Trauma treatment

Treatment includes wound toilet, local anesthesia, examination, surgical treatment and suturing. The tissues should be treated as carefully as possible.

Toilet Wounds

Both the wound and the surrounding skin are washed. The subcutaneous tissues of the wound are rather delicate, they should not be treated with irritating substances (for example, concentrated iodine solutions, chlorhexidine, hydrogen peroxide) or rub it roughly.

Removal of the hair from the edges of the wound for its hygiene does not matter, but in the scalp (the head) due to this the wound becomes more accessible for processing. If necessary, cut off the hair with scissors rather than shave; The blade inflicts skin with microtrauma, which can become a gateway for the penetration of microorganisms from the surface of the skin, which increases the risk of infection. Hair is cut before washing the wound so that any wounded hair is washed from there. Eyebrows are never shaved, since the border of hair and skin is necessary for optimal matching of the edges of the wound.

Wash the wound is not very painful, but usually at the beginning of the local anesthesia, except in cases of severely contaminated wound. In this situation, before anesthesia, rinse the wound with a stream of running water with soap. The water from the tap is clean, does not contain pathogenic microorganisms typical for wounds, and in this application hardly increases the risk of infection. Then the wound is washed with a stream of liquid under pressure and sometimes wiped with a soft sponge; Brushes and coarse materials should be avoided. A stream sufficient for rinsing can be created using a 20 or 35 ml syringe with a 20 G needle or attached catheter. A sterile 0.9% solution of sodium chloride is quite effective; the use of special cleaning solutions is expensive, their additional advantages are doubtful. If the probability of microbial contamination is high (for example, a bite, old wounds, "organic rubbish" in the wound), a solution of povidone-iodine in a ratio of 1:10 can be added in a 0.9% solution of sodium chloride. This concentration is effective and does not irritate the tissue. The required volume varies. Irrigation is continued until the visible contaminants are removed, which is usually required from 100 to 300 ml (larger wounds require a larger volume).

Treatment of the skin around the wound with povidone-iodine solution before suturing it reduces the contamination of the skin, but the solution can not be allowed to enter the wound.

Local anesthesia

As a rule, local injection anesthesia is used, but in some cases an effective use of surface anesthesia is possible.

The standard injection anesthetics include 0.5.1 and 2% lidocaine and 0.25 and 0.5% solution of bupivacaine, both anesthetics from the group of amides; to the group of ethers include procaine, tetracaine and benzocaine. The most commonly used lidocaine. The effect of bupivacaine develops more slowly (several minutes compared with the almost immediate action of lidocaine), but the duration of action is much longer (2-4 hours against 30-60 minutes in lidocaine). The duration of action of both drugs increases with the addition of epinephrine at a concentration of 1: 100,000 as a vasoconstrictor. Because vasoconstrictors can weaken the protection of the wound, they are used mainly only in well-circulating zones (for example, the face, the scalp); To avoid tissue ischemia, they should not be used on the lower extremities and other distal parts of the body (for example, nose, ears, fingers, penis).

The maximum dose of lidocaine is from 3 to 5 mg / kg (1% solution = 1 g / 100 ml = 10 mg / ml), bupivacaine 2.5 mg / kg. The addition of epinephrine increases the tolerable dose of lidocaine to 7 mg / kg, and bupivacaine up to 3.5 mg / kg.

Side effects of local anesthesia include allergic reactions: rash, sometimes anaphylaxis and sympathomimetic effects of adrenaline (eg, palpitations and tachycardia). Real allergic reactions occur rarely, especially on the amide group of anesthetics; in most cases, patients' complaints are the result of fear or vagal reactions. Moreover, allergic reactions often occur on methylparaben, a preservative added to vials containing many doses of anesthetic. If the drug that causes allergies is known, it can be replaced with a drug of another class (for example, ether instead of amide). If the allergen is not known, make a sample with a subcutaneous injection of 0.1 ml of lidocaine without preservative (from a vial / ampoule containing a single dose); if there is no reaction after 30 minutes, the drug can be used.

Superficial anesthesia does not involve injections and is absolutely painless, which is most convenient for children and fearful adults. Usually one of the two mixtures is used. TAC consists of a 0.5% solution of tetracaine, epinephrine in a 1: 2000 dilution and 11.8% cocaine solution. LET consists of lidocaine 2-4%, epinephrine in a dilution of 1: 2000 and a 0.5-2% solution of tetracaine. Gauze napkins or balls according to the size of the wound are impregnated with several milliliters of solution and placed in the wound for 30 minutes, which in most cases is sufficient for adequate anesthesia. Sometimes an additional injection of an anesthetic is necessary. Due to the presence of the vasoconstrictor, these solutions are used mainly on the face and scalp, avoiding their use in the area of the auricles, nose wings, distal extremities. Very rarely, deaths can be a consequence of the absorption of cocaine through the mucous membranes, and therefore, they should not be used near the eyes and lips. LET is considered safer.

