Wounds and wound's process. Prophylaxis of development of an infection into the wound. Treatment of clean wounds.

Infected wounds.

The closed damages of soft tissues of a skull, a thorax, bodies of a abdominal cavity.

 

WOUNDS

1. Definition

Wounds (vulnus) are the mechanical damage of the organism, which occur from destroying the integrity of the covered tissues - skin or mucous membrane. During this damage there can be destroyed more deep tissues, inner organs (damage of the brain, liver, stomach, kidneys and others). The injury of the covered tissues separates the wound from other kinds of damage. For example the injury of the liver, which is caused by the dull trauma of the abdomen without destroying the skin, is the rupture and the damage during the stroke by a knife in the abdominal region-wound of the liver, because we observe the destroying of the skin.

2. The main features of the wounds

The main clinical features of the wounds are pain, bleeding and hiatus. Their development depends on the localization of the wounds, mechanism of the damage, volume and deepness of the injury, and common condition of the patient.

(1) Pain (dolor)

It caused by direct damage of the nerves in the wounds region, and in result if its freezing during the development of the swelling. The pain can be localized not only in the place of damage but also it can be spread over the whole region of innervation.

The intensivity of pain syndrome in case of the wound by the next features is determined:

1.     Localization of the wound.

2.     Injuries of the big nerves trunks are present.

3.     The character of the weapon and the frequency of causing and wound the weapon is sharp and the damage of the receptor is less, and the pain is less.

4.     Nerves psychological condition of the organism. Pain feeling can be decreased when the patient is in the condition of effect, shock, alcohol or narcotic influence. Pain is not present during the operation with anesthesia, and during such a disease, like syringomyelia (the damage of the gray instances of the spinal cord).

Pain is the protective reaction of the organism, but long and intense pain causes exhaustion of the central nervous system.

(2) Bleeding (haemorrhagia)

Bleeding the constant feature of the wound because of the damage of the tissue starts from skin and mucous tissues and it is accompanied by the disturbance of the integrity of vessels. The intensity of the bleeding can be different from capillary to arterial bleeding.

It is determined by:

1.     The presence of damage of big (or middle) vessels: arterial or vein ones.

2.     Localization of the wound. The most intensive bleeding is in injuring of the face, head, neck, manus the tissue of these parts of the body has more blood than others.

3.     The character of the weapon.

4.     The condition of local and common hemodynamics. When the arterial pressure is decreasing or squeezing of the magistral vessel the intensity of the bleeding decreases.

5.     The condition of the coagulation system.

(3). Cleft (Hiatus)

The hiatus of the wound is caused by the contraction of the elastic fibers of the skin. Expressivities divergention of the skins borders of a wound first of all is determined by correlation of its axis to the Langergans lines. These lines shoe the main direction of the rough skin structures situation. For example, for decreasing of the hiatus during the operation of the extremities the surgeons choose the longitudinal directions of the incisions. The special means of direction of the incision is in cosmetic and plastic surgery during closed skin defects. For big hiatus of the wound (incisions of the festering) the incision is made perpendicularly to the Langergans line.

Classification of the wound

1.     Classification according to the origin

All the wounds are divided into two groups: operative and accidental.

Operative wounds are caused deliberately, with treatment or diagnostic aim, in special aseptic conditions, with minimal damage of the tissues, during the anesthesia, with a thorough hemostasis and by joining with stitches of the incisive anatomical structures. In such condition the pain is not present in case of the operative wounds, the possibility of the bleeding is minimal, and the hiatus of the wound is removed at the end of the operation by applying stitches, it means that the main wound features are removed artificially.

The operative wounds heal by the primary tension.

All other kinds of wounds are accidental. The common thing of the wounds is that they are caused contrary to the will.

2.     Classification according to character of tissue injure:

1.           cut or incised wound (vulnus incisum);

2.           stub or pierced wound (vulnus punctum);

3.           contused wound (vulnus contusum);

4.           lacerated wound (vulnus laceratum);

5.           crushed wound (vulnus conqvassatum);

6.           sabre or slash wound (vulnus caesum);

7.           bite wound (vulnus morsum);

8.           mixed wound (vulnus mixtum);

9.           gunshot wound (vulnus sclopetarium).

 

1.     Cut wound (Vulnus incisum)

A sharp object causes these wounds. During the influence of the tissues the effort is concentrated on the concrete area, and this area has the high pressure, and this influence divides the tissue in the direction of sharp objects action. The surrounding tissues damage is not substantial. But the sharp object goes down to the internal organs and tissues. These wounds lead to a faint pain syndrome, big bleeding, and the hiatus depends on the correlation of the axis to the Langergons lines. Cut wound is dangerous with the vessels damage; nervous damage if this trauma does not have such complications the wound is going to heal by primary tension.

2.     Stab wound (Vulnus punctum)

Stab wound is caused by narrow and pointed object. The anatomical peculiarities are large depth and small area of the injured skin and mucous tissue.

The pain syndrome is slight, hiatus is the absent, the external bleeding is absent, but hematoma can develop. Its special feature is damage of the inner vessels, nerves and organs. Thats why this kind of wound has the difficult diagnostics. During the stab wound the injure can be simple or with serious complications of the liver, stomach and others this condition can lead to death. This wound can lead to spreading of infection.

3.     Contused wound (Vulnus consutum)

A blunt object causes these wounds. Before the damaging of skin, the blunt object has to injure the soft deep tissues or organs (muscles, bones). Around the wound appears the wide zone of damage saturated with blood and destroying life activity (necrosis). Contused wound causes pain syndrome (big and injured zone), but the external bleeding is small (vessels wall is damaged spreading a large area being thrombosed fast), but there can be hemorrhages. According to these complications contused wound heals by secondary tension.

4.     Lacerated wound

A blunt object causes these wounds but this object is directed under the acute angle to the skin. We can observe a big separation and sometimes to scalp of the skin. According to this separation skin can necrotize. Sometimes this kind of wounds can be caused by fractured parts of bones.

5.     Crushed wound

The mechanism of this damage is equal to the vulnus consutum and vulnus laceratum, but the degree of injury is maximal. These wounds seldom can lead to the incision of the skin, because the injured zone is very large. Crushed wound heals worse, and there can be infections.

6.     Slash wound

Slash wound caused by big and sharp object, thats why these wounds take the medium place between cut (incised) wound and contused wound. During this kind of wound the internal organs and bones are damaged very often. Such a wound may lead to spreading necrosis. Pain syndrome is very strong. Bleeding not severe, but massive diapedesis hemorrhages are present.

7.     Bite wound

The special features of this wound are bite by animals or man. Bite wound is more infected than other wounds. This wound may be complicated by acute infection, but the zone of damage is small. Some toxins may intoxicate the saliva (snake bite). Besides that, the bite wound may be contamination by tetanus.

8.     Mixed wound

These wounds may connect two and more kinds of wounds.

9.     Gunshot wound

a) This wound has three zones of damaging. For all kinds of wounds is characteristic the presence of 2 zones of damage: wound canal and traumatic necrosis. The observation of gunshot wounds determined that they differ by a long period of healing. The main difference of gunshot wound is high speed of object (bullet, splinter). Common knowledge is that the energy of free moving object is equal mV2/2. According to this the damage of the tissues is very strong. A sharp bullet more easily goes through the tissues but if the bullet looses stability, it starts to rummage. In such case the bullet returns its energy to the tissues. During the penetration of the bullet into the tissues the area of increased pressure is formed which has the compressed tissues. This compression expands from the bullet. This is the phenomenon of side stroke. According to this a temporary cavity is formed. This cavity may be pulsatile and the tissues with great speed contact relax, mutually displace. The pressure in the inner part of the cavity is 1000 atm, and the load on the wall of a vessel is 120 kg/sm2. Such mechanism causes 3 zones of damage (Borst, 1917 year).

The zones of damage:

1.     wound canal. In some cases there can be a bullet, or parts of necrotic tissue, blood and bacterias.

2.     direct traumatic necrosis. Appears during the influence of kinetic energy. It consists of viable or unviable tissues, which are saturated with blood.

3.     the zone of molecular contusion. It consists of tissues, which have malfunction of metabolism and of cellular structures. During the uncomfortable conditions, for example, the decreasing of perfusion, oxygenation, developing of the infection, the tissues devitalize (die). This zone is called a stockpile of the following necrosis. This zone causes problems with treatment.

b) Complex anatomical character of damage

High kinetic energy causes not only presence of three zones, but also their complex anatomical character. What does it mean?

During the damage very often injure of some cavities of the organism is observed. Sometimes we can meet splinter fractures of the bones, and during injure of inner organs we can observe their rupture. Not always the wound canal is the direct line from the entrance to the exit aperture. It may look as indmeet line and may cause the damage of different organs.

c) High level of infection

Gunshot wound is very often complicated by the development of infection. High level of infection with the necrotic mass increases the risk of suppuration. And according to big damage of the muscle and small diameter of the entrance aperture, the access for the oxygen is very difficult, and this is the big evidence for the development of anaerobic infection.

d) Additional classification.

According to the character of wound canal:

1.     A thorough damage it has entrance and exit apertures (a bullet is out of the organism).

2.     Blind injury in has only entrance aperture (bullet is at the end of wound canal).

3.     Tangential the damage of superficial tissues, without the penetration to the cavities of the organism.

According to the factor of damage:

1.     Small speed damage gunshot. The speed of the bullet is 600 m/s. The wound canal more often may be direct and blind. Such wound has, as a rule, a small entrance aperture and not big tissue damage.

2.     High-speed damage. The speed of the bullet is 900 m/s and more. These wounds have small entrance aperture and wide, with defect of tissues, exit aperture. Wound canal winding, thats why we may observe the injury of many organs and tissues. More destroying effect may be caused by explosive shells.

3.      Shot wounds. These wounds have many separate apertures, bleeding, the contusion of organs and tissues.

According to the zone of damage:

1.     Wounds with a small zone of damage. These wounds have a small border of the incision and the necrotic zone is very small. The wounds with small zone have no complications, small hiatus.

2.     The wounds with a large zone of damage. These wounds have insignificant hemorrhage, strong pain, long healing, and many complications.

 

3. Classification according to the level of infection

1.     Aseptic.

2.     Fresh infected.

3.     Suppurative.

1). Aseptic wounds

This wound is caused in the operative room with norms of aseptic. Such wound heals soon, and they do not have any complications.

But the operative wounds may be different: for example the operation of the vessels infection is minimal and appendicitis a high level of infection.

According to the level of microbial contamination all operation are divided into four kinds:

        Aseptic operation (planned primary operation without the opening of cavity of inner organs).

        Conditionally aseptic there may be infection in some cases.

        Operation with big danger of infection conditionally infected.

        Very high level of infection infective operations (purulent processes).

2). Fresh-infected wounds

This is the wound, which was made outside of the operation or during 3 days from the moment of damage. The level of infection in this wound is different and it depends on the kind of an object, conditions of damage. Fresh-infected wound have quantity of microorganisms not more than 105 per 1g of tissue.

3). Suppurative wounds

They are infected too. But they differ from fresh infected with the presence of the infective process. This infection causes inflammatory reaction, necrosis, formation of the suppuration, and general intoxication.

 

4. Classification according to the serious:

There are simplex and complex wounds. Simplex wound is the damage of skin, sub skin and muscle.

Complex wound is the damage if inner organs, bones, magisterial vessels and nerves trunks. For the diagnostics of the inner organs there are special symptoms. The damage of arterial vessels of the extremities are absence of pulse, paleness, increasing of the temperature in the region of bleeding. Venous stagnation are the extremities become cold and swollen, cyanosis. The cut of nerve trunks are loss of sensitivity and moving function of the extremities.

5. Classification in dependence of the relation of the wounded defect to the cavities if the body:

There are penetrated and not penetrated wounds. Penetrated wounds they make a connection between the cavity of the organism and environment. For this there should be a damage of one of these membranes: hard membrane of the brain, parietal pleura, parietal peritoneum, and capsule of the joint.

Penetrated wounds are the most serious and dangerous. During the damage of thorax there may be pneumothorax, hemothorax.

During the damage of the abdominal cavity it is necessary to exclude the injury of parenchymatous organs, intra-abdominal bleeding. It is important to notice that during the penetrative injury there may be infection of the suppurative meningitis, empyema of the chest, peritonitis, and suppurative arthritis. If the wound is not penetrative such infection is not possible.

It is important to know what organs are injured in penetrative wound. Thats why such a patient has the operation: opening the cavity and making the revision of all organs and remove the injury.

6. Classification according to the region of saturation:

There are wounds of neck, head and trunks, upper and lower extremities and so on. Sometimes wounds connect two parts of the body, they are called complex wounds.

According to the number of injuries they determine single and plural.

7. Combinative damages

Besides the mechanical and other injures there can be combinative damages.

C h a r a c t e r i s t i c s o f w o u n d p r o c e s s

Wound process this is the complex of successive changes, which take place in a wound, and connective reactions of all organism.

