanitized, drainages are installed.

Common methods of treatment include a strict prohibition of feeding during illness (but milk must be expressed), use of drugs that suppress lactation.

When verifying the causative agent of the disease, antibiotic therapy is carried out, antibiotics are administered intravenously. Depending on the severity of the disease, detoxification therapy, vitamin therapy, and correction of water and electrolyte metabolism are sometimes indicated.

28. Mumps

Parotitis is a disease accompanied by purulent inflammation of the parotid salivary glands. Microorganisms-causative agents are similar to pathogens of other forms of purulent infection. The infection can penetrate into the gland directly through the excretory duct (retrograde way), by the lymphogenous way (for example, with festering tooth cysts) or, which is much less common, by the hematogenous way. The danger of the disease lies in the possible melting of the connective tissue partitions and the spread of inflammation to the cellular spaces of the neck, and sometimes even the mediastinum. Perhaps the development of paresis of individual branches and the main trunk of the facial nerve.

The onset of the disease is usually acute. The patient complains of weakness, malaise, lethargy and other manifestations of purulent intoxication. The formation of abscesses in the gland is accompanied by the appearance of puffiness, swelling and redness of the cheek, under the lower jaw. The skin becomes smooth, taut, in some places the symptom of fluctuation can be determined, here the skin is maximally thinned. On palpation, sharp pain is noted. The pain associated with the occurrence of edema and its spread to the surrounding tissues accompanies chewing, swallowing, opening the mouth, so patients prefer not to talk, consume only liquid food. With a detailed picture, it is possible to make a diagnosis already when examining a patient - the appearance of a patient with mumps is so typical. The oval of the face is deformed due to the protrusion of the cheek. When examining the oral cavity, one can note some swelling of the mucous membrane of the cheek, soft palate and pharynx from the side of inflammation. In the general analysis of blood, leukocytosis with a shift of the leukocyte formula to the left, an increase in ESR are possible.

Inpatient treatment is being carried out. The patient needs to ensure the rest of all muscles and formations involved in the process. To do this, it is completely forbidden to talk, chew, liquid food is allowed, preferably several times a day in small portions, preferably mechanical and chemical sparing, the food taken should not be hot or cold. Conservative treatment is possible in the early stages of the disease (UHF currents, warming compresses, etc.). Be sure to carry out antibiotic therapy, taking into account the sensitivity of the microorganism to it. Surgical treatment is indicated for the ineffectiveness of conservative therapy, the appearance of fluctuations. The incisions are made in places of determined softening, however, the topography of the facial nerve is strictly taken into account: one of the severe complications of the operation is paralysis of its branches due to their intersection. Be sure to conduct a thorough revision of the wound with the removal of all streaks, tissue detritus, purulent discharge, then washing with a solution of hydrogen peroxide and installing several drains at the incision sites. Washing the wound and replacing the drains is carried out daily.

29. Abscess and gangrene of the lung

Lung abscess is a limited focus of purulent inflammation of the lung tissue. The most common causative agent of purulent inflammation in the lung is Staphylococcus aureus. Gangrene of the lung is an unlimited inflammatory process in its tissue.

The clinical picture consists of general symptoms of purulent infection and local manifestations of the disease. The period of abscess formation is marked by the appearance of high fever (mainly in the evenings), accompanied by shaking chills. There is pain in the chest associated with the involvement of the pleura in the process.

Patients may complain of coughing with a scant amount of mucopurulent or purulent sputum. The appearance of shortness of breath of a mixed nature during physical exertion, and with a pronounced process, even at rest.

On examination, one can note an increase in the frequency of respiratory movements and the lagging of the diseased half of the chest from the healthy one in the act of breathing. Clinical research methods make it possible to identify the area of dull percussion sound and the area of increased voice trembling corresponding to it, and weakened vesicular breathing is determined by auscultation. After formation, the abscess usually opens either in the bronchus, or with a subpleural location in the pleural cavity.

It is possible to suspect a breakthrough of a lung abscess into the bronchus when there are complaints about the discharge of a large amount of purulent fetid sputum with a full mouth, after which the patient feels significant relief almost immediately. Body temperature returns to normal, chest pain and shortness of breath decrease.

Clinical methods of examination make it possible to detect during this period a tympanic sound on palpation, and auscultatory - localized in accordance with the zone of the focus coarse moist rales. In the general blood test, changes typical of purulent inflammation are revealed.

Gangrene of the lung is accompanied by extremely severe intoxication of the body. The disease quickly leads to the formation of respiratory failure. The sputum that is coughed up is hemorrhagic in nature. Clinical examination methods allow you to determine a dull percussion sound over the entire area of \uXNUMXb\uXNUMXbthe lung tissue. Auscultation reveals moist rales over the entire lung area.

The initial task is to cleanse, and subsequently the complete elimination of the focus of purulent inflammation. To do this, depending on the localization of the abscess, either it is drained, or instrumental drainage of the abscess and intrabronchial administration of antibiotics are used.

Surgical treatments for gangrene of the lung include removal of a lobe of the lung (lobectomy) or the entire lung (pneumonectomy).

Conservative methods of treatment after opening an abscess through the bronchus to improve drainage may include the use of expectorants, sputum thinners.

Currently, the main method of treatment of such diseases is antibiotic therapy.

30. Pleural empyema

An empyema is a collection of pus in body cavities. Inflammation of the pleural cavity, in which the exudate accumulating in it is purulent in nature, is called pleural empyema.

Empyemas are classified according to the location and extent of inflammation into limited and unlimited. Localized limited empyema are divided into apical (in the region of the apex of the lung), basal (in the region of the diaphragmatic surface of the lung), mediastinal (projected onto the medial surface of the lung facing the mediastinum), parietal (projected onto the lateral surface of the lung). Unlimited are divided into total, subtotal and small.

Acute empyema is accompanied by the presence of general and local symptoms. The onset of the disease is acute: fever appears, the temperature rises to significant values. Unlimited empyema is accompanied by the appearance of symptoms of intoxication. Involvement in the process of the pleura leads to the appearance of pain in the chest, aggravated by a deep breath. Often there are complaints of coughing with a small amount of sputum, symptoms of respiratory failure. On examination, a pronounced diffuse gray cyanosis is determined, patients often take a forced position with a raised head of the bed or sitting. When examining the chest directly, asymmetry is noted during breathing of the healthy and diseased half of the chest. When determining voice trembling over the area of inflammatory effusion, it is sharply reduced or not detected, percussion reveals a dull percussion sound. A tympanic percussion sound is determined above the compressed exudate of the lung. Auscultation over the purulent discharge reveals the absence of respiratory noises, hard breathing is determined over the compressed lung. A general blood test reveals general inflammatory changes - an increase in ESR, leukocytosis with a shift of the leukocyte formula to the left, sometimes a decrease in hemoglobin level is noted. In the biochemical analysis of blood - hypoproteinemia, hypoalbuminemia, dysproteinemia. The area of accumulation of pus is defined on the radiograph as a homogeneous blackout, a massive effusion can be suspected based on the presence of an oblique border of the shadow corresponding to the Ellis-Damuazo-Sokolov percussion line.

Treatment of the disease is divided into conservative and surgical methods. This is a pleural puncture that provides both a diagnostic and therapeutic effect. In addition to the passive, there is an active method of washing the pleural cavity - pleural lavage. It is advisable to take vitamin preparations, biogenic stimulants, such as tincture of ginseng, magnolia vine. Having diagnosed pleural empyema, it is necessary to immediately begin antibiotic therapy: first, with broad-spectrum antibiotics, after clarifying the sensitivity of microorganisms, prescribe the necessary antibiotic in compliance with the principles of antibiotic therapy.

31. Purulent mediastinitis

Mediastinitis is a purulent inflammation of the tissue of the mediastinum. The disease occurs during the transition of the inflammatory process from the cellular spaces located in the immediate vicinity (for example, tissue of the neck, penetrating wounds of the esophagus, purulent inflammation of the pleural membrane) or direct penetration of an infectious agent in case of injuries of the mediastinal organs.

Etiology. Pathogenic microbes that cause the development of inflammation of the mediastinal organs are not specific - they can cause purulent inflammation of any localization. First of all, they include staphylococci, streptococci, Escherichia coli, Proteus, Pseudomonas aeruginosa, etc.

