Surgical wound management instructions

First, the skills not mentioned in the book.

Scope of application of iodophor and alcohol. Iodophor is complex iodine, which is ineffective or ineffective for greasy wounds or sebaceous glands. Alcohol or iodine can be degreased, which can better fix the protein of bacteria, and it is more penetrating in places with rich sebaceous glands. So it will be applied around the scalp wound. However, both of them are irritating to a certain extent. Therefore, open wounds cannot be applied. -

The application of physiological saline is mainly irrigation and humidification, because it may be a large area wound or an uneven wound. It is hoped that washing can remove some impurities and infections. Insulin is mainly used for unhealed wounds of diabetic patients. The purpose of hypertonic salt is that the local swelling of the wound has not healed, but it can achieve local dehydration, just like some honey. There are also local wounds such as gentamicin needles, which are mainly infected. This is not a principle. Just like before, destroy it with new cleaning. May not be very confident about the efficacy of iodophor. Use iodine and alcohol in an emergency. -

Choice of seasoning. How much seasoning should I choose? This has to start with the growth of the wound. In the first few days, the growth of the wound was mainly granulation tissue. It needs a relatively humid environment, so several layers of dressing can be used a few days ago to keep the wound relatively moist. The growth of the wound in the later stage is mainly the growth of keratin. At this time, the wound needs a relatively dry environment, so the dressing should be as thin as possible under the premise of isolation. Why do some people always fail to see the healing of the wound cuticle in the later stage? I think it has something to do with it.

The purpose of our surgical dressing change is:

First of all, provide a relatively sterile environment for the wound to avoid being attacked again.

Second, provide a relatively favorable environment for the growth and healing of wounds, so that they can heal as soon as possible.

The main purpose of dressing change is:

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Remove necrotic tissue

Clean the wound

4. Smooth drainage

5. Promote tissue growth,

Third, simple irrigation is sometimes difficult to clean the wound, can it be used? Take a shower? Although there are reports in the literature that the infection may spread, I think how many times should I change it? Bath water? The possibility of spread of infection is almost impossible. Studying the wet surface of the wound is conducive to tissue growth, which is also the main reason why we usually like to cover the wound with physiological saline gauze. At the same time, physiological saline gauze also has the function of unobstructed drainage. However, because the humid environment is also a hotbed for the growth of bacteria, the bacteria will enter the logarithmic proliferation period after 6-8 hours, so it is necessary to change the dressing frequently (preferably 3-4 times a day) for severely infected wounds. Many people like to add gentamicin to the wound at the same time. -

Vaseline gauze can provide a moist environment conducive to the growth of granulation on the wound surface and reduce the exudation of tissue fluid. Early wound can also stop bleeding, but it should be used with caution for severely infected wounds, because poor drainage can easily aggravate infection.

Hypertonic glucose is a dehydrating agent, which can enhance the osmotic pressure of plasma and produce dehydration. It has obvious curative effect on local malnutrition, large wound area, infectious wound with poor or ineffective effect after dressing change with other drugs, skin erosion and ulcer on varicose veins of lower limbs, difficult wound healing, obvious edema in small area of superficial second degree to deep second degree burn, slow wound healing, bedsore, etc. Hypertonic glucose can be evenly distributed on the wound surface, resulting in hypertonic environment, which can dehydrate bacterial cells, make bacteria lose their reproductive ability and die, dehydrate local cells in the body, reduce edema of wound surface and granulation tissue, form a protective film, prevent cells from further invasion and infection, improve local blood circulation, improve nutrition around the wound surface and promote wound healing; In addition, glucose can also promote granulation growth, reduce wound pain and promote wound healing.

It's best not to let alcohol penetrate into an open wound when dressing change, because alcohol is not good for wound healing (this is the doctor's opinion during my internship).

In addition, iodine -2 wine -3 is a classic disinfection method in orthopedics. When I first arrived in orthopedics, the leader asked us to strictly abide by the debridement in the new outpatient department.

