RU2372927C1 - Method for bite wound healing - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to traumatology and orthopaedics and can be applied for bite wound healing. It involves a plastic operation aiming at closing of the wound defect. Thereafter, "ФАП" 15-20 ml of activity 1000-2000 ME/ml is drained into the operative wound chamber twice a day during 8-10 days at exposition 30-40 minutes.

EFFECT: method allows reducing risk of suppurative complications.

2 cl, 2 ex, 1 tbl, 7 dwg

Description

The invention relates to medicine, more specifically to traumatology, and can be used for the treatment of bite extensive and crushed wounds.

In recent years, the proportion of injuries resulting from animal bites has been increasing in the structure of urban trauma, with the most severe injuries caused by dogs. According to the Moscow Department of Health, they account for more than 70%.

When animal bites, damage to the skin occurs, crushing of soft tissues, spreading beyond the skin wound, primary infection. Moreover, even with small sizes of wounds, due to damage to the capillaries, thrombosis occurs in the damage zone, which leads to an increase in the volume of damage and severe suppuration, leading to deaths.

Currently, by order of the Health Committee of Moscow No. 459/139/235 of 08/11/98. “On the organization of a set of measures for the prevention of rabies” - the method of treating bitten wounds is regulated, it includes copious washing of the wound, scratches, abrasions, places of salivation under a running stream of water with soap or any detergent for 20 minutes, treating the edges of the wound with 70 ° alcohol or 5% tincture of iodine, applying a sterile dressing to the wound with an antiseptic, for example, an aqueous solution of chlorhexidine; it is forbidden, in the first three days after receiving an injury, to excise damaged tissue and suture wounds. An exception is damage to the hands and face, requiring special surgical interventions.

Limited surgical tactics are due to local prophylaxis of the spread of rabies virus. Further treatment of wounds is carried out with a periodic change of dressings with antiseptics.

The disadvantage of this method is: not enough cleaning of the wound from necrotic detritus is provided, a "nutrient medium" is formed, leading to purulent complications.

The objective of the invention is to reduce purulent complications due to the lysis of necrotic tissue and fibrin in a bite wound.

The problem is solved in that in a method of treating bitten wounds, including a toilet of wounds, applying dressings to a wound with a medicine and performing reconstructive surgery, fibrinolytically active plasma (FAP) with an activity of 1000-2000 international units per ml is used as a medicine (IU / ml), and the dressing is changed 1 time per day until granulation - 1 time in 3 days with daily wetting of its FAP, and during reconstructive surgery aimed at closing the wound defect, by core 15-20 ml are injected into the cavity of the surgical wound twice a day with an exposure of 30-40 minutes for 8-10 days. FAP course dose from 400000-800000 IU.

FAPs are obtained from the blood of suddenly dead people from cardiovascular insufficiency, myocardial infarction in accordance with Order No. 482 of the USSR Ministry of Health dated June 14, 72 “On improving the provision of medical institutions and clinics with cadaveric tissues, bone marrow and blood.” FAP examination is similar to donor blood examination, in accordance with the regulatory documents of the Blood Service, as well as the order mentioned above. A toxicological, pathoanatomical study of FAP is carried out with the determination of the activity allowed for clinical studies in accordance with the regulatory documents of the blood service.

A distinctive feature of FAP is the ability to prevent blood clots and to carry out the lysis of a blood clot. This property of FAP is used in its local application, which leads to improved perfusion in the capillaries and restoration of the viability of damaged tissues. We conducted studies of cadaverous plasma with different plasma activity, which provides thrombolysis in a bitten wound, therefore, for local treatment, we used FAP with an activity of 1000-2000 IU / ml. This provided the necessary thrombolysis in the wound and had a moderate overall effect on the rheological properties of peripheral blood.

The method is as follows.

After performing a toilet of a bitten wound, including abundant washing of the wound (scratches, abrasions, places of soreness) under a running stream of water with soap or any detergent for 20 minutes, treating the edges of the wound with 70 ° alcohol or 5% tincture of iodine, apply a sterile dressing to the wound moistened with fibrinolytically active plasma.

The indication for the use of FAP was the presence of a bitten wound in the patient with a size of at least 5.0 centimeters, with extensive areas of crushing and soft tissue defects, as well as wounds complicated by a purulent-inflammatory process. Dressings are changed at least 1 time per day for 3-5 days before the appearance of granulations, after the appearance of granulations, dressings are changed 1 time in 3 days, with daily wetting of dressings FAP 20.0 ml with an activity of 1000-2000 IU / ml.