In the presence of penetrating wounds, it is quite easy to suspect the occurrence of mediastinitis when typical symptoms appear. Some difficulties can be caused by the diagnosis of mediastinitis against the background of other inflammatory diseases. The classical picture of the disease is characterized by the appearance of predominantly acute, intensely dull pain in the depths of the chest, a feeling of heaviness, fullness, also spreading to the neck and (respectively, the area of pus localization) to the anterior or posterior surface of the chest. The pain is aggravated by pressure on the chest, with deep breathing. Compression of the lungs by inflammatory-enlarged organs of the mediastinum leads to the appearance of intense mixed dyspnea. Signs of a general inflammatory process are clearly manifested. They can appear against the background of complete well-being or join the existing symptoms of an inflammatory disease. Often there is a pouring sweat, chills, hectic body temperature. To confirm the diagnosis, an x-ray examination helps in many ways, which makes it possible to determine an increase in the shadow of the mediastinum in one direction or another, sometimes a compression of the lung.

Treatment of this disease is carried out in accordance with the basic rules of purulent surgery. So, surgical treatment includes determining the shortest access to the focus, removing detritus, tissue remnants, pus, washing the wound with an antibiotic solution, and draining. Active drainage can be performed with the injection of an antibiotic solution under low pressure and its subsequent aspiration through another drainage tube. It is necessary to inoculate the purulent discharge, determine the sensitivity of the microorganism to antibiotics and, in accordance with the information received, prescribe the necessary antibiotic (preferably parenteral administration of the drug). Until then, a broad-spectrum antibiotic may be used. If the cause of mediastinitis was a penetrating wound of the neck, esophagus, trachea, an operation is initially performed to restore the integrity of the damaged organ. If mediastinitis has developed as a transition of inflammation from the cellular spaces of the neck, it is first necessary to sanitize the primary focus of infection, carefully removing detritus and possible pus streaks.

32. Furuncle, carbuncle

A furuncle is an inflammation of the hair follicle, the sebaceous gland adjacent to it, and the tissue around these formations.

Carbuncle is a more extensive process involving several sebaceous glands, hair follicles, surrounding tissues, not only with skin, but also with subcutaneous fat. The most common causative agents of these diseases are strepto- or staphylococci.

The entire period of formation and reverse development of a boil, as a rule, does not take more than 5-7 days. Multiple boils are called furunculosis. In the center of the head of the boil is a hair. The furuncle itself is at first a pustule (abscess) of a bright scarlet color with a purulent white head on its top. In patients, it causes unpleasant painful sensations when touched, sometimes a slight itch.

On palpation, an infiltrate is determined around the boil. The top of the abscess first dries up, and then is rejected along with pus, hair, necrotic tissues. After cleansing, the wound heals.

Frequent localization of the carbuncle is the scalp, neck, back, lower back. The carbuncle has a larger size, the beginning of its formation is associated with the appearance of an infiltrate with a diameter of up to several centimeters. The skin over the infiltrate is stretched, hyperemic, shiny. On top of it there are multiple whitish heads. After some time, they are rejected, as a rule, along with necrotic tissues, hair shafts. In its place, a more significant skin defect is formed.

Common complaints with carbuncles and boils: body temperature is often subfebrile, malaise, headache, loss of appetite are slightly expressed. A complete blood count reflects nonspecific signs of purulent inflammation - an increase in ESR, leukocytosis with a shift of the leukocyte formula to the left, sometimes signs of anemia.

The general methods of influencing the patient's body include measures of the regimen and proper nutrition. Bed rest is preferred. Meals should be high in calories, but easily digestible carbohydrates should be limited. It is desirable to introduce more than normal, the amount of protein-rich foods.

Local treatment is prescribed depending on the stage of the disease. At the beginning of the disease, it is possible to use physiotherapy procedures. Immediately after the diagnosis, it is necessary to start antibiotic therapy (broad-spectrum antibiotics) using intramuscular injections, local dressings with an ointment containing an antibiotic.

Surgical intervention - dissection of the formation with a cruciform incision in compliance with the rules of asepsis and antisepsis. Purulent discharge and altered tissues are removed, the wound is washed with an antibiotic solution and an aseptic dressing is applied to it with a solution of an antibiotic or proteolytic enzymes.

33. Abscess

An abscess is a formation limited by an infiltrative capsule, inside of which there is a cavity containing purulent exudate. The abscess does not tend to spread to surrounding tissues. An abscess can occur in any part of the body.

Etiology. The causative agent of the disease can be staphylococci, streptococci, E. coli, less often - other microorganisms. The formation of an abscess is associated with the penetration of microorganisms into tissues directly, for example, with injuries, wounds, injections of intact tissues or suppuration of infiltrates, hematomas and similar formations, suppuration of cysts. The conditions for the formation of abscesses in some organs are a violation of the outflow of contents from the glands and the attachment of an infection. Multiple abscesses in various organs occur with sepsis. An abscess is manifested by local and general symptoms of a purulent infection. Spontaneous breakthrough of an abscess into cellular spaces, body cavities is an unfavorable outcome. For recovery, it is necessary to cleanse the abscess from purulent contents by opening it outward.

The disease usually begins acutely. Common symptoms include fever, malaise, weakness, headache, loss of appetite. Local symptoms are represented by the main signs of inflammation - redness, pain in the projection of the abscess, hyperemia, swelling and dysfunction of the organ in which the abscess is located.

Usually, the presence of complaints is associated with any traumatic effects or medical manipulations carried out in violation of the rules of asepsis and antisepsis. If the abscess is located close under the skin, all signs of inflammation are well visualized.

An abscess is characterized by a symptom of fluctuation: a few days after the onset of an abscess, a softening appears in its center, which is easily determined by a bellied probe.

At the very beginning of the disease, when the abscess has not yet formed, but there are anamnestic data that suggest the possibility of its occurrence, it is permissible to use conservative methods of treatment.

These include physiotherapeutic methods, exposure to UHF currents. The presence of a purulent cavity is an indication for surgical treatment.

Its principles are identical for ulcers of various localizations. Sometimes, with a small abscess, a puncture is performed and the purulent exudate is removed.

When sowing it on nutrient media, the pathogen microorganism and its sensitivity to antibiotics are identified.

After that, it is advisable to conduct antibiotic therapy, taking into account the results of sowing.

After a puncture, solutions of antibiotics or antiseptics are injected into the cavity of the abscess, most often hydrogen peroxide. Sometimes, after a puncture, an incision is made along the needle to cleanse the cavity, remove streaks and detritus, then the cavity is washed with antibiotic solutions, dried and drains are installed. The drains are changed daily and the abscess cavity is sanitized.

34. Phlegmon

Phlegmon is a purulent inflammation of cellular spaces that does not tend to limit. Phlegmon is accompanied by more pronounced general symptoms than an abscess. The causative agents of phlegmon can be the same microorganisms that cause the formation of an abscess.

The causes of phlegmon are varied. To explain the mechanism of occurrence, it is necessary to know in detail the anatomical features of the cellular spaces and their relationship with various formations.

So, phlegmon can occur when an abscess breaks into the cellular spaces, suppuration of extensive hematomas, injuries and direct entry of infectious agents into the cellular spaces.

Having arisen in one place, pus begins to spread through the cellular spaces, fascial sheaths of muscles, along the course of the neurovascular bundles. This is extremely dangerous, because it leads to the appearance of foci of inflammation in other organs and cavities, and can lead to the appearance of purulent meningitis, sepsis, and arrosive bleeding.

The disease begins acutely, the general phenomena are very pronounced: weakness, irritability, malaise. The fever is hectic in nature, rises in the evening and is accompanied by chills. Symptoms of intoxication appear: lethargy, drowsiness, loss of appetite, tachycardia, increased respiratory movements, pallor of the skin.

Local manifestations of the disease include diffuse hyperemia, swelling, soreness. The skin becomes hyperemic, hot. Above the phlegmon, there is marked pain on palpation and a symptom of fluctuation.