Inspection

The wound is examined to the full depth for the purpose of detecting foreign bodies, identifying possible damage to the tendons. Foreign material is best revealed by a characteristic tapping with a careful palpation of the wound with the tip of the blunt-ended clamp. Deep wounds near large arteries should be inspected by the surgeon in the operating room.

Surgical treatment of the wound

When surgically treated with a scalpel and scissors, dead and obviously nonviable tissues are removed, as well as contaminations adhering tightly to the wound (eg, grease, paint). When processing a wound of complex shape, you do not need to convert it into a linear one. The edges of macerated and ragged wounds are excised, usually 1-2 mm are enough. The undercut edges of the wound are sometimes treated so that they become perpendicular.

Sewing

The need to repair the wound depends on its location, the time from the moment of injury, the cause, the degree of contamination and risk factors in the patient. Most wounds can be stitched immediately (primary suture). This applies to clean wounds within 6-8 hours after trauma (up to 18-24 hours on the face and scalp) without signs of infection.

Other wounds can be stitched in a few days (primary delayed seam). This refers to wounds with a period of more than 6-8 hours, especially with initial signs of inflammation, as well as to wounds of any term with significant contamination, especially residues of organic substances. The possibility of applying a primary delayed suture is reduced in patients who have a high risk of disrupting the healing process. At admission, perform anesthesia, examination, surgical treatment as with any other wounds (maybe a little more carefully), and then the wound loosely tampon with wet wipes. Bandages are changed at least once a day and after 3-5 days determine the possibility of its suturing. If there is no evidence of infection, the wound is sutured according to a standard procedure. Closure with leading sutures at the beginning is inefficient and unacceptable because of the almost inevitable gluing of the edges of the wound.

Some types of wounds should not be sutured. To such wounds include bites of cats, any bites of hands and feet, punctured and gunshot wounds.

Materials and methods

Traditionally, stitches have been used to correct traumatic wounds, but now metal staples, adhesive tapes and liquid fabric adhesives are also used for some wounds. Regardless of the material selected, the management of the wound remains unchanged. At the same time, a typical mistake is the examination of wounds during treatment without sanation, in connection with the planned non-invasive wound closure (adhesive tapes), which does not require local anesthesia.

Staples easily and quickly superimposed, the skin is a minimum of foreign material, the probability of infection is lower than with suturing. However, they are suitable mainly for straight, even cuts with perpendicular edges in areas of slight skin tension and do not have great cosmetic capabilities. Successful use of staples usually requires the participation of two people. One forceps compares and twists the edges of the wound, and the other surgeon works as a stapler. A common mistake is incorrect turning of the edges of the wound.

Tissue adhesives used in the USA contain octylcyanoacrylate. It freezes for a minute; durable, non-toxic and waterproof. It has antibacterial properties. However, the glue can not be injected into the wound. Infectious complications are unlikely, in most cases it is possible to achieve a good cosmetic result. Tissue glue is good with simple, standard wounds; it is not suitable for wounds with tension. For wounds requiring rehabilitation, subcutaneous suturing, or under local anesthesia, the benefits of reducing pain and duration of intervention are minimized. As for the staples, you need the participation of two people: one compares the edges of the wound, the other applies glue. For the most durable connection of the wound, 3-4 layers of glue are necessary. Glue is rejected spontaneously within a week. Accidentally applied excess glue is removed with any ointment on a vaseline basis or, in areas far from eyes and open wounds, with acetone.

Adhesive tapes, apparently, are the fastest way to connect the edges of a wound with a very low probability of infection. They can be used in the same clinical situations as tissue glue, with the same limitations. An additional difficulty in using adhesive tapes is associated with application in areas with a mobile skin (for example, the back surface of the hand) due to the tendency of the edges of the wound to tuck. Adhesive tapes are particularly suitable for wounds on the limbs immobilized by a plaster bandage (the latter prevents the removal of a conventional suture). Before using the tape, the skin should be drained. Most doctors use tincture of benzoic acid to strengthen the gluing effect. Adhesive tapes can be removed by the patient himself.

Seams are optimal for complex wounds of irregular shape, with a defect in the skin, with the tension of the edges and when subcutaneous sutures are required.

