BANDAGINGS — the medical and diagnostic actions applied at the pathological processes connected with injury of skin (at wounds, ulcers, burns, freezing injuries, necroses, outside svishchaz, etc.).
At P. carry out survey and a toilet of a wound, influence a wound remedies, make anemic manipulations (sounding of the fistular courses, a fistulografiya and a fistuloskopiya, an anemic necretomy, etc.) and apply bandages a wound. All this is carried out, as a rule, at repeated P. Pervaya P. of a fresh wound has nek-ry features. It is made usually on site getting injured, and practically it is the first act of rendering medical aid to the victim, the purpose to-rogo — a stop of bleeding and protection of a wound against secondary infection. The first P. often consists only in imposing on a wound (at an opportunity after processing of surrounding skin spirit solution of iodine, solution of Iodonatum or tetraethyl-diamino-triphenyl-carbohydride sulfate) a dry aseptic bandage, most often with use of a first-aid dressing kit (see. Package dressing individual ). Nek-ry surgeons prefer to speak not about the first bandaging, and about imposing of primary bandages (see).
Repeated P. carry out in dressing rooms (see) on special tables (see. Dressing tables ) with use of surgical instruments — tweezers, clips, packers, scissors, scalpels, etc. (see. Surgical tools ), and also dressing material (see), drainage tubes etc. As a dressing material apply gauze balls, tampons, napkins, vatu (see), etc., for fixing of bandages gauze or elastic tubular bandage (see), kerchiefs, kleol (see), etc. At primary toilet of skin around a wound use at first gasoline or alcohol (at their absence — 0,5% solution of ammonia, refined turpentine, the camphoric alcohol mixed in equal parts with ether, etc.), and then the means applied to processing surgery field (see): 5-— 10% spirit solutions of iodine, solution of Iodonatum, 3 — 5% solutions of potassium permanganate, 1 — 2% spirit solutions of tetraethyl-diamino-triphenyl-carbohydride sulfate, etc.
For treatment of wounds use chemical antiseptic agents: 3% solution of hydrogen peroxide, solution of Furacilin (1: 5000), 0,25% and 10% solutions of silver nitrate, 3% solution boric to - you (or its powder — for dusting of the wound infected with a pyocyanic stick); sulfanamide drugs — Etazolum, streptocide in the form of ointments, pastes, solutions; 0,1% solution of furagina-potassium; dyes — 1 — 3% spirit solution methylene blue, solution of Aethacridinum of a lactate (Rivanolum) in cultivation 1: 1000, etc. Apply also antibiotics in the form of ointments, solutions, powders taking into account sensitivity to them microbic flora, 1% solution of a hlorfillipt, etc.
For acceleration of clarification of purulent wounds at P. solution of sodium chloride, proteolytic enzymes of an animal and bacterial origin — ribonuclease, trypsin, chemical opsin, chymotrypsin, etc. use 10%. Apply complexes of a collagenase with methyluracil to stimulation of regenerative processes (meturakol) and sea-buckthorn oil (regional stake), etc. '
For the purpose of prevention of intrahospital infection of a wound (see. Intrahospital infections ) at P. rules shall be followed strictly asepsises (see) and antiseptic agents (see). The dressing nurse prepares for P. the same as for operation: processes hands on one of the existing ways (see. Processing of hands ), puts on a sterile mask, a dressing gown, gloves; then lays a dressing table sterile sheets, displays tools, a necessary dressing material in a certain order, to-ry it is stored in steam sterilizers near a tool table. At a small amount of P. the dressing .medsestra can help the doctor at P.'s carrying out or independently carry out simple P. under control of the doctor. At the large volume of work and difficult P.' presence in a dressing room there have to be two nurses: one of them gives tools, a dressing material, another helps the doctor at the Item. Doctors carry out P. by means of tools, previously having processed hands and having put on sterile gloves (see. Gloves medical ).
P.'s frequency depends on a phase and character of a wound process, quantity wound separated (see. Wounds, wounds ). After operations with suture the first P. is made on 7 — the 9th day when it is necessary to remove seams, or earlier in case of blotting of a bandage and suppuration of a wound. At treatment of purulent wounds in a stage of an acute inflammation when a large amount of pus is allocated, P. make daily; in a stage of a granulation of the cleared wound — in 3 — 4 days; at wounds and fistulas with plentiful allocation a calla, urine, etc. — several times in days. The wet drying bandages change daily, ointment — in several days. As the indication to extraordinary (emergency) P. serve sudden plentiful blotting of a bandage as blood, pus; emergence or strengthening of pains in the field of a wound, disturbance of local blood circulation; deterioration in the general condition of the patient, suspicion on development of a wound mephitic gangrene (see).