Treatment is similar to that previously described for abscesses. The only difference can be the need for immediate antibiotic therapy, taking into account sensitive microflora and surgical treatment in compliance with the imposition of aperture and counter-opening, cleansing of streaks, removal of pus and necrotic tissues. The wound must be washed with solutions of antibiotics or antiseptics, several drains should be applied to improve the outflow of the contents. If necessary, detoxification therapy is carried out using hemodez, plasma transfusion, saline solutions.

35. Erysipelas

Erysipelas affects mainly the skin, sometimes mucous membranes. The causative agent of erysipelas is group A b-hemolytic streptococcus. Erysipelas is usually localized on the skin of exposed areas of the body: limbs, face, neck. For the occurrence of the disease, it is necessary for the pathogen to enter the damaged skin. This leads to the occurrence of serous inflammation of the skin. Depending on the level of the lesion, several clinical forms of the disease are distinguished. These are erythematous (reddening of the skin), bullous (blistering), phlegmonous and necrotic forms.

The erythematous form of erysipelas has such signs as very intense skin hyperemia, the contours of which are uneven and very clear, the area of hyperemia can be of any size, rises above the level of the skin. Subjectively, patients compare the sensation at the site of erysipelas with a nettle burn, in addition, they note intense pain. On palpation, swelling of the site, an increase in skin temperature and pain on palpation can be noted, but unlike pain, it is localized along the edge of the erythematous spot. Upon recovery, these changes undergo a reverse development.

The bullous form of the disease is characterized by the appearance of blisters filled with serous exudate against the background of the area of hyperemia, sometimes it takes on the character of serous-hemorrhagic.

The phlegmonous form of erysipelas is localized under the dermis in the subcutaneous fat, where the pathogen causes the development of purulent inflammation. Its localization on the extremities with mild changes in the skin makes it possible to differentiate this form from the usual phlegmon.

Extremely severe variants of the disease are manifested by necrotic changes in the skin. General symptoms of the disease, characteristic of all inflammatory diseases, manifest themselves to varying degrees depending on its form.

With the erythematous form, treatment at home is possible. But in any case, it is necessary to take into account the high degree of contagiousness of the patient. The degree of intoxication (in severe cases of the course of the disease) determines the detoxification therapy according to indications. With a significant increase in temperature, it is advisable to use antipyretic analgesics. Early antibiotic therapy allows you to interrupt the progression of the disease at the very beginning. Can be used drugs sensitive to streptococcus, from the group of penicillins (ampicillin, oxacillin, etc.), preferably parenteral administration of drugs. Local treatment for the bullous form of the disease can be carried out using antibiotic ointments. Phlegmonous and necrotic forms of the disease require surgical intervention in accordance with the general principles of surgical treatment for pyoinflammatory diseases.

36. Osteomyelitis

Osteomyelitis is an inflammatory process localized in the bone tissue. In this disease, the bone marrow is involved in the pathological process, as well as all the constituent parts of the bone tissue, the periosteum.

Etiology - pathogenic microbes common to all purulent-inflammatory diseases. They cause nonspecific osteomyelitis. Specific osteomyelitis can be caused by Mycobacterium tuberculosis, the causative agent of syphilis, and some others. The pathogen enters the bone structure in various ways. Direct penetration of microorganisms by direct contact is observed in the presence of open fractures and non-compliance with the rules of asepsis and antisepsis, when the pathogen penetrates the periosteum directly through the wound surface. Contact penetration of the pathogen is observed with a gunshot wound to the bone.

Another way of penetration - through the bone marrow - is carried out by the hematogenous route. It is realized in the presence of a focus of acute or chronic purulent-inflammatory disease in the body. With the blood flow, the microbial agent can be brought into the bone, while the inflammation spreads from the inside out. Children are most often affected by osteomyelitis, because the type of blood supply to the bone predisposes them to the penetration of microbes.

The clinical manifestations of the disease depend on the body's response to the introduction of an infectious agent. So, the disease can be manifested only by local symptoms or a pronounced reaction from all organs and systems of the body.

General symptoms of a purulent disease can be significantly expressed in osteomyelitis: an increase in body temperature to febrile numbers, headache, drowsiness, decreased performance. According to the temperature, the number of heart contractions, the frequency of respiratory movements increase, pallor of the skin may appear. Complaints intensify during the course of the underlying disease, or these complaints appear shortly after the inflammatory disease. Local symptoms of the disease may appear against the background of a gunshot wound or suppuration of a wound located on the limbs. Local symptoms are manifested by pain or a feeling of heaviness, bursting inside the bone. The affected limb swells, becomes hyperemic, the skin over the site of inflammation can be hot, the function of closely located joints is sharply disturbed. The patient spares the affected limb in every possible way, tapping along the axis of the limb is painful. The diagnosis becomes more obvious in the case of a purulent fistula that opens on the surface of the bone, from which pus is separated with pieces of necrotic bone.

Local treatment consists in creating an outflow for pus, cleansing the medullary canal and draining it. General treatment consists of detoxification, antibiotic therapy, adequate diet therapy, inpatient treatment with mandatory immobilization of the affected limb.

37. Purulent-inflammatory diseases of the hand

Purulent-inflammatory diseases of the hand are quite widespread among the population.

Their danger lies in the fact that with untimely treatment, the likelihood of complications is very high, among which there may even be a partial, and in rare severe cases, a complete loss of hand function. This is very important, because professional skills are lost, and it becomes necessary to retrain for another type of work.

Hand diseases are widespread among people engaged in physical labor, mainly workers of various profiles, etc.

Predisposing factors are violations of the rules of personal hygiene, as a result of which pathogenic microorganisms constantly accumulate on the hands. Basically, these are the same microbes as the causative agents of other purulent-inflammatory diseases, among them staphylococci, streptococci, Pseudomonas aeruginosa, Escherichia coli, Proteus, etc. skin, to which a person does not pay due attention, does not treat with an antiseptic solution, does not apply an aseptic bandage.

Especially conducive to the development of inflammation is the presence of a foreign body in the wound (for example, splinters or glass fragments). Microbes can penetrate into the soft tissues of the finger and with an accidental injection.

As a result of the changes described above, a typical inflammatory reaction occurs with the development of general and local changes. General changes do not differ from those in other purulent-inflammatory processes, the degree of their severity depends on the extent of the inflammatory process and the general reactivity of the organism. At the same time, there is a universal rule according to which the indication for surgical treatment of these diseases is the first sleepless night since the onset of the disease, associated with the severity of pain.

In addition, there is an increase in body temperature (sometimes up to febrile values), symptoms of purulent intoxication - headache, weakness, deterioration in performance, apathy, adynamia, loss of appetite, drowsiness, or, conversely, sleep disturbance.

Local symptoms of the disease include local signs of inflammation: this is pain at the site of inflammation, with the greatest pain occurring on palpation at the site of fluctuation, hyperemia, swelling, hot-to-touch skin over the site of inflammation, smoothness of the contours of the furrows and lines.

On examination, it is noted that the skin, hot to the touch, is thinned, tense, hyperemic, and shiny. The symptoms listed above are nonspecific and can be observed in any clinical form of purulent-inflammatory diseases of the hand. In addition, there are specific symptoms for each individual disease. Depending on the localization, it is possible to determine the involvement of certain areas in the pathological process and the likelihood of complications.

38. Clinical forms of felons. General principles of treatment

There are the following types of felons: cutaneous, subcutaneous, paronychia, articular, subungual, bone, tendon, pandactylitis.

Cutaneous panaritium is the most favorable and safe form of all panaritiums. In this case, the discharge accumulates under the epidermis, visually defined as a bubble filled with pus or hemorrhagic discharge. Its treatment consists in opening, treating with an antiseptic solution, and applying an aseptic dressing.

Subcutaneous panaritium is an accumulation of a predominantly purulent discharge under the skin. At the same time, general symptoms of a purulent disease may be noted, but most often they are expressed slightly. When viewed on one of the phalanges of the fingers, mainly proximal, a zone of swelling, hyperemia is determined, when examined with a bell-shaped probe, fluctuation can be determined, smoothness of the interphalangeal skin fold is noted.

Paronychia is inflammation of the periungual fold. On examination, its swelling, hyperemia, swelling, pain on palpation and pain in the area of the periungual roller are noted.

