Purulent infection contamination of wounds

Purulent infection contamination of bullet wounds - one of challenges of field medical surgery. Basic value has a question on a source of hit of a microflora in a bullet wound. Distinguish primary (­ at the moment of wound) and secondary (in the season after wound) microbic ­ contamination of a wound. Hence, for preventive maintenance of secondary microbic contamination of a wound it is necessary ­ to apply a primary medical bandage carefully.

Microbic contamination of a wound is a condition for development in it of a microflora, i.e. Already certain strains ­ of microorganisms, capable to exist in traumatic cреде long time.

Wound microflora - result of biological selection of microorganisms which grow and educe in a traumatic detritis. It is obvious, that the wound microflora can strongly differ depending on localisation and gravity of wound, [qualities of an effected surgical treatment, methods of the general and aboriginal treatment of the wounded man. At the same ­ wounded men at the plural or admixed wounds ­ the microflora of wounds can be absolutely different. The important practical conclusion from this follows, that at a surgical treatment ­ and a dressing of different wounds at one wounded man it is necessary ­ to use separate sterile instruments.

That fact, that the modern microflora which is screened out from purulent wounds in hospitals, in overwhelming majority of cases appears a little sensitive or in general tolerant to modern antibiotics, should not keep from their application with the preventive purpose "immediately in the field of fight or at the advanced stages ­ of medical evacuation. The microflora which has got to a wound in the field of fight, almost for certain will appear sensitive to modern antibiotics of a wide action spectrum, that in a combination to a high-grade surgical treatment will serve as a reliable interrupting to wound fever development.

Wound fever occurrence is not only a consequence of disturbance of the general defence reaction of an organism, but also result of serious alterations in aboriginal, traumatic ­ immunodefence, result of change of a sensibility of tissues to a microflora.

Any infectious process does not arise immediately the incubation Season compounds for Gram-positive strains till 12 o'clock, for Gram-negative - more than 12 hours. If the originator had a passage in an animal or a human body its productive capacity shows immediately. Development in an infection contamination wound is caused by the several causes and first of all serotinal rendering - the surgical ­ help which is in turn defined by a tactical and medical situation, and also serious ­ complications, for example a shock, interfering ­ timely realisation of a surgical treatment. ­ Occurrence of suppurative processes in a wound in many respects ­ is promoted by the defective surgical treatment, the insufficiently carefully spent hemostasis, the foreign bodys which have remained in a wound, a bad drainage of a wound in ­ the postoperative season. The regional ischemia of tissues results in purulent complications owing to damage ­ of arterial highways. One of the causes of development ­ of postoperative purulent complications is absence or a bad immobilisation.

Aboriginal purulent infection contamination

Aboriginal purulent infection contamination - morphological substrate of infectious complication of a wound when process is localised ­ in the field of a wound.

Distinguish a primary purulent infection contamination, at which pyoinflammatory process educes almost in parallel ­ with occurrence of a traumatic edema of a wound (for 2-4 days), and secondary when this process educes later, in an eclipse phase of a traumatic edema.

Abscesses on a course of the traumatic canal or nearby from it are formed when any part of a diapyetic wound appears isolated owing to what ­ the pus unit ­ is impossible or is sharply complicated. Development ­ of abscesses is promoted by a number of circumstances, in particular ­ dilatings on a course of the traumatic canal, arising at the moment of wound, hematomas or foreign bodys. From them on the first place ­ it is necessary to put free osteal fragments; metal splinters of a shell, globules, etc. have smaller value.

The abscess on a course of the traumatic canal usually has ­ the irregular form and is unbound from surrounding tissues a pyogenic ­ cover. Arising abscesses can be emptied ­ in a lumen or give become numb, fistulas.

