DECUBITUSES (decubitus, the singular) — the pathological changes of fabrics of dystrophic or ulcer and necrotic character arising at the bed weakened patients on the places which are exposed to systematic pressure.
In emergence and development The item the main role is played by two factors — deep trophic frustration in an organism and a long prelum of soft tissues. Depending on dominance of one of these factors of P. divide on exogenous and endogenous.
In emergence exogenous The item the main role is played by a factor of long and intensive squeezing of soft tissues. The factor of weakening of an organism at this type of P. only creates conditions under which P. develop quicker and extend more widely and more deeply, than at healthy faces. Exogenous P. happen outside and internal. Outside exogenous P. arise during the squeezing of soft tissues (especially if they do not contain muscles, napr, in anklebones, a hillock of a calcaneus, condyles and spits of a hip, an elbow shoot, etc.) between a bone (usually bone ledge) and any external subject (a surface of a mattress, a bandage, the tire, etc.). In most cases such P. occur at the operated patients who are is long in forced situation, and also at travmatol. patients with incorrectly applied plaster bandage or the tire, it is inexact the adjusted prosthesis, a corset, to lay down. orthosis. Internal exogenous P. arise in walls of a wound, a mucous membrane of body, a vascular wall as a result of long stay in depth of a wound or appropriate authority of rigid drainage tubes, a dense tampon, a tracheostomy tube, a denture, a catheter.
In emergence endogenous decubituses the major role is played by a factor of weakening of an organism, deep disturbance of its main vital signs and a trophicity of fabrics. Detailing endogenous P.' etiology, they are divided on mixed and neurotrophic. The endogenous mixed P. arise at the exhausted seriously ill patients with deep circulator disturbances who are quite often suffering from a diabetes mellitus forced to lie for a long time in a bed not movably without having the power independently to change position of a body or its separate parts (legs, hands). In this case even small pressure on the limited site leads to ischemia of skin and subjects of fabrics (see. Ischemia ) and to formation of the Item. Decubituses arise: at position of the patient on spin — in the field of hillocks of calcaneuses, a sacrum and a tailbone, shovels, on a back surface of elbow joints, is more rare over acanthas of chest vertebrae and in the field of an outside occipital ledge; at situation on a stomach — on a front surface of shins, especially over front edges of tibial bones, in patellas and upper front ileal awns, and also at edge of costal arches (fig.); at edgewise position — in a lateral anklebone, a condyle and a big spit of a femur, on an inner surface of the lower extremities in places of their close prileganiye to each other; at a forced sitting position — in the field of sciatic hillocks.
Endogenous neurotrophic P. arise at patients with organic disturbances of a nervous system (a break and a contusion of a spinal cord, a hematencephalon, a softening and tumors of a brain, damage of large nervous trunks, napr, a sciatic nerve, etc.). The main role in emergence of this type of P. is played by sharp neurotrophic frustration (see. Trophicity ), so breaking exchange processes and microcirculation in fabrics that for P.'s emergence there are sufficient pressure of a sheet, a blanket or even weight of own skin located over bone ledges. Endogenous P. over upper front ileal awns at the patients with injury of a spinal cord lying on spin are so formed.
In development of necrobiotic processes at P. distinguish three stages. The I stage (circulator frustration) is characterized by blanching of the respective site of skin, a cut quickly is replaced by a venous hyperemia, then cyanosis without clear boundary; fabrics take an edematous form, to the touch cold. In this stage at exogenous P. process is reversible: elimination of squeezing of fabrics leads usually to normalization of local blood circulation. At decubitus of an endogenous origin (and with the proceeding pressure upon fabrics at exogenous P.) at the end of the I stage on skin there are bubbles which, merging, cause amotio of epidermis with formation of excoriations (tsvetn. fig. 1, and, b).
The II stage (necrotic changes and suppuration) is characterized by development of necrotic process (see. Necrosis ). In addition to skin, hypodermic cellulose, a fascia, sinews, etc. can be exposed to a necrosis (tsvetn. fig. 2, and, b). At exogenous P. formation of a dry necrosis is more often observed, rejection to-rogo proceeds with participation of a saprophytic infection (see. Wound fevers ); at endogenous P. the inflammatory process caused by pathogenic microflora usually joins and wet develops gangrene (see) with the phenomena of intensive suppuration (see. Purulent infection ).