Subungual felon in some cases develops as a complication of paronychia, in others - as an independent disease. In this case, the purulent discharge accumulates under the nail plate, which leads to its swaying, pain on palpation of the distal phalanx and nail plate, and ultimately to its discharge.

Articular panaritium develops when the joint area is injured and infection occurs. At the same time, pain, swelling, swelling and hyperemia are most pronounced in the area of the affected joint, it is in a bent position, movements in the joint are impossible.

Bone panaritium is a complication of other types of panaritium, in which the inflammatory process extends to the bone. After a certain time, a purulent scanty discharge with detritus comes out through the wound.

Depending on the stage at which the inflammatory process is located, preference can be given to both conservative and surgical methods of treatment. So, at the initial stage of tissue infiltration, measures are shown that contribute to the resorption of the infiltrate. These are physiotherapeutic procedures, in particular electrophoresis, UHF.

At the stage of fluctuation, which is easily determined by a button-shaped probe during palpation of the inflammation zone, a surgical operation is performed in accordance with the basic rules of purulent surgery: an incision is made taking into account the anatomical and topographic formations of the hand, the cavity is cleaned of pus and tissue detritus, washed with an antiseptic solution, and installed drainage. Antibiotic therapy is shown taking into account the sensitivity of the isolated microflora to antibiotics.

39. Tetanus

Tetanus is a specific surgical infection, manifested by typical symptoms of tonic muscle contraction, in the most severe cases leading to the death of the patient from asphyxia.

There are general and local tetanus, as well as several clinical forms in accordance with the severity of the disease. Tetanus bacillus is an anaerobic microorganism that forms spores. It can stay in the soil for a long time in an inactive state (in the form of spores), and it enters the human body when injured. Penetrating into the body, the pathogen begins to release toxins: tetanospasmin and tetano-lysine. Tetanospasmin causes spasm and development of spasms of skeletal muscles, and tetanolysin - hemolysis of erythrocytes. The incubation period for tetanus is 4 to 15 days (sometimes extended to 31 days).

Local tetanus develops when the toxin acts on a limited area of the body, such as tetanus in one of the limbs. Often, local manifestations of tetanus precede its general manifestations. In addition to acute, there are chronic and erased forms of tetanus, as well as pronounced tetanus.

The disease begins with a prodromal period, the manifestations of which are common to many infectious diseases. This is a general malaise, weakness, headache.

The main sign suggesting tetanus at this stage of the disease is muscle contractions near the contaminated wound and at a short distance from it. After a few hours (sometimes days), the general symptoms worsen.

Among the specific symptoms of general tetanus, the appearance of convulsive twitches, and then tonic and clonic convulsions of the striated muscles of the body, is noted. The facial expression is called a sardonic smile. Tonic convulsions become more and more pronounced, then they acquire the character of a clonus. Spasms gradually involve in the process all the striated muscles of the body.

In the most severe cases, clonic convulsions take on the character of opisthotonus, which means that the contraction of all muscles acquires a maximum character.

Non-specific methods of treatment include a number of activities. Depending on the patient's condition, detoxification therapy, anticonvulsant therapy, including muscle relaxants, barbiturates, and tranquilizers, are indicated. Detoxification therapy is carried out with transfusion blood-substituting fluids (hemodez, plasma), saline solutions are used. Be sure to produce a wound toilet with the removal of all purulent-necrotic masses and washing the wound with an antiseptic solution. The operation ends with the obligatory installation of drains.

The methods of specific therapy for tetanus include the use of anti-tetanus serum and anti-tetanus gamma globulin.

40. Peritonitis. Etiology and pathogenesis

Peritonitis is an inflammation of the peritoneum with exudate, often of an acute nature, accompanied by pronounced shifts in the functioning of all organs and systems, severe disorders of water and electrolyte metabolism.

Anatomical features of the peritoneum. The peritoneum is a serous membrane. It has two sheets - visceral and parietal. The visceral sheet covers the internal organs of the abdominal cavity, and the parietal sheet from the inside is adjacent to the abdominal wall. Between the sheets there is a minimum amount of liquid that ensures the sliding of the sheets relative to each other. The serous membrane has a large number of receptors; therefore, exudate in the peritoneal cavity or fibrin filaments irritate the receptors, causing intense pain. The peritoneum provides metabolism and fluids. This provides a protective function of the peritoneum: the loss of fibrin threads and the participation of the omentum cause a limitation of the inflammatory process in the abdominal cavity. Such peritonitis are called abdominal abscesses. The nature of the exudate, as in other inflammatory processes, may be different. These are serous, purulent, serous-purulent, sometimes hemorrhagic and putrefactive contents. The limitation of inflammation in a certain area is usually carried out by soldering the sheets of the peritoneum using fibrin threads.

Etiology. The microbes that cause peritonitis are diverse. These include staphylococci, streptococci, Escherichia coli, Pseudomonas aeruginosa, Proteus, but mixed microflora predominates. In addition to nonspecific, specific peritonitis is also distinguished, for example, peritonitis with a tuberculosis infection of the body. For the occurrence of inflammation of the peritoneum, a change in the macroorganism is necessary - a violation of nonspecific resistance.

The infection penetrates into the peritoneal cavity in acute inflammatory diseases of the abdominal organs - appendicitis, pancreatitis, purulent cholecystitis, and usually in this case, purulent inflammation of the hollow organ first leads to an increase in the permeability of the organ wall and penetration into the abdominal cavity of microorganisms and discharge.

With the progression of the process and the absence of adequate therapy, the likelihood of perforation of the organ and the penetration of purulent contents in large quantities into the abdominal cavity increases.

Another cause of peritonitis is the penetration of infected contents during perforation of internal organs. This is extremely dangerous, because when a hollow organ is perforated, an extremely virulent microflora enters the peritoneum, causing a typical inflammation process.

An infectious agent can penetrate into the peritoneal cavity directly with penetrating wounds in the abdomen, after surgical operations if aseptic and antiseptic rules are not followed or sutures are not properly applied.

41. Peritonitis. Clinic and treatment

The onset of the disease is manifested by signs of a disease or pathological condition that led to the development of peritonitis.

At the beginning of the disease, the pain is located directly above the organ, the disease of which caused the development of peritonitis. The pain is very intense, it is constant, it is not relieved by antipyretic analgesics, patients tend to take a forced position.

An objective symptom of inflammation of the peritoneum is the Shchetkin-Blumberg symptom.

With limited inflammation of the peritoneum, this symptom can be positive only over the area of inflammation. On examination, local or extensive tension of the muscles of the anterior abdominal wall is noted, and with diffuse inflammation, scaphoid muscle retraction may be noted.

The most favorable outcome of the disease is the limitation of inflammation in a certain area.

In the initial phase of inflammation, vomiting may occur. In addition to the symptoms of the underlying disease that caused the development of peritonitis, there is a group of symptoms associated with the development of an extensive inflammatory process.

For the diagnosis of peritonitis, tachycardia is very important, since this disease has a characteristic symptom - a discrepancy between tachycardia and body temperature.

During laparoscopy at the beginning of inflammation, the peritoneum looks hyperemic, edematous, thickened, dull, sometimes rough. Usually, these changes are maximally expressed directly above the zone of the inflammatory focus.

A blood test reveals leukocytosis, initially insignificant, with a shift of the leukocyte formula to the left, ESR slightly above normal.

A biochemical blood test reveals a decrease in total blood serum protein, an increase in the level of fibrinogen, C-reactive protein, with inflammation of the internal organs, the appearance of specific markers may be noted.

Significant intoxication leads to the appearance of a characteristic appearance that appears with peritonitis. The face of such a patient is pale, the eyes are sunken, the facial features begin to sharpen, the nose and cheekbones protrude significantly on the face.

The next stage of the disease develops 3 days after the onset of the disease. There are severe disorders of hemodynamics, disruption of the activity of all organs and systems of the body, which in the final stage can lead to multiple organ failure and death.

At the initial stage of the disease, access should be able to eliminate the original cause of the disease. Produce median laparotomy, providing the necessary access to all organs of the abdominal cavity. The initial goal of treatment is to eliminate the immediate cause of the development of peritonitis. Then it is necessary to remove the exudate and sanitize the peritoneal cavity.