Conditionally, we may divide this into general reactions of the organism and healing of the wound.

1. General reaction

The complex of the biological reaction of the organism during the influence of damage we may observe like 2 successive stages.

1). During 1-4 days from the moment of trauma there is observed the excitation of sympathetic nervous system, the elimination of the hormones of adrenal glands insulin, ACTE, and glucocorticoids, into the blood. According to this the process of life activity becomes stronger: increase the main change process; decrease the mass of the body; increase the destruction of the proteins, lipids, and glycogen, decrease the penetration of cellular membrane.

In the cavity of a wound there is some quantity of microorganisms and destroy tissues, which dissolve and phagocytes. According to this, all process, which is present in the surrounding tissue of the wound, causes the general reaction in the whole organism. As a result, in the first period there is observed the increase of the body temperature, weakness, decrease the workability.

The analyses of blood notes the increase of the leucocytes quantity, sometimes a small shift of leukocyte formula to the left. In analysis of urine may be proteins. During the general bleeding there is observed the decrease of hematocrit, quantity of erythrocytes, hemoglobin.

2). Starting from 4-5 days, the character of general reactions depends on parasympathetic nervous system. The main important components are mineral-corticoids, somatotrophic hormone, aldosterone, and acetylcholine.

They observe the increase of the body mass, the normalization of proteins, the mobilizing of reparative abilities of the organism. In 4-5 days when the complications are absent; the intoxication, inflammation, pain are decreased. The analysis of blood and urine becomes normal.

2. Healing of the wound

The reparation of the wound the reparative process of damage tissue with resumption its integrity and firmness.

For closing of the tissue defect there can be 3 main processes.

The formation of the collagen by fibroblasts. During the reparation of the wounds fibroblasts activates by macrophages. They proliferate and migrate to the place of injury, and connect with fibril structures through the fibronectin. In one time fibro plates synthesize the substance of extra cellular matrix. Collagens provide the liquidation of tissue defect and firmness of the stitch formation.

Epithelization of the wounds becomes under the influence of migration of the epithelial cells from the border of wound to its surface. The end epithelization of wound defect causes the barrier for microorganisms. But the migration from the border cannot close the defect, which does necessary in some cases to carry out a dermal plasty.

The decrease of the wound surface provides effect of tissue tension (the contraction of miofibroblasts).

Phases of wounds reparation

Rufanov differ 2 phases: hydration and dehydration.

Girgolav determined 3 period of wounds reparation:

1.     preparing period.

2.     the period of regeneration.

3.     the period of stitch formation.

In present time the most popular classification is (Cusin, 1977 year):

1.     the phase of inflammation (1-5 day). It has period of vessels changes and period of purifying of the wound from necrosis.

2.     the phase of regeneration (6-14 day).

3.     the phase of formation and stitch reorganization (begin from 15-th day).

 

1)                           Inflammation phase

Period of vessels changes

Trauma cause such destroys, which connects with microcirculatory vessels. Besides the rupture of vessels there may be short time contraction and after that the dilatation of micro-vessels. Biogenic amines, the system of complement cause the vasodilatation and increasing of penetration of vessels. According to this the blood stream becomes slower which makes the blood curdling harder and as a result the cellular and venues thrombosis takes place.

The increasing of perfusion provide to decreasing of oxygenation of tissues in region of wound. Acidosis, destroys the proteins change develops. During the destruction of cell proteins with destruction of cell free ions of K+ and H+, which increase the osmotic pressure in tissues, makes the setback of the water, hydration of the tissues.

Prostaglandines cause vasodilatation, pirogenic reaction and pain syndrome. Such changes of microcirculation provide to appearance of extra-vessels changes: exudation of the plasma and lymph, excretion and migration of leucocytes in wounds region.

According to this develops the edema and leucocytes infiltration of tissues, prepares the condition for clean of the wound.

The period of the wound clean from necrotic tissues

The most important components in the period are blood elements and enzymes. In first days appears leucocytes surround the wound. 2-3 days appears lymphocytes and macrophages.

Neutrophilic leucocytes make fagocytation of the microorganisms necrotic mass, make the extra cellular proteolysis, and excrete the mediators of inflammation.

The main functions of macrophages - are excreting proteolytic ferments and phagocitosis of destructive by leucocytes necrotic tissues, take part in immune reactions.

2)                           Phase of regeneration

Two main processes take place in a wound: wounds collagenisation, intensive growth of the blood and lymphatic vessels. In wound decrease the number of neutrophils, and increase the number of fibroblasts (cells of connective tissue which can synthesize the macromolecules of intracellular matrix). The main role of fibroblasts is synthesis of the components of connective tissues and formation of the collagens and elastic fibers. In this time the recanalisation and growth of blood and lymphatic vessels in wound region starts. The proliferation of capillaries becomes. Inflammatory process becomes less.

3)                           Phase of formation and reorganization of the stitch (15day 6 month).

In this phase the synthetic activity of fibroblasts and other cells stops, and the main process led to strengthening of the stitch by the way of formation of the net by the help of elastic fibers, and appearance transferal between different bundles of collagen. Stein wounds recovered only 70-90% of the primary skin. The tissues with difficult structure have less possibility to regenerate. There can be stitch, but it cannot do the same function.

The factors, which have influence on healing of the wound:

                 age of the patient;

                 the condition of nutrition and body mass;

                 the presence of secondary infection of the wound;

                 the condition of blood circulation in zone of damage and organism in general;

                 the presence of destroys of water-electrolytic balance;

                 the immune status of the organism;

                 chronic bypasses diseases;

                 using anti-inflammatory medications.

The best reparative process has the child organism, it caused by presence in period of development anabolic processes. In such condition the reparation is shorter and is not so dangerous.

Classical types of reparation:

        reparation by primary tension;

        reparation by secondary tension;

        reparation under the crust.

1). Reparation by primary tension

Sanatio per primam intentionem is the most profitable heal of the wound. In such case stitch is thin and strong. Operation wounds have primary tension when the borders of wound connected. The quality of necrotic mass is small and small inflammation.

After the inflammation and clean from death cells in phase of regeneration between the walls of wound canal form the connection by connective tissue and by collagen and vessels. In this time becomes the growth of epithelial tissue from the borders of wound, and this is the barrier for microbial penetration.

Wounds, which have small diameter (1cm), can repartee by primary fibrinous commissure.

Primary tension has only uninfected wounds, or wounds with small infection.

According to this there is some aspects for primary tension:

        no infection in wound;

        connection the borders of wound;

        absence of the hematoma and other objects in wound;

        absence of the necrotic mass;

        good condition of the patient.

2). Sanatio per secundam intentionem heals by suppuration by the help of granulate tissue. In this type of heals we can observe inflammation.

a). Conditions to heal by secondary tension:

        big quantity of microbes in wound;

        big defect of the skin;

        the presence of some objects or hematoma;

        the presence of necrotic mass;

        unfaourable condition of the patient.

b). The specialties of the inflammatory phase

The inflammation is stronger. Phagocytosis and lysis of devitilizative cells cause high concentration of toxins in surrounding tissue. This process cause bad microcirculation and increase the inflammation. This wound characterize by invasion of microbes to surrounding tissues. On the border of this penetration is forms leukocytic accumulation.

After the cleaning of the wound starts second phase this is phase of regeneration.

c). Structure and functions of the granulative tissue.

Granulative tissue this is the special kind of connective tissue, which forms only during heal of the wound by second tension. In normal, granulative tissue does not develop without damage.

The formation of the granulative tissue.

During the regeneration by primary tension in second phase, wound process fills by granulative tissue.

The main component of the reparative process is the growth of the vessels. They go from deep to the surface and after that, make the land and go down to the fundus of the wound in this regions blood elements form, form fibroblasts, which give the growth of the connective tissue.

The islands of the granulative tissue appear in not clean wound (during the necrosis 2-3 day). The granulative tissue may form not only by the help of infection but also in clean wounds. It may happen in such case, when diastasis can be more than 1 sm., and when the capillaries do not go to the other side of the wound.

Components of the granulative tissue

The main components are 6 layers:

        Superficial leukocytic-necrotic layer. It consists of leucocytes, detritus and skinned cells. This layer is the whole period of reparation.

        Layer of the band vessels. Besides the vessels it consists of polyblasts. In this layer collagenic fibers may be formed.

        Layer of the vertical vessels. It is constructed from perivascular elements.

        Developing layer. This is the deepest part of the previous layer; this layer is characterized by polymorphism of the cells formation.

        Layer of the horizontal fibroblasts. It consists of monomorphic cellular elements, collagen fibers.

        Fibrous layer. It shows the process of granulative growing.

The means of granulative tissue:

1.                                Change the wound defect: the main plastic component.

2.                                This is the protection of the wound from microorganisms and some objects.

3.                                Sequestration and excretion of the necrotic mass.

During the normal process there develops not only granulative tissue but also starts the epithelization step by step, the granulative tissue transforms into rough connective tissue scar forms.

Pathological granulation

During the influence of the bad factors, the process of granulation destroys. The granulation becomes pathological. Clinical symptoms are absence of the wound connection and appear the change of granulative tissue, which we observe. The wound becomes dim, acyanotic, sometimes cyanotic. It loses a turgor, becomes covered by a fur of a fibrin and pus.

The pathological granulation may be with formation of tubercles hypertrophied granulations. They stop the granulation.

Reparation under the crust

This reparation takes part during the small damage of the skin.

This process starts from the blood clotting, lymph clotting. Crust is the biological bandage. Under the crust starts regeneration of the tissue (3-7 days). Its not necessary to cut crust if there is not inflammation.

But if under the crust there is necrotic mass, the operation is necessary.

Crust is medial stage between primary and secondary tension.

 

TREATMENT OF WOUNDS

Despite many specific peculiarities of different wounds, main stages of their healing are mostly the same. There are also common tasks, that surgeon face while treating any wound.

1.     Dealing with early complications.

2.     Prophylaxis and treatment of infection in the wound.

3.     Reaching the healing in the closest time.

4.     Full stabilization of function of damaged organs and tissues.

Dealing with these tasks should be started at the very beginning of providing the first aid.

1. FIRST AID

While giving the first aid one should:

        exclude early complications of the wound that are dangerous to life of the patient,

        prevent the following infection of the wound.

(1) FIGHTING AGAINST COMPLICATIONS THREATINING THE LIFE

The hardest early complications of the wound are: bleeding, development of traumatic shock and injuring of life important organs.

Intensivity of the hemorrhage depends on type of damaged vessel and its size. Massive blood loss is caused by injuring of magistral arteries and veins, which may lead to development of hemorrhagic shock with disorder of whole hemodynamics, incompatible to life. Thats why in massive hemorrhage first task is to stop the bleeding using a tourniquet (if arteria is injured), or pressing of veins distally to injury on time of treating of the wound with later applying of a pressing bandage, or other temporary methods of stopping of the hemorrhage.

If theres a danger of development of traumatic shock during pre-hospital stage injection of strong analgesics is provided (including the narcotic ones) and contra-shock medications.

In case of penetrative injuring of thoracic cavity and development of hemothorax applying of hermetic (occlusive) bandage with using of special sterile gum fabric is necessary. In such way pleural cavity is hermetic and pneumothorax will not develop during the transportation.

In case of a big penetrative wound of anterior abdominal wall damage of internal organs may occur. To prevent the following falling out and infecting wide aseptic bandage should be applied.

(2) PROPHYLAXIS OF FURTHUR INFECTING

Independently on character and localization all accidental wounds are contaminated with bacteria. But besides the primary infecting of the wound, further bacterial penetration from the patients skin, air, different objects is possible. Thats why for avoidance of additional invasion of bacteria into the wound during providing of the first aid dirt from the surrounding skin covers cotton or cloth tampon, moistened with alcohol, ether or other solution that has antiseptic and clearing action, eliminates.

Than the margins of the wound should be smeared with 5% infusion of iodine (or alcohol, brilliant green etc.) and apply an antiseptic bandage, and a pressing one id needed.

One should not clean the wound and exclude foreign bodies from it.

Besides treatment of the wound in massive traumas of soft tissues of the limbs and also in fractures of the bones to avoid the development of injury transport immobilization should be provided.

Further measures of treatment of the wound are first of all determined by its kind according to stage of infecting. Thats why there is a differentiation of treatment of operative (aseptic), fresh infected and purulent wounds.

2. TREATMENT OF OPERATIVE WOUNDS

Treatment of an operative wound on the operation table starts, when the surgeon tries to provide the best condition for its healing.

(1) PROVIDING CONDITIONS FOR HEALING BY PRIMARY COVERING DURING THE OPERATION

Operative wounds are conditionally aseptic, cut. When these wounds occur, all the conditions for heeling by primary tension are provided: prophylaxis of infection, safe hemostasis, foreign bodies and necrotic tissues are absent in the wound. At the end of operation the margins of the wound are put close together by stitches. If the probability of accumulating of exudates occurs the drainage is left there. Applying of an aseptic bandage finishes the operation.