The III stage (healing) is characterized by dominance of reparative processes, development of granulations (see. Granulyatsionnaya fabric ), scarring (see. Hem ) and partial or full epithelization of defect (tsvetn. fig. 3, and, b).
The clinical picture
the Clinical picture can be various depending on P.'s etiology, a condition of the patient, existence of pathogenic microflora, character of a necrosis, etc.
To the I stages patients seldom complain of severe pains, more often they note weak local morbidity, feeling of numbness. At patients with injury of a spinal cord the erythema can arise in several hours, and in 20 — 24 hours in the field of a sacrum there are already small sites of a necrosis (see. Sacral area ). At the endogenous mixed P. transition patol, process in the II stage happens much more slowly.
When P. develops as a dry necrosis, the general condition of the patient considerably is not burdened, the phenomena of intoxication do not arise. Mummifications (see) strictly limited site of skin and subjects of fabrics is exposed, there is no tendency to expansion of a necrosis on the area and in depth. After several weeks the mummified fabrics begin to be torn away gradually, the wound cicatrizes. Similar the wedge, P.'s current is optimum for the patient.
At P.'s development as a wet necrosis, devitalized fabrics take an edematous form, from under them fetid muddy liquid separates. In the breaking-up fabrics piogenic or putrefactive microflora begins to breed violently (see. Putrefactive infection ) also the wet gangrene which received the name of dekubitalny gangrene develops. Process of disintegration and suppuration extends on the area and in depth of fabrics, quickly reaching bones which are quite often bared in the field of P.
Dekubitalnaya gangrene leads to serious deterioration in the general condition of the patient. Clinically it is shown by signs is purulent - resorptive fever (see) — a podja of megohm of temperature to 39 — 40 °, increase of breath, tachycardia (see), muting of cordial tones, decrease in the ABP, increase in a liver. In blood it is found leukocytosis (see) with a neutrocytosis, acceleration of ROE, a disproteinemia (see. Proteinemia ); it is noted anemia (see), proteinuria (see), hamaturia (see), a pyuria (see. Leukocyturia ), etc.
Decubituses can become complicated phlegmon (see), abscess (see), purulent zatekam (see), an erysipelatous inflammation (see. Ugly face ), purulent tendovaginitis (see) and arthritises (see), gas phlegmon (see. Mephitic gangrene ), cortical osteomyelitis (see), etc. The most typical complication for sharply weakened patients is sepsis (see).
Necessary conditions for successful treatments decubituses the exception of continuous pressure upon the struck area, treatment of a basic disease and providing a careful nosotrophy are (see. Leaving ).
At exogenous P. topical treatment should be directed on that. not to allow transition of a dry necrosis to wet. For this purpose a scab and skin around it 5 or 10% with spirit solution of iodine or 1% solution of potassium permanganate grease, 1% solution of tetraethyl-diamino-triphenyl-carbohydride sulfate which promote drying of nekrotizirovanny fabrics. The area P. is closed a dry aseptic bandage. Before rejection of devitalized fabrics salve and water dressings are inadmissible. For the purpose of prevention of infection of P. apply UF-radiation. After rejection of nekrotizirovanny fabrics and emergence of granulations apply salve dressings, at indications make skin plastics (see).
At endogenous P. the main efforts go for treatment of the disease which resulted the patient in serious condition. For a raising of forces of the patient widely use (taking into account indications) disintoxication actions (see. Disintoxication therapy ), the stimulating therapy, hemotransfusion (see), injection blood-substituting liquids (see), vitamin therapy (see) to lay down. food (see. clinical nutrition ), etc.
Topical treatment is directed to acceleration of rejection of nekrotizirovanny fabrics. Proteolytic enzymes (see Peptid-gidro-lazy), hypertensive wet drying are most effective in this respect bandages (see).
