Download fever syndrome in surgical infections

THE MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
THE TASHKENT MEDICAL ACADEMY
Department of Surgery for General Practitioner
"APPROVED"
……………………….
……………………….
FEVER SYNDROME IN SURGICAL INFECTIONS
(methodological manual)
Tashkent-2012
THE MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN
THE TASHKENT MEDICAL ACADEMY
Department of Surgery of General Practitioner
Authors:
S.N. Navruzov- Dr.med.,Prof. Director of the Republic Scientific Centre of
Oncology
O.R. Teshaev- Dr.med, Prof. Head of the Department of General PractitionerSurgery
A.E. Rustamov- MD, PhD, Associate professor of the Department of General
Practitioner-Surgery.
MD. Ph.D Yunusov I.I - Assistant Professor of Surgery for
GeneralPracitioners
Reviewers:
Dr.med, Prof.: Ataullaev H.A.
Dr.med, Prof.: Mahkamova M.N.
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METHODOLOGICAL MANUAL IS INTENDED FOR THE 6-7 COURSE STUDENTS OF
THE DEPARTMENT OF GENERAL PRACTITIONER-SURGERY, TASHKENT
MEDICAL ACADEMY
Structure
• Introduction
• Inter subject integration (vertical integration) - anatomical and physiological,
clinical and biochemical features.
• Theoretical part (Aetiopathogenesis, diagnosis, clinical features, treatment,
highlights), diff. diagnosis all disease entities of this syndrome, the rare forms of
disease, the tactics of GPs in various forms of course of the syndrome and its
nosological forms.
• Prevention (primary, secondary, tertiary).
• Rehabilitation of patients after hospital treatment
• Scenario POI in this syndrome
• Practical skills for this syndrome (according to the list of skills-GP Surgery) – Step
by step performance with the interpretation of drawings
• Case studies (№ 10) for different disease entities of the syndrome
• The test questions (№ 60) - 5 types of tests
• References (core, additional)
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Introduction
The concept "surgical infection" includes diseases of infectious nature, which are treated by surgical
methods, and wound infections caused by the introduction of pathogens into the wound, resulting in
injury or during surgery. Fever is an important and sometimes the only symptom of surgical infection.
Syndrome of fever in surgical infection has a distinctive feature and shows the characteristic temperature
curve. Crucial is the role of this symptom in early detection of postoperative complications. Fever reflects
the reactivity of the organism in the development of surgical infection and is the result of absorption of
the decay products of the tissues.
The development of surgical infection is closely associated with the course of wound healing and has the
same phase - phase. In terms of pathophysiology distinguish phase alteration, exudation and proliferation
(granulation). Clinical symptoms in surgical infection is determined by: the stage of wound healing,
wound area, depth of lesion, the composition of the microflora involved in the development of a common
source of infection and the patient (concomitant diseases). The degree of violation of general and local
circulation determines the lack of delivery to the site of the introduction of cellular and chemical
structures that are necessary to deal with the microflora and tissue regeneration. The essential point that
determines the development of purulent process is the nature of the dose and virulence of
microorganisms. A role in early detection of surgical infection belongs to the relevant knowledge of
anatomy - the structure of the fascial sheaths and their importance in the spread of infection.
Despite improved diagnosis and continuous improvement of antibiotic surgical infection still poses a risk
to the operating surgeon as well as for GPs. According to the Republic Scientific Centre of
Coloproctology (RSCC) of Uzbekistan, at 8.7% of patients after surgery for colon there are various postoperative complications, among which attention is drawn to the post-operative peritonitis, which is 67%
of cases leads to death. Based on these data can be regarded as a problem of diagnosis, prevention and
treatment of surgical infections is very important.
Etiology.
The first scientific study of pathogens of purulent infection complied R. Koch (1878), which laid the
foundation for the study of the specificity of the bacteria. Performing the injection of purulent material to
animals, it caused a clinically well-circumscribed infectious processes and showed that each of them is
called respective views of the microorganism. Due to its proposed in 1881 by the methods of cultivation
of microorganisms on solid and transparent media, he was able to identify different species of bacteria,
making them carry pure cultures. This was followed by the opening stage of the various agents of
purulent processes and determine their location, living conditions, the ability of resistance, etc. Gradually,
the number of excited-makers purulent diseases and purulent inflammation of wounds increased by
opening a specific and nonspecific bacteria: pneumococcus (1883-1884), gonorrhea (1879-1885),
Escherichia coli (1885), Proteus (1885), Pseudomonas coli, pathogens anaerobic infections (1892 and
later), fungi, etc.
At the same XXIV Congress of the International Society of Surgeons was noted that there is already 29
aerobic and anaerobic bacteria, 9 fungi and 8 viruses. It was pointed out that since 1956, the cases of
infections caused by Gram-negative bacteria.
Analysis of materials of domestic and foreign literature suggests that the main causative agents of surgical
infection at this stage are pathogenic plasma coagulating staphylococci MDR Gram-negative bacteria and
various family Enterobacteriaceae and the genus Pseudomonos, i.e. representatives of conditionally
pathogenic microflora, which normally handles the body due to the prevailing evolutionary natural
protective factors that undergo marked disturbances after surgery.
Noting the important role of staphylococci in the occurrence of surgical infection, it is necessary to
distinguish two major factors affecting the growth of infectious complications in the hospital now. This,
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above all, widespread pathogenic staphylococci and a large percentage of their carriage among healthcare
workers and patients in hospitals. As well as the ability of pathogenic staphylococci to adapt quickly to
chemotherapeutic drugs and, mainly, to antibiotics widely used in surgical practice.