After applying of the stitches on a deep wound of the limb with damaging of muscles, tendons, vessels and neural trunks the immobilization with plaster languet is useful. This technique provides functional rest, acceleration of heeling and decreasing of pain during the postoperative period.

The important moment is providing of antibiotics prophylaxis, the main principle of which is injection of antibiotic before an operation (or on the operation table) and during 6-48 hours after it. The most frequently used are cephalosporines of 2nd and 3rd generation. The scheme of introduction of antibiotics is presented on the scheme:

1.     Clean operations antibiotic prophylaxis is not indicated.

2.     Clean operations with possible infecting introduction of an antibiotic during the operation and during 8-24 hours after it (1-2 introductions).

3.     Operations with high risk of infecting introduction of an antibiotic during the operation and during 24-48 hours after it.

4.     Operations with a very high risk of infecting introduction of an antibiotic during the operation and during 3-5 days (treatment of main pathological process.

The main conditions for heeling of the wound by primary covering are provided during the operation.

(2) TREATMENT OF THE WOUND IN POSTOPERATIVE PERIOD

After the operation it is important to solve following four tasks:

    anesthesia;

    prophylaxis of secondary infection;

    acceleration of heeling processes in the wound,

    correction of general condition of the patient.

a)    Anesthesia

Anesthesia in postoperative period can be provided by different methods depending on traumaticity of invasion and expression of the pain syndrome.

b)    Prophylaxis of secondary infection

After the operation aseptic bandage is applied on the wound. It is has changed to be changed in 24 hours after the operation, and than according to needs.

For prophylaxis of infection complications it is important to look after the condition and functioning of drainages, they have to be removed in time (not functioning drainage may be a source of infection.

c)     Acceleration of heeling processes

For prophylaxis of hematome during the first 24 hours after the operation the ice bag is applied to the wound. Starting from the third day the heat procedures, physiotherapy is used (quartz).

For improving of blood circulation and metabolic processes early activation of the patient is necessary.

d)    Correction of general condition

During postoperative period it is necessary to carefully watch after general condition of the patient to find out and correct any factors, harmful for heeling in time (anemia, hypoproteinemia, blood circulation insufficiency, discharge of water-electrolyte balance etc.).

(3) HEELING OF WOUNDS AND REMOVING OF STITCHES

Using of these methods of prophylaxis of complications and treatment of operative wounds in majority of cases provides their heeling by primary covering. The end of this process is formation of postoperative scar.

Terms of heeling of the wounds depending on their localization:

Face, head 3-4

Anterior surface of the neck 4-5

Posterior surface of the neck 6-7

Lateral surface of chest and abdomen 7-8

Wounds of the abdomen on medial line 10-11

Back 10-11

Shoulder 5-6

Forearm 6-7

Hand 5-6

Thigh 5-7

Shin 7-8

Foot 10-12 days

Formally a wound becomes a scar after removing of stitches. Terms of removing of stitches (therefore terms of heeling of the wound) are determines by localization of the wound and condition of the patient.

Different terms of heeling of wounds of different localization (see in table) are first of all explained by peculiarities of blood supply. On the face, anterior surface of the neck the blood supply is very good, wounds heel quickly. On the legs, especially on the feet, blood supply is worse and wounds heel longer.

Presence in general condition of factors, harmful for heeling (old age, anemia, accompanying illnesses etc.), prolongs terms of heeling.

3. TREATMENT OF FRESH INFECTED WOUNDS

Taking into consideration all the accidental wounds are primarily infected, tactics of treatment depend on character and localization of the wound, on volume and remoteness of an injury. Fresh superficial wounds, scratches need only treatment by antiseptics and an aseptic bandage (see appendix 13).

Such wounds heel by themselves without applying of stitches by primary covering or under a scab. Nevertheless even having such wounds one should not forget about possibility of penetration of causative agents of tetanus (usually if the wound or instrument have touched soil) and rabies (in animal bites). In such cases anti-tetanus serum and anti-rabies vaccine are injected.

In majority of fresh infected wounds surgeon faces a task of preventing of development of infection (suppuration) and providing conditions for its quick heeling. According to this the main measure in treatment of fresh infected wounds is primary surgical treatment (PST) of a wound.

(1) PRIMARY SURGICAL TREATMENT OF A WOUND

a)     Determination and stages

PRIMARY SURGICAL TREATMENT OF A WOUND is the first surgical operation, provided in aseptic conditions, with anesthesia, which contains the following stages:

        Cutting of the wound.

        Revision of the wound channel.

        Removing of the margins, walls and bottom of the wound.

        Hemostasis.

        Rehabilitation of injured organs and structures.

        Applying of stitches on the wound with leaving of drainages (according to indications).

Therefore thanks to primary surgical treatment of a wound accidental infected wound becomes cut and aseptic, which provides possibility of its quick heeling by primary covering.

Cutting of the wound is necessary for total under eye control revision of zone of spreading of wound channel and character of injury.

Removing of margins, walls and bottom of the wound is held for removing of necrotic tissues, foreign bodies and also all wound surfaces, which was infected while injured. After providing of this stage the wound becomes cut and sterile. The following manipulations should be provided only after changing of instruments and gloves.

It is usually recommended to cut the margins, walls and bottom of the wound out by one block on around 0.5-2.0 cm. Also the localization of the wound, its depth and kind of damaged tissues should also be taken into consideration. In dirty and squashed wounds, wounds of lower extremities the cutting out should be wide enough. In wounds on the face only necrotic tissues are removed and in cut wound the cutting out of the margins is not provided at all. Livable walls and bottom of the wound are prohibited to cut out if they are presented by tissues of internal organs (brain, heart, intestine etc.).

After cutting out an accurate hemostasis is provided for prophylaxis of hematome and possible infection complications.

Recovery stage (stitching of nerves, tendons, vessels, connecting of bones etc.) should be provided during the PST, if qualification of a surgeon lets to do so. If no it is possible to provide a repeated operation with a delayed stitching of a tendon or a nerve, provide a delayed osteosynthesis. Recovery measures in the whole volume should not be provided during the PST in wartime.

Sewing of the wound is the finishing stage of PST. There are such possible variants of finishing of this operation.

1.     Layer-by layer sewing of the wound

It is provided in small wounds with a little zone of injury (cut, stab-wounds etc.), not much dirt, if the wound is localized on the face, neck, trunk and superior extremities and if not much time passed since the moment of injuring.

2.     Sewing of the wound with leaving of drainage (drainages)

It is provided in case of risk of development of infection, but if its small or the wound is localized on a foot or shin, or zone of damage is big, or PST is provided in 6-12 hours since the moment of injury, or patient has an accompanying pathology, that is harmful for heeling process etc.

3.     The wound is not sewed

If there is a high risk of infection complications:

        late PST,

        massive dirtying of the wound with soil,

        massive damaging of tissues

        accompanying illnesses (anemia, immune deficiency, diabetes mellitus),

        localization on a foot or shin,

        middle age of the patient.

Gunshot wounds and also any wounds if the aid is provided in wartime should not be sewed. Sewing of the wound closely with presence of harmful factors is a totally unwarranted risk and a clear tactic mistake of a surgeon!

b)     Main kinds

The earlier since the moment of injury PST of the wound is provided; the lower is the risk of infection complications.

Depending on remoteness of the wound three kinds of PST are used: early, delayed and late.

Early PST is held in a term till 24 hours since the moment of wound formation, it includes the principal stages and usually finishes by applying of primary stitches. In massive damage of subcutaneous cellular tissue, impossibility of full stopping of capillary bleeding drainage is left in the wound for 24-48 hours. Later the treatment is provided like in clean postoperative wound.

Delayed PST is provided from 24 till 48 hours after injuring. In these period effects of inflammation is develop, edema and exudates appear. The difference from early PST is providing of the operation on the background of injection of antibiotics and finishing of operation leaving the wound open (not sewed) with following applying of primarily delayed stitches.

Late PST is provided after 48 hours, when the inflammation is close to the maximum and the development of infection process begins. Even after PST probability of suppuration stays high. In such situation it is necessary to leave the wound open (not to sew) and provide a course of antibiotic therapy. It is possible to applying early secondary stitches on 7th -20th day, when the wound is totally covered with granulations and obtains relative resistance to development of infection.

c)      Indications

Presence of any deep accident wound during 48-72 hours from the moment of injury is the indication for providing of PST.

The following kinds of wounds are not objects of PST:

-         superficial wounds, scratches, abrasions,

-         little wounds with divergence of margins less than on 1 cm,

-         multiple little wounds without damaging of deep tissues (like small shot injury),

-         stab wounds without damaging of internal organs, vessels and nerves,

-         in some cases through gunshot injuries of soft tissues.

d)     Contraindications

There are only two contraindications fro providing of PST of the wound:

1.     Signs of development of purulent process.

2.     Critical conditions of the patient (terminal condition, shock of the III stage).

(1)              KINDS OF STITCHES

Prolonged existing of the wound does not promote faster functionally advantageous heeling. It is especially observed in massive injuries, when significant loss of fluid, proteins, and electrolytes takes part and there is a big risk of suppuration. Besides this filling of the wound with granulations and closing with epithelium go very slowly. Thats why its important to put the margins together as soon as possible using different kinds of stitches.

Advantages of applying of stitches:

  acceleration of heeling,

  decrease of losses through the wound surface,

  decrease of probability of repeated suppuration of the wound,

  increasing of functional and cosmetic effects,

  facilitation of treatment of the wound.

There are primary and secondary stitches.

a)                Primary stitches

Primary stitches are applied on the wound before the beginning of development of granulations, the wound heels by primary cover.

Usually primary stitches are applied right after finishing of the operation or PST of the wound in absence of high risk of development of purulent complications. Primary stitches should not be used in late PST, PST in wartime and PST of gunshot wound.

Removing of the stitches is provided after development of rough connective tissue commisura and epithelization in certain terms.

Primarily delayed stitches are also applied on the wound before development of granulation tissue (wound heels like primary covered). They are used in case of risk of development of infection.

Technique: the wound should not be sewed after operation (PST), inflammatory process is under control and when it goes down primarily delayed stitches are applied on 1st-5th day.

A variety of primarily-delayed stitches are tension stitches: after the end of operation stitches are applied but threads are not knotted, in such way margins of the wound are not close. Threads are knotted on 1st-5th day when the inflammation process calms down. These stitches neither differ from the usual ones in a neither way that there is nor need to do repeated anesthesia and sewing of the margins of the wound.

b)                Secondary stitches

Secondary stitches are applied on granulative wounds, that heel by secondary cover. The sense of using of secondary stitches is to decrease or to remove a wound cavity. Decrease of volume of wound defect leads to decreasing of quantity of granulations, necessary for its feeling. As a result terms of heeling decrease, and content of connective tissue in heeled wound is much smaller, comparatively to wounds that heeled in an opened way. It is advantaging for appearance and functional peculiarities of a scar, its size, firmness and elasticity. Putting closer the margins of the wound diminishes potential entering gates for infection.

Indication for applying of secondary stitches is a granulative wound after elimination of inflammatory process, without purulent leaking and purulent content, without areas of necrotic tissues. For sureness of clamed down inflammation inoculation of the wound content can be used if there is no growth, secondary stitches can be applied.

There are early secondary stitches (they are applied on 6th-21st day) and late secondary stitches (plying is provided after 21st day). The principal difference between them is in that till 3 weeks after operation in margins of the wound scar tissue is developed, that prevents both from touching of the margins and process of their joining. Thats why while applying early secondary stitches (before scarring) its enough simply to sew the margins of the wound and put them together knotting the needles. While applying late secondary stitches it is necessary to cut out scarred margins of the wound in aseptic conditions (freshen up the margins), and after that to apply stitches and tie the needles.

For accelerating of heeling of granulative tissue besides applying of stitches, joining of the margins by stripes of plaster also can be used. This method doesnt as fully liquidate a wound cavity, but it can be used before absolute calming down of an inflammation. Joining of the margins of the wound by plaster is widely used for acceleration of heeling of purulent wounds.

4.                             TREATMENT OF PURULENT WOUNDS

Treatment of purulent wounds consists of two directions local and general treatment. Besides that character of treatment is determined by phase of wound process.

(1)  LOCAL TREATMENT OF PURULENT WOUNDS

a) Tasks of treatment in phase of inflammation

In first phase of wound process (inflammation stage) the surgeon faces the main problems:

-             Fighting against microorganisms in the wound.

-             Providing of adequate drainage of exudates.

-             Assistance to fast clearing of the wound from necrotic tissues.

-             Decrease of manifestation of inflammatory reaction.

In local treatment of a purulent wound methods of mechanical, physical, chemical, biological and mixed antiseptics are used.