The use of dressings with FAP helps to quickly cleanse the wound from necrosis against the background of the formation of granulation tissue. After filling the wound defects with granulation tissue, epithelization occurs until the complete secondary healing of the wound. After the formation of a full-fledged granulation tissue, reconstructive surgery is performed aimed at closing the wound defect - dermoplasty for large superficial wounds or secondary surgical treatment of the wound with suturing and active drainage of the wound. Drainages are introduced through contrapertura into the cavity of the sutured wound. Through the installed drainage, 15-20 ml of FAP (1000-2000 IU / ml) are injected into the wound cavity twice a day with an exposure of 30-40 minutes for 8-10 days until clean washings appear. After that, the drains are removed, and FAP is injected into the remaining cavity within 1-3 days 1 time per day with a gradual decrease in the volume of administration. Active drainage using FAP helps to improve blood circulation in the area of operation.

Clinical example 1. Patient Zheva S.V., 42 years old, and / b No. 14600, was admitted for treatment in 2 traumatology department of the Research Institute of SP named after N.V. Sklifosovsky with a diagnosis; Bite wounds with crushing left shoulder, left forearm. Bitten fracture of the left ulna. Hematoma of the left half of the chest wall.

On admission: Complaints of pain in the left shoulder, forearm, left side. According to the patient, she was bitten by an unknown bear. The bite is provoked. Transferred from the Central Hospital of Kashira.

Condition at the time of admission: Severe.

Examined by: Traumatologist, surgeon, neurosurgeon, resuscitator, vascular surgeon.

Locally: Extensive with crushing wounds of the left shoulder, forearm. Edema, hematoma, soreness of the left forearm. Hematoma of the left half of the chest wall.

Patient produced: x-ray examination. Ultrasound of the abdominal cavity and chest. ECG. Scintigraphy.

A wound toilet was made; dressings with a left-ointment ointment were applied according to the severity of the condition and the amount of damage to the patient. A fracture of the left ulna was fixed with a plaster cast.

Intensive care, blood transfusion, antibiotic therapy, daily dressings with ointments of the bitten wounds of the left shoulder and forearm, secondary surgical treatment, drainage were performed at the intensive care unit, with the examination revealed extensive crushing of the pectoralis muscle, long biceps head, subcutaneous fat, capsule joint. FAP was administered in the drains at 10.0 ml twice a day for 10 days.

After stabilization of the condition on the 13th day from the moment of the injury, she was transferred to the 2 trauma unit, where antibiotic therapy was continued under the control of crops for microflora composition and sensitivity, infusion detoxification therapy, FTL, immobilization, local treatment of FAP wounds was continued. On the 12th day from the moment of the operation, the drains were removed into the cavity, FAP of 3.0 ml was administered daily for 7 days until the canals were closed. The wounds on the shoulder against the background of local application of FAP cleared of necrosis, healed by secondary intention, without signs of inflammation. The patient refused the proposed autodermoplasty operation. The development of movements in the shoulder elbow joints has begun. She was consulted by an oncologist about the tumor-like formations of the left mammary gland, an ultrasound scan of the left mammary gland was performed.

ARIG with s-126 t-22.9 ml was introduced, an initial course of vaccination was carried out (CoKAV s-776 on days 0, 3, 7, 14, 30). The patient is warned about the rules of vaccination: do not drink alcohol, do not swim in open water, do not sunbathe, do not give other vaccinations during the course of CoCAV and within 6 months after the last injection of CoCAV.

Tetanus prophylaxis was carried out: PSS c110 3000 IU according to the scheme, AS s8-4 1.0. At discharge, the condition is satisfactory, a bitten fracture of the left ulna has fused.

The study of hemorheological parameters revealed an increase in blood viscosity at low shear stress up to 11.8 cP (N-9.5 ± 0.5 cP), red blood cell aggregation up to 12% op. pl. (N-10 ± 0.2% opt. Pl.), Platelet aggregation up to 38.8% op. pl. (N-30.0 ± 2.0% opt. Pl.), Fibrinogen concentration up to 5.0 g / l (N-3.1 ± 0.1 g / l) and shortening of blood coagulation time to 4.0 min (N-6 ± 0.5 min).

At discharge, there was a tendency to normalize the main indicators of homeostasis. The patient was discharged in satisfactory condition.

Figure 1 presents: a) a view of the wounds from the back on the first day after the secondary surgical treatment on the 3rd day after the injury, b) a front view of the wounds on the first day after the secondary surgical treatment on the 3rd day after the injury.