Finish the operation with the installation of drains. An antibiotic solution is injected into the peritoneal cavity.

42. Burns. Degrees of damage to the skin

Burns are damage to the skin as a result of exposure to high temperatures, concentrated acids or alkalis, and other chemically active substances.

According to the etiological basis, the following groups of burns can be distinguished: from exposure to high air temperature, high temperature liquids or solids, acids, alkalis and other chemically active substances. According to the nature of the skin lesion, coagulative necrosis and colic necrosis are distinguished.

Coagulation, or dry, necrosis occurs when the surface of the skin is exposed to acids, high temperatures (more than 60 ° C). The damage in this case is superficial, a hard dark crust forms on the skin - a scab - with clearly defined contours. Coliquational, or wet, necrosis occurs when the skin is exposed to alkalis, temperatures, relatively low - less than 60 ° C. In this case, the damage is deeper and spreads over a much larger area than the initially acting alkali.

According to the depth of the lesion, deep and superficial burns are distinguished. There is a classification according to which the depth of tissue damage during burns is divided into several degrees.

I degree - superficial burns, only the upper layer of the epidermis is affected, only hyperemia of the skin is visually determined. Subjectively, there is a feeling of heat, burning of the skin. Such burns often occur in people with a light skin type when exposed to sunlight. They require only conservative symptomatic treatment and pass on their own, leaving no permanent skin changes behind.

II degree - superficial burns, however, in addition to hyperemia, at the site of exposure to the factor, blisters with serous contents appear, resulting from the peeling of the surface layers of the epidermis from the underlying ones. Subjectively, more pronounced symptoms are noted: burning sensation, heat, pain, palpation of the damaged area - soreness. Such burns are most often observed in everyday life, sometimes sunburns of this severity are noted. Treatment is conservative, it is forbidden to open blisters.

III degree - superficial burns, however, necrosis of the surface layers of the skin is noted. These burns are much more severe both in terms of the reaction from the whole organism, and in terms of the duration of recovery from them. Nevertheless, with this degree, the possibility of self-restoration of the upper layers of the skin remains.

IIIB degree - deep burns, the death of the entire dermis is noted with the involvement of hair follicles, sweat and sebaceous glands. When examining a burn, sensitivity to painful stimuli in the area of damage is determined. Deep burns are accompanied by loss of pain sensitivity. Urgent hospitalization in a burn hospital is required for adequate local (surgical) and general treatment.

IV degree - deep burns, in which not only all layers of the skin, but also the underlying subcutaneous fat, muscle tissue and even bone can be damaged.

43. Determination of the area of the burn. The pathogenesis of the lesion

In order to determine the area of the burn, several methods are used. The simplest, not requiring additional tools and fairly accurate method is the "palm" method. After some research, it was reliably revealed that the size of the human palm corresponds to 1% of the skin of the human body. Thus, by comparing the area of the burn with the size of the palm, the exact area of the burn can be determined. Another rule for determining the area of a burn is also quite simple - this is the rule of "nines". It is known that the area of various areas of the body is 9% of the total surface of the skin, with the exception of the perineum, the area of which is 1%. 9% of the total area corresponds to the upper limb, thigh, lower leg with foot, as well as the head and neck. 18% of the total area are the anterior and posterior surfaces of the body.

Burn disease is a complex of pathophysiological changes in the body, the most important of which are hemodynamic disorders, severe intoxication of the body. Burn disease has several stages in its development. The first of these is burn shock. The leading pathogenetic aspect of its occurrence is severe dehydration of the body. This is hypovolemic shock. As a result of dehydration, there is a decrease in the volume of circulating blood. There is a discrepancy between the volume of the vascular bed and the amount of circulating blood. In addition, an increase in blood viscosity, resulting from the release of the liquid part of the blood into the tissues, causes a violation of microcirculation, blood slugging. Compensatory centralization of blood circulation occurs. Clinically, burn shock can be suspected in a patient if, during dynamic observation, a drop in blood pressure, an increase in heart rate, tachypnea, lethargy, and drowsiness are noted. It is necessary to make dynamic monitoring of renal function. Patients note thirst, during examination, dryness of the skin, mucous membranes, and tongue is noted.

If the burn shock was successfully stopped, the next stage of the course of the burn disease begins - acute burn toxemia. It is accompanied by the entry into the blood of a significant amount of toxic substances formed as a result of tissue breakdown. Toxico-resorptive syndrome is accompanied by the appearance of fever, its degree depends on the extent of the lesion. In addition, a significant amount of toxins affects all organs and systems, significantly disrupting their activities. Dynamic monitoring of laboratory parameters is necessary for the timely diagnosis of organ failure. The next period of septicotoxemia is accompanied by the development of purulent complications.

A burn wound is a gateway for the penetration of infectious agents into the body, and the purulent process can take on any character, up to sepsis.

44. Treatment of burns

Skin lesions in the form of burns are often found in young children as a result of insufficient attention from adults. Occupational burns occur as a result of non-compliance with safety regulations when working with chemically active and explosive substances. Burns as a result of exposure to various types of weapons are found among fighters in the battle zone. Sometimes burns occur during suicidal attempts.

Treatment depends on the degree, stage, extent of damage. It is generally accepted that treatment is divided into conservative and surgical, as well as local and general. Before treatment, it is necessary to make a primary toilet of the burn wound, treating its circumference with sterile cotton swabs dipped in warm soapy water. Foreign bodies, scraps of clothing, exfoliated epidermis are removed, blisters are opened with sterile instruments. There is an open way to treat burns. To do this, it is necessary to maintain a constant temperature in the room (to prevent the development of pneumonia and other complications, since the patient must lie without clothes) and optimal humidity. In order to prevent the development of purulent complications, the patient should be in an individual ward. Care for such patients should be extremely thorough, it is necessary to constantly straighten the sheet carefully to avoid the formation of bedsores. The surface of the burn wound is usually treated with antiseptic ointments. Depending on the degree of the burn, it is necessary to carry out adequate anesthesia, in severe cases even using narcotic analgesics, this will help alleviate the course of burn shock. Surgical treatment is indicated for deep burns. In the early stages, it consists in removing necrotic tissue. Deep burns are an indication for transplantation of the superficial layers of the skin. From an immunological point of view, in order to avoid the development of rejection, it is necessary to use your own surface layers of the skin as a donor, which are taken with a special tool. The skin flap is incised in a certain way, which allows it to stretch, and applied to the affected areas. Of great importance in the prevention and treatment of burn shock is adequate fluid transfusion. Hypovolemia, intoxication and thickening of the blood are indications for transfusion of hemodez, rheopolyglucin, saline solutions, plasma, albumin. Quite often appointment of antihistaminic preparations is shown.

If the burn occurred due to contact with the skin of chemicals, it is necessary to immediately begin washing the burn site under cool running water for 15-20 minutes. Usually this time is sufficient for complete removal of the substance from the surface of the skin. The same first aid for thermal burns. After that, it is necessary to apply a dry, clean bandage and consult a doctor. It is forbidden to treat the surface of the burn yourself, pierce or cut the bubbles.

45. Frostbite

Frostbite is a skin lesion resulting from disorders of microcirculation in the vessels associated with exposure to low temperatures on the skin. Exposure of the skin to cold leads to vasospasm.

Classification of frostbite by depth.

I degree - superficial frostbite, in which morphological changes in the skin do not occur, all the changes that have occurred are reversible. It is manifested by blanching of the skin, sometimes paresthesia in the form of tingling, however, pain sensitivity is completely preserved, since necrotic changes in the skin are not observed.

First aid for frostbite consists in warming the limb by any means, rubbing the affected area. The surface of the skin is treated with an alcohol solution and insulated, previously covered with a sterile bandage.

II degree - superficial frostbite, in which the surface layer of the epidermis is damaged. Despite this, the full restoration of the skin also occurs, but somewhat longer (up to 10 days).

A distinctive sign of frostbite of this degree is the appearance of blisters filled with serous contents at the site of the lesion. After opening the bladder, the skin looks thin, hyperemic, shiny, easily injured and very painful on palpation. The treatment of such frostbite is conservative; immediately after opening, an aseptic bandage is applied to them.