In case of inflammation of postoperative wound it sometimes is enough to remove stitches and widely spread the margins. If this isnt enough, it is necessary to do secondary surgical treatment (SST) of the wound.

b) Secondary surgical treatment of the wound

The indication to SST is presence of purulent source, absence of adequate outflow from the wound (delay of puss), formation of wide zones of necrosis and purulent leaks. The contraindication is only terminally bad condition of the patient, in this case only opening and draining of purulent source is provided.

Tasks that surgeon providing SST of wound:

-         opening of purulent focus;

-         cutting of unlivable tissues.

-         providing of adequate drainage of the wound.

Before the beginning of SST it is necessary to define the visible borders of inflammation, localization of region of purulent fusion, the shortest access to it taking into consideration situation of the wound, and also possible ways of spreading of infection (on the way of nerve-vascular bundles, muscular-fascia vaginas). In this case besides palpatory examination different kinds of instrumental diagnostics are used: ultrasound method, tomographic, x-ray (in osteomyelitis) and computer tomography.

Like primary surgical treatment, SST is an independent surgical interruption. It is provided in operating room by a brigade of surgeons with the usage of anesthesia. Only an adequate anesthesia allows solving all the tasks of SST. After the opening of the purulent seat a careful instrumental and finger revision on the way of the wound and possible leaks is provided. The leaks are later also opened through the main wound or a contraperture and than drained. Finishing the revision and determining the volume of necrosis and evacuation of pus is provided and cutting out of unlivable tissues (necrectomia). One has also to remember that closely to or in the wound itself major vessels and nerves may be situated, which should be saved. Before finishing of the operation the wound cavity is abundantly washed by antiseptics solutions (hydrogen peroxide, boric acid, etc.), tamponned by gauze napkins with antiseptics and drained. The most advantageous method of treatment in massive purulent wounds is washing-through draining. In case of localization of the injury on the limb the immobilization is necessary.

c) Treatment of a purulent wound after the operation

After performing of SST or simple opening of the wound on each redressing a doctor examines the wound and evaluates its condition, defining the dynamics of the process. The margins are treated with alcohol and iodine containing solution. The cavity of the wound is cleaned from pus and free sequestered areas of necrosis by a gauze ball or napkin, necrotic tissues are cut out in a sharp way. Than they are washed by antiseptics, draining (according to indications) and tamponing.

In the first stage of heeling, when massive exudation occurs, the ointment preparations cant be used as they form an obstacle for an outflow of detached substances, in which many bacteria are situated, products of proteolysis, necrotic tissues. In this period the bandage has to be maximally hygroscopic and contain antiseptics. They can be: 3% solution of boric acid, 10% solution of sodium chloride, 1% solution of dioxydine, 0.02% solution of chlorhexidine etc. Usage of water-soluble ointments: Levomekolum, Levosynum, Levonorsynum, Sulfamekolum and 5% dioxudine ointment is available only on 2nd- 3rd day.

Chemical necrectomia with the help of proteolytic ferments that make a necrolytic and anti-inflammatory action have a certain meaning in treatment of purulent wounds. Tripsine, chymotrypsine, chymopsyn are used for this. Preparations are poured into the wound in dry condition or injected in solution of antiseptics. For active removing of purulent exudates sorbents are placed into the wound, the most widely spread of which is poliphepan.

To increase the effectiveness of SST and further treatment of purulent wounds in nowadays conditions different physical methods of influence are used. Ultrasound cavitation of wounds, vacuum treatment of purulent cavity, treatment by pulsing stream, different methods of using of laser are widely used. All these methods stimulate the cleaning from necrotic tissues and have a damaging effect on microbial cells.

d) Treatment in the phase of regeneration

In the phase of regeneration, when the wound is cleared from unlivable tissues and inflammation quiet down, a second stage of treatment takes place, the main tasks of which are suppression of infection and stimulation of reparative processes.

In the second phase of heeling process of formation of granulative tissue plays the leading role. Despite it has a protective function; the repeated inflammation cannot be totally excluded. In this period in case of absence of complications, exudation decreases and necessity in hygroscopic bandage, using of hypertonic solutions and draining disappears. Granulations are very tender and vulnerable, thats why it is necessary to use preparation on ointment basis, which prevent mechanical traumatization. Antibiotics (syntomycine, tetracycline, hentamycine ointments etc.), stimulating substances (5% and 10% methyluracyl acid, Solcoseryl, Actovegyn) are introduced into the content of ointments, emulsions and liniments.

Multicomponent ointments are widely used. They contain anti-inflammatory, regeneration stimulative substances and substances wich improve the regional blood circulation, antibiotics. These are: Levometoxyd, Oxyzon, Oxycyclozol, balsamic liniment after A.V. Vishnevsky.

For accelerating of heeling methods of applying of secondary stitches (early and late) and also putting together of margins of the wound by plaster are used.

e)     Treatment of the wounds in phase of formation and reorganization of a scar.

In the third phase of heeling the main task is to accelerate the epithelization of the wound and to protect it from additional traumatization. Bandages with indifferent and stimulating ointments, physiotherapeutic procedures are used for this reason.

f)      Physiotherapeutic treatment

Physiotherapeutic procedures play an important role in curing of purulent wounds.

In the first phase to decrease the acute manifestations of inflammation, to decrease edema, pain syndrome, to accelerate seizure of necrotic tissues it is used electric field of UHF (ultra-high frequencies) and ultraviolet radiation in erythematic dose, which also stimulates phagocytic activity of leucocytes and possesses an antimicrobic action. For local introduction of antibiotics, anti-inflammatory and analgesic preparations electro- and phonophoresis are used. In incomplete outflow of purulent content physiotherapeutic procedures lead to worsening of purulent-inflammatory process.

In the second and third stages of wound process UV-radiation and laser radiation by defocused ray are used for activation of reparative processes and epithelization. Magnetic field also possesses a vasodelatative and stimulative activity. In the influence of pulsing magnetic field the growth of nervous fiber is activated, synaptogenesis is increased; the size of a scar is decreasing.

During the whole period of wound process hyperbaric oxygenation is used, which improves the oxygen supply of the tissues.

g) Treatment in abacterial environment

In massive wound defects and burns treatment in controlled bacterial medium is successfully used. There are isolators of common and local types. Isolation of the whole patient is necessary is in treatment of patients with decreased tolerance to infection: after oncology operations, supported by massive chemical therapy or radiation treatment, in transplantation of the organs, combined with constant taking of immune depressants, that decrease the reaction of tearing away, and also in different diseases of blood, which cause the disorder and depressing of lymph- and leucopoiesis.

Treatment in abacterial medium is provided without applying of a bandage, which promote drying of the wound, which is damaging to microorganisms. The following parameters are maintained constant: temperature 26-32ºC, pressure 5-15 mm Hg, relative humidity 50-65%. They can be changed depending on character of proceeding of wound process.

(2)  GENERAL TREATMENT

General treatment of wound infection has several directions:

          Antibacterial therapy.

          Desintoxication.

          Immune correcting therapy.

          Anti-inflammation therapy.

          Symptomatic treatment.

a)     Antibacterial therapy

Antibacterial therapy is one of the components of complex therapy of purulent illnesses and purulent wounds in particular. It is mainly used at first and second stages of the wound process.

In case of absence of signs of intoxication, not large sizes of the wound, maintaining of integrity of bone structures, magisterial vessels and absence of accompanying illnesses it is usually enough to use only principles of local treatment. In other case antibacterial therapy has to be started as soon as possible.

One of the main principles of the therapy is using of a preparation to which micro flora of the wound is sensitive. But it sometimes takes more than 24 hours from the moment of taking of the material till receiving of the results of the tests. So, it is better to inject the antibiotic to which a supposed infection is usually most sensitive. In this case the definition of peculiarities of the pus, characterizing a particular microorganism may be useful.

Staphylococci usually form dense yellow pus, streptococci liquid yellow-green or plasma-like pus, escherichia colli brown pus with a specific smell. A rod of blue-green pus gives a corresponding color with a sweet smell. Proteus also possesses similar features but it doesnt have a green color. It is important to remember that there is usually a mixed kind of infection in a purulent wound, thats why its better to prescribe antibacterial preparations with wide spectrum of the action at the primary stages of the treatment. After definition of sensitivity the change of an antibiotic or its dosage may be made.

A part of antibacterial therapy is also preparations, strictly directed to particular bacteria or their groups. Different bacteriophages are also used streptococcal, staphylococcal, proteus, colli-phage and also complexed phages, like piophage, which contains several kinds of bacteriophages. For passive immunization antistaphylococci γ-globulin, different kinds of plasma hyperimmune antistaphylococci, antieschericia, antipolisaccharide (against gram-negative microorganisms) is introduced. Active immunization with anatoxins and vaccines is used with the prophylaxis aim to prepare the patient to struggle with infection by his own strength. As usual staphylococci anatoxin, polyvalent vaccine and others are used.

b)    Desintoxication

A big volume of necrosis and developing infection caused filling of the organism with toxins. In a patient with a purulent wound in first phase all the signs of intoxication are observed (chills, fever, sweating, weakness, headache, loss of appetite), inflammation changes grow in analyses of blood and urine. All these are the indications to providing of deintoxicating therapy, which contains several methods, presented below in turn of growth of their difficulty and effectiveness:

        Infusion of salt solutions

        Method of forced diuresis

        Using of desintoxicative solutions

        Extracorporal methods of detoxication.

The choice of the method of desintoxication depends first of all on expressiveness of intoxication and on difficulty of patients condition.

In regeneration phase and phase of scar formation there is usually no need in providing of desintoxication therapy.

c)     Immune correcting therapy

In case of appearing of purulent process in the wound and development of intoxication, we often observe the decrease of resistance of the organism, level of production of antibodies, phagocytic activity, deficiency of subpopulations of lymphoid tissues and slowing down of their differentiation. This is also caused by long-lasting usage if antibacterial preparation.

These changes lead to next development of infection, enlarging of a zone of secondary necrosis and progressing worsening of condition of the patient. To correct this temporary deficiency immune-modulators are used.

Interferon, levamysol, preparations of thymus (thymalin, thymosyn, T-activin) are most widely used. Nevertheless in prolonged introduction and big dosage these preparations decrease the production of own immune cells. Lately, much attention is paid to method of gene engineering of cytokines, interleukines in particular, which have wide indications for using in immune deficiencies. Human recombinant interleukine-1 (Betaleukine), interleukine-2 (Ronkoleukine) has been created and are used nowadays.

d)    Anti-inflammation therapy

Anti-inflammation therapy is not a leading method of treatment of the wounds, is used rather rarely and contains introduction of preparation of salycylatis group, steroid and nonsteroid anti-inflammation remedies. Due to this signs of inflammation, edema cool down, perfusion and oxygenation of surrounding tissues increase, metabolism improves. This leads to speeding-up of formation of demarcation line and fast cleaning of the wound from necrosis.

e)     Symptomatic treatment

In phase of inflammation due to edema of tissues pain syndrome develops. It significantly decreases in adequate draining of the wound. In case of necessity analgetics are additionally introduced (usually non-narcotic). In case of fever febrifugal preparations are used.

In patients with hard dysfunction of different organs and systems caused by trauma or complications of the purulent wound correction becomes necessary. In case of massive blood-loss hemotransfusion, transfusion of its components and blood substitutes is provided.

In case of massive wound defects with loss of fluid, proteins and electrolytes protein hydrolysates, native plasma, mixes of amino acids and pillion solutions are included into infusion substitution therapy. Into general therapy vitamins of different groups (C, B, E, A) and stimulators of regeneration (methyluracyl, pentoxyl, potassium orotate, anabolic hormones) are used. At the same time treatment of accompanying illnesses that worsen general condition of the patient and heeling of wounds (correction of diabetes mellitus, normalization of blood circulation etc.)

5.     PECULIARITIES OF TREATMETN OF GUN-SHOT WOUNDS

Nowadays gunshot injuries are widely observed not only in war zones but also in everyday life. Thats why patients with such injuries get both in military medical institution and in common hospitals.

Treatment of gunshot wounds has several principal differences. Each gunshot injury is considered highly infective. While providing PST, taking into consideration wide zone of injuring of tissues, cutting is done in big volume if possible, which is connected with presence of zone of molecular concussion. All the foreign bodies should be excluded. Bullets and splinters, which lay closely to vital organs, are the exceptions. They may be not excluded. Later covered by antibiotics therapy they become encapsulated and make no big harm for the organism. Although one has always to remember that any foreign body is the potential source of infection.

The peculiarity of small-shots injuries and consequences of using of special kinds of weapon (plastic mines etc.) is the presence of a big quantity of foreign bodies, placed in different parts of the organism. In such injuries without massive necrosis of tissues the PST is usually not provided and foreign bodies are excluded only if infectious complications appear.

The frequency of suppuration of gunshot wounds is very high, thats why after the PST of the wound primary stitches are not applied, and primary delayed or secondary stitches are used. Wounds are often treated in an open way and adequate draining has an important meaning. In some cases planned revision of the wound with narcosis is used for finding of sources of secondary necrosis in time.