For contaminated oily wounds, we use turpentine to wash away the oil stains here-

On the use of oil gauze 1. It is used to drain the abscess after incision, and at the same time compress and stop bleeding on the abscess that has just been cut. Can be directly placed on the wound to promote granulation growth. Its replacement cycle depends on the wound. If the wound exudes more, it should be replaced every day, and it should be replaced for the first time in 5-7 days, and then it depends on the situation. 5.

Second, the management of common wounds-

1. Clean the wound and disinfect it with iodophor, which has little irritation and good effect; For clean new granulation wounds, vaseline gauze can also be used to cover them, so as to relieve the pain of patients during dressing change and reduce the leakage and loss of tissue fluid. -

2. Wounds with abundant blood supply and little chance of infection can be simply moistened with normal saline and bandaged with sterile auxiliary materials. -

3. For the wound with skin defect, the defect area should be washed repeatedly with salt water, and the surrounding area can be disinfected with iodophor. After disinfection, cover with saline gauze or vaseline gauze. Saline gauze is beneficial to keep the wound fresh and dry, while vaseline gauze is beneficial to the growth of granulation. -

4. The principle of infection or pollution of wound is to discharge pus. If necessary, open the suture, enlarge the wound and drain thoroughly. The wound should be washed repeatedly with hydrogen peroxide and normal saline. If there is necrotic tissue, debridement is needed. Antibiotic gauze can also be used to fill wounds. It is best to use iodine twice and alcohol three times to deodorize the wound. Of course, dressing changes for infected wounds should be done every day. -

In addition, when dressing the suppurative incision, don't dislike the stench. Be sure to carefully wipe off the pus coating at the incision, and don't be afraid to touch the incision because of the patient's pain. After the pus coating is removed, there should be slight blood oozing, which will help the incision heal as soon as possible! -

5. Infected wounds such as bedsore and suppurative osteomyelitis: iodophor is disinfected around the wound, and at the same time, the wound is washed with hydrogen peroxide and normal saline and covered with gentamicin dressing. -

6. For osteomyelitis with bone exposure, dressing should be changed frequently first, because there is much exudation and dressing change. During dressing change, the necrotic tissue should be removed at any time, and gauze can be placed in the medullary cavity. The empirical method is to wash the wound with salt water first, then with 0. 1% iodophor, then with hydrogen peroxide, and finally wet compress it with gauze and cover the dressing. When the granulation of the wound surface is fresh and exudation is less, the dead bone and hardened bone are surgically removed, and the wound surface is covered with proper myocutaneous flap and fixed outside the external fixator. After the flap survived, the bones were elongated. -

7. The dressing change of patients with open fracture treated by external fixation follows the following principles: firstly, iodophor disinfection (while cleaning to remove necrotic tissue), secondly, hydrogen peroxide disinfection, then physiological saline washing, and finally, nitrofuracilin packing to cover the wound. Wait for granulation to grow and cover it with free flap.

8. Incision fat liquefaction: Fat liquefaction is easy to occur in fat-rich places. At this time, extensive incision (all areas of fat liquefaction are opened), culture+drug sensitivity, and strengthening dressing change. This kind of incision needs long-term replacement. In order to shorten the time, gentamicin was injected subcutaneously after preliminary disinfection, and glucose powder was placed in the incision, and the dressing was changed every day. After the wound oozes less blood, use oil gauze to stimulate the growth of granulation, and sew it in the second stage after it is fresh or wrap it with butterfly tape.

9. Long-lasting wounds should be treated with traditional Chinese medicine. Traditional Chinese medicine dressing change has its own uniqueness, but there is usually no aseptic concept. For example, for refractory sinus (such as sinus caused by brain surgery, heart bypass surgery or chronic osteomyelitis), Berdan or Jiuyidan+red ointment is generally used to expel putrefaction and pus in the early stage, and Shengjisan+red ointment is used to close the mouth in the later stage. The effect is very good, even Pseudomonas aeruginosa or drug-resistant Staphylococcus aureus infection can be cured well.

10. For polluted oily wounds, we use turpentine to wash away oil stains.

1 1. For old granulation wounds: this granulation tissue has poor regeneration ability (dark red, old and uneven color, sometimes with old bleeding appearance), and the surrounding tissues are not easy to heal. Scrape or cut off the granulation tissue on the surface with a scraper to make it bleed, expose fresh granulation, and apply adhesive tape externally (this is the theory of removing putrefaction and promoting granulation in traditional Chinese medicine, and western medicine will rinse it with hydrogen peroxide). If there is pus, observe whether there is pus cavity or sinus, and pay attention to the change of patient's body temperature.