Microbial associations with the growth of microbial antibiotic resistance began to meet frequently. If,
before the widespread use of antibiotics in surgical infection pathogens play a major role streptococcus,
whereas in the late 40s of this century took first place staphylococcus.
Of representatives of Proteus group in the festering wounds more common in Proteus mirabilis. Proteus
can aggravate the severity of the purulent process burden for staph infection. Being in a symbiotic or
antagonistic relationship with other infectious agents, Proteus, and Escherichia as Pseudomonas bacillus,
can create conditions for the growth of some pathogens and inhibit the growth and reproduction of others.
In this regard, the use of antibiotics to fight wound infection should be sure to include deliberate action on
the whole association of microbes.
In recent years, selected group of pathogens of purulent-inflammatory diseases - non-clostridial
anaerobes, group not previously detected opportunistic pathogens. The latter can be independent agents or
to be in association with aerobes. In the etiology of pyogenic infections are the most important:
Bacteroides, Peptococcus, Pep-tostreptococcus, Fusobactcrium, B.fragilis.
Pathogenic microorganisms of various purulent diseases
isolated from wounds.
Clinical groups of purulent diseases
Pathogens
Acute purulent diseases of soft tissue (mastitis,
boils, carbuncles, festering atheroma,
gidradenity, panaritiums and others)
Staphylococcus spp., P. aeruginosa, Streptococcus
spp. Non-clostridial anaerobic microflora
Postoperative purulent wounds of soft tissues
(cellulitis anterior abdominal wall after
appendectomy, laparotomy, bowel surgery,
after a plastic reconstructive surgery of the
FIR, etc.).
E. coli, Proteus spp. P. aeruginosa,
Enterococcus spp.
Non-clostridial anaerobic microflora. Mushrooms
Post-traumatic soft tissue wounds festering
limbs with damage and without damage to the
bone
P. aeruginosa
S. aureus, S. Epidermidis
Non-clostridial anaerobic microflora
Postoperative or posttraumatic osteomyelitis
with purulent wounds of soft tissues
Staphylococcus spp. Enterobacter spp.
P. aeruginosa, Klebsiella spp.
Proteus spp. Non-clostridial anaerobic microflora
Chronic purulent tissue wounds, sores,
decubitus
Non-clostridial anaerobic microflora. E. coli,
S. aureus, S. Epidermidis
Mushrooms, Enterococcus spp.
Proteus spp. P.aeruginosa
Sepsis
S. aureus, S. Epidermidis
Enterobacteriaceae. P. aeruginosa, Enterococcus
spp. Mushrooms.
"Diabetic foot", gangrene of the foot and lower
leg
Non-clostridial anaerobic microflora. S. aureus, S.
Epidermidis
E. coli, Klebsiella spp.
Proteus spp. P. aeruginosa. Enterococcus spp.
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Enterobacteriaceae. Mushrooms.
Important role in the etiology of surgical infections are asporogenous, anaerobic bacteria.
By asporogenous anaerobes include:
1. Gram-positive bacteria (Actinomyces, Arachiie, Lactobacillus);
2. Gram-negative bacteria (Bacteroides, Fusobacterium, Campilobacter);
3. Gram-positive cocci (Ruminococcus, Peptococcus, Peptostrep);
4. Gram-negative cocci (Viellonella).
Table 2 presents the non-clostridial anaerobes isolated from wounds in different clinical groups of
purulent diseases. At all listed diseases among asporous anaerobics are found out B. Fragilis,
Peptococcus, Peptostreptococcus. When lung abscesses are distinguished as F. nucleatum, Fusobacterium
spp., in postoperative septic wounds, diabetic gangrene and phlegmon, limfideme complicated by
erysipelas inflammation - P. melaninogenica.
The clinical group
Non-clostridial anaerobes isolated from wounds
with various purulent diseases
Types of non-sporogenic anaerobes
Lung abscesses
F.nucleatum. Fusobact spp,
P. melaninogen.
Peptococcus. Peptostreptococ.
Cholangitis
B. fragilis
Peptococcus. Peptostreptococ.
Acute purulent diseases of soft tissues
Peptococcus. Peptostreptococ.
B. fragilis
Post-traumatic wounds
Postoperative septic wounds
Peritonitis, cellulitis of the abdominal wall
Diabetic phlegmon, gangrene
Lymphedema complicated by erysipelas
inflammation
Long crush syndrome soft tissue
B. fragilis, Peptococcus. Peptostreptococ.
B. fragilis
Peptocoecus. Peptostreptococ.
P. melaninogen.
B. fragilis. Peptococcus. Peptostreptococ.
P. melaninogen. Peptococcus.
Peptostreptococ. B. fragilis
P. melaninogen. Peptostreptococ. Peptococcus
B. fragilis
P. melaninogen.
Peptococcus. Peptostreptococ.
B. fragilis
Frequency of occurrence, probability of development of wound infections is directly associated with character
of performed surgical intervention.
1). Pure surgical interventions (for example, hernia repair) become complicated with wound infections in 1-2 % of
cases. Because of small probability of suppuration, the operative wound is closed tightly.
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2). Pure operative interventions with probable contamination (for example, cholecystectomy). Risk of
development of purulent complications - 5-15 %. Operation is usually finished with primary sutures.
3). Surgical interventions with higher risk of contamination (for example, hemicolectomy, apendoctomy for a
destructive appendicitis, cholecystectomy in the case of empyema or an infected cholangitis). The risk of development
of purulent complications makes 10-20 %. A skin wound usually closed with drainages.