During the treatment much attention is paid to creating of optimal conditions for oxygenation of surrounding tissues, which helps to minimize the zone of necrosis, which serves as a nutritive medium for bacteria, and to decrease the risk of development of anaerobe infection.

In traumatic amputation of the limb during the PST reamputation in healthy tissues is provided.

General treatment is different only in increased antibiotic and desintoxicative therapy, which is necessary in massive volume of necrotic tissues.

 

PUTRID WOUNDS INFECTION. MODERN PRINCIPLES OF TREATMENT

Infections of surgical significance may occur spontaneously, develop in wounds after trauma, or arise in remote areas of the body as postoperative complications. Spontaneous infections, such as acute appendicitis and acute cholecystitis, will be discussed elsewhere in the text. While many infections, such as pneumonia and pyelocystitis, may develop during the postoperative state in tissues or organs remote from the region of an operative area, most surgical infectious lesions are the result of the growth of bacteria introduced through a portal of entry caused by some type of trauma.

When infections develop in wounds resulting from accidental injury, violence, or planned operative procedures, they may have a profound effect on mortality, morbidity and the final result of the injury or the operation. Death, loss of limb, or disability, which may be prolonged or permanent, may result. The complication of infection, particularly in large wounds almost certainly increases the period of morbidity after operation, since infection, the greatest enemy of wound healing, produces further destruction of tissue and suppresses the process of healing. Tissue destroyed by infection is usually replaced by scar tissue, which may affect cosmetic appearance as well as function.

In recent years considerable attention has been focused throughout the world on the incidence of postoperative wound and other hospital-acquired infections produced by antibiotic-resistant bacteria. The number of infections has apparently increased, and this trend has been ascribed to such factors as indiscriminate antibiotic prophylaxis, over-confidence in the effectiveness of these agents, a disregard of important operating room principles and techniques, discontinuation of the principle of isolation, and a continuing and progressively active reservoir of antibiotic-resistant and virulent bacteria in the hospital environment.

The problem of hospital infection, just as with other wound infections, is a double problem one of contamination and one of effect of the various factors that provoke its actual development.

GENERAL CONSIDERATIONS

The primary essential for the development of infection within wounds is the growth of bacteria. Experience and experimental work have shown that all injuries resulting in penetration of the skin or the mucous membrane are associated with contamination of the wounded tissues by microorganisms of various types. Some may be highly virulent, others less so, and still others saprophytic. Airborne microorganisms contaminate even clean surgical wounds, which heal per primam. Their presence in wounds may or may not be followed by infection, depending upon certain factors that influence the growth of bacteria and determine not only the development of any septic process but also its characteristics. These factors include the following:

1. The virulence, the types and the numbers of contaminating bacteria

2. Devitalized tissue within the wound

3. The presence of foreign bodies

4. The nature, the location and the duration of the wound

5. The local and general immunity response of the individual

6. The type and the thoroughness of treatment

7. The general condition of the patient

The number and the types of contaminating bacteria have long been known to increase the probability and the severity of wound infection, and the premise that infection is the unfavorable result of the equation of close multiplied by virulence and divided by resistance still holds. However, it must be remembered that the more presence of virulent bacteria in a wound does not make infection of that wound a certainty. The evidence indicates that the physiologic state of the tissues within the wound before and after treatment is more important than the presence of bacteria per se. The synergistic or cumulative activity of the bacteria present may also determine to a large extent the nature and the severity of the infection.

Unhealthy, irritated or dead tissue in wounds invites and supports the growth of virulent and nonvirulent organisms, since it has limited or little power of resistance to their growth and action. Conversely, healthy tissue fortunately possesses a remarkable capacity to kill bacteria or withstand their effects.

Foreign bodies, particularly those of organic composition or contamination, carry large numbers of bacteria into wounds and further the probability of infection through their local irritative action on the tissues. It must be remembered that suture material buried within a wound may act as a foreign body and therefore must be used intelligently, just enough being employed to approximate live tissues and obliterate "dead pockets" as much as possible.

The type of wound is also an important factor. Extensive wounds containing large amounts of devitalized tissues, especially muscle, fascia and bone, furnish excellent culture media for bacteria. Injuries of the thigh or the buttocks may severely damage a pound or more of muscle, and these greatly devitalized masses may become severely infected. Wounds produced by crushing and associated with heavy contamination are frequently multiple and are characterized by extensive tissue destruction, severe shock and early virulent infection.

The location of the wound is another significant consideration. Not only are the various tissues known to have different powers of local resistance to infection, but the resistance of these tissues also varies with their location in the body. For example, lacerations of the face and the neck are prone to heal kindly unless they are in communication with the mouth and the pharynx, while wounds of the perineum practically always become infected to some degree.

The multiplicity of severe wounds in one person may so compromise the treatment that adequate debridement of one or more of the wounds is not possible. Because of associated severe shock, hemorrhage, or wounds of the chest or the head, the local treatment of wounds necessarily assumes a minor role in relation to the general treatment of the patient. If the period of time required for the successful general treatment exceeds 6 to 8 hours, often infection will have occurred before local definitive treatment can be started.

The immunity response of the individual may be local, regional or general, as has been discussed previously. Local immunity depends somewhat on the type of tissue, especially its vascularity. The term is used mostly to describe the local resistance, which an area develops after righting off an infection so that the same organisms can no longer invade, at this point at least, though they may still get a foothold in some other part of the body. After a consideration of the available evidence, Topley concluded that "it is possible to induce an immunity which is confined to the neighborhood of the treated area, and is not shared by the body as a whole".

The resistance of the body ordinarily is largely due to a general immunity. The possession of such immunity is specific and resides in the body as a whole, although the protein, particularly the globulin fraction of the plasma, and the cells of the so-called reticulo-endothelial system are primarily involved in the mechanisms of immunity. A third and important factor in resistance is the protective action of the lymph nodes. The development of leukocytosis during infections is also a manifestation of resistance. Natural immunity refers to resistance inherent or at least obtained in some unknown spontaneous way or congenitally. Acquired immunity, on the other hand, is the result of defenses built up in fighting a previous infection. Artificial immunity is a similar defense obtained, however, by passive or active immunization. Of the two, the latter is especially important in the prevention of tetanus.

Treatment influences the development of infection more than most physicians realize. Of primary importance is the surgical excision or removal of all dead or devitalized tissue and foreign bodies within the wound, preferably within 4 to 6 hours after injury in order to remove any potential pabulum for bacterial growth. Of almost equal importance, however, is the prevention of the development of devitalized tissue during the postoperative state. Impairment of the local blood supply by damage to or ligation of large vessels, by displaced fractures, by pressure of hematomas, by tourniquets or ill-applied and ill-fitting casts, or by increased subfascial tension due to edema, hemorrhage or sutures, decreases local resistance of tissues and favors the development of infection.

: 62

Fig. . The low extremities is located in plastic isolator ATU-5

: IMGA0486

Fig.. Treatment of a wound by laser.

The alteration of the "normal" bacterial flora of patients by antibiotic agents may suppress sensitive microorganisms and permit the emergence of resistant and virulent forms. The latter may then become invasive and pathogenic.

The physical condition of the patient is an important predisposing factor to infection, and dehydration, shock, malnutrition, exhaustion, uncontrolled diabetes and anemia may lower his resistance sufficiently to permit bacterial invasion.

PRIMARY AND SECONDARY BACTERIAL CONTAMINATION AND INFECTION

Bacterial contamination of wounds may be either primary or secondary, depending upon the time when bacteria are carried into the wound. Contamination occurring at the time of or within a few hours of injury is considered primary, while that occurring 24 hours or more after trauma is secondary. The infection caused by these methods is likewise designated as primary and secondary.

Primary Contamination The sources of primary contamination include the patients skin or hair, clothing, various foreign bodies carried into the wound, such as wood splinters, the missile, soil, pieces of glass, etc., and discharges from various tracts including the upper respiratory, the genital, or the gastro-intestinal. The more common types of bacteria associated with primary contamination and infection include staphylococci, entero-bacilli such as E. coli, B. proteus and the Clostridia of gas gangrene and tetanus.

Secondary contamination may be caused by contact or by airborne spread. It emanates primarily from the respiratory tract of the patient or other persons in his vicinity, particularly those treating or observing his wound. Other sources include unsterile dressings, the fingers of anyone touching the wound, dust of the operating room or the hospital ward, and contaminated dressings, instruments, or utensils. Care should be exercised in the dressing of wounds to prevent cross-contamination and secondary infection. These precautions include the wearing of the mask, the avoidance of touching the wound with the bare fingers, and the avoidance of using any instruments, material, or dressings, which are not sterile.

Primary infection tends to disappear at variable rates in different wounds, depending on the type of infection, the severity of the wound and the presence of sloughs, sequestra or foreign bodies.

Secondary Infection Primary infection is gradually replaced, often during the second week, by the stage of secondary infection caused chiefly by the pyogenic cocci, especially the hemolytic Staphylococcus aureus and Streptococcus hemolyticus and to a lesser extent by B. pyocyaneus, E. coli and Proteus vulgarly.

Hare and Fleming believed that the hemolytic Streptococcus was the most important agent in secondary infection, but it has been another experience that the hemolytic Staphylococcus aureus is both more prevalent and more important.

It is interesting to recall that Lord Lister laid great stress on airborne infections, but until very recently their importance has been underestimated or overlooked. Unless strict precautions are taken, secondary or cross infections are bound to occur in a surgical ward, the longer a wound is allowed to remain open the greater is the chance for secondary contamination and infection.

METHODS OF DIAGNOSIS OF SURGICAL INFECTIONS

Accurate and prompt methods of diagnosis of surgical infections are more important now than ever, the discovery and general use of antibiotics notwithstanding. The reasons for this continued importance of early and accurate diagnosis will be discussed in detail later.

The diagnostic methods useful in determining the location and the nature of surgical infections include the following:

1. A careful history and physical examination, coupled with a general knowledge of surgical infections and their etiology, may lead to the presumptive diagnosis of the lesion and the causative organism. For example, the early diagnosis of acute hematogenous osteomyelitis can be made entirely upon the history and the physical examination long before positive x-ray findings are present. In addition, we know that approximately 80 to 88 per cent of such cases are caused by the hemolytic Staphylococcus aureus, and that some form of gram-positive cocci causes approximately 99 per cent. In this manner it is possible to make a presumptive diagnosis of the lesion and the etiologic agent early in the course of the infection when antibiotic therapy will give the best results.

2. Laboratory data, such as red blood counts, hemoglobin, white blood counts, differential counts and urinalysis, are important sources of information which aid in differential diagnosis. Of particular importance in many patients with severe infections is the physician's recognition of the presence of diabetes by urinalysis and blood sugar determinations, because of the susceptibility of diabetics to infection and the difficulty in controlling the combined diseases. Generally speaking, patients with infections exhibit varying degrees of leukocytosis, and valuable information regarding the nature and the course of the infection can be gained from serial counts. Every patient with a surgical infection of moderate or greater severity should have complete blood counts daily for 3 days and then at least twice weekly thereafter until the infection is well under control.

A study of circulating leukocytes in the blood may be very helpful in the diagnosis of surgical infections. Many infections produce only slight or moderate increases in the total count, which may not be particularly useful in establishing a specific diagnosis. Differential counts frequently are useful in arriving at a diagnosis; the shift to the left in suppurative infections, the relative lymphocytosis of tuberculosis, the eosinophilia of certain mycotic infections, and the toxic granulation of the cells are examples of the value of differential counts. Overwhelming infection may be associated with absence of elevation or even a reduction of the total white cell count. Other surgical infections may be associated with very high total white blood cell counts (leukemoid response), and examples are pneumococcal peritonitis, retroperitoneal phlegmon, septicemia, suppurative pancreatitis, etc.

White blood cell counts are an important part of the initial workup of patients with surgical infections and a valuable means of assessing the progress of treatment thereafter. Infections caused by hemolytic bacteria such as the Streptococcus hemolyticus or Cl. welchii may produce profound anemia.

3. Special procedures, such as roentgen examinations, are of considerable aid in the localization of the infection and its spread.

4. Infectious exudates should be obtained whenever possible from the area of infection by swab or aspiration for examination, 4 general procedures being possible.

Direct observation of the pus to detect its color, consistency, odor and other physical characteristics is often of great diagnostic help to the experienced surgeon.

Direct microscopic examination of a smear stained by the Gram stain, acid-fast, or other technics may yield immediate information regarding the type or general types of microorganisms present. It may also show the types of leukocytes predominant in the wound.

Culture of the pus under aerobic, micro-aerophilic and anaerobic conditions may indicate the specific organism or organisms causing the infection. Cultures made of infectious material should be placed immediately into appropriate media and then into the incubator for cultivation. Every effort should be made to do this rather than keep the material overnight in an icebox or at room temperature, which favors drying of the specimen and death of all but the hardiest organisms, which unfortunately are often not the true pathogens.