Since the seams can serve as a gateway to infection and represent a significant amount of foreign material under the skin, they become infected most often. Basically, there is a monofilament and woven, non-absorbable and absorbable suture material. Characteristics and applications vary; usually a resorbable material is used for subcutaneous sutures, and non-absorbable material is used to join the edges of a skin wound. It is believed that the braided suture material has a slightly higher risk of infection than the monofilament, but it is softer, easier to tie and more firmly holds the knot.

Subsequent treatment of injuries

According to the indications, it is necessary to prevent tetanus. The expediency of using ointments with antibiotics is not always obvious, but, probably, they do not bring harm, and some clinicians consider them useful; in any case, they should not be used together with fabric glue or adhesive tapes. Systemic antibiotic prophylaxis is not indicated, except for some bitten wounds, wounds with damage to tendons, bones penetrating the joint cavity and, possibly, the wound of the mouth, as well as massively contaminated wounds. If antibiotics are needed, they are prescribed as soon as possible, and the first dose should be administered parenterally. Excessive mobility of the damaged area interferes with healing. When wounds of the hand and fingers are immobilized, cotton-gauze bandages are used. Patients with wounds of the lower limbs (with the exception of minor injuries) require bed rest for several days; you can use crutches.

The wound should be clean and dry; after 48 hours the bandage is removed and examined by the wound. A small, clean wound can be examined by a reliable patient himself, but if the patient can not be trusted and the wound is severe, the doctor should perform the examination.

Infection complicates the course of 2-5% of wounds; The first manifestation is often persistent aggravating pain, the first signs are redness and swelling. Systemic administration of antibiotics effective against cutaneous microflora begins; Usually, cefalexin is administered at a dose of 500 mg orally 4 times a day (antibiotics of the penicillin line 500 mg orally 4 times a day for oral infections). Infection, developed after 5-7 days, gives reason to think about the foreign body left.

After 48 hours, the well-healing wound can be gently cleansed of the remnants of the wound separated by water or half diluted with hydrogen peroxide and left open (with wounds on the face, this can be done earlier and more often, leading them without bandage from the very beginning).

Short-term moisturization of the wound under the shower is safe, but prolonged wetting should be avoided. Suture material, excluding tissue glue, is removed in terms that depend on localization. On the face, the sutures are removed on the 3-5th day to prevent the formation of visible traces from the joints and junctions; some doctors prefer to reduce the wound on the face with strips of plaster, which are usually kept for several days longer. Stitches and staples on the trunk and upper limbs are removed on the 7-10th day. Stitches on the extensor surfaces of the elbow joint, knee joint and the areas below should remain up to 10-12 days.

Abrasions - skin lesions that do not penetrate the epidermis. Inspection, sanitation and treatment of abrasions are carried out in the same way as for wounds. Abrasions harder to anesthetize. However, a special problem is created by large amounts of dirt, small pebbles or glass fragments, which is quite often. Sometimes, regional anesthesia or intravenous sedation may be required for treatment. After a thorough sanitation, you can apply an ointment with an antibiotic (eg, bacitracin) and a non-adhesive gauze dressing. You can use other commercially available versions of dressings, the purpose of which is to protect the wound from drying (as it slows down the re-epithelialization) without sticking to it.

Damage to the musculoskeletal system includes fractures, dislocations of joints, stretching and damage to ligaments, muscles and tendons. Damage can be open (in conjunction with the wound of the skin) or closed. Some damage can lead to rapid blood loss, sometimes internal. Fat embolism is life-threatening, but preventable complication of fractures of long tubular bones. With fractures of the bones, nerve damage, including the spinal cord, is possible.

With limb injuries, complications that threaten the viability of the limb or its permanent dysfunction are rare. The most serious threat to the limb is damage that disrupts the blood supply, first of all, a direct trauma to the arteries and sometimes veins. Closed lesions can lead to ischemia due to rupture of the artery, as may be with posterior dislocation of the knee joint, dislocation of the femoral joint and with supracondylar fractures of the humerus with displacement. With some damages, a compartment syndrome (increased tissue pressure within the fascial space with impaired blood supply and tissue perfusion) is possible. Penetrating wounds can severely damage the peripheral nerves. Dull, closed trauma can lead to nevrapraxia (injury of the peripheral nerve) or to axonotomesis (crushing of the nerve), more severe damage. Dislocation (complete dissociation of articular surfaces of the bones forming the joint) can be accompanied by vascular and neurological disorders, especially if restoration of anatomical relationships (reposition of bone fragments or elimination of dislocation) is delayed. Open damage can lead to infection. Closed and uncomplicated fractures, partial ligament injuries, sprains and tendon ruptures are much less likely to lead to serious complications.