Become numb

The term «the purulent has become numb» designate ­ canals intercommunicating ­ with a diapyetic wound which are formed on a course of layers of a quaggy fat, along sheaths, ­ fascias, vascular - the excitatory fascicle etc. Then - passive diffusion of pus on histic clefts for limens of the traumatic canal. At streaks become perceptible aboriginal and general reaction of an organism. They educe mainly at fire fractures of bones of an extremity, especially hips, anticnemions, pelvic bones. The causes streaks are the complicated outflow and a long delay abjointed in a wound.

Near-wound phlegmon

As a result of a diffusive active is purulent-infiltrative inflammation of tissues surrounding to the traumatic canal their phlegmonous inflammation without the accurate borders, passing in the intact histic structures educes. Sometimes massive fusion of tissues leads to formation of abscesses and purulent streaks.

Fistulas

These are narrow canals through which the locus of a pyesis in the heart of a bullet wound intercommunicates with an external environment or with a hollow organ. They are formed when traumatic foramens are carried out by granulations, and in depth the pyesis yet has not ended. It is observed mainly at fire fractures of bones and at presence in the heart of the traumatic canal of the foreign bodys bolstering a pyesis. Fistulas arise also at damage of a hollow organ, a secret or which contents, constantly being excreted through a wound, interferes with its healing (intestinal, cholic, urinary, etc.).

The fistula is formed on a course of the former traumatic canal, a postoperative wound or lays a path through the intact tissues.

Thrombophlebites

The purulent thrombophlebitis is among frequent complications of a pyesis of wounds, especially fire osteomyelitis. It usually educes in 2-3 months after wound.

The thrombophlebitis can be a double parentage: as the secondary process which has educed as a result of diffusion of a pyesis from a wound on a paravenous fat, and then both on a side of a vein and as consequence of reproduction of microorganisms in a thrombus with the subsequent inflammation of a side of a vein; thus microbes get to a thrombus at the moment of its formation.

Lymphadenites and lymphangites

The purulent lymphangitis and regional lymphadenitis are found usually only in the presence of badly treated extensive diapyetic wounds, fire fractures of bones of the extremities which treatment descends without an immobilisation.

Toxic resorptive fever, a sepsis

The purulent infection contamination of wounds is accompanied always by the general reaction of the organism which degree of manifestation is proportional to prevalence and character of process. Degree of the general reaction of an organism on a pyesis depends not on the "special" structure of microbic associations, and from character of wound, features of a wound and quality of a surgical treatment. This implication so-called Toxic resorptive fever (a traumatic toxemia).

Theoretically any even the most insignificant purulent ­ process should be accompanied by the general phenomena. Expression of the general reaction is directly proportional to gravity of purulent process which defines size of a resorption from a wound of products of purulent-ichorization tissues, toxins and microorganisms.

The major feature Toxic resorptive fever - its constant dependence on a primary suppurative focus: the suppurative focus and is liquidated at once the purulent resorptive fever, as a rule, disappears. If infectious complication of a gunshot wound does not begin to decline after elimination of the primary locus it is necessary to speak about a sepsis.

Wounded men with a purulent resorptive fever require the most careful observation and treatment as defective medical actions can lead very quickly to attrition of reserve possibilities of an organism and sepsis occurrence and then even carefully executed surgical treatment not always gives effect.

The sepsis represents qualitatively new nonspecific infectious process caused various, more often pyogenic, by originators. It is characterised by appreciable changes of reactance of an organism and proceeds under the special unfavorable immunobiological conditions, is frequent with development of purulent metastasises in various ranges of a body. Thus, a sepsis - original roughly proceeding infectious process in which further development the predominating role belongs to an organism with its multilateral reactions regulated by the central excitatory system.

Prominent features of a sepsis are different terms of an incubation and its duration which can compound from several o'clock at so-called lightning forms till several years at a chronic ­ sepsis.

In clinical practice distinguish general, fixing, often relapsing and chronic forms of a sepsis. As result it is long an existing purulent resorptive fever or a traumatosepsis excrete so-called ­ traumatic attrition which at unfavorable conditions can reach extreme degrees. For it ­ areactivity of an organism of the wounded man and attrition are characteristic.