Examination of a wet preparation of the exudate, treated with 15 per cent sodium hydroxide solution, under a cover glass or by the hanging-drop technic may demonstrate the presence of yeast or fungi.

In obscure infections in which there is no purulent exudate, material aspirated by needle and syringe from cellulitic areas or areas of suspected infection may establish the diagnosis and indicate the infecting agent by examination of the smear and culture.

5. Culture of the blood also can provide diagnostic information. This may be the only manner of identifying the ctiologic agent when pus is not available for culture or when the primary focus is hidden, obscure, or silent. Whenever possible, the blood cultures should be taken as close to the onset of a chill as possible, or when the temperature is rising rapidly.

6. Biopsy of the lesion in granulomatous infections, particularly tuberculous, syphilitic or mycotic, gives material for microscopic examination, which may be of great value in arriving at a definite diagnosis in difficult cases.

Other special diagnostic procedures that may be used include agglutination tests made with the patients serum and skin tests made with various antigens. The latter may be used as aids in establishing the diagnosis of lesions such as lymphopathia venereum, tuberculosis, blastomycosis, histoplasmosis and coccidioidomycosis.

7. Bacteriophage Typing. Bacteriophage typing may be useful in the identification of different strains of the Staphylococcus and the Pseudomonas. This technic may also provide information on the virulence and the epidemic potential of these bacteria, particularly the Staphylococcus.

TREATMENT OF SURGICAL INFECTIONS

Great advances have been made during the past 70 years in the prevention and the control of surgical infections, particularly during the last 15 years. Today it is routinely possible to prevent infection in planned operative wounds, an achievement, which is one of the great milestones of surgery. In addition, considerable progress has been made in preventing or attenuating infection in accidental wounds or wounds of violence. The outlook of surgical patients with established lesions or operations performed in contaminated fields has become vastly improved. Many of the surgical infections commonly seen can now be controlled effectively in conjunction with operative intervention when indicated. However, there are still many surgical lesions of microbial etiology, which are refractive to any known form of chemotherapy.

prophylaxis

In addition to directing treatment toward overcoming the various factors that predispose to the development of surgical infections, such as early excision of devitalized tissue, removal of foreign bodies, preservation of blood supply, and immobilization of injured extremities, other means of preventing infections are available.

antibiotic agents may be used to considerable advantage, but the indications for their use in civilian surgical practice are considerably more limited than those generally practiced. Their indiscriminate or blind use is to be discouraged.

1. In contaminated wounds of violence and burns, adequate debridement often cannot be accomplished and devitalized tissue and bacteria may remain to cause infection. The systemic administration of an agent such as penicillin is indicated and usually will inhibit the growth of hemolytic streptococcal infections and prevent infection by this organism. There is no definite evidence that systemic antibiotic therapy also reduces the incidence of other invasive infections produced by the Staphylococcus, Bacillus pyocyaneusy, Escherichia coli, Aerobacter aerogenes and other gram-negative bacilli. There is some clinical evidence to indicate that excessive doses may increase the probability of secondary bacterial invasion in patients with burns or other severe trauma.

2. In elective procedures performed through or in contaminated areas such as the gastro-intestinal, the respiratory, or the genitourinary tracts, prophylactic therapy may be useful. Here, again, unavoidable contamination of the wound by pathogenic bacteria occurs in such numbers that development of infection becomes a real probability unless the patient has the added defense of prophylactic antibiotic treatment.

3. The use of antibiotics is warranted in an effort to prevent infection in patients who have associated derangements of the urinary tract or require indwelling catheters as part of their surgical care.

4. It is also indicated in patients with preexisting valvular heart disease who receive injuries or require elective surgical procedures in the oral or pharyngeal cavities. The well-known relationship of the initiation of sub-acute bacterial endocarditis under these circumstances warrants the use of penicillin or sulfadiazine as prophylaxis against this dreaded complication.

5. Prophylactic antibacterial treatment should be considered in patients requiring emergency operative surgical treatment in the presence of associated but unrelated infections, such as tonsillitis.

6. For elective preoperative preparation of the gastrointestinal tract, selected antibiotics administered orally prior to operation reduce both the numbers and the virulence of intestinal organisms that may accidentally contaminate the required operative wound.

7. In elderly people with pre-existing pulmonary disease who require essential operative treatment antibiotics may be useful in controlling existing subclinical infection or postoperative complications. If this is done, great care should be exercised because of the clanger of precipitating an antibiotic-resistant infection as a complication in such patients.

The prophylactic application of antibacterial agents in circumstances other than these is usually unwarranted and potentially dangerous. The routine use of such agents in clean surgical procedures may lull the physician into a feeling of false security that infection will not occur. Such treatment may partially abort a developing infection or mask its usual and recognizable clinical signs long enough to permit serious and extensive damage to occur before its diagnosis. Some "masked infections" may even become lethal without the appearance of clinical signs diagnostic of virulent infection.

Moreover, the indiscriminate prophylactic use of antibacterial agents is causing sensitivity of an increasing percentage of the population to the various antibiotics. This may be dangerous or even fatal. It also denies the patient the benefit of that antibacterial agent in the future, should he need it. It is also possible for antibiotics used prophylactically to cause serious superimposed or secondary infections by resistant bacteria such as staphylococci or fungi, which may be more serious than those to be prevented. Finally, antibiotic agents may be harmful to the patient as a result of toxicity, overdosage, or idiosyncrasy.

serotherapy may be useful to a limited degree in prophylaxis. The two surgical infections which may be considered in this regard are gas gangrene and tetanus. Experimentally and clinically, prophylactic serotherapy against gas gangrene has been found to be without benefit for practical purposes, and its use is not recommended.

immunity AGAINST TETANUS is of great value and is an essential part of the treatment of all accidental wounds.

Passive immunity can be produced by the hypodermic injection of tetanus antitoxin as soon after the injury as possible. The usual patient who is seen within 24 hours after injury should receive 1,500 units of tetanus antitoxin after proper skin-testing has shown no sensitivity to horse serum in the antitoxin. Recently it has been recommended that the prophylactic dose of tetanus antitoxin be increased to a minimum of 5,000 units. In experience at the Cincinnati General Hospital, a dose of 1,500 units is adequate, provided that it is given shortly after injury and certainly within 24 hours. If the wound is large and grossly contaminated, or if the patient has co-existing diabetes mellitus, the dose should be 3,000 or more units. If the patient is seen more than 24 hours after injury, the dose should be doubled for each 24 hours of elapsed time up to a maximum dose of 12,000 units. Under circumstances of delayed definitive treatment of the wound or manipulations of the injured area, passive immunity should be maintained by the injection of 1,500 units of tetanus antitoxin repeated in 7 days. Patients who show evidence of sensitivity to horse serum may be given passive immunity by the use of homologous hyperimmune gamma globulin prepared from hyperimmunized human donor's blood. The average adult will maintain apparently adequate passive protection for at least 3 weeks by an intramuscular injection of 5 units per kilogram. This gamma globulin must be given intramuscularly and cannot be given intravenously.

Active immunity against tetanus can be attained by 2 or 3 injections of tetanus toxoid at intervals of 3 to 6 weeks, followed by a booster injection at the time of injury. Individuals who have this active basic immunity do not require antitoxin in the prophylaxis of tetanus, but can be protected by reactivation of the immunity by injection of a booster dose of toxoid after injury.

therapy of established infections

Factors and Principles to be Observed

1. You must realize that the use of the newer antibiotic agents is adjunctive to the employment of old and established surgical principles.

2. Antibiotic agents used properly can produce profound effects in the prevention and the control of infections, but when used improperly their clinical effects may be limited, incomplete or absent.

3. You must recognize that early diagnosis is of great importance in the control of surgical infections, affecting morbidity, mortality and function. If the diagnois is established early when infections are in the diffuse or cellulitic stage, antibacterial therapy is most apt to produce a prompt and rapid control of the invasiveness with both complete and spontaneous resolution of the infection or minimal complications. This is due to 2 factors. The capillary circulation is intact and can deliver adequate doses of the antibacterial agent throughout the zone of infection. There is also greater susceptibility of the bacteria to the antibiotics while they are rapidly proliferating. However, if the diagnosis is made late, the infectious process usually has become more established, and either local necrosis or abscess formation has occurred, or systemic invasion has developed. If the blood supply to an area is impaired or destroyed, insufficient concentrations of antibiotics are carried to the area of infection. In those cases in which the infection has become disseminated before a diagnosis has been made, with the production of metastatic abscess or secondary infectious complications in remote areas, the control of the infection is considerably more difficult.

For the most efficient control of surgical infections, not only must the diagnosis be early, but it must be accurate and complete. The necessity of a correct clinical diagnosis as well as an evaluation of the patient's condition for intelligent treatment is obvious. This implies the recognition of the existence and the site of metastatic abscess or other complications. Failure of the elevated temperature and other general signs of infection to recede within 72 hours of the start of antibacterial therapy and other treatment generally imply the co-existence of a neighboring abscess, one or more complicating metastatic infections, resistance of the infecting bacteria to the antibiotic in use, or the development of vegetative endocarditis. This emphasizes the wisdom of re-evaluating the patient's disease and his treatment every 72 hours if a satisfactory response has not been obtained.

The importance of obtaining information regarding the infecting microorganism is increasing. Such information can be obtained by the immediate examination of stained smears of the pus and by culture of exudate obtained by incision and drainage or aspiration with needle and syringe from the actual site of infection. Biopsy of the lesion is often very helpful in establishing the nature of the infection, particularly in chronic infection of a specific nature, such as tuberculosis, syphilis and actinomycosis.

Errors in Diagnosis In this regard it must be kept in mind that errors in diagnosis can be made very easily by accepting the report of the laboratory on cultures made of surface lesions. Such positive cultures may actually represent contaminants or secondary invaders, not the true pathogens which may be much more difficult to cultivate. This trend is of clinical significance, since it re-emphasizes the necessity of sound clinical diagnosis.

The selection of the proper chemotherapeutic agent is extremely important in the modern control of surgical infections. The choice of an antibiotic effective for the particular etiologic agent in any given case is obviously desirable. Whenever possible the selection should be made on the basis of data resulting from studies of the gram-stained smears, cultures of exudates obtained from the lesions and sensitivity tests. Also, whenever possible one agent should be used instead of a shotgun mixture of 3 or 4. If no infectious exudate can be obtained, or if no local lesion is demonstrable in a patient with a severe systemic infection, the selection of the anti-bacterial agent must be made necessarily on a presumptive diagnosis until the nature of the causative organism is determined. Such a procedure is necessarily blind.

It is important to realize that there is considerable variation in natural bacterial resistance within strains of bacteria. Consequently, the haphazard selection of an antibiotic agent, which presumably should be effective for a given etiologic agent, may yield an uncertain result or a failure. Many strains of bacteria in our environment, particularly in hospitals, are gradually acquiring resistance to various antibiotics. For example, only 25 to 50 per cent of the strains of hemolytic Staphylococcus aureus are still sensitive to penicillin, and sensitivity tests are particularly important in the management of infections caused by it.

sensitivity studies are of considerable value in the selection of the antibiotic agent or agents of choice for the treatment of a given infection. Sensitivity determinations may be done in the laboratory by the serial dilution tube method or the disk method, using commercially prepared disks. The latter method is considerably less accurate than the former but is the only one that is available for general clinical use. Although not infallible, this method gives information on a qualitative basis valuable for clinical use, and it is sufficiently simple for any laboratory employing a technician trained in bacteriology. In our experience there generally has been good correlation between the results of in-vitro sensitivity tests, as determined by the serial dilution tube method and the clinical responses obtained.

In the treatment of serious mixed infections produced by a variety of gram-positive and gram-negative aerobic and anaerobic bacteria, it may be advisable to select 2 antibacterial agents for treatment of such conditions as acute septic peritonitis, intra-abdominal abscess, perinephritic abscess, urinary tract infections and various types of wound infections. Usually, aqueous penicillin G and one of the broad-spectrum group such as chloramphenicol, tetracycline, chlortetracycline, oxytetracycline, declomycin or streptomycin are selected. There is some test-tube evidence that antagonism may occur between two or more antibiotics, which may decrease their effectiveness, but fortunately there is no significant evidence of this antagonism existing in vivo. There is also some in-vitro evidence that synergism or increased antibacterial power occurs with the use of combinations of some of the agents such as penicillin and streptomycin.