III degree - these frostbites are considered deep. Morphological changes that distinguish this form of lesion are accompanied by necrotic changes in the surface layer of the skin, dermis, up to the subcutaneous fat. When warmed, necrosis of the skin develops, regeneration does not occur, granulation tissue is formed, and subsequently a connective tissue scar is formed. When viewed after warming, the frostbite area looks extremely edematous, the skin is sharply hyperemic, cyanosis is noted in some places, sometimes blisters may form, their contents include an admixture of blood. It is necessary to treat microcirculation disorders. Produce intravenous infusions of rheopolyglucin, polyglucin, in order to prevent the development of purulent-inflammatory complications, antibiotic solutions are administered, to reduce the likelihood of blood clots - heparin, trental.

IV degree - deep frostbite - the highest degree of depth of damage when exposed to low temperatures. Necrotic changes develop not only in the skin, but also in the underlying tissues. Reverse regeneration is not possible. Reaction to any kind of stimuli is lost. The limb looks cyanotic, the skin is cold to the touch, active and passive, movements in the joints are impossible. After warming the limb, its color changes to dark qi-anotic, significant edema develops not only above the affected area, but also for a considerable distance from the site of the initial injury.

46. Soft tissue injuries

There are open (with damage to the integrity of the skin) and closed (without violation of the integrity of the skin) damage to soft tissues.

A bruise is a closed injury to soft tissues resulting from the impact of a mechanical factor of varying intensity. The main objective sign of a bruise is hemorrhage.

A bruise is accompanied by such a subjective symptom as pain at the site of injury. With small injuries, pain is not very significant, only when an extensive hematoma is formed, the pain can be intense. The bruise is accompanied by edema and swelling in the area of injury. Treatment of bruises is mainly symptomatic and consists in the local application of cold and various absorbable lotions.

Stretching and tearing. These injuries are also associated with the impact of a mechanical factor. This type of injury is typical for muscles and tendons. Both sprains and ruptures of muscles and tendons are accompanied by symptoms such as pain, swelling, swelling, dysfunction. The rupture is accompanied by a greater severity of subjective sensations, the pain at the time of the rupture is extremely intense, edema and swelling are expressed directly above the injury zone, the function of the muscle or tendon is completely lost.

Treatment for incomplete damage (stretching) is conservative, treatment for ruptures is surgical and consists in suturing the muscle or tendon in the most gentle position of the limb (most often flexion). Subsequently, the limb is immobilized in a functionally advantageous position until the integrity is fully restored.

Transport immobilization is a set of measures aimed at creating immobility of the body during transportation to the hospital.

Standard splints are represented by Cramer's ladder splint, the frame of which is effectively modeled for immobilization of the upper or lower extremities.

The Dieterikhs tire is used for immobilization of the lower extremities. It consists of wooden plates moving relative to each other, a plywood sole, fixed with special fasteners.

For immobilization in case of damage to the cervical spine, a Shants collar is used, which with its ends should rest against bone formations - the chest and mastoid processes of the temporal bone.

Pneumatic tires are very easy to use, the principle of operation of which is based on the creation of immobilization due to forced air.

Among the available tools, boards, sticks, even branches from trees, ski fragments are used. Fixation is carried out with the help of scarves, scarves, pieces of durable matter.

When carrying out transport immobilization, certain rules must be observed. Two adjacent joints must be fixed. Since the fixation is made to a solid base, it is necessary to protect the soft tissues from damage.

47. Bone fractures

A fracture is a damage to the bone resulting from mechanical impact, leading to a violation of its integrity. Fractures are classified according to the violation of the integrity of the skin into open, in which bone fragments damage the skin from the inside and can be seen in the depth of the wound on examination, and closed, when the skin is not damaged, and a fracture can only be judged by the presence of certain signs of a fracture. According to the nature of the damage, fractures are divided into transverse, helical, comminuted, oblique. This is judged by the nature of the relative position of the fragments of the distal and proximal ends of the bone, according to X-ray examination. According to the principle of displacement of fragments, fractures with displacement and without it are distinguished. The displacement of fragments can be rotational, and can occur along the length, width, axis. To determine the displacement, it is necessary to draw imaginary lines on the x-ray image corresponding to the axes of the distal and proximal fragments.

Closed fractures can be suspected in the presence of the following signs: the anamnesis reveals the presence of any injury with a typical mechanism, after which the patient felt pain, swelling, hyperemia, and sometimes dysfunction.

Swelling immediately forms at the fracture site as a result of swelling of the surrounding tissues.

On palpation and an attempt to displace the distal and proximal fragments, it is possible to determine the crunch of rubbing limbs (crepitus) and this is a pathognomonic sign of a fracture. The fracture causes pathological movement of the limb at the site of the fracture, there is a significant impairment of function, and active movement may be completely lost.

Open fractures are accompanied by the appearance of all the above symptoms, the presence of bone fragments in the wound is a reliable sign of a fracture. These fractures are accompanied by a significantly greater number of complications than closed ones. These include damage to the nerve trunks and vascular bundles, infectious complications, damage to internal organs, and malunion.

To confirm the presumptive diagnosis, it is necessary to produce x-rays, at least in two projections. The frontal (or frontal), lateral (or sagittal) and 3/4 views are usually required. X-ray images allow you to reliably diagnose the fact of a fracture, to clarify its nature.

If the victim has a closed fracture, it is strictly forbidden to perform reduction at the scene. It is necessary to perform anesthesia, transport immobilization with standard or improvised means, close the wound with an aseptic dressing, if necessary, stop the bleeding and take the patient to a specialized hospital. If the fracture is closed, after transport immobilization, the patient is taken to the hospital.

48. Principles of treatment of fractures

Treatment of fractures in the hospital consists of various methods of repositioning and fixing fragments in the required position. The general principles of treatment include proper nutrition and the use of drugs that accelerate the formation of bone regenerate.

For adequate anesthesia, it is enough to introduce 20-50 ml into the fracture area (depending on the massiveness of the damage, fractures of large bones require a larger amount of anesthetic). For anesthesia, the needle is injected directly into the hematoma, then the syringe plunger is pulled towards itself and, if blood appears in the syringe, the contents of the syringe are injected into the hematoma area. After anesthesia, repositioning is possible. Distinguish between open and closed reduction. Open reposition is carried out directly in the wound if the fracture is open. In addition, indications for open reposition is the interposition of soft tissues or bone fragments between fragments. Closed reposition is carried out by means of traction along the axis of the limb and control of its distal fragment. For repositioning, an assistant is needed to hold the proximal bone fragment. In accordance with the nature of the fracture, established by x-ray, reposition of fragments is performed. So, displacement along the axis is eliminated by traction along the axis of the limb, displacement along the width - by traction of the distal fragment in the opposite direction to the displacement. Rotational displacement is eliminated by traction along the axis of the limb with simultaneous rotation of its distal fragment in the direction opposite to the displacement, while simultaneously holding the proximal one. The effectiveness of manual reposition is controlled by the results of the X-ray image. If manual repositioning did not completely restore the axis, it is necessary to resort to hardware repositioning methods. Fixation of fragments in the correct position can be carried out by applying a plaster bandage that holds the fragments in the correct position.

There are methods of hardware reposition and fixation that allow not only to eliminate the displacement, but also to keep the fragments in the correct position until the bone regenerate is formed. These methods include skeletal traction, in which special spokes are passed through various bone protrusions, to which a load is attached. During reposition, the correct axis of the limb is determined by the proximal fragment. The largest load is used for fractures of the femur. Displacements are eliminated by creating a thrust opposite to the displacement of fragments. Fixation methods include closed and open osteosynthesis. Special tires CITO, the Ilizarov apparatus are widely used.

A favorable outcome of a fracture may be a complete restoration of the integrity of the bone with preservation of its function, less favorable - a fused fracture with partial dysfunction, the formation of a false joint, improperly fused fractures with preservation of function and its partial loss.

49. Sepsis

Sepsis is a generalization of an infection that occurs due to a breakthrough of the infectious onset into the systemic circulation. In the presence of a purulent focus and an increase in signs of intoxication, therapeutic measures to remove a local infection should be started as soon as possible, since purulent-resorptive fever turns into full-blown sepsis in 7-10 days.