Position about independence of the general phenomena at a sepsis from the primary locus demands a critical assessment as at absolutization of this position the surgeon can ­ refuse treatment of the primary locus or anyway pay it insufficient attention. It will be an error as in initial stages of implications of a traumatosepsis ­ such dependence absolutely clearly shows and starts to weaken gradually and becomes smaller in an end-stage though full independence practically ­ does not exist.

Sepsis clinic

To catch an accurate side between the beginning of septic process and implications Toxic resorptive fever it is difficult.

At the patient with a sepsis in an initial stage a blush on cheeks, but in the subsequent, especially in the ending, it is replaced by the expressed pallor, is frequent with yellowness of scleras. Last at a traumatosepsis is observed a little bit earlier,­ than at a peace time sepsis. The frequent phenomenon at a sepsis - the petechial hemorrhages more often appearing on a skin of intrinsic surfaces of forearms and anticnemions. At pyaemic forms of a sepsis in a depth of a skin and in a hypodermic fat there can be pustulous ­ inflammations of the different dimensions.

One of the most nonperishable symptoms at a sepsis ­ is the fever which, as a rule, does not differ ­ accurate pattern. It constantly heat, remittent temperature with big range ­ indicators in the morning and in the evening, intermittent and constantly low temperature. At last, there can be irregular a curve when the rising seasons alternate with the seasons of normal temperature. For patients with a sepsis ­­ the sleeplessness, excitation, ­ irritability are characteristic enough the noncritical attitude to the ­ condition up to euphoria­. Sphygmus, as a rule, is speeded up, at sepsis advance the tachycardia strengthens, sphygmus filling decreases. Arterial pressure tends to depression, and then progressively drops. The anaemia accrues, the haemoglobin content decreases to 4-5 mmol/l and more low, the number of erythrocytes decreases, in serious cases business can reach a hemolysis of erythrocytes. The number of leucocytes up to leukemoid tests grows. . The sepsis can proceed at normal and even the lowered quantities of leucocytes. Sharp alteration of the blood count to the left with presence of unripe forms is characteristic. An ESR at a sepsis it is usually raised.

Changes in a wound are characteristic. Usual flow of process in a wound is slowed down, granulations from the pink and juicy turn in dark, acyanotic, very easily bleeding. There are white, difficultly separable scurfs. The cuticularization along the edges of a wound is intercepted. The wound discharge becomes poor, often fetid. In tissues surrounding a wound appears and the edema accrues. One of signs of a septic wound - dropping of painful sensitivity or, on the contrary, appearance of pains.

Treatment of purulent complications of bullet wounds

The clinical picture and wound fever flow can be various. At the lowered immunologic responses against an adynamia, slackness, inflammation signs in a wound are expressed moderate temperature reaction weakly: edges and are covered its bottom by grey fibrinous scurf with moderate quantity of liquid pus. Further purification of a wound from necrotic tissues is late, its lumen is slowly filled with flaccid atrophic granulations. In peripheric blood at this bunch of patients in is degenerate-inflammatory changes against insignificant leukocytic reaction the neutrocytosis with a deviation to the left and presence of pathological granularity of neutrophils accrues: level of crude protein of blood serum gradually decreases.