They treat hemorrhagic shock. Damaged arteries, with the exception of small arterial branches in a zone with good collateral circulation, are restored surgically. Severe nerve damage is also treated surgically; The primary treatment for neurapraxia and axonotmesis usually consists of observation, supportive measures and, sometimes, physiotherapy.

Identifying the most frequently missed damage

Symptom	Inspection result	Damage
Pain in the shoulder joint	Restriction of passive external rotation during flexion in the elbow joint	Posterior dislocation of the shoulder
	Impossibility at moderate resistance of active lead in the shoulder joint to 90 ° and holding the hand in this position	Rupture of the rotator cuff of the shoulder
	Soreness in palpation in the sternoclavicular joint	Damage of the sternoclavicular junction
Pain or swelling in the wrist	Tenderness on palpation in the projection of the "anatomical snuffbox" (limited by the styloid process of the radius, the tendon of the long extensor of the thumb of the hand, the tendons of the short extensor and the long muscle that removes the thumb of the hand)	Fracture of scaphoid bone
	Soreness in the pit of the semilunar bone (base of the metacarpal III bone) and pain with axial load on the third finger	Fracture of the semilunar bone
Pain in the hip joint	Lower extremity in the position of external rotation, pain with passive rotation in the joint, restriction of active flexion in the hip joint	Medial fracture of femur
Pain in the knee joint in children or adolescents	Pain with passive hip rotation with knee joint bent	Hip joint injuries (juvenile epiphysis, Legg-Calve-Perthes disease
Pain in the knee joint or swelling in the joint	Insufficiency of active extension in the knee joint	Damage to the quadriceps femoris, patellar fractures

Most of the injuries, especially with severe instability, are immediately immobilized by tires (immobilization by unhygienic and non-captive devices) to prevent further soft tissue damage in unstable fractures and pain reduction. In patients with fractures of long tubular bones, splinting can prevent fat embolism. Treat pain usually with opioid analgesics. The final treatment often involves repositioning, usually requiring anesthesia or sedation. If possible, they carry out a closed reposition (without cutting the skin); otherwise, an open reposition is performed (with a cut of the skin). After a closed reposition of fractures, a plaster is usually applied; with some dislocations, only a tire or a fixing bandage is sufficient. When the reposition is open, a variety of metal structures are usually used (for example, knitting needles, screws, plates, external fixatives).

Local treatment

Patients with soft tissue injuries, with or without musculoskeletal injuries, are best treated with rest, cold, compression and elevated position. Peace prevents further damage and can accelerate healing. Ice in a plastic bag wrapped with a towel should be periodically applied in the first 24-48 hours after the injury (for 15-20 minutes, as often as possible), which reduces swelling and pain. Compression with a tire or elastic bandage, or pressure bandage Jones (several elastic bandages, separated by tissue) help reduce swelling and pain. Stacking a damaged limb above the heart level within 2 days after trauma allows thanks to gravity to help the process of draining the edematous fluid, which also reduces swelling. 48 hours after the injury, periodic application of heat (for example, heaters) for 15-20 minutes can reduce pain and accelerate healing.

Immobilization

Immobilization facilitates healing, preventing further trauma, except for very quickly healing lesions. It is necessary to immobilize joints proximal and distal to the site of injury.

Usually a gypsum dressing is used. Sometimes, in rare cases, the build-up of edema under the gypsum can cause the compartment syndrome. If significant swelling is expected, the gypsum is cut all over the middle and side (bivalve). Patients with gypsum should be given instructions for plaster bandages in writing (for example, to keep the plaster dry, never put objects under the plaster bandage, seek medical help in case of an unpleasant odor from the dressing or when the body temperature rises, which can serve as signs of infection). It is necessary to observe the rules of hygiene. Bandages made from gypsum must be dry.

To fix some stable damage, you can use tires. The tire allows the patient to attach ice, move more, it is not associated with the risk of developing compartmental syndrome.

Immobilization with bed rest, which is sometimes necessary for fractures (for example, some fractures of the pelvis), can cause problems (for example, deep vein thrombosis, UTI). Problems can also be caused by the immobilization of an individual joint (eg, contracture, muscle atrophy). Early activation is always useful when it is possible, in some cases - already in the first days. This approach minimizes the likelihood of contractures and muscular atrophy, and hence accelerates functional recovery.