The entrance gate is the site of infection. As a rule, this is an area of damaged tissue.

Distinguish between primary and secondary foci of infection.

1. Primary - an area of inflammation at the site of implementation. Usually coincides with the entrance gate, but not always.

2. Secondary, so-called metastatic or pyemic foci.

Sepsis classification

According to the location of the entrance gate.

1. Surgical:

1) acute;

2) chronic.

2. Iatrogenic.

3. Obstetric-gynecological, umbilical, neonatal sepsis.

4. Urological.

5. Odontogenic and otorhinolaryngological.

In any case, when the entrance gate is known, sepsis is secondary.

Sepsis is called primary if it is not possible to identify the primary focus (entrance gate). In this case, the focus of dormant autoinfection is assumed to be the source of sepsis.

By the rate of development of the clinical picture.

1. Lightning (leads to death within a few days).

2. Acute (from 1 to 2 months).

3. Subacute (lasts up to six months).

4. Chroniosepsis. By gravity.

1. Moderate severity.

2. Heavy.

3. Extremely heavy.

There is no mild course of sepsis. By etiology (type of pathogen).

1. Sepsis caused by gram-negative flora.

2. Sepsis caused by gram-positive flora.

3. Extremely severe sepsis caused by anaerobic microorganisms, in particular bacteroids.

phases of sepsis.

1. Toxemic.

2. Septicemia.

3. Septicopyemia (with the development of pyemic foci).

One of the important criteria for sepsis is the species uniformity of microorganisms sown from primary and secondary foci of infection and blood.

50. Pathogenesis of sepsis

Microorganisms are still considered the main cause of sepsis, which determines its course, and the virulence of the pathogen, its dose are of decisive importance (the titer of microorganisms must be at least 10: 5 per gram of tissue). The state of the patient's body should also be recognized as extremely important factors influencing the development of sepsis, and factors such as the state of the primary and secondary foci of infection, the severity and duration of intoxication, the state of the body's immune system are of decisive importance. Generalization of infection occurs against the background of allergic reactions to a microbial agent. With an unsatisfactory state of the immune system, the microorganism enters the systemic circulation from the primary focus. The intoxication that precedes and is maintained by the primary focus changes the general reactivity of the organism and forms a state of sensitization. The immune system deficiency is compensated by increased reactivity of nonspecific defense factors (macrophage-neutrophilic inflammation), which, coupled with the body's allergic predisposition, leads to the development of an uncontrolled inflammatory reaction - the so-called systemic inflammatory response syndrome. In this condition, there is an excessive release of inflammatory mediators both locally in the tissue and into the systemic circulation, which causes massive tissue damage and increases toxemia. Sources of toxins are damaged tissues, enzymes, biologically active substances of inflammatory cells and waste products of microorganisms.

The primary focus is not only a constant source of the microbial agent, but also continuously maintains a state of sensitization and hyperreactivity. Sepsis can be limited only to the development of a state of intoxication and a systemic inflammatory reaction, the so-called septicemia, but much more often pathological changes progress, septicopyemia develops.

Secondary purulent pyemic foci occur during metastasis of the microflora, which is possible with a simultaneous decrease in both the antibacterial activity of the blood and the violation of local protective factors. Microbial microinfarcts and microembolism are not the cause of the pyemic focus. The basis is a violation of the activity of local enzyme systems, but, on the other hand, the resulting pyemic foci cause activation of lymphocytes and neutrophils, excessive release of their enzymes and tissue damage, but microorganisms settle on the damaged tissue and cause the development of purulent inflammation. When it occurs, the secondary purulent focus begins to perform the same functions as the primary one, that is, it forms and maintains a state of intoxication and hyperreactivity. Thus, a vicious circle is formed: pyemic foci support intoxication, and toxemia, in turn, determines the possibility of developing foci of secondary infection.

51. Surgical sepsis

Surgical sepsis is an extremely severe general infectious disease, the main etiological moment of which is a violation of the functioning of the immune system (immunodeficiency), which leads to generalization of the infection.

By the nature of the entrance gate, surgical sepsis can be classified into:

1) wound;

2) burn;

3) angiogenic;

4) abdominal;

5) peritoneal;

6) pancreatogenic;

7) cholangiogenic;

8) intestinal.

Traditionally, the clinical manifestations of sepsis are considered to be such signs as:

1) the presence of a primary purulent focus;

2) the presence of symptoms of severe intoxication, such as tachycardia, hypotension, general disorders, signs of dehydration;

3) positive repeated blood cultures (at least 3 times);

4) the presence of the so-called septic fever;

5) the appearance of secondary infectious foci;

6) pronounced inflammatory changes in the hemogram.

A less common symptom of sepsis is the formation of respiratory failure, toxic reactive inflammation of organs, and peripheral edema. Often myocarditis develops. Violations in the hemostasis system are frequent, which is manifested by thrombocytopenia and increased bleeding.

For the timely and correct diagnosis of sepsis, it is necessary to have a solid understanding of the signs of the so-called septic wound. It is characterized by:

1) flaccid pale granulations that bleed when touched;

2) the presence of fibrin films;

3) poor, serous-hemorrhagic or brown-brown discharge from the wound with an unpleasant putrefactive odor;

4) cessation of the dynamics of the process (the wound does not epithelize, ceases to be cleaned).

To diagnose sepsis, blood cultures should be repeated despite negative results, and blood should be taken at different times of the day. In order to make a diagnosis of septicopyemia, it is necessary to establish the fact that the patient has bacteremia.

According to modern recommendations, the mandatory diagnostic criteria are:

1) the presence of a focus of infection;

2) previous surgical intervention;

3) the presence of at least three of the four signs of systemic inflammatory response syndrome.

52. Septic complications. Sepsis treatment

Infectious-toxic shock has a complex pathogenesis: on the one hand, bacterial toxins cause a decrease in the tone of arterioles and a violation in the microcirculation system, on the other hand, a violation of systemic hemodynamics is observed due to toxic myocarditis. In infectious-toxic shock, acute cardiovascular failure becomes the leading clinical manifestation. Tachycardia is observed - 120 beats per minute and above, heart sounds are muffled, the pulse is weak filling, systolic blood pressure decreases (90-70 mm Hg and below). The skin is pale, the extremities are cold, sweating is not uncommon. There is a decrease in urination. As a rule, a harbinger of shock is a sharp increase in temperature with chills (up to 40-41 ° C), then the body temperature drops to normal numbers, a complete picture of shock unfolds.

The main links of treatment.

1. Elimination of intoxication.

2. Sanitation of purulent-inflammatory foci and suppression of infection.

3. Correction of immune disorders.

In many ways, the same measures are used to achieve these goals (as detoxification therapy)

1. Massive infusion therapy. Up to 4-5 liters per day of plasma-substituting solutions (neocompensan, gemodez, rheopolyglucin, hydroxylated starch). When carrying out infusion therapy, special attention should be paid to the correction of electrolyte disturbances, changes in the acid-base state (elimination of acidosis).

2. Forced diuresis.

3. Plasmapheresis.

4. Lymph and hemosorption.

5. Hyperbaric oxygenation.

6. Removal of pus.

For the rehabilitation of foci of infection - local treatment:

1) removal of pus, necrotic tissues, wide drainage of the wound;

2) the use of topical antibacterial agents (levomecol, etc.).

Systemic treatment:

1) massive antibiotic therapy with the use of at least two broad-spectrum or targeted drugs, taking into account the sensitivity of the isolated pathogen. Antibiotics only parenterally (muscle, vein, regional artery or endolymphatic).

2) antibiotic therapy is carried out for a long time (for months) until a negative result of blood culture or clinical recovery, if the initial culture did not give growth.

Various methods can be used to correct immune disorders: the introduction of a leukocyte suspension, the use of interferon, hyperimmune antistaphylococcal plasma, in severe cases, the use of glucocorticosteroids.

53. Fundamentals of surgical oncology

Oncology is a science that studies the problems of carcinogenesis (causes and mechanisms of development), diagnosis and treatment, and prevention of tumor diseases. Oncology pays close attention to malignant neoplasms due to their great social and medical significance. Oncological diseases are the second leading cause of death (immediately after diseases of the cardiovascular system). Every year, about 10 million people fall ill with oncological diseases, half as many die from these diseases every year. At the present stage, lung cancer occupies the first place in terms of morbidity and mortality, which has overtaken stomach cancer in men, and breast cancer in women. In third place is colon cancer. Of all malignant neoplasms, the vast majority are epithelial tumors.