It is advisable to repeat cultures and sensitivity tests at weekly intervals in severe prolonged infections because of the possibility of acquired bacteria resistance or development of secondary infections. Apparently, bacteria may acquire resistance to all of the antibiotic agents in varying degrees except polymyxin B and neomycin. Occasionally, suppression of sensitive bacteria in mixed infections by antibiotics may permit other bacteria normally of lesser virulence to become invasive and to invade the blood stream, the meninges or some other tissue system. Infections produced in this manner are known as superinjections or superimposed infections, and they might be overlooked unless repeated cultures are taken.

adequate dosage implies the use of the antibiotic agent in doses sufficiently large to produce antibacterial concentrations in the blood and intercellular fluids and tissues for a period of time long enough to permit the natural defense mechanism of the body to dispose of the inhibited but often still viable bacteria. The majority of the agents exert only a bacteriostatic effect, which is greatest on actively growing and reproducing bacteria. In the case of some of the antibiotics, particularly penicillin, the evidence suggests that progressively large doses have an increasingly greater clinical effect and at times a bactericidal action.

time element Antibiotic treatment should be started as promptly as possible after injury. Its use may keep any infection localized, attenuated, or dormant. In established infections early antibiotic therapy gives a better chance of producing rapid and prompt control of invasiveness. Late treatment usually results in a more limited or delayed effect, and complications are more numerous, including local necrosis, abscess formation or systemic invasion.

method of administration. This is worthy of some discussion. The systemic administration of antibiotics is generally by the paren-teral or oral routes, depending upon the agent used and various other factors. Local application of chemotherapeutic agents to wounds is seldom indicated. In traumatic shock the absorption of antibiotics from the gastrointestinal tract or muscular areas may be retarded. Consequently, the intravenous administration of aqueous penicillin G or other antibiotics is recommended during traumatic shock to guarantee rapidly an adequate blood and fluid concentration.

The timing of surgical intervention with antibiotic therapy is of special importance. Necessary operative procedures should not be delayed unless the patient's condition is too poor to withstand anesthesia and surgery. On the other hand, care should be taken to perform necessary operative procedures after the start of antibiotic treatment if possible and before the development of bacterial resistance. In general, the principles of operative treatment of surgical infection have not been changed significantly by modern chemotherapy. In serious infections such as septic peritonitis secondary to perforated appendicitis or peptic ulcer, a best result have been obtained by the parenteral administration of antibiotics preoperatively and as soon as possible after the patient has been seen. This rapidly produces a bacterial-inhibiting concentration at the site of the infection, retards the progress of the infection and makes unnecessary the local application of antibiotics within the peritoneal cavity.

Supportive treatment is valuable in the management of many patients with surgical infections. Obvious local and general physiologic derangements are frequently overlooked or disregarded in present-day practice. If they are not corrected, the full therapeutic effect of the antibacterial agent will not be obtained.

Untoward reactions following the administration of antibiotic agents have been shown to be of 3 general types: toxic reactions related to the amount of the drug given, sensitivity reactions due to idiosyncrasy or sensitization of the patient, or secondary inflammations or ulcerations produced by superimposed infections. Each of the agents has been shown to be capable of producing one or more of these types of reaction. Those produced by over-dosage can be readily prevented or controlled. Those secondary to sensitization of the host are becoming more and more important, particularly in the case of penicillin. Many patients, some of whom were sensitized during the misuse of penicillin, are now deprived of its benefits and apparently will be hereafter.

idiosyncrasy Certain of the antibiotic and chemotherapeutic agents (chloramphenicol and the sulfonamides in particular) are capable of producing severe depression of the bone marrow, probably on the basis of an idiosyncrasy. When medications having this possibility are used, repeated and regular blood cell counts during their administration are indicated to monitor the bone marrow response.

As more antibiotics have been developed the choice between those to which the offending organism is sensitive is more and more dictated by the relative safety of the drugs.

Secondary or superimposed infections caused by the suppression of susceptible microbial agents and overgrowths of those resistant to the antibiotic administered have become of increasing importance. The most severe form has been the pseudomembranous enterocolitis, which has developed in some cases, usually after the use of chlortetracycline, oxytetracycline, tetracycline or neomycin, although it has been noted occasionally after other forms of antibacterial therapy, and even in the absence of such treatment. Fortunately, these severe and potentially fatal infections can be treated successfully by methicillin, erythromycin or chloramphenicol. If they are associated with septic shock, hypotension and urinary suppression, active supportive treatment is also recommended, including the intravenous administration of norepinephrine and large doses of steroids.

Specific serotherapy with biologic antigens or antitoxins is of limited use in surgery for the control of established infections. Vaccines or suspensions of bacteria killed by heat or chemicals occasionally are of great value in the management of infections resistant to all other forms of therapy. As the result of numerous advances in the field of antibiotic therapy during the past 10 years, the antisera have assumed lesser importance in the control of infections. Their use in established infections is probably limited to the antitoxins of tetanus and gas gangrene and will be discussed elsewhere in the text.

Occasionally, specific staphylococcal bacteriophage may also be used to advantage.

CLASSIFICATION OF WOUND INFECTIONS

Infections may be monomicrobic or poly-microbic, depending upon the presence of one or more varieties of infecting bacteria. Many early infections of wounds are pyogenic, the staphylococcus being the most frequent cause, the streptococcus the next. Mixed infections by aerobic and anaerobic, gram-negative and gram-positive bacteria may also occur, particularly in extensive wounds with retained dead tissue. Anaerobic cellulitis, clostridial myositis (gas gangrene), wound diphtheria, tetanus, anthrax and rabies are less frequent lesions.

The following is a brief classification of infections that may develop in wounds:

1. Staphylococcal

2. Streptococcal

A. Aerobic

B. Micro-aerophilic

C. Anaerobic

3. Gram-negative bacillary

4. Mixed

5. Clostridial

6. Tetanus

7. Diphtheritic

8. Rabies

9. Mycotic

A. Actinomycotic

B. Blastomycotic

C. Coccidioidomycotic

D. Sporotrichotic

10. Miscellaneous

A. Anthrax

B. Granuloma inguinale

C. Lymphopathia venereum

D. Histoplasmosis

staphylococcal infections

Staphylococcal infections are usually localized and are characterized by an area of cellulitis and erythema, which subsequently may undergo central necrosis or abscess formation with thick, creamy, odorless, and yellowish or reddish-yellow pus.

The hemolytic Staphylococcus aureus, which liquefies gelatin and produces a locally necrotizing toxin, is the most important variety of staphylococcus. The coagulation of plasma by its enzyme, coagulase, favors the development of thrombosis and thrombophlebitis in the adjacent veins and is generally indicative of the pathogenicity of that particular strain. The symptoms of staphylococcal infection include swelling, erythema, and local pain, which is throbbing and often synchronous with the heart beat. Fever and leukocytosis are usually present. The process may become invasive and complicated by lymphangitis, lymphadenitis, or thrombophlebitis. As a distributing focus it may produce a bacteremia and broadcast bacteria through the blood stream.

Staphylococcal infections that patients acquire during hospitalization may be particularly serious. Such infections are nearly always caused by a highly virulent staphylococcus, which is resistant to most of the commonly used and available antibiotic agents. They may be characterized in some instances by a sudden onset, high fever and a fulminating course. They may have epidemic potentiality as manifested by persistent recurrences of less serious but equally refractive infections lasting for many months or years and by spread to other members of the families with whom they come in contact. Typing of the staphylococci associated with hospital-acquired infections by specific bacteriophage has revealed that the organisms responsible are one of three or four types, the most common ones being the 80-81 and the 77 strains.

The successful management of such infection necessarily requires the careful observance of established surgical principles and asepsis, meticulous selection of the proper antibiotic agent, general supportive care and active stimulation of immunity.

Folliculitis, furuncles and carbuncles are types of local Staphylococcal infection of the skin and the subcutaneous tissues, which usually begin spontaneously as infections of hair follicles and progress to produce small areas of induration of varying size with central necrosis. These lesions occur most frequently on the back of the neck, the face, the axillae, the groins, the buttocks and the fingers.

Treatment. The treatment of established staphylococcal infections is definitely influenced by early accurate diagnosis and consists of rest, heat, and elevation of the infected area, adequate surgical drainage when pus has formed, and antibiotic therapy. Acute spreading processes should not be traumatized by incision or otherwise until the invasive characteristics have been brought under control. When pus or necrotic tissue develops in localized infections, its removal is extremely important for healing.

Infected wounds should be reopened with a hemostat at the point of maximum pain, swelling, or fluctuation, followed by removal of all skin sutures to enlarge the size of the cavity. In abscesses developing without reference to a wound, drainage is advocated by an adequate incision made over the area in such a manner as to avoid disfiguring scars, disabling contractures, or injury to important structures. Drainage of the wound is facilitated by finc-mesh gauze laid loosely in the cavity to keep the wound edges separated. Care should be taken not to pack the gauze tightly into the wound and thereby interfere with free drainage. The drain may be removed within 48 to 72 hours and may or may not be replaced, depending on the existing circumstances.

Antibiotic therapy should be started promptly, preferably before operation, so that a bacteriostatic concentration is produced in the blood stream to inhibit any bacteria distributed by operative manipulation. Aqueous sodium or potassium penicillin G in doses of 500,000 units every 8 to 12 hours is the agent of choice. As an alternative method penicillin may also be administered effectively as a mixture of 300,000 units of procaine penicillin and 100,000 units of aqueous penicillin G every 12 to 24 hours until the infection is definitely under control. Erythromycin in doses of 100 to 200 mg. every 6 hours orally is likewise effective. The drugs of second choice include chloramphenicol, tetracycline, oxytetracycline and chlortetracycline in doses of 250 to 500 mg. every 4 to 6 hours. Declomycin and vancomycin may also be of great value in the control of these infections. In severe or fulminating cases with septicemia, aqueous crystalline penicillin G may be administered in doses of 100,000 to 200,000 units every 3 hours or 500,000 units intra-muscularly every 6 to 8 hours. One of the broader-spectrum antibiotics may be used if the organism is resistant to penicillin. Bacitracin is also effective, but its administration should be controlled by daily urinalysis to detect any evidence of nephrotoxicity.

Recognition of penicillinase-producing strains of staphylococci and the attendant resistance to penicillin G may not be possible until sensitivity studies are completed. If the staphylococcal infection is hospital-acquired" or happens as a part of an in-hospital epidemic, it is more than likely that the organism is not sensitive to the basic penicillins. In this circumstance, the empiric use of the biosynthesized penicillins is indicated, particularly if the infection is life-endangering or occurs in debilitated patients. Sodium oxacillin (in oral divided doses of 3 to 4 Gm. daily) or methicillin (in parenteral divided doses of 4 to 6 Gm. daily) are indicated in such circumstances.

streptococcal infections

Streptococcal infections are produced most frequently by the aerobic Streptococcus hemolyticus, although some are caused by the Streptococcus nonhemolyticus, the Streptococcus viridans, the Streptococcus anaerobicua, or the micro-aerophilic Streptococcus.

Lesions caused by the aerobic Streptococcus hemolyticus characteristically are invasive and run a rapid course initially. They may develop within 12 to 48 hours after injury, or as late as 7 to 14 or more days. The incidence of infection by this organism in open wounds increases with the duration of the wound as a result of secondary contamination. In its early stages the process is usually one of diffuse inflammation with cellulitis, lymphangitis, lymphandenitis, or extension along fascial planes in deep wounds. There is little tendency to form abscesses, but gangrene of the overlying skin or thin watery pus may result. Invasion of the blood stream is frequent, and this complication should be recognized early to minimize the distribution of virulent bacteria throughout the body. Bacteremia is suggested by the development of chills, high fever, rapid thready pulse, prostration and other signs of toxemia.

Surgical scarlet fever may occur infrequently in a postoperative wound in association with the hemolytic streptococcus. The lesion is characterized by spreading cellulitis with redness, swelling, and frequently bullous formation in and about the margins of the wound. A typical scarlatiniform eruption may occur 2 to 4 days after injury or operation, starting at the wound and spreading peripherally. The local lesion may be very severe, but the general reaction may not be.

Erysipelas, also produced by the hemolytic streptococcus, may occur about small wounds, usually about the face and the neck. After an incubation period of 1 to 3 days, it is usually ushered in by chills, high fever, rapid pulse and severe toxemia. It is characterized by a spreading cellulitis with raised, irregular, indurated margins. Its appearance is characteristic, and its course is often self-limited in 4 to 8 days. Hemolytic streptococcal gangrene occasionally follows some relatively minor injury in the extremities and is an epifascial, spreading, subcutaneous gangrene with thrombosis of the nutrient vessels and slough of the overlying skin. At the onset it is associated with pain and marked swelling at the site of wounds, chills, elevation of the temperature to 39 to 41 C., tachycardia, toxemia, marked prostration, and a rapidly spreading, painful cellulitis. The overlying skin of the diffusing cellulitis shows bullous formation and a peculiar patchy and coalescing necrosis. Hemolytic streptococci, often in pure culture, may be found in the fluid aspirated from the bullae or areas of subcutaneous slough.