12. For the wound infected by Pseudomonas aeruginosa, it is characterized by a light green pus with a special sweet smell. If the wound scabs, pus accumulates under the scab and there is necrotic tissue, the scab skin, pus and necrotic tissue should be removed. Early suppurative infection of burn wounds can be removed by escharectomy and skin grafting. You can also wet compress with 1%~2% phenoxyethanol, or wet compress with 0. 1% gentamicin, 1% silver sulfadiazine, 10% methanesulfonic acid, etc. If the wound is small, it can be wet compressed with 3% acetic acid, 10% chloral hydrate and other solutions.

13. It is best to change the dressing with nitrofurazone solution close to body temperature for replantation or vascular anastomosis flap surgery, and it will be scolded to change the dressing with alcohol; Finger dressing gauze should avoid circular dressing, and it is best to fill it with broken gauze locally.

14. For the refractory sinus caused by brain surgery, heart bypass surgery or chronic osteomyelitis, Baerdan or Jiuyidan+red paste is generally used to expel putrefaction and pus in the early stage, and Shengjisan+red paste is used to seal it in the later stage. The effect is very good, even the infection of Pseudomonas aeruginosa or drug-resistant Staphylococcus aureus can be cured well.

15. For the old granulation wound: this granulation tissue has poor regeneration ability (dark red, old and uneven color, sometimes with old bleeding appearance), and the surrounding tissue is not easy to heal. Scrape or cut off the surface granulation tissue with a scraper to make it bleed, expose fresh granulation, and apply it with rubber (this is the theory of Chinese medicine to remove rot and promote granulation, and western medicine will rinse it with hydrogen peroxide to achieve the purpose of removing rot).

Third, matters needing attention

1. Generally speaking, local swelling and exudation were observed in aseptic primary wounds 24 hours and 72 hours after dressing change.

2. It is very important to change the dressing for 24, 48 and 72 hours for three consecutive days after open wound surgery, pay special attention to hematoma or drainage, and eliminate the danger in time.

3. The most common infected wounds in orthopedics are skin necrosis and bedsore wounds. Hypertonic saline is generally used for wounds with serious infection and exudation in a certain period of time, which can quickly reduce the edema of wounds and granulation tissue and reduce exudation.

4. It is best to use nitrofurazone solution with similar body temperature for replantation operation or vascular anastomosis flap operation. Finger dressing gauze should avoid ring ligation, and it is best to fill it with broken gauze locally.

5. For large-area wounds, we should first pay attention to debridement, and we should not tolerate necrotic tissues, including necrotic tendons and vascular tissues, and strive to cut them decisively once the boundaries are obvious in several dressing changes. Reluctantly staying will only delay the growth of granulation and even cause infection.

6. For wounds that have removed most of the necrotic tissue, pay attention to the growth of granulation. Granulation tissue itself has the ability to resist infection. If there is no obvious exudation, don't use antibiotics or other potions to change the medicine. Disinfect the wound skin with iodophor only and cover it with wet saline gauze.

7. Don't put the oil gauze on the wound, but put it on the salt water gauze to prevent the salt water from evaporating too fast.

8. Pay attention to a bacterial culture+drug sensitivity before dressing change for infected wounds to avoid being passive in the future.

Fourth, commonly used drugs for dressing change

1. Salt water

It can improve the nutrition of granulation tissue, absorb shaving secretion and has no adverse stimulation to granulation tissue. Wash the wound with isotonic saline cotton ball and gauze, wet compress the wound and fill the abscess cavity; Wash the injured mouth with isotonic saline solution; 3% ~ 10% physiological saline has strong dehydration effect and is used for wounds with obvious granulation edema.

2.3% hydrogen peroxide

After contact with tissue, oxygen is released, which has bactericidal effect. Used for cleaning traumatic wounds or foul-smelling wounds, especially for wounds infected by anaerobic bacteria.