Manipulations at P. carry out in a certain sequence: removal of the previous bandage; primary toilet of skin around a wound; primary survey of a wound; toilet of a wound; repeated survey of a wound; performance of diagnostic or to lay down. procedures; repeated toilet of skin, imposing of a bandage.
If P. is inevitably connected with considerable pain, then apply anesthesia. The choice of a method of anesthesia and anesthetics shall be individualized depending on P.'s character and a condition of the patient; at the same time apply injections of solutions of analginum, Promedolum, morphine, fentanyl, short-term inhalation (Penthranum, constant boiling mixture) or not inhalation (hexenal, Sombrevinum) an anesthesia (see. Inhalation anesthesia , Not inhalation anesthesia ).
At removal of a bandage it is necessary to aim at the minimum traumatizing fabrics. The dried bandages before removal moisten with solution of an antiseptic agent (hydrogen peroxide, Furacilin, furagina-potassium, potassium permanganate) or isotonic solution of sodium chloride, solution of novocaine; sometimes the extremity is placed in a bathtub or a basin with solution of an antiseptic agent. The soaked bandage is removed by means of tweezers, raising it on a longitudinal axis of a wound.
Primary toilet of skin is made for the purpose of removal from the sites of skin of blood, pus, a kleol, etc. surrounding a wound (at wounds of pilar body parts shave off hair). The toilet is carried out gauze (or wadded) the balls moistened in gasoline, alcohol etc.; leather is processed from edges of a wound to the periphery, watching that liquid from skin did not get to a wound.
After that the wound is examined, note the changes which happened in it, existence of bleeding, wound separated and the inflammatory phenomena, a condition of granulations, existence of epithelization.
At survey of aseptic wounds with the put stitches pay attention to emergence of local signs of an inflammation (a hyperemia, hypostasis, a vrezyvaniye or eruption of seams). In the absence of the inflammatory phenomena and well lying seams the wound in the area of seams is greased by 5% with solution of iodine or 1% solution of tetraethyl-diamino-triphenyl-carbohydride sulfate, 3 — 5% solutions of potassium permanganate and apply an aseptic bandage from a gauze napkin, to-ruyu fix a kleolovy sticker, tubular or usual bandage (see. Desmurgy ). At symptoms of suppuration in whole or in part remove seams. At survey of a purulent wound pay attention to character of wound separated. Color, a smell, a consistence of exudate are defined by a type of a contagium: the ichorous, fetid smell, dirty-gray color of pus are characteristic of putrefactive flora; green color — for the green staphylococcus; blue-green — for a stick of blue-green pus etc.; the smell of the decaying meat is noted at development in a wound of Cl. sporogenes; ammonia, the decaying urine — at development in a wound of aerobic putrefactive flora (V. of coli commune, Proteus vulgaris, etc.); decayed, a mold — in the presence of bacteria of fuzospirokhetozny group of causative agents of a putrefactive infection.
Essential value for assessment of a wound process has an appearance of the wound. At development putrefactive infection (see) the surface of a wound differs in dryness, lack of granulations, availability of nekrotizirovanny fabrics, a gray, dim type of muscles. On skin around a wound there can be dirty-green spots owing to treatment by products of hemolysis. The symptom of crepitation meets seldom. Regional lymphadenitis is noted. At development of a mephitic gangrene of edge of a wound are edematous, and pressing by a finger does not leave a mark in edematous fabrics; protrusion of muscles, traces of impression of a bandage, a vrezyvaniye of the put stitches are noted, the symptom of crepitation demonstrates presence at fabrics of gas. The slightest suspicion on existence of a mephitic gangrene is an alarm signal and demands acceptance of urgent measures. In the subsequent a putrefactive smell, scanty, dense, crimson color the discharge from a wound will be pointed to progressing of a mephitic gangrene; increase in the quantity separated serous, and then its purulent character — on a stop of process.
If during P. at touch to a wound tweezers or a gauze ball convulsive twitchings of muscles in a wound appear, it is necessary to think of a possibility of tetanus; suspicion of tetanus shall amplify if the wounded notes the shooting, pulling pains in a wound with irradiation on nervous trunks, burning and a pricking in a wound, emergence of paresthesias, and at survey are defined increase in a muscle tone, unusual position of an extremity, the raised local sweating (see. Tetanus ).
In the course of survey of a wound take wound prints for a cytologic research and material for bacterial, crops.