4). Surgical interventions with very high risk of contamination (for example, the opened abscess). The probability
of wound infections exceeds 50 %, therefore the skin is usually single-sutured and the space between them is widely
drained. Healing goes with the secondary intention.
It is necessary to refer the following risk factors of occurrence of postoperative suppurations:
 Performance of operations in more than 12 hours after wounding;
 Duration of operation, so the increase in time of performance of operation over 3 hours raises the risk of
infection 5 times;
 The rough operative technique - in 3,8 times;
 Presence of the exudates in the abdominal cavity - 2,7 times;
 Operation for malignancy - 3 times;
 Drainage and tampon a wound and abdominal cavity -2,3 times;
 Considerable tension of the wound edges; a wound location on the legs, forearms and especially in area of
feet, hands.
Also plays a role:
 Opening of hollow organs during the operation;
 Superfluous subincisionaneous fat
 Presence of accompanying diseases;
 Casual violation of rules of aseptic and emergency operations.
Development
of
suppuration
depends
on
the
following
basic
conditions:
1) an extensive trauma of the tissues surrounding a wound and their expressed inflammatory changes, 2) presence in
the wound of necrotic or bruising nonviable tissues, a hematoma or blood clots and foreign bodies that is caused by
defective surgical debridement of a wound, the bad hemostasis, inadequate comparison of edges of a wound, 3)
microbic pollution of the wound above critical level (10 5 microbic bodies on 1 gramme of a tissue), 4) disorder of the
general condition of an organism - traumatic shock, intensive haemorrhage, the changed reactivity.
Classification of surgical infection.
The term "surgical infection" is accepted to include both acute and chronic suppurative disease or
traumatic injuries that are associated with inflammation and at certain stages require surgical treatment.
The classification of surgical infection offered by V.I.Struchkov, V.K.Gostishchev, U.V.Struchkov (1984)
is most acceptable.
According to clinical course and changes in tissues from all kinds of a surgical infection differ aincisione
and chronic infection.
1. Aincisione surgical infection: the purulent; the putrefactive; anaerobic; specific (a tetanus, the Siberian
ulcer - antrax, etc.).
2. Chronic surgical infection: the nonspecific; specific (tuberculosis, a syphilis, аctinomycosis, etc.).
At some types of surgical infection may dominate local manifestations (local surgical infection), and
others - common phenomenon with septic course (overall surgical infection).
For purulent surgical diseases according to the principle that forms the basis of their division, several
classifications have been proposed:
I. By the nature of the causative agent of purulent surgical infection is classified as follows:
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1. aerobic monoinfection
A gram-positive: stafilokkoki, streptokkoki, pnevmokkoki.
B. Gramnegative: colibacteria, Pseudomonas aeruginosa, Proteus, meningococci, gonococci.
2. Anaerobic monoinfection:
A clostridial
B. non-clostridial (asporogenous) infection.
3. mixed infection
A. aerobic-aerobic;
B. Anaerobic-aerobic;
C. Aerobic-anaerobic VA
II. According to the structure of pathology:
a) Surgical infectious diseases;
b) Infectious complications of surgical diseases;
c) postoperative infectious complications;
d) Infectious complications in closed and open injuries.
III. Localization:
a) skin lesions, subcutaneous fat and muscle (surgical infection of soft tissues).
b) The destruction covers the skull, the brain and its membranes;
c) damage the neck;
d) lesions of the chest wall, pleural cavity, lungs;
e) the lesion of mediastinum;
f) The destruction of the peritoneum and abdominal organs;
g) the destruction of the pelvis;
h) the destruction of bones and joints;
I) heart disease and blood vessels (heart abscesses, thrombophlebitis, suppurative complications of
injuries and wounds of the heart, reconstructive operations on blood vessels).
IV. On the clinical course:
1. Acute purulent infection:
The general;
The local.
2. Chronic purulent infection:
The general;
The local.
The pathogenesis of surgical infections and fever syndrome
Pathogenesis of wound infection is determined by the interaction of pathogen with macroorganism.
For the development of wound infection pathogens requires a combination of the following conditions:
1. The high number of bacteria in the wound;
2. The ability of bacteria to penetrate the protective barriers and propensity for translocation;
3. The high pathogenicity;
4. The high virulence;
5. The high toxicity;
6. Low sensitivity to drugs;
7. Ability to multiply inside the cells.
The development of microbes in their penetration through the defect of skin and mucous membranes are
favorable:
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a) the presence in the area of trauma medium (hemorrhage, necrosis), presence of blind pockets, foreign
bodies;
b) the simultaneous entry of several microbes (polyinfection) that have a synergistic effect;
c) the penetration of microbes increased virulence, such as pollution damage to the wound of another
patient's discharge.
"Critical level" bacterial infection of wounds is the number of microorganisms 105 for 1 gram of tissue,
above which may be accompanied by the penetration of infection into the deeper layers of the wound with
the breakthrough of the demarcation of the shaft and the development of septic complications.
"Critical level" can be much less if the wound a large number of dead tissue, foreign bodies, as well as in
violation of the protective reactions of humoral and cellular immunologic factors. As a result, necrotic
wound process may occur in the presence of the wound 103 - 104 microorganisms per 1 gram of tissue.
Reaction to the introduction of microbes is accompanied by local and general manifestations.
At the present time for surgical infection treated as a variant of the cascade reaction to the focus of
inflammation (systemic inflammatory response syndrome - SIRS). The term adopted by the consensus
conference on sepsis in Chicago in 1991 (Bone RC et al., 1992).
