category: Medicine, health

purulent infection of wounds.

Purulent infection of gunshot wounds - one of the difficult problems of military field surgery. Fundamental importance is the question of the source entering the microflora in
gunshot wound. There are primary (at the time of injury) and secondary (after the injury) microbial contamination of wounds. Consequently, for the secondary prevention of microbial contamination of the wound must be carefully cast primary
Dressing.

Microbial contamination of wounds is a prerequisite for the development of its microflora, ie, already
certain strains of microorganisms that can exist in the wound Wednesday for a long time.

microflora of the wound - the result of biological selection of microorganisms
that grow and develop in wound detritus. Obviously, the microflora of the wound can be very different depending
the localization and severity of injury, [the quality produced by surgical treatment, methods of general and local treatment
wounded. At the same injuries with multiple injuries or mixed microflora of wounds may be quite different. This implies important
practical conclusion that the surgical treatment of various wounds and bandaging the wounded one must use separate
sterile instruments.

The fact that modern microflora, sow from festering wounds in hospitals, in
vast majority of cases is not very sensitive or even insensitive to the modern
Antibiotics should not be deterred from their use as a prophylactic measure "directly on the battlefield or at best
stages of medical evacuation. Microflora, which fell into the wound on the battlefield, will almost certainly be sensitive to modern broad-spectrum antibiotics, which in combination with high-grade surgical treatment will serve as a reliable barrier to the development
wound in-fektsii.

emergence of wound infection is not only a consequence of violations of common defensive reaction
organism, but the result of severe changes in local, wound immunity, the result of changes in susceptibility of tissues to
microflora.

No infectious process does not occur immediately incubation period is
for Gram-positive strains of up to 12 hours for Gram-over
12 hours if the agent had a passage in the animal or human body, its ability to reproduce is manifested
immediately. Development of wound infection is determined by several factors and especially the late delivery - surgical care, which in turn is determined by the tactical and medical conditions, as well as severe complications, such as shock,
hinder the timely implementation of surgical treatment. Emergence suppurative
processes in the wound contribute significantly to an incomplete surgical treatment, not thoroughly carried haemostasis, remaining in the wound foreign bodies, poor drainage of the wound in the postoperative period. To
suppurative complications resulting REGIONAL tissue ischemia due to damage to arterial highways. One reason for the development of postoperative purulent complications is the lack of or poor fixation.

local purulent infection

local purulent infection - morphological substrate
infectious complications of the wound, when the process is localized in the wound.

Distinguish primary abscesses, in which purulent-inflammatory process develops almost simultaneously with the emergence of traumatic edema of the wound (for 2 to 4 days), and secondary, when the process
develops later, during the disappearance of traumatic edema.

Abscesses along the wound channel or its vicinity are formed when any department is festering wounds
isolated, resulting in separation of pus is impossible or severely hampered. Development of abscesses to a number of circumstances,
in particular the expansion along the wound channel, emerging at the time of injury, hematoma, or foreign bodies. Of these, the first
place should be set free bone fragments; lesser importance are metal projectile fragments, pellets, etc.

abscess in the course of the wound channel usually has an irregular shape and is separated from the surrounding tissue pyogenic membrane. The resulting abscess can be emptied in the cavity or give zateki, fistulas.

Zateki. The term "burrowing pus" denote communicating with the festering wound channels that are formed along the layers of loose tissue, along the aponeurosis, fascia, vascular nervnoto beam, etc. Then - passive spread of pus in tissue
cracks beyond the wound channel. When zatekah marked local and general reaction of the organism. They
develop mainly in gunshot fractures of limbs, especially the femur, tibia, pelvic bones. Reasons
zatekov are impeded outflow discharge and the long delay in the wound.

Okoloranevaya abscess. As a result of active diffuse infiltrative-purulent inflammation of the tissues surrounding the wound channel is developing their phlegmonous inflammation without clear boundaries, passing in the intact tissue structure. Sometimes massive
fusion of tissues leads to the formation of abscesses and burrowing pus.

fistula. This narrow channels through which the center of suppuration in the depths of a gunshot wound
communicates with the external environment or with a hollow body. They are formed when a wound hole
performed granulation, and deep suppuration is not yet over. This is observed mainly in gunshot fractures of the bones and the presence in the depth of the wound canal foreign bodies,
supporting fester. Fistulas also arise when damage of the hollow body, the secret or the contents of which are constantly -lyayas through the wound, preventing its healing (intestinal, biliary, urinary, etc.).

fistula formed in the course of the former wound channel, postoperative
wounds or pave the way through the intact tissue.

thrombophlebitis. Purulent thrombophlebitis refers to the number of parts
complications of suppuration of wounds, especially firearms osteomyelitis. It usually develops within 2-3 months
after injury.