Necrotizing fasciitis is an infection, which involves the epifascial tissues of an operative area, laceration, abrasion, or puncture wound. It may either spread rapidly over large areas of the body or remain dormant for 6 or more days before beginning its rapid spread. In those cases, which we have seen, the hemolytic staphylococcus or the hemolytic streptococcus has been found. Undermining of the skin is marked, and gangrenous changes in the skin may occur late or be absent. High fever, dehydration, anemia, marked leukocytosis and, occasionally, jaundice occur. The process may become chronic and may be characterized by multiple draining sinuses connected with areas of necrotic underlying fascia.

The treatment of hemolytic streptococcal infections consists of the preliminary control of their invasive characteristics by antibiotic therapy, rest and hot applications, followed by surgical drainage if abscesses or cutaneous gangrene develop. Penicillin, erythromycin, sulfadiazine, or one of the broad-spectrum antibiotics is very effective, but penicillin is usually the agent of choice in doses essentially the same as those described earlier for the treatment of staphylococcal infections. Operative treatment should be delayed until the invasive qualities of the infection have been controlled. Free drainage of collections of pus should be done along with the removal of necrotic tissue, infected hematomas, or foreign bodies. After incision, the wound is left open for further drainage and healing by granulation. The topical application of antibiotics in such wounds is unnecessary. If sup-purative thrombophlebitis exists, proximal ligation or excision of the involved vein should be considered.

In hemolytic streptococcal gangrene emergency drainage with longitudinal incision is often necessary as early as possible. It is important to make long incisions through and beyond the gangrenous area as an emergency measure without attempting to wait for control of the invasiveness by antibiotic therapy, in contrast with the usual treatment for streptococcal cellulitis. After operation rest, elevation of the part if possible, and application of moist compresses treats the wound. The removal of slough by sharp dissection without bleeding during subsequent dressings is possible. Before and after operation antibiotic therapy should be given in adequate amounts as in other aerobic streptococcal infections.

Streptococcal Fasciitis As soon as the diagnosis of streptococcal fasciitis is established, drainage by long incisions made throughout the entire area of involvement should be made as described for hemolytic streptococcal gangrene. The skin and the subcutaneous tissues should be separated from the deep fascia. Involved necrotic fascia should be excised completely and the wound covered with fine-mesh gauze. When adequate granulations have developed, skin grafting usually is necessary.

In many streptococcal infections, general supportive therapy consisting of the intelligent administration of adequate fluid and electrolytes is very important. Daily blood transfusions may be helpful, but care must be taken not to overload the heart and produce pulmonary edema. Frequent examinations for metastatic infectious complications are necessary, and any that may have developed is treated according to its individual location and characteristics.

Micro-aerophilic Streptococci Infections caused by micro-aerophilic streptococci develop and progress more slowly as a rule. Two illustrative examples are chronic burrowing ulcer and chronic progressive cutaneous gangrene. Chronic burrowing ulcer is an infrequent lesion caused by a micro-aerophilic hemolytic streptococcus and is characterized by the progressive extension of burrowing sinus tracts through the underlying tissues. Invasion and penetration of fascia, hone, muscle, peritoneum, meninges or brain have been noted. The sinus tracts usually become lined with indolent granulation tissue. General signs of infection associated with this are minimal, a low-grade fever and marked pain being likely to appear during the acute exacerbations of the lesions.

The treatment of choice consists of the radical incision and drainage of the sinus tracts throughout their entire extent or radical excision of the sinuses in association with antibiotic therapy. Penicillin, erythromycin, bacitracin, chloramphenicol, or one of the broad-spectrum agents may be used. Antibiotic treatment without surgical treatment is inadequate.

Chronic progressive cutaneous gangrene (known also as Meleney's synergistic gangrene) may complicate operations for purulent infections of the chest or the peritoneal cavity. It is caused by the synergistic action of a micro-aerophilic nonhemolytic streptococcus and an aerobic hemolytic staphylococcus. After an incubation period of 7 to 14 days after operation for a wound involving the gastrointestinal, the genitourinary, or the respiratory tracts, the surrounding skin becomes tender, red and edematous, particularly about stay sutures. The appearance of the lesion is characteristic. A wide area of bright-red cellulitis develops about a central purplish area, which widens, becomes gangrenous and finally ulcerates. The base of the ulcer is covered with dirty infected granulation tissue, and the margin is purplish black, slightly undermined, and very painful.

This ulceration is slowly progressive, and ultimately it may denude larger areas and cause death unless treated adequately. Systemic manifestations at first are slight, but in neglected cases profound derangements in physiology may develop, with wasting of the muscles, low-grade fever, anemia and chronic septic shock.

Local excision of gangrenous margins or other conservative methods usually fail to check this process. Radical excision of the ulcerated lesion and its gangrenous borders is indicated, along with systemic antibiotic treatment with penicillin G or erythromycin. There is some evidence that bacitracin is particularly valuable in the treatment of this condition.

During treatment of patients with chronic progressive cutaneous gangrene with penicillin the hemolytic staphylococcus may disappear and be replaced by a strain of Proteus sp. In some instances, a synergism between Proteus sp. and nonhemolytic and micro-aerophilic streptococcus can exist primarily to cause the lesion.

Anaerobic streptococcal infections may occur as either acute or chronic lesions. In the acute type, they may occur with or without bacteremia, particularly in wounds that involve or penetrate the genital, the intestinal or the respiratory tracts. Metastatic abscesses in distant regions such as the brain may develop. These infections, which usually progress more slowly than other streptococcal infections, are characterized by the development of marked induration, foul-smelling and thick pus, extending necrosis of the involved tissues and progression along fascial planes or in muscle.

Streptococcal myositis is an infrequent type of anaerobic streptococcal infection. It is associated with massive involvement of muscle, local pain and generalized toxemia. Discoloration, edema, and crepitation of the muscle are characteristic, and a foul odor is generally apparent. Differentiation of streptococcal from clostridial myositis is its more pronounced cutaneous erythema, discolored muscle, which is still viable and reactive to stimuli, the different odor, and the demonstration of vast numbers of streptococci in gram-stained smears of the exudate.

The management of anaerobic streptococcal infections is dependent upon early diagnosis, operative treatment, antibiotic therapy and supportive treatment. Abscesses, areas of fasciitis, or infected groups of muscle should be incised and drained promptly, and ulcers showing phagedenic progression should be excised. Antibiotic therapy is of considerable benefit, and metranidazolum, dioxidini, klindamycini are the agents of choice in doses somewhat larger than those recommended for aerobic streptococcal infections. Amynoglikosids, cefalosporins and polysynthetic penicillins are used too. Bacitracin or the broader-spectrum antibiotics are alternate choices.

gram-negative bacillary infections

Gram-negative bacteria of the gastrointestinal, the urinary, or the genital tracts may produce infections. Escherichia coli, Pseudomonas aeruginosa, Proteus vulgaris and Salmonella typhosa are examples of organisms capable of causing wound infections. Invasive lesions with bacteremia may occur. Often these gram-negative bacilli are relatively nonvirulent, but in the presence of such factors as necrotic tissue, general debility, or cortisone therapy, they may produce serious infections. Organisms of this group, particularly Pseudomonas aeruginosa, have become the chief cause of infectious death associated with severe burns. A relatively long incubation period is also characteristic of postoperative wound infections by these bacilli.

The treatment of these lesions is dependent upon incision and drainage of abscesses, excision of necrotic tissue, and antibiotic therapy based upon in-vitro sensitivity tests. Chloramphenicol has been particularly useful in these infections. Polymyxin B and sodium colistimethate and (Coly-Mycin) are recommended for infections produced by Ps. aeruginosa. A recently developed antibiotic, garamycin, is showing promise in the control of established gram-negative bacillary infection and is exceptionally valuable in the treatment of those due to Pseudomonas aeruginosa.

Bacteroides infection occasionally occurs as a monomicrobial infection whose outward manifestation may be thrombophlebitis without apparent cause. Unimpressive pulmonary or pelvic infection often precedes the development of venous thrombosis in these patients, and pulmonary infarction due to embolus may he the presenting finding. Persistent bacteremia or septicemia from the infected clot requires operative ligation of the involved vein and prolonged antibiotic therapy with sulfonamides or tetracycline for effective control.

Septicemia due to various species of gram-negative bacilli has become an increasing threat to hospitalized patients in the last 10 years. This progressive increase is probably related to an increase in major trauma and to iatrogenic factors including continuous intravenous administration, tracheostomy wounds and their care, respiratory assistance therapy, steroid therapy, and intensive or excessive antibiotic therapy. The mortality rate from this form of septicemia remains high at about 60 per cent.

Mixed or Synergistic Infections

A large and miscellaneous group of infections with a polymicrobic etiology are found in surgical practice, particularly in association with injuries or operations on the gastro-intestinal, the respiratory, or the genito-urinary tracts. Symbiosis of aerobes and anaerobes may exist and determine the characteristics of the lesions. The bacterial toxins and enzymes usually cause a necrotizing and suppurative infection, beginning in the wound and extending along fascial and areolar tissues. Cellulitis, abscesses, necrosis and bacteremia may develop. Examples of mixed infections include deep infections of the neck, human-bite infections, putrid empyema, peritonitis and nonclostridial cellulitis.

Human-bite infections (morsus humanus) are usually severe and occur when a human being voluntarily bites another or strikes a blow with his hand, which is cut by the teeth of the intended victim. The wound is usually a puncture wound through the various levels of tissue, which supports the growth of the mouth organisms contaminating the tissues. A mixture of bacteria is usually found consisting of aerobic nonhemolytic streptococci, anaerobic streptococci, Bacterium melaninogenicum, spirochetcs or staphylococci. In our experience spirochetes have never been found alone in these infections, but they are associated with the more severe lesions. If the original bite wound is treated by limited or inadequate surgical measures, evidence of inflammation appears within the first 1 to 3 days after injury and progresses steadily thereafter. Swelling, redness, pain, and limitation of motion develop and are followed by fever, which is usually moderate but may be as high as 41 C. Systemic reaction is occasionally profound, and the appearance of the local infection soon becomes alarming. Granulation tissue forming within the wound becomes shaggy, gray, cyanotic and edematous and exudes a thick, foul, purulent material. Progressive necrosis extends through the tissues, particularly the areolar ones.

The prevention of infections of this type is the most effective form of treatment. Adequate excision of the wound, as soon as the patient is seen, followed by immobilization and antibiotic therapy, usually with penicillin, is the most effective means of preventing human-bite infections. When tendons are severed by human bites, primary tenorrhaphy should not be attempted. When infection has become established, radical decompression of the infected area and tissue planes by incision is extremely important, accompanied by antibiotic therapy.

Crepitant (nonclostridial) cellulitis is a mixed infection, which is usually seen as a complication of wounds of the perineum, abdominal wall, buttocks, hip, thorax, or neck, which have been contaminated by discharges from the intestinal, the genitourinary, or the respiratory tracts. When it occurs in the region of the perineum or inguinal area, its spread is often beneath Scarpa's fascia into the abdominal wall and flank. Bacteria other than the clostridia, no single type of etiologic agent being found consistently, cause it. Those associated with this process include strains of the coliform group, the anaerobic Bacteroides group such as Bacterium melaninogenicus and Bacillus thetoides and the anaerobic streptococci. The areolar and fascial tissues usually become necrotic and develop a putrid odor similar to that of an appendiceal abscess. Progressive gangrenous changes in the skin occur as a result of thrombosis of the nutrient vessels. As the process extends, toxemia usually becomes evident, with dehydration, fever, a weak and thready pulse, prostration, and elevation of W.B.C. to 20,000 or more.

Prompt surgical decompression of all involved areas by multiple incisions is imperative to control this process. Antibacterial, massive desintoxical and immunotherapy must are used. Supportive therapy may be life-saving. These infections are serious, but the prognosis is good for patients treated promptly and adequately. After the infection has been controlled and healthy granulation tissue has developed, skin-grafting is usually necessary to cover the large residual cutaneous defects.

Care of patient with an intercostal drain

        Rapid full expansion of a completely collapsed lung may lead to pulmonary oedema. For very large effusions, clamp the tube for 1 hour after 1.5 litres have drained, before allowing free drainage. Make sure all staff are aware the tube is clamped and what time the clamp is to be removed.

        Instruct the patient to keep water bottle below waist level, to remember it is attached and not to pull it accidentally.

        For mobile patients, a weighted metal stand should be used to carry the bottle and to prevent it falling over.

        Prescribe adequate analgesia (pethidine or morphine may be required) remember the surgical injury you have caused is equivalent to a stab wound.

        Adjustment of position: If drain is too far in, it is acceptable using sterile technique and after careful antiseptic swabbing, to loosen the retaining stitch and retract the drain a few cm before resecuring it, taking care not to withdraw so far that the side holes leave the pleural space.

        The drain should NEVER be advanced further into the chest after the initial insertion this carries infection forward into the pleural space.

        Only clamp a chest drain if draining a very large effusion (see above), if the bottle breaks or the tube becomes disconnected.

        If a patient with a chest drain in situ requires transfer by ambulance a trained nurse with experience in the management of chest drains must be part of the escortAlastair Innes, April, 2007