The center of surgical infection (the focus of inflammation) leads to the activation and entry into the
blood of many and multifaceted inflammatory mediators (kinins, serotonin, prostaglandins, etc.). Effect of
inflammatory mediators in peripheral vessels leads to dilation or constriction of arterioles and venules, in
stasis, aggregation and microembolization, damage to the vascular endothelium. Mediators also have a
direct effect on the myocardium. Further development of the systemic response to infection manifested
surgical center violation tissue perfusion, decreased peripheral vascular resistance, organ dysfunction.
INFLAMMATORY
PROCESS
STATE OF
MACROORGANISM
EXCITER
Form
State of
activity
Combination
of agents
Hyperergic
Local
anatomical
and
physiological
conditions in
the area of
pathogen
introduction
Nature of the
blood supply
In the development of a systemic reaction to inflammation marked phasic (focus of purulent infection,
sepsis, severe sepsis and septic shock). With inadequate treatment is the generalization of local infection
with the formation of sepsis.
Intoxication is composed of: 1) exposure to toxins and suction decay products, and 2) endotoxemy,
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disorders of homeostasis due to losses through the wound surface proteins, electrolytes.
The main difference between the overall reaction to suppurative process from sepsis is that all the
symptoms of her sharply or disappear at the opening of a purulent focus and create good drainage; with
sepsis do not.
The penetration of microorganisms into the tissue causes a local reaction, which is manifested in changes
in the neuro-circulatory reflex nature: first, developing arterial hyperemia, then venous stasis with
formation of edema, pain, local temperature rise, violated functions. In the inflammatory exudate
accumulates a large number of neutrophils. The degree of severity of local symptoms and the speed of
development depends on the reactivity of the organism.
The result of the local host's reaction to the penetration of the infectious agent is the development of
protective barriers. First of all, formed leukocyte shaft, limiting source of infection from the body's
internal environment, such as barriers are lymph vessels and nodes. In the development of tissue reaction
around the purulent center and cell proliferation of the connective tissue is formed granulation shaft,
which is more reliably limits the purulent focus. With long-term existence of the limited purulent process
from the surrounding granulation shaft a dense pyogenic membrane, which serves as a reliable barrier that
limits the process forming an abscess.
In the highly virulent infections and weak response of the body protective barriers are formed slowly,
which often leads to a breakthrough infection through the lymphatic pathway (vessels, nodes) in the
bloodstream. In such cases, sepsis develops.
Wound process - a complex set of general and local biological reactions in response to damage to organs
and tissues, usually ending their healing (M.I. Kuzin.)
Wound infection - the main type of surgical infection in hospitalized patients.
Characteristics of the main phases of wound healing
The development of surgical infection is closely associated with the course of wound healing and has the
same phase - phase.
It should be divided into 3 successive phases:
1. Purulent-necrotic phase of inflammation (degradation, hydration, exudation), consisting of two
consecutive periods - vascular changes and wound cleansing by suppressing the microflora and the
rejection of non-viable tissue. Purulent-necrotic phase of inflammation characterized by the presence of
necrotic tissue, purulent discharge from the wound, infiltration of the wound edges (Fig. 1). In this phase,
there is a high level of bacterial infection. In wound received fluid containing plasma proteins, blood
cells, fibrin, and antibodies. Violation of metabolic processes leads to increased osmotic pressure in the
tissues, resulting in acidosis develops and disturbance of microcirculation in the inflammation that leads
to secondary necrosis. Directly in the depth of the wound, in the zone of secondary necrosis, rather than
localized on the surface microflora, which determines the development of pathological process.
2. Phase appearance of granulation (dehydration, proliferation). In this phase is cleansed the wound of
necrotic purulent secretions, there is serous discharge, significantly reduced hyperelastic tissue edema
and infiltration. Neutrophilic leukocytes (macrophages) phagocytize cellular detritus, micro and small
foreign matter.
Productive nature of wound healing seen the emergence and development of granulation tissue, which
gradually fills the wound. Recanalization occurs lymphatic vessels starts sprouting of blood vessels,
forming a lot of capillaries that feed the fibroblasts. Wound healing macrophages activated fibroblasts.
Fibroblasts proliferate and migrate to the site of injury by binding to fibrillar structures in fibronectin. At
the same time, they actively synthesize extracellular matrix substances, including collagen. Collagen
provides the closure of tissue defects and the strength of the forming scar.
3. Epithelialization phase - clinically epithelization of the wound surface and reorganization
(ogrubevaniem) scar. Epithelization of the wound.
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In Fig. 1. The stages of wound healing I. exudation; II. granulation;
Takes place as the migration of epithelial cells from the wound edges on its surface. Migration of
epithelium from the wound edges can not provide the healing of large wound areas, this may require skin
grafts.
The reduction of wound surface and provides the effect of closing the wound tissue contraction, to a
certain extent due to the reduction of myofibroblasts.
Clear boundary between the regenerative phase, and no scarring. Healing begins rapidly during the 2nd
phase and then gradually fades. By this time the wound is reduced synthetic activity of fibroblasts and
other cells. Amount of collagen during this phase practically does not increase, it is restructuring and
formation of cross-links between collagen fibers, which grows at the expense of the strength of the scar.
With increasing density of collagen formation of new blood vessels slows down, and scar tissue gradually
fades.
Development of the wound healing process is significantly different in wound healing as primary,
secondary intention healing, or under a scab (crust).
The initial tension - the healing of the wound edges with intergrowths in the absence of infection. Healing
occurs within 6 - 8 days.
Secondary tension - the healing of the wound in the presence of the defect, a large number of nonviable
tissue, blood clots, foreign bodies, and the microbial flora above the critical level (105 for 1 gram of
tissue).