Thrombophlebitis can be of two origins: as a secondary
process, developed by the spread of suppuration
the wound on paravenoznuyu fiber, and then to the vein wall and as a consequence of reproduction in E kroorganizmov
in the thrombus, followed by inflammation of the walls of the veins, while the microbes get into the thrombus at the time of its formation.

lymphadenitis and limfangity. Purulent lymphangitis and regional lymphadenitis are usually found only
if poorly handled large festering wounds, gunshot bone fractures of extremities, treatment
which occurs without immobilization.

toxic-resorptive fever, sepsis

purulent infection of wounds is always accompanied by the general reaction of the organism, the severity of which is proportional to the prevalence and nature of the process. The degree of overall reaction of the organism to fester not depend on "special" composition of microbial associations, and
the nature of the injury, wound characteristics and the quality of surgical treatment. This is a manifestation of the so-called toxic-resorptive fever (wound
toxemia).

Theoretically, any, even the most insignificant purulent process should be common phenomena. Expression of the overall reaction is directly proportional to the gravity of purulent process, which determines the amount of resorption of wound products
suppurative ichorization tissue, toxins and microorganisms themselves.

most important feature of toxic-resorptive fever - its constant
dependence on primary purulent focus: purulent focus and eliminated immediately, as a rule, disappears purulent-resorptive fever. If an infectious complication of a gunshot wound is not going to wane after the removal of the primary focus, then
should speak of sepsis.

wounded with purulent-resorptive fever need to be very
careful observation and treatment, because of inferior medical events can quickly lead to depletion of reserve capacity of the organism and the emergence of sepsis, and even then carefully performed surgical treatment does not always produce the effect.

Sepsis represents a qualitatively new nonspecific
infectious process caused by different, often pus, pathogens. It is characterized by significant changes in the reactivity of the organism and proceeds
under special immunobiological adverse conditions, often with the development of purulent metastases in various areas of the body. Thus, sepsis - a kind of fulminant infectious process, further
development of which belongs to the primacy of the body with its multilateral reactions
regulated by the central nervous system.

characteristic features of sepsis are different periods of incubation and its duration, which can range from a few hours at both
called lightning forms to several years in chronic sepsis.

In clinical practice, distinguished general, protracted, often recurrent
and chronic forms of sepsis. As a result of long-existing purulent-resorptive fever or wound sepsis
emit so-called wound depletion, which under unfavorable conditions may reach extreme degrees. It is characterized by body areaktivnost wounded and depletion.

position on the independence of common phenomena in sepsis by
primary focus requires a critical evaluation, since the absolute position of the surgeon may refuse to treat primary focus or at least
case to give it scant attention. This would be a mistake, because in the initial stages of wound sepsis manifestations of this dependence is quite
clearly seen, and begins to weaken and become smaller in the terminal stage, although full independence virtually non-existent.

Clinic sepsis. To catch a clear distinction between the beginning of the septic process and manifestations of toxic-resorptive fever is difficult.

patients with sepsis in the initial stage of a blush on the cheeks, but later, especially in the finale, it is replaced by severe pallor, often with yellow sclera. The latest in wound sepsis occurs somewhat earlier than in sepsis peacetime. Frequent phenomenon in sepsis - petechial hemorrhages, most often appear on the skin
inner surfaces of the forearms and shins. When piemicheskih forms of sepsis in the thickness
skin and subcutaneous tissue may occur pustular inflammation of various sizes.

One of the most persistent symptoms in sepsis is fever, which,
generally does not differ a clear pattern. This constantly high fever, remittent fever with great
scope of indicators in the morning and evening, intermittent and constant low temperature. Finally, it may be an irregular curve, when
increasing periods alternate with periods of normal temperature. For patients with sepsis is characterized by fairly uncritical attitude to his condition until the euphoria, insomnia, agitation, irritability.
Pulse, as a rule, learning, with the progression of sepsis increased tachycardia, reduced filling pulse. Arterial
pressure tends to decrease, and then progressively decreases. There is growing anemia, hemoglobin decreased to 4.5 mmol / l and below, reduces the number of red blood cells, in severe cases
it can reach the hemolysis of red blood cells. The number of white blood cells until the leukemoid reactions ..
Sepsis can occur in normal or even low numbers of leukocytes. Characteristic sharp
shift formula of the blood to the left with cash immature forms. ESR is usually increased in sepsis.

characteristic changes in the wound. The usual course of the process is slowed down in the wound, granulation of pink and juicy turn into dark, pale, easily bleeding appear white, hard separable raids. Epiteliza-tion on the edges of the wound
stops. Discharge wound becomes scarce, often smelly. In the surrounding wound tissue appears and increases swelling. One of the signs of septic wounds - decrease pain
sensitivity or, conversely, the appearance of pain.