At patients with the raised immunologic reactions from first days of development of an infection contamination in a wound substantial increase of a body temperature with cold fits, abundant then, a headache, a sleeplessness is observed. Aboriginal changes are characterised by edema increase, a hyperemia and infiltrations of edges. Within the next few days in a wound there is a considerable quantity of nonviable tissues; inflame-telnye also necrotic processes extend on interhistic copulative layers and lead to formation of abscesses, phlegmons, lymphadenites. ­ In parallel with development of aboriginal changes in a wound ­ the general implications of infectious process are registered­: the condition ­ of patients worsens, the body temperature accepts hectic character, accrue cardiovascular and ­ respiratory insufficiency. Overdue granulations have a cyanotic shade, sometimes with petechial hemorrhages­. The cuticularization is late, wound edges gradually become inactive, scleroid. In ­ peripheric blood at the height of inflammatory changes in a wound the appreciable leukocytosis, ­ a deviation to the left, a lymphocytosis are observed­; an eosinophilia; against gradual reduction of a haemoglobin content and blood serum crude protein increase alpha-2 and gamma globulin fractions becomes perceptible. Thus, wound fever treatment should be spent differential depending on response of an organism to a trauma and an infection contamination.

Complex treatment of a wound fever at patients with ­ the relaxed reactions should include application of specific vaccines and Serums against introduction of antibiotics, sulfanilamide preparations, blood, albuminous and a glucose of keeping solutions. Active and passive ­ immunization is an obligatory part of the general treatment of this bunch of patients with a wound fever. The special role belongs to passive immunization by means of antistaphylococcal plasma and an antistaphylococcal gamma-globulin;

At patients with the raised responses the great value has carrying out of nonspecific hyposensitizing therapy which includes application of antihistamine preparations, preparations of calcium and ­ Sodium thiosulfatum, Acidum ascorbinicum in the big doses.

The most essential moment at the patients which wound fever proceeds on an allergic background, ­ is dynamic equilibrium disturbance between ­ the activated proteolytic enzymes and their ­ natural inhibitors: augmentation of proteolytic ­ activity of plasma and insufficiency of inhibitors. Researches ­ testify to high efficacyy of inhibitors ­ of proteases at treatment of contaminated wounds at the patients which wound fever proceeded on an allergic background.

The main condition of success in treatment of purulent complications of wounds - a primary surgical treatment. The maximum excision of the tissues necrotic and doomed to a necrosis frames in a wound congenial conditions for wound fever and neogenesis depressing. The adequate drainage of a wound and building of appropriate conditions for free outflow of the traumatic abjointed are especially important.

In protection of an organism against the taken root microflora the serious role is played by «a traumatic barrier» in the form of cellular infiltration round a wound. But the advantage of a surgical intervention enriching blood supply of tissues and providing unobstructed outflow abjointed, exceeds the relative harm caused by disturbance of a traumatic barrier.

The major component of influence on a wound is use of the agents normalising a trophicity, microcirculatory, metabolic processes as weakening of protective mechanisms involves not only weakening of immunologic protection, but also depression of activity of fermental systems of the macroorganism.

Applied to treatment of purulent wounds enzymes Сhуmорsinum. Chymotrypsin, Streptokinasa quickly solve and clear a wound of fibrin, render distinct necrolitic and a promoting effect on reparative processes. Enzymes enlarge sensitivity of a microflora to antibiotics, reduce its virulence.

Depending on a wound process phase bandages with solution of Furacilinum and a hypertonic salt solution of sodium of Sodium chloridum can be used. Have well proved abundant bathings of the wound during dressings as weak solutions of antiseptics (3 % solution of peroxide of hydrogen and solution of Furacilinum 1:5000, admixed in peer quantities). At deep wounds a lavage effect through earlier introduced - polyvinylchloride and rubber tubes. An active aspiration carry out before sharp reduction of a purulent exudation, and drainages abandon for 1-2 days. At a significant amount of necrotizing tissues to an acceleration of purification of a wound apply proteolytic enzymes a locally both in a dry kind, and in 2 % solution with which impregnate wads introduced into a wound. An aboriginal enzymotherapy spend before performance of a lumen of a wound by healthy juicy granulations and appearance of an active cuticularization.