Under these conditions, the healing begins festering wound by replacement of the wound defect with
granulation tissue and scar formation. Healing is a matter of weeks.
Wound healing under a scab occurs in the presence of surface wounds, when it is covered with a crust of
blood and cellular elements.
Intoxication and the temperature increase in surgical infection consists of:
1. Exposure to toxins from the suction of decay products of damaged tissue.
2. Disorders of homeostasis due to losses through the wound surface proteins, electrolytes and other vital
substances needed for the body.
Clinic and diagnosis of inflammatory diseases
Clinical symptoms
Reaction to the introduction of microbes is accompanied by local and general manifestations.
At the present time for surgical infection treated as a variant of the cascade reaction to the focus of
inflammation (systemic inflammatory response syndrome - SIRS).
Clinical manifestations of surgical infection depends on many factors: 1) the breadth and nature of injury
(area of the wound, the depth of injury), 2) the stage of wound healing, and 3) the nature of the
microflora, and 4) the presence of concomitant diseases.
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Clinical manifestations of the general reaction is to increase body temperature, chills, excitement, or,
conversely, weakness, blackout, and sometimes unconsciousness, headache, general malaise, weakness,
rapid pulse, abnormal liver function, kidney disease, lowering blood pressure, stagnation in the
pulmonary circulation. These symptoms may be pronounced or be inconspicuous.
Fever with wound infection - the most important clinical symptom, which occurs as a result of absorption
of the decay products of the tissues. When surgical infection the body temperature often reaches 40 0 C
and above.
In debilitated and elderly patients the temperature of the reaction can not be. There are repeated chills,
painful headaches, sharply reduced hemoglobin, erythrocyte count, the number of leukocytes (up to 25-30
 10 9 / L). In blood plasma globulin content increases and decreases the concentration of albumin.
Characterized by a sharp acceleration of erythrocyte sedimentation rate. Appearing at the beginning of the
process, it is usually observed for a long time after elimination of the infectious process. Sometimes
patients with increased spleen, liver, appears icteric coloration of sclera. In patients with appetite,
disturbed bowel function, there is a delay in stool, urine protein detected, and cylinders.
In the dynamic studies of wound infection of the blood picture reveals the usual increase in erythrocyte
sedimentation rate, increasing the number of leukocytes, leukocyte shift to the left, lymphopeny.
Criteria for evaluation of wound healing in the festering wounds in the table. 3.
TABLE 3
Comparative characteristic features of wound healing by first intention with uncomplicated wound
healing process and festering wounds
SPOT
GENERAL
Evidence
1.
Normal uncomplicated healing
2.
Healing, complicated by a
festering wound
3.
Improvement does not occur,
weakness, malaise, sleep
disturbed due to pain
Intense, often pulsating, or
moderate, but with no
tendency to decrease
Increase to 38-390 C or
persistent low-grade fever
37.2 -37.60 C
The general
condition
Slight deterioration after
surgery, normalization to 2.3
day, sleep is not disturbed
Pain
Mild, aching, disappear in 2-3
days
Temperature
Rise after surgery to 37,5-380
C, normalization of 2-3 days
Blood test
ESR acceleration up to 15-20
mm / h, leukocytosis, and a
small shift to the left, full
normalization of the day by 6-7
Changes growing positive
dynamics without
(LII) on KalfCaliph
<1,4
> 1,4
Lymphangitis,
lymphadenitis
There has been no
There is often in the affected
limb
Hyperemia
A slight, quickly resolved
Puffiness
A slight, quickly resolved
Infiltration of
tissues
A slight, quickly resolved
Moderate or severe, with no
positive dynamics
Moderate or severe, often
growing
Moderate, often increases are
determined by deep
infiltration
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Discharge
1.
Virtually no
No growth, or (rarely) the
number of bacteria flora
nizhe105 per 1 g of tissue
3.
The growth of
microorganisms, the number
of bacteria equal to or
exceeding 105 per 1 g of
tissue
рН
Early acidosis and rapid
alkalization of the wound
environment from 5.0 to 8.0
Persistent acidosis, the pH
below 7.0
The protein
concentration
Rapidly decreases from 15-25 to
2.6 g / l
Increases or is stable at 20-30
g / l.
Cytology
Cellular elements of blood
neutrophils in most cases
saved, the rapid emergence
of poliblastov, fibrocytes,
fibroblasts.
Most neutrophils in varying
degrees of degradation. The
microflora within and
extracellularly in the
process distorted or
incomplete phagocytosis
Bacteriology
wound
Clinical Laboratory
Serous exudate rapidly
becomes purulent or profuse
serous discharge impregnating
fabrics
2.
To determine the dynamics of wound healing and the degree of endotoxemy can be used for LII KalfCaliph.
Ya Ya Kalf-Kalif empirically derived leukocyte index of intoxication - LII (cited by C. Wernicke, 1972):
LII = (4M+3Y+2S+C)  (Pc 1)
(L+Mo) (E+1)
where M - myelocytes, Y - young, S - stab;
C - segmented neutrophils; Pc - plasma cells Turk;
L - lymphocytes, Mo. - monocytes, E - eosinophils.
By Kalf-Caliph, in healthy people LII = 1,0  0,5, by C. Wernicke (1972), 0,5  0,07. In most patients
with inflammatory infiltrates LII than 1.5 (S. Wernick, 1972). At surface infiltrates LII is 1,8  0,22, in
the deep - 2,6  0,26, or even higher - 5,2  1,6. Patients with higher LII 3, there are usually events
purulent resorptive fever. With a smooth postoperative course LII averages 0,6  0,09. If LII exceed 1.4,
then, as a rule, there are complications.