Treatment of purulent complications of gunshot wounds

clinical picture and course of wound infection may be different.
At low immunological reaction to the background
adinamii, lethargy, moderate temperature reactions signs of inflammation in the wound are mild: the edges and its bottom covered with a gray fibrinous coating with a moderate amount of liquid pus. Further purification of the wounds of necrotic tissue is delayed, the cavity is filled it slowly wilted atrophic granulation. In the peripheral blood of this group of patients during
degenerative and inflammatory changes in the background of low leukocyte reaction increases neutrocytosis
with a shift to the left of leukocyte formula and the presence of abnormal granulation of neutrophils: the level of total protein serum is gradually reduced.

patients with elevated immunological reactions in the first days of infection in the wound, there is a significant increase in body temperature with a fever, copious sweat, head
pain and insomnia. Local changes characterized by an increase of edema, hyperemia and
infiltration edges. In the coming days, the wound appears a large number of nonviable tissue; vospali and conservatory
and necrotic processes are distributed intertissue bonding layer and lead to
formation of abscesses, phlegmon, lymphadenitis. In parallel with the development of local changes in the wound recorded
common manifestations of infection: state of the patient deteriorates, the body temperature takes hectic nature, growing cardiovascular and respiratory
insufficiency. Belated granulation have cyanotic hue, sometimes with petechial hemorrhages.
Epithelization delayed wound edges gradually become inactive, scleroid. In
peripheral blood at the height of inflammatory changes in the wound, there are significant leukocytosis, left shift in leukocyte formula, lymphocytosis, eosinophilia, against the background of a gradual reduction of hemoglobin and serum total protein
Blood marks an increase of alpha-2-and gammaglobulinovyh factions. Thus, treatment of wound infection should be differentiated depending on
response of the organism to trauma and infection.

Complex treatment of wound infection in patients with weakened responses should include the use of specific vaccines and serums against the introduction of antibiotics, sulfanilamides, blood, protein
and glyukozosoderzhaschih solutions. Active and passive immunization as a mandatory part of the
treatment of this group of patients with wound infection. A special role belongs to the passive immunization with
antistafilokokkovoy antistafilokokkovogo plasma and gamma globulin;

patients with elevated responses is important for the nonspecific hyposensitization therapy
which includes the use of antihistamines, calcium supplementation and sodium thiosulfate, ascorbic
acid in large doses.

most significant factor in patients with wound infection
which occurs on the allergic background, is a violation of the dynamic equilibrium between the activated proteolytic
enzymes and their natural inhibitors: increased proteolytic activity
plasma and lack of inhibitors. Studies have shown high efficiency of protease inhibitors
in the treatment of infected wounds in patients with wound infection which occurs on the allergic background.

main condition for success in the treatment of purulent complications of wounds - primary surgical treatment. Maximum udalelenie necrotic and
doomed to necrosis of tissue in the wound, creates favorable conditions for the suppression of wound infection and regeneration. Particularly important adequate drainage of the wound and the creation of appropriate conditions for the free outflow of wound.

in protecting the body from taken root microflora plays a major role "of the wound barrier in the form of cellular Institutefiltration around the wound. But the benefits of surgical intervention, improves blood supply of tissues and provides
unimpeded flow discharge exceeds the relative harm caused by violation of the wound barrier.

important component of the impact on the wound is the use of normalizing trophism, microcirculatory, metabolic processes,
since the weakening of protective mechanisms involves not only the weakening of
immunological protection, but also decrease the activity of enzyme systems macroorganism.

used for the treatment of purulent wounds enzymes himopsin. chymotrypsin, streptokinase rapidly dissolve and cleanse the wound by fibrin, have a distinct nekroliticheskoe and stimulating effect on reparative processes. Enzymes increase the sensitivity of microflora to antibiotics, reduce its virulence.

Depending on the phase of wound healing can be used dressings with a solution furatsilinom and hypertonic sodium chloride.
Well proven copious lavage wound dressings during a weak antiseptic solution (3% hydrogen peroxide solution
and the solution furatsilinom 1: 5000, mixed in equal quantities). In deep wounds lavage produced a previously imposed --
PVC and rubber tubes. Active aspiration to carry out a sharp decrease purulent exudation, and drains left for another 1-2 days. With a significant number nekrotizi-doped fabric
to accelerate the cleansing wounds topically applied proteolytic enzymes in dry form, so
and a 2% solution, which pervades introduced into the wound swabs. The local fermentoterapiyu spend up to perform oral wounds juicy healthy granulation and the emergence of active epithelization.

in regenerative phase of wound healing process the most effective
methods of local effects on the wound, accelerates healing, should be considered
approximation of edges and plastic closure of the wound surface mesh skin grafts. When granulating wounds with mobile and non-fixed edges
No scars apply early secondary suture, or bring together the wound strips of sticky
plaster. Particular in cases with significant development of scar tissue and the impossibility
bring the wound edges to touch the past and impose excise late secondary suture. Particular attention is paid to adequate drainage is closed
secondary sutures wound through the introduction of rubber drains in the corners or through specially deposited near the opening of the main wound.

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