3.0.02% potassium permanganate solution

Oxygen decomposes and releases slowly, but its effect is lasting, and it has the functions of cleaning, deodorizing, antisepsis and sterilization. Used for cleaning rotten, smelly and infected wounds, especially for wounds suspected of anaerobic infection, anus and perineum. Clinically, 1:5000 solution is commonly used for wet compress.

4.0. 1% Rivnuel ； 0.02% furacilin solution

It has antibacterial and bactericidal effects. Used for cleaning and wet compress of infected wounds.

5. Solution (bleaching powder, boric acid)

Has antibacterial, antiseptic, deodorizing, and necrotic tissue dissolving effects. Used for cleaning and wet dressing wounds with pus and necrotic tissue. This preparation should be kept in a closed place and away from light, and should not be kept for a long time, and the storage time should not exceed one week. Not suitable for large area wounds, avoid absorbing too much chloride ion.

6. polyvinylpyrrolidone iodine

It is a new bactericide, which is effective for bacteria, fungi and spores. 0.05% ~ 0. 15% solution is used to wash mucous membrane, wound and abscess cavity; 1% solution is used to cover aseptic incision; 1% ~ 2% solution is used to wet compress infected wounds, which is most suitable for chronic and cancerous ulcers of lower limbs.

7. Antibiotic solution

Commonly used solutions are 0.5% neomycin solution, 0. 16% gentamicin, 0.5% chlortetracycline, 2% bacitracin, 2% ~ 5% kasugamycin, etc., which are used for wet dressing of contaminated wounds and wounds with large wounds (such as burns) before skin grafting. The dressing should be changed 1 time a day. Chloramphenicol dripping pills were directly implanted into infected wounds, each LCM 2 1 pill, once a day 1 time.

8. 1% ~ 2% phenoxyethanol solution

It has bactericidal effect on Pseudomonas aeruginosa with the best effect. The wound surface is continuously wet-compressed.

9.0.0 1% ~ 0.05% bromogeramine and 0.02% chlorhexidine solution

Field combat is better than wound cleaning, and the latter is better than the former.

10. 10% garlic solution

It has the functions of sterilization and enhancing the phagocytosis of tissues and cells, and has a good curative effect on Staphylococcus aureus infection.

1 1.2% ~ 4% methyl violet (gentian violet) solution

Has the functions of sterilization and convergence. It can be used to disinfect superficial skin or mucosal ulcer and promote the healing of dementia.

12. Pure carbolic acid solution

Has the functions of antisepsis and sterilization. Burn anal fissure and chronic sinus with cotton swab of pure carbolic acid solution, so that unhealthy granulation tissue will be necrotic and fall off, and promote healing. After use, wipe it with an alcohol cotton swab to neutralize it, and then wipe it with an isotonic saline cotton swab.

13. 10% ~ 20% silver nitrate solution

It is used to cauterize anal fissure, chronic sinus and corrode granulation tissue. After use, it should be wiped with an isotonic saline cotton swab.

14. Oil gauze

It has the functions of drainage, wound protection, dressing not easy to dry and prolonging dressing change time. Those with less wound secretion can be replaced once every 2 ~ 3 days. Commonly used are: ① vaseline gauze; ② Cod liver oil gauze: It can nourish and promote granulation and epithelial growth, and is used to heal slow wounds.

15. Powder and ointment

(1) iodoform yarn strip: It has antibacterial, antiseptic, astringent, deodorizing and granulation promoting effects. It is used for chronic sinus with glandular secretion, such as anal fistula and wounds after tuberculosis focus is cleared. Iodoform is toxic and should not be used for a long time.

(2) 10% ~ 20% fish fat cream: it has anti-inflammatory and repercussive effects and is used for early abscess;

(3) 10% zinc oxide ointment: it is applied to the skin surface to protect the skin from secretion erosion, and is often used for the skin around intestinal fistula and biliary fistula;

(4) Streptomycin ointment: applied to gauze for external use to treat tuberculous wounds;

(5)2% polyvinylpyrrolidone iodine ointment: it is used to treat burns and chronic ulcers with satisfactory curative effect;

(6) Baiduobang ointment: used for infectious wounds.