Local purulent infection - morphological substrate of an infectious wound complications, when the
process is localized in the wound area.
Local symptoms of wound infection (redness, swelling, pain, impaired function) depends on the location
and phase of the purulent process. For example, in lesions of the skin, subcutaneous tissue and muscle
there are characteristic signs of inflammation, as redness, swelling, pain, increase the local temperature
fluctuation appears in abscess formation.
Distinguish hyperergic, ratergic, hypoergic and anergetic form of inflammatory reaction.
Hyperergic reaction is characterized by rapid development of suppurative process spreads to the
surrounding tissue and the vascular bundle, accompanied by the formation of thrombosis, extensive
edema, and involvement in the process of lymphatic vessels, nodes and development is not only an
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extensive local, but also severe general reaction. This hyperergic reaction, despite the timely and efficient
treatment often leads to death.
In other cases the inflammatory process is slower, less grasping tissue, with a slight swelling. The general
reaction to the penetration of the microorganism is reflected in a slight increase in temperature, change in
composition of blood, but it does not have a pronounced character. This ratergic response to purulent
infection and local suppurative process is fairly easy to wound treated early.
Anergetic form of inflammatory reaction characterized by mild local and general reactions. Inflammation
limited to the localization process (abscess, etc.), swelling of surrounding tissue is almost absent;
lymphangites, lymphadenitis, thrombosis not observed temperature increases are insignificant.
In chronic purulent infection is characterized by signs of chronic inflammation: prolonged fever,
increased erythrocyte sedimentation rate, lymphocytosis, changes in protein fractions, etc. In a long-term
chronic infection can develop amyloidosis of the internal organs. Local changes in surface localization of
the process are characterized by long-existing infiltrate, often - with the presence of a fistula.
Temperature curves for different forms of surgical infection:
Temperature sheet
OPERATION
(Surgical treatment
of purulent foci)
Temperature sheet
opening burrowing
pus
Fever in the event of septic complications
~ 13 ~
Temperature sheet
operation (surgical
treatment of purulent
focus, the primary
joints, drainage)
flushing of
drainage
Temperature sheet
Against the background of traumatic wounds joined
pneumonia
Temperature sheet
rashes on the skin
fever in erysipelas
~ 14 ~
Diagnosis of inflammatory diseases
Diagnosis of wound infection is carried out based on the following attributes:
• purulent wound drainage, or;
• identification of microorganisms in the inoculation of the wound;
• the wound itself or diverges surgeon opened in the presence of signs of inflammation in a patient (more
than 38o C temperature of the patient and there is local pain in the surgical sutures);
• symptom of "fluctuations" of soft tissue in the wound area.
Surgical incision infection of the surface seen in a period of 30 days after surgery (Fig. 2). Affected only
the skin and subcutaneous tissue in the incision. To identify surgical infection requires one of the
following three criteria:
Purulent discharge from the superficial incision.
Isolation of organism from culture of aseptically taken fluid or tissue surface of the cut.
The presence of one of the hallmarks of inflammation:
pain on palpation, local swelling, redness of the skin
around the wound, fever, and the fact that the
intentional opening of a surgeon cut surface, although
the cut was not isolated culture of the microorganism.
Surgical infection cloven appear in a period of 30 days
after surgery (no implants) or a period of 1 year (with
implants). It is characterized by lesions of deep soft
tissue.
For the diagnosis of surgical infection cloven need
one of the following four criteria:
Purulent discharge from a deep cut.
Spontaneous disclosure cloven him intentional or
open surgery when the patient has at least one of the
hallmarks of inflammation: fever above 38o C,
In Fig. 2. Suppuration of the wound
after surgery appendectomy. Surgical
infection of incision.
localized pain or tenderness.
The presence of painful infiltrate in the deep cut.
Surgical infections organ / space infection caused in the organs or cavities by surgical intervention. For
example, after surgery appendectomy formed subdiaphragmatic abscess. The latter should be recorded as
intra-abdominal infection.
Infection in this group appear in a period of 30 days after surgery (no implants) or a period of 1 year (with
implants). For the diagnosis of surgical infection organ / space must have one of the following criteria:
Purulent drainage, installed by puncture or surgery.
Isolation of microorganisms from aseptically remove fluid or tissue / body cavity.
The presence of an abscess or other manifestations of infection, sweeping body / cavity and detected by
direct examination, during reoperation, or by histopathological radiological examination.
Bacteriodiagnosis agents of wound infection should include both qualitative and quantitative analysis
(Table 4).
~ 15 ~
TABLE 4
A bacteriological study of wound infection pathogens
Blood, urine, swab from the wound, biopsies, sputum, punctate, extracted from
drainage
Qualitative research
Quantitative research
Aerobic
Anaerobes
microorganisms
The content of bacteria
Gram+
Gram Gram +
Gram in the wound (based
1. Isolation of pure cultures of microorganisms
on 1 gram of tissue or
1 ml of secretions)
2. Identification of bacteria
3. Susceptibility to antibiotics
Qualitative bacteriological examination consists of three stages:
• selection of pure cultures of microorganisms,
• identification of microbes,
• determination of their sensitivity to antibiotics.
Isolation of pure culture should begin with a coloring material of the native Gram. Then produce seed in
dense media and liquids.
As liquid culture media using sugar or meat-peptone broth. Of solid culture media should be used 5%
blood agar (for detection of bacteria, demanding to nutrients), milk-yolk-salt agar (for detection of
staphylococci), Endo medium (for the detection of enterobacteria and non-fermenting Gram-negative
bacteria) and, if necessary - a number of special selective media: acetimedic agar, agar brilliant green etc.