At purulent complications or dekubitalny gangrene resort to surgery — opening of phlegmon, purulent zatek, necretomies (see), a drenirova a niya of wounds (see. Drainage ), etc. The physiotherapeutic procedures accelerating rejection of nekrotizirovanny fabrics are effective: at deep P. with plentiful purulent separated apply electric field of UVCh in a thermal dosage (see. UVCh-therapy ), at superficial P. with scanty separated — an electrophoresis of antibiotics and proteolytic enzymes (see. Electrophoresis ). After subsiding of pyoinflammatory process and end of a nekrolizis instead of the dry and wet drying hypertensive bandages appoint salve dressings with Shostakovsky's balm, eucalyptus oil, etc. For reduction of a plazmopotera and prevention of consecutive infection at the shift of a bandage the wound is closed a collagenic film. P.'s mud cure is effective, a cut promotes rejection of nekrotizirovanny fabrics and development of granulations.
Locally apply an electrophoresis of biostimulators (an aloe, a vitreous, honey), UF-radiation, aero ionization, light bathtubs, darsonvalization and other types of physical therapy to stimulation of a wound repair. In the presence of indications make to thermoplastic. At all stages of treatment of the complicated P. carry out crops of the character separated for studying and sensitivity of the allocated microflora, apply antibiotics and other antimicrobic drugs (streptocides, nitrofurans, immune drugs, etc.).
Forecast at exogenous P. favorable. After the termination of pressure upon fabrics necrobiotic process is exposed to involution. Internal exogenous P., napr, walls of a large blood vessel, a gut, etc. are dangerous. The forecast at endogenous P. usually serious; it depends generally on weight and character of the basic disease which served as the reason of formation of the Item.
For the prevention of exogenous decubituses it is necessary to exclude a possibility of rough and long pressure upon the same sites of skin and subjects of tissues of the patient with unsuccessfully applied plaster bandage or a splint, transport or to lay down. tire, orthosis, adhesive bandage, etc. At the slightest suspicion of technology of imposing it is necessary to replace them with errors or to correct. The drainage tubes which are in a wound, catheters and t of the item periodically change or give them other situation.
For prevention endogenous P. the weakened immobilized patient is stacked horizontally on a bed with a board to reduce pressure upon sacrococcygeal area; the service personnel are obliged to turn it 8 — 10 times a day.
Turning of the patient is facilitated during the use of a special bed, in a cut of the patient is not movably fixed to a krovatny cloth by special straps and can be turned together with a cloth (around a longitudinal axis) on any side, a stomach and a back. For reduction of pressure upon fabrics in the most vulnerable areas at this patient use poorly mumpish rubber circles, and also water cushions, porolonovy linings, etc. It is necessary to watch that sheets did not get off in folds, and underwear was without rough seams.
Special attention is paid to purity of skin since on the contaminated P.'s skin arise quicker. Two-three times a day wash skin in the most vulnerable areas of a body a cold water with soap and wipe with the napkins moistened with camphoric alcohol, vodka, cologne and then wipe dry. At emergence of sites of reddening, suspicious on the beginning P., the listed events hold more intensively; appoint physiotherapeutic procedures (electric field of UVCh, UF-radiation), etc.
To the purposes of prevention of P. serve also adequate general treatment of the patient, elimination of those patol, the phenomena which served as the reason of formation of the Item.
Bibliography: Bazilevskaya 3. B. Prevention and treatment of decubituses, M., 1972; Bazilevskaya 3. Century and Polozova I. G. Decubituses and a mephitic gangrene at injury of a backbone and spinal cord, Surgery, No. 12, page 83, 1973; Yelizarov V. G. and Klyuchevsky V. V. The prevention of decubituses at treatment of patients with injury of a spinal cord, Ortop. and travmat., No. 9, page 63, 1975; Komarko K. A., etc. Treatment of trophic ulcers and decubituses radioactive applications with P32, Te204 and Sr90, Medical radio-gramophones., t. 19, No. 3, page 33, 1974; Kucherenko A. E. and and l and e N to about B. I. Prevention of decubituses at fractures and dislocations of cervical department of a backbone with injury of a spinal cord, Klin, hir., No. 7, page 41, 1975; R e at N. I. t and To and V. I. O N to prevention of decubituses at spinal patients by means of multiple skeletal traction, Ortop. and travmat., No. 9, page 75, 1974; Yumashev G. S., etc. Use of a collagenic sponge at treatment of decubituses, in the same place, No. 12, page 36, 1978; Viïain R. Prophylaxie et traitement des escarres de décubitus, P., 1960.
I. D. Kanorsky.