In a regenerative phase of a wound process on a wound, accelerating healing, it is necessary to consider as the most effective methods of aboriginal influence rapprochement of edges and plastic closure of a traumatic surface ­ by dermal mesh grafts. At granulating wounds with mobile unstable edges and ­ absence of cicatrixes apply an early secondary seam or pull together edges of a wound adhesive plaster strips. On occasion at appreciable development of a cicatrical tissue and ­ impossibility to reduce edge of a wound before contact the last ­ exsect and impose a serotinal secondary seam. ­ The special attention give to an adequate drainage of the wound occluded by secondary seams by introduction of rubber drainages ­ in its angles or through specially put foramens near to the basic wound.

The important conditions of successful treatment of purulent ­ complications of bullet wounds are influence on ­ the macroorganism and rising of its resistibility. From these positions ­ on the first place there is a hemotransfusion, especially direct, or transfusion citrate to blood. Obligatory ­ elements of the general treatment - a high-grade and vitamin-rich food, medical gymnastics physiotherapeutic ­ procedures. Actions of medical character about which there was a speech with reference to a wound fever, ­ completely concern and a traumatosepsis.

Sepsis treatment - a problem difficult and in a general plan ­ of medical actions the first place shunt to an operative measure - to elimination of entrance infection atriums. Operation at the wounded man with a sepsis has urgent character. Operation should be timely, essentially radical. Purulent become numb well drain, and ­ impregnated with the pus, the fused tissues and sequesters delete. In case of a serious purulent lesion of an extremity ­ is inadmissible to hesitate with ablation. In the presence of indications to ablation it effect at once, not assigning unreasonable hopes of a wound surgical treatment. The ablations ­ executed late, as a rule, are noneffective. In process of ­ revealing of their purulent metastatic locuses it is necessary ­ to dissect in due time and well to drain. At a septic ­ thrombophlebitis excising of veins is shown. It is necessary ­ to apply powerful antibiotics, to transfuse blood and plasma, to provide rational, high-grade (sometimes and probe) a food and good leaving. Inhibitors of proteases (Contrykal, Trasylolum, Gordoxum) are an effective remedy of treatment ­ of a sepsis.

Wounded men with a sepsis and traumatic traumatic attrition ­ are nontransportable before full recover. Obligatory conditions of enriching of healing of wounds ­ are rest and a good immobilisation.

In connection with appearance of steady forms of microbes at treatment of purulent complications of the wounds accompanying a purulent resorptive fever, apply the big doses ­ of antibiotics.

To treatment of a purulent wound fever apply ­ a composition from several ­ antibiotics supplementing each other on a spectrum­. Along with traditional methods ­ of introduction use intravenous, intraosteal, endarterial introduction of antibiotics, and whenever possible - and a partial perfusion. At impossibility to provide sufficient contact of a microflora and an antibiotic through ­ a blood channel resort to aboriginal application of antibiotics­. For aboriginal application use mainly ­ antibiotics which arrive in the locus in the active ­ form - Penicillinum, streptomycin, Tetracyclinum, Neomycinum.

Effective enough method of treatment is ­ introduction of antibiotics immediately in tissues surrounding purulent process. For high-grade use of antibiotics ­ definition of character of a microflora and ­ its sensitivity to antibiotics is necessary­. Together with it it is necessary to mean, that a hemolitic streptococcus and clostridiums are sensitive enough to Penicillinums, preparations of a tetracycline number, Chloramfenicolum, erythromycin, gentamycin. Anaerobic ­ streptococcuses are sensitive to the same antibiotics­. The golden hemolitic staphilococcus,­ sow at the first surgical intervention, is usually enough sensitive to Penicillinum, however at repeated sowings he finds insusceptibility to Penicillinum in 50-90 % of cases. In connection with the big role of staphilococcuses in development of postoperative purulent processes at treatment of wounded men apply such antibiotics,­ as Oxacillinum, ampicillin, gentamycin.

Because of augmentation of frequency of allergic responses ­ in the course of treatment prescribe the preparations reducing ­ hypersensitivity (Dimedrol, Pipolphenum).