Using such a broad range of culture media for planting of the material allows for one-stage selection of
microorganisms and microbial inoculation to ensure the growth of which is suppressed ongoing antibiotic
therapy.
Produce a quantitative count of colonies in various dilutions and calculate the average number of bacteria
per 1 sq. km. see the surface or at 1 g of tissue. Identification of the isolated microorganisms is carried out
based on a study of their morphological and biochemical properties.
Determination of microbial sensitivity to antibiotics can be done by several methods: agar diffusion
method using paper disks by serial dilution in broth or agar with the E-test and the automated program.
Biology of asporogenous anaerobes (in particular, the rapid death when exposed to oxygen and high
nutrient requirements) determines the special methods of their selection at all stages of the bacteriological
diagnosis, which are fundamentally different from traditional used when working with aerobic and
facultative anaerobic microorganisms. Framework for the diagnosis of these bacteria are strict anaerobic
techniques technology, as observed by a fence from the date of pathological material to identify pure
cultures. As you know, nonsporogenous anaerobes are the dominant part of the normal human microflora,
and therefore the chances of contamination of the pathological material, and hence obtaining false
positive results. With this in mind, using well-defined species of the material: the abscess - abscess cavity
contents, obtained by puncture, with purulent diseases of soft tissue - biopsies of tissues. The most
important condition during transport of specimens to the laboratory is the lack of contact with
atmospheric oxygen. To comply with this condition using a number of techniques. If the amount of
material is less than half the amount used when taking the syringe, the material is delivered in a syringe,
the needle tip closed with sterile rubber stopper. With a small sample volume, it is placed in special tubes
pre-filled CO2 and sealed with rubber stoppers. Dense samples of pathological material delivered to the
transport medium Carrie Blair. Blood carries oxygen-free transportation in special environments.
For the cultivation of anaerobes use mikroanaerobic apparatus , which is one of the most reliable and
easy-to-use devices. Anaerobic conditions are created in them, or as a result of chemical processes in gasgenerators, or by pumping air out of them and filling the oxygen-free gas mixtures. Full bakteriologic
~ 16 ~
study on isolation and identification of anaerobes nonsporogenous takes 5-7 days to 2 weeks. As a rapid
diagnosis of anaerobic nonporogenous use two methods: 1) microscopy of the native material, stained by
Gram stain, and 2) the study of pathological material to UV light.
The treatment of purulent wounds and acute purulent surgical diseases.
Basic principles of active surgical treatment of purulent wounds and acute purulent surgical
diseases
Treatment of extensive wounds festering, purulent surgical diseases is carried out according to the
principle of active surgical treatment. The essence of this method - as soon as possible to close the wound
and get good functional results. The principles of active surgical treatment of purulent wounds:
1. Surgical treatment of purulent wounds or purulent focus.
2.Drenirovanie wound perforated vinyl chloride drainage and prolonged irrigation with antiseptics in the
postoperative period.
Possible early closure of the wound surface with a primary, primary delayed, early secondary sutures or
autodermoplasty. General and local antibiotic therapy.
Increase of specific and nonspecific reactivity.
The main provisions of the surgical treatment of purulent wounds are shown in Fig. 3.
The first stage of treatment - incision and drainage of purulent focus, debridement with removal of all
nonviable tissue within healthy. Inadequate debridement - a source of septic complications.
Surgical treatment of purulent wounds involves radical removal of all nonviable tissue. However, this
goal can not always be achieved due to extensive damage, the lack of clarity demarcation of nonviable
tissue, complicated surgery is inexpedient in the important anatomic structures or complex contour
wounds. In such cases, a phased treatment, ie necrectomy, which is produced at the border of dead tissue.
Necrectomy can eliminate the bulk of nonviable tissue in the wound and make a difference during the
wound healing process.
Necrectomy in its purest form - non-radical surgery and involves subsequent or local medical treatment,
or repeated surgery (landmark necrectomy) for a complete cleansing of the wound of nonviable tissue.
The following types of surgical treatment of wounds:
1. Primary surgical treatment under the primary surgical treatment of purulent wounds should be
understood first in a row in a given patient interference produced by the primary reasons. Primary
surgical treatment of wounds is carried out in "fresh" (without signs of inflammation) injury in the
first hours after the occurrence, based on the advance of infection, and ends with sutures.
2. Secondary surgical treatment means intervention in the conductivity of the secondary readings, ie, at
the secondary changes in the wound (eg, recurrent purulent process, the development of streaks) or
before closing the wound with stitches or autodermoplasty. Secondary surgical wound treatment is
carried out if, after the primary surgical treatment of the wound develops an inflammatory process
with the formation of purulent discharge and secondary necrosis.
3. Delayed surgical wound treatment is carried out in cases where the operation is forthcoming after a
certain preparation for surgery the patient (for example, to rehabilitation wounds with antiseptics for
2 - 5 days). Often these operations are aimed at closing the wound surface.
Distinguish between full and partial treatment of purulent wounds or purulent focus. Complete
debridement of purulent wound excision includes it within healthy tissue. In cases where the anatomical
conditions and the extent of the inflammatory process did not allow for treatment of purulent wounds in
full, suggests partial surgical treatment, in which the limited disclosure of streaks, drainage, and only
partial removal of necrotic tissue.