The toilet of a wound consists at a distance from it wound separated (blood, pus, serous liquid) or intestinal contents, bile, urine, etc. by drying by gauze balls, tampons, napkins. The wound is washed out solution of an antiseptic agent a stream from the syringe, pears or just pour solution in a wound and then dry up by blotting. From the antiseptic agents used for these purposes solution of hydrogen peroxide is preferable 3%, at connection the cut with wound separated is formed the foam promoting removal it from a wound, and the elemental oxygen which is emitted at the same time has bactericidal effect. At a toilet of a wound delete possible foreign bodys, independently separated bone sequesters (at osteomyelitis). The torn-away nekrotizirovanny fabrics which are freely lying in a wound delete with tweezers or wash away.
After a toilet of a wound it is repeatedly examined and carry out necessary medical and diagnostic procedures. According to indications remove or put stitches (see. Primary seam , Surgical treatment of wounds ); do anemic necretomy (see). Sounding of a wound is admissible only at a delay of pus, the created fistula; are more informative, than sounding (see), fistuloskopiya and Fistulografiya (see).
From to lay down. methods apply physical therapy, radiation of a wound an out-of-focus laser beam of low power (see. Laser ); irrigation (see) or insufflation (see) antibacterial and other pharmaceuticals; introduction antibacterial and absorbable gelatin sponge; less often pharmaceuticals enter into surrounding fabrics by injections (deep antiseptics). Check correctness of situation and efficiency of functioning of drainages and tampons, and if necessary correct, delete or replace them. At secondary bleeding the wound is tamponed. As the gauze tampon which is soaking up only several hours does not provide the long drainage, at a large number separated together with it or separately use rubber; chlorvinyl and other tubes (see. Drainage ). On the end of a tube do additional openings and after introduction to a wound fix a tube to exclude as its loss from a wound. and an uskalzyvaniye in the drained cavity. The tube can be connected to permanent vacuum system aspiration drainage (see).
The term of stay of tampons in a wound can be various. The tampon entered for the purpose of a hemostasis is deleted not earlier than in 2 — 4 days after a tamponade. The delimiting tampons entered into an abdominal cavity during operation delete consistently on 5 — the 8th day after operation. The indication to immediate removal of a tampon is bleeding from under it or accumulation of pus under it. The tampons moistened with antiseptic agents, antibiotics delete (or replace), as a rule, in 1 — 2 day.
Have special value to lay down. actions at P. of wounds with fistulas of various bodies. Continuous pollution of skin intestinal contents, pancreatic juice, bile, urine, pus leads to its maceration, inflammation (piodermit, furuncles, an ugly face, etc.) and to an ulceration. For reduction of the hit by skin separated from fistulas use obturators, pilots, intestinal prostheses, occlusive salve dressings, etc.
Upon termination of medical and diagnostic procedures make a repeated toilet of skin around a wound. At uncomplicated wounds skin is cleared of the medicinal solutions which got on it, by blood etc. and grease with one of antiseptic agents (5 — 10% solutions of iodine, solution of Iodonatum, 3% solution of potassium permanganate, etc.).
At P. of the wounds complicated by fistulas, matserirovanny skin 5 — 10% with solutions of a tannin or 3 — 5% solutions of potassium permanganate grease, 1% spirit solution of methylene blue and apply on it Las-sar's paste, zinc oxide ointment or powder it with powder of the calcinated gypsum or chalk, talc; it is possible to process leather also tserigely, BF-6 glue, creating a protective film.
For the purpose of an inactivation of the digestive enzymes getting on skin apply 0,1 N solution salt to - you, the beef-infusion broth, acidophilic milk, to-rymi moisten bandages or irrigate a wound through the microirrigators brought to a wound during P., on skin impose mincemeat. In especially hard cases because of the expressed changes of skin and impossibility to provide its protection resort to open, a demon-povyazochnomu for a method of treatment of fistulas.
Final manipulation at P. is imposing of a bandage. The dry aseptic gauze bandage is applied a fresh wound during the rendering the first medical aid, after surgical treatment of wounds and aseptic operations, wounds with the entered dry tampons or drainages, at fistulas. On purulent wounds in a phase of hydration impose, as a rule, wet drying, in a phase of dehydration — salve dressings. At long-term bandages often over a layer of a purified cotton impose the second layer to prevent blotting of a bandage. The bandage is fixed one way or another (see. Desmurgy ).
According to rules of an asepsis first of all tie up postoperative patients with a smooth current of a wound process, then — patients with suspicion on an inflammation of a wound; patients with purulent wounds are tied up in special dressing rooms.
V. K. Gostishchev.