Figure 2 presents: a) a front view of the wounds on the 19th day after the secondary surgical treatment, (b) a front view of the wounds on the 19th day after the secondary surgical treatment.

Figure 3 presents a view of wounds from the back 6 months after the injury.

Clinical example 2. Patient M, 60 years old, and / b No. 13726, was admitted for treatment to the 2nd traumatology department of the NIISP named after N.V. Sklifosovsky with a diagnosis of Multiple bite wounds of the right forearm and shoulder, left thigh.

A famous dog bit in the Moscow region. The patient was sent to hospitalization from RTP.

On admission: Produced toilet wounds. Tetanus prophylaxis was performed: AS - 1.0 s 6-13, D - 0.1 s 30, PSS 3 thousand ME. A course of anti-rabies vaccinations has begun: anti-rabies immunoglobulin (ARIG) s-4 t-207 - 14.4 ml. CoKaV - 1.0 for 0. 3, 7, 14, 30 day.

After the toilet of wounds, bandages with FAP were applied to the wounds, local treatment of wounds was continued using sterile wipes moistened with FAP once a day for 5 days. On the 5th day, the wound was filled with full granulation, the dressings were performed with FAP once every 3 days, wetting the dressings daily with FAP. In the department received antibiotics. On day 21, free dermoplasty with a split flap was performed. Engraftment 100%. After dermoplasty, the wound healed without complications 100%.

Upon admission, the patient showed an increase in blood viscosity at low shear rates up to 14.8 cP (N-9.5 ± 0.5% cP), red blood cell aggregation up to 13.5% op. pl. (N-10 ± 0.2% opt. Pl.) Platelet aggregation up to 42.5% op. pl. (N-30.0 ± 2.0% opt. Pl.) Against the background of increasing fibrinogen concentration to 5.7 g / l (N-3.1 ± 0.1 g / l) and shortening the blood coagulation time to 4 min (N-6.0 ± 0.5 min), which indicated marked violations in the homeostasis system.

At discharge, there was a tendency to normalize the main indicators of homeostasis. The patient was discharged in satisfactory condition.

Figure 4 presents: a) the type of wound upon admission, b) the type of wound after necrectomy.

Figure 5 presents: a) a view of the forearm during treatment of FAP, before surgery, b) a view of the wound before surgery after a course of treatment of FAP.

Figure 6 presents: a) a wound after plastic surgery, b) a wound after 1 day after plastic surgery.

Figure 7 presents a view of the wound (treatment result) before discharge.

A positive effect was determined in 100 patients who had bitten injuries: wounds without bone fractures, open bitten fractures treated in the traditional way (control group) and 100 patients with similar injuries treated by the proposed method (main group).

As can be seen from the table, in the patients of the main group the formation of full-fledged granulation tissue took place twice as fast, which made it possible to perform reconstructive and reconstructive operations at 10-14 instead of 23-25 days, which ultimately affected the length of stay patients in the hospital, who were in the control group 25-37 days, and in the main group 16-21 days. Deep purulent complications in the control group developed in 21 patients and were significantly more likely to require surgical treatment, and in the main group there were only 2 cases. The development of purulent complications in the main group was due to the late start of local treatment with FAP - 3 days from the time of hospitalization.

The use of FAP on the wound surface enhanced the local lysis reaction both due to its own enzymes and due to the activation of the macrophage reaction, improving perfusion in damaged tissues, which reduced the number of purulent complications by 5 times.

Comparison of treatment results for patients bitten with trauma treated in the traditional way (control group) and the proposed method (main group). NUMBER OF PATIENTS CONTROL 100 BASIC 100 Terms of formation of full granulation tissue (in days) 23-25 10-14 Dates of reconstructive operations 23-25 10-14 The number of patients whose healing occurred under the scab 25 28 Duration of hospital stay (in days) 25-37 16-21 The number of patients who have purulent complications. 25 5

Claims (2)

1. A method of treating bitten wounds, including a wound toilet, applying a dressing with a drug to a wound, performing reconstructive surgery, characterized in that the dressing with fibrinolytically active plasma (FAP) is first applied to the wound, then reconstructive surgery is performed, aimed at closing the wound defect, after the operation on the drainage, carried out through the counter-hole, into the cavity of the surgical wound twice a day with an exposure of 30-40 minutes for 8-10 days 15-20 ml of FAP with an activity of 1000-2000 IU / ml. 2. The method according to claim 1, characterized in that the dressing is changed 1 time per day until the appearance of granulations, and after the appearance of granulations - 1 time in 3 days with daily wetting of its FAP with an activity of 1000-2000 IU / ml.

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