Benign tumors, as the name implies, are not as dangerous as malignant ones. There is no atypia in the tumor tissue. The development of a benign tumor is based on the processes of simple hyperplasia of cellular and tissue elements. The growth of such a tumor is slow, the mass of the tumor does not grow into the surrounding tissues, but only pushes them back. In this case, a pseudocapsule is often formed. A benign tumor never metastasizes, no decay processes occur in it, therefore, with this pathology, intoxication does not develop. In connection with all the above features, a benign tumor (with rare exceptions) does not lead to death. There is such a thing as a relatively benign tumor. This is a neoplasm that grows in the volume of a limited cavity, such as the cranial cavity. Naturally, tumor growth leads to an increase in intracranial pressure, compression of vital structures and, accordingly, death.

A malignant neoplasm is characterized by the following features:

1) cellular and tissue atypia. Tumor cells lose their former properties and acquire new ones;

2) the ability to autonomous, i.e., uncontrolled by organismal processes of regulation, growth;

3) rapid infiltrating growth, i.e. germination of surrounding tissues by a tumor;

4) the ability to metastasize. There are also a number of diseases that are precursors and harbingers of tumor diseases. These are the so-called obligate (a tumor necessarily develops in the outcome of the disease) and optional (a tumor develops in a large percentage of cases, but not necessarily) pre-fights. These are chronic inflammatory diseases (chronic atrophic gastritis, sinusitis, fistulas, osteomyelitis), conditions accompanied by tissue proliferation (mastopathy, polyps, papillomas, nevi), cervical erosion, as well as a number of specific diseases.

54. Classification of tumors

Classification by tissue - the source of tumor growth.

1. Epithelial:

a) benign;

b) malignant (cancer).

2. Connective tissue.

3. Muscle tissue.

4. Vascular.

5. Nervous tissue.

6. Blood cells.

7. Mixed tumors.

8. Tumors from pigment cells. International Clinical Classification for TNM

The letter T (tumor) denotes in this classification the size and prevalence of the primary focus. Each tumor localization has its own criteria, but in any case, tis (from the Latin Tumor in situ - "cancer in place") - not germinating the basement membrane, T1 - the smallest tumor size, T4 - a tumor of significant size with germination of surrounding tissues and decay .

The letter N (nodulus) reflects the state of the lymphatic apparatus. Nx - the state of regional lymph nodes is unknown, there are no distant metastases. N0 - verified the absence of metastases in the lymph nodes. N1 - single metastases in regional lymph nodes. N2 - multiple lesions of regional lymph nodes. N3 - metastases to distant lymph nodes.

The letter M (metastasis) reflects the presence of distant metastases. Index 0 - no distant metastases. Index 1 indicates the presence of metastases.

There are also special letter designations that are placed after a pathohistological examination (it is impossible to set them clinically).

The letter P (penetration) reflects the depth of tumor penetration into the wall of a hollow organ.

The letter G (generation) in this classification reflects the degree of differentiation of tumor cells. The higher the index, the less differentiated the tumor and the worse the prognosis.

Clinical staging of cancer according to Trapeznikov

I stage. Tumor within the organ, no metastases to regional lymph nodes.

II stage. The tumor does not grow into surrounding tissues, but there are single metastases to regional lymph nodes.

III stage. The tumor grows into the surrounding tissues, there are metastases in the lymph nodes. The resectability of the tumor at this stage is already doubtful. It is not possible to completely remove tumor cells surgically.

IV stage. There are distant metastases of the tumor. Although it is believed that only symptomatic treatment is possible at this stage, resection of the primary focus of tumor growth and solitary metastases can be performed.

55. Etiology, pathogenesis of tumors. Diagnosis of a tumor disease

A large number of theories (chemical and viral carcinogenesis, disembryogenesis) have been put forward to explain the etiology of tumors. According to modern concepts, a malignant neoplasm occurs as a result of the action of numerous factors, both external and internal environment of the body. The most important of the environmental factors are chemicals - carcinogens that enter the human body with food, air and water. In any case, the carcinogen causes damage to the genetic apparatus of the cell and its mutation. The cell becomes potentially immortal. With the failure of the immune defense of the body, further reproduction of the damaged cell and a change in its properties occur (with each new generation, the cells become more and more malignant and autonomous). Violation of cytotoxic immune reactions plays a very important role in the development of a tumor disease.

After about 800 divisions of the original cell, the tumor acquires a clinically detectable size. The entire period of the preclinical course of a tumor disease takes 10-15 years. 1,5-2 years remain from the moment when a tumor can be detected to death (without treatment).

Atypical cells are characterized not only by morphological but also by metabolic atypia. Due to the perversion of metabolic processes, the tumor tissue becomes a trap for the energy and plastic substrates of the body, releases a large amount of under-oxidized metabolic products and quickly leads to exhaustion of the patient and the development of intoxication. In the tissue of a malignant tumor, due to its rapid growth, an adequate microcirculatory bed does not have time to form (the vessels do not have time to grow behind the tumor), as a result, the processes of metabolism and tissue respiration are disturbed, necrobiotic processes develop, which leads to the appearance of foci of tumor decay, which form and maintain state of intoxication.

In order to detect an oncological disease in time, the doctor must have oncological alertness. Establishing a diagnosis based on obvious clinical signs (bleeding, sharp pains, tumor disintegration, perforation into the abdominal cavity, etc.) is already belated, since the tumor manifests itself clinically in stages. For the patient, it is important that the neoplasm be detected as early as possible, at stage I, then the probability that the patient will live after the treatment for 5 years is 80-90%. In this regard, screening examinations, which can be carried out during preventive examinations, acquire an important role.

Examination of an oncological patient must be completed with a histopathological examination of a suspicious formation. The diagnosis of a malignant neoplasm is untenable without morphological confirmation.

56. Cancer treatment

Treatment should be comprehensive and include both conservative measures and surgical treatment.

Surgical treatment may precede conservative measures, follow them, but a complete cure for a malignant neoplasm without removal of the primary focus is doubtful.

Surgery for cancer can be:

1) radical;

2) symptomatic;

3) palliative.

Radical operations imply the complete removal of the pathological focus from the body. This is possible due to the implementation of the following principles:

1) ablastics. During the operation, it is necessary to strictly observe ablastics, as well as asepsis. The ablasticity of the operation is the prevention of the spread of tumor cells in healthy tissues. For this purpose, the tumor is resected within healthy tissues, without affecting the tumor. In order to check the ablasticity after resection, an emergency cytological examination of the imprint smear from the surface remaining after resection is performed;

2) zoning. This is the removal of nearby tissue and regional lymph nodes. The volume of lymph node dissection is determined depending on the prevalence of the process, but it must always be remembered that the radical removal of lymph nodes leads to the occurrence of lymphostasis after surgery;

3) antiblasts. This is the destruction of locally advanced tumor cells, which in any case dissipate during surgery. This is achieved by chipping the circumference of the pathological focus with antitumor drugs, regional perfusion with them. Palliative surgery is performed if it is impossible to carry out a radical operation in full.

Symptomatic operations are performed to correct emerging disorders in the activity of organs and systems associated with the presence of a tumor node, for example, the imposition of an enterostomy or a bypass anastomosis in a tumor that obstructs the outlet section of the stomach.

Surgical treatment of tumors is usually combined with other methods of treatment, such as radiation therapy, chemotherapy, hormonal and immunotherapy. Radiation therapy and chemotherapy can be applied in the preoperative period in order to reduce tumor volume, remove perifocal inflammation and infiltration of surrounding tissues. As a rule, the course of preoperative treatment is not long, since these methods have many side effects and can lead to complications in the postoperative period. The bulk of these therapeutic measures is carried out in the postoperative period. If the patient has stages II-III of the process, surgical treatment must necessarily be supplemented with a systemic effect on the body (chemotherapy).

Authors: Mishinkin P.N., Neganova A.Yu.

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