16. Traditional Chinese Medicine

Such as red ointment, Shengji powder, Shengji Yuhong ointment, burn ointment, MEBO, Daqing ointment, etc. It has the functions of relieving pain, expelling toxin, promoting granulation, expelling pus, removing putrefaction and promoting granulation.

Iodine and alcohol can only be used where the epidermis is intact. Iodophor is not suitable for places with rich sebum. Glucose and insulin provide nutrition for wound granulation, hypertonic saline can dehydrate edema granulation, and physiological saline only plays the role of wet compress. When granulation grows excessively, it should be corroded by silver nitrate. When granulation grows well, vaseline gauze can be used to protect it.

The principle of dressing change is to clarify the purpose of dressing change in surgery, and what dressing change to use depends on the wound condition.

1. iodine+alcohol deiodine disinfectant

2. Vaseline gauze-the anti-inflammatory effect is slightly weak, but it promotes granulation growth.

3. Iodophor-there are two shades, and it is moist in nature.

4. Yousuo-Anticorrosion

5. Hypertonic glucose+insulin+(growth promoting factor)-an incurable wound for diabetic patients.

6. Hypertonic salt reduces granulation edema

7. Gentamicin injection infected wound; osteomyelitis

8. Disinfect with clean water or hydrogen peroxide or metronidazole-it can be washed and covered, and it is anaerobic.

9. Antibiotic powder (cephalosporin, etc. )-According to drug sensitivity test.

10. Yunnan Baiyao (Capsule)-Traditional Chinese Medicine

1 1. Honey and sugar-folk prescription

12.SD-Ag, SD-Zn- convergence

13. scabies black ointment-traditional Chinese medicine formula

14 exposed neurovascular tendons-do not use irritating drugs.

15. Lithospermum oil gauze-removing putrefaction and promoting granulation

16. Vaseline gauze can be used as a carrier of other drugs, which is oily (it can separate fingers and toes, separate blood scabs, and prevent adhesion of adjacent wounds).

17. iodine+gentamicin-can be used for bedsores.

18. erythromycin ointment, etc. -the epidermis is damaged, and it is not bandaged when smeared.

19. The wound with excessive exudation was treated with osteomyelitis lotion-dry dressing to raise the affected limb.

20. Cut as needed, and take out stitches by experience.

2 1. Pay attention to whether the patient feels uncomfortable after dressing change-whether there is pain caused by drugs; Whether the incision has continuous leakage of cerebrospinal fluid; Whether the wound continues to ooze blood; Do you have joint dislocation or fixed shadow?

Five, the secret recipe

There is also a clinical situation, that is, eczema-like changes around the wound, skin redness, rash, easy to break. At first, I used various methods to change the dressing, such as iodophor gauze, vaseline gauze and erythromycin eye ointment. But we can't change it well. Finally, gently wipe it with a cotton ball of normal saline and cover it with dry gauze, which will soon improve. The reason is unknown

For some sinuses, white sugar can be used to change the dressing. Aseptic operation should not be too concerned, and it can generally be changed. However, some sinuses communicating with joints are difficult to heal. My method is to scrape off the aged granulation in the sinus to make it ooze blood, and then put a cotton ball on the sinus to close it under pressure without dressing change for a week. The key is to keep a certain pressure all the time. I believe that when you open them, you will jump with excitement.

The secret recipe for treating bone exposure:

1, 100 Egg yolk is cooked with egg butter, roasted in an iron pan with slow fire, and filtered with gauze.

2. Radix Arnebiae, Radix Angelicae Sinensis, Carthami Flos, Sanguisorba officinalis 10g, and sesame oil (250g) were soaked for 3 to 5 days, and the weather was hot and the time was short.

Decoct with slow fire until the traditional Chinese medicine turns black and floats, and filter with gauze twice. At 60℃, add egg butter and vaseline, stir evenly into paste, and autoclave for later use. (Sometimes it is not autoclaved) When the bone is exposed more than 2x50px, drill a hole with a bone drill until there is bleeding in the bone, apply three layers externally, change the dressing four days after the first time, and change the dressing the next day. Don't change the dressing too often. You can refer to some dressing change methods of Bao Mei or Shengji Ointment.