~ 17 ~
The main provisions of the surgical treatment of purulent wounds
I. Surgical treatment of purulent wounds
II. Additional methods of treatment of a wound
• Treatment of purulent wounds pulsating stream of antiseptic;
• Vacuum treatment of purulent wounds;
• Treatment of purulent wounds of laser beams;
• Treatment of purulent wounds with ultrasound;
• Cryosurgery of purulent wounds
III. Drainage of purulent wounds
Suturing and systems for
continuous flow irrigation
I. Antibacterial therapy
II. Prevention of dysbiosis
III. Prevention of fungal infection
IV.Detoxification therapy
V. Immunocorrection
Filling of the wound swabs
with appropriate medication
phase of wound healing
Treatment in a
controlled
abacterial
environment
Reconstru
ctive
plastic
surgery
Methods of drainage of purulent wounds
An important step is the surgical drainage of the wound. It allows you to quickly achieve the purification
of purulent wounds, to arrest the inflammatory process, providing a flow of fluid and the continuation of
effective antimicrobial therapy.
Drainage - a device or a device designed to remove liquids or gases from the wounds, both natural and
pathological body cavities. The probe can also be attributed to a variety of drainage, especially when it is
used for the evacuation of the gastrointestinal tract.
Types of drains
A). Private drains - tubes that connect the body cavity with a pressurized tank.
1) Postural drainage provides a constant flow of fluid under the influence of gravity ¬ eat into the tank,
located below the drained cavity.
2) Siphon drainage works on the principle of communicating vessels. The end of the drainage tube is
placed in a sealed container of water drained below the cavity: thus prevent the backflow of air into the
body and streamed liquid. These systems are usually used for drainage of pleural cavity (drainage
Byulau).
3) Aspiration drainage. Creating a negative pressure in the receiver-(active drainage) can evacuate a
larger volume of fluid from the cavity and to eliminate voids and ensure a better matching of surfaces of
fabrics.
B). Open drains. Their application is accompanied by a high risk area drained by the lack of integrity.
This is the oldest and simplest form of drainage is still widely used in many clinics.
~ 18 ~
In). Double lumen drainages. In one channel is fed air or washing liquid, otherwise there is an active
aspiration. When the air supply is used retentive micro filter. This type of drain used for the evacuation
of specific environments (eg, detritus from the abscess cavity) or prolonged washing difficult
pathological cavities (eg, deep abscesses of the abdominal cavity).
Drainage materials must meet the following requirements: they must not have a significant mechanical
irritation to the tissue to be biologically intact, as long as possible to maintain the functional (drainage) of
the property.
As the drainage materials used vinyl chloride,
siliconized, rubber tubes. Drainage tubes may be
single or Double lumen may use tubes from single
systems for blood transfusion .. On the part of the
drainage tube to be aligned in the cavity, causing
Fig.4 Drainage of the wound with tube
multiple side holes for better drainage of exudate (Fig. 4).
The process of drainage may be passive, where the removal
of the exudate is due to natural drainage, and active through the creation of special conditions.
For the active drainage include aspiration, aspirationflushing, the flow-washable.
Fig.5 Vacuum drainage of the
wound
Aspiration (vacuum) drainage used in suture closed wounds. For this purpose a special device in the form
of an elastic reservoir-type bellows, rubber bulb or apparatus for vacuum aspiration type of OP-1 (Figure
5).
Optimum conditions for a vacuum aspiration system in the range of 80 - 120 mm of water. of Art. The
disadvantage of other systems, providing vacuum drainage of purulent cavity, is an uncontrolled level of
dilution, since depression can have a damaging effect on the tissue, causing a vacuum flushing tissues.
Aspiration-flushing drainage involves the use of two drains: one for the introduction of a purulent cavity
antiseptic solutions, and another - for aspiration of the wash liquid and exudate. This type of drainage
requires an airtight system, which is achieved by closing the cavity by suturing the wound. Lavage and
drainage can be fractional.
Flow-flushing drainage. The method is based on continuous prolonged washing purulent cavity with an
antiseptic solution. For this purpose, the cavity drained by two drainage tubes, which hold the top and
bottom points of the purulent cavity. Through the top of the drainage tube is constantly fed antibiotics
that pass through the cavity, carrying fluid, microbial flora. Exudate was removed by drainage, which
~ 19 ~
they brought to the lower pole of the purulent
cavity. For this type of drainage cavity should be
closed by sutures (Fig. 6).
Fig.6 Flow wash drainage
For the drainage of deep-seated abscesses, such as
appendicular between intestinal abscess,
previously used so-called cigar drainage. It
consists of a portion of a rubber surgical glove,
which has cut off the fingers and palm of left it in
the form of a tube, which is used as a cover for a
gauze pad. In this case administered 1 to 2 gauze
and the resulting drain is introduced into the cavity
of the abscess, but next to the cigarette drain or
through it injected into the cavity of the same
vinyl chloride or rubber tube for the introduction
of antibiotics. Drainage is used in cases where you
need to create a wide drainage channel. Its
advantage is that the rubber sheath drainage does
not adhere to tissues and can be easily removed
when no longer a need for drainage, and,
moreover, does not remove the rubber membrane
can be replaced by gauze pads as needed, ie when
they lost their drainage properties.
Use as a stand-alone drainage gauze impractical because quite quickly, in less than a day, gauze loses its
drainage properties and turns into a traffic jam that violates the outflow of fluid. Gauze is used as
haemostatics in cases where there is an increased bleeding tissue. When the swab loses its hemostatic
function, it is removed.
To improve the drainage of wounds (Izmailov S.G, Izmailov GA, Podushkino I. B, V.I. Loginov, 2003)
used a combined drainage system consisting of two tightly interconnected hollow parts (Fig. 7). Drainage
has a simple structure in the form of an elastic, soft, flexible porous cylindrical body.
Corrugated is a major part of it is in the cavity of the wound and performs the basic function, which
carries the drainage device. It is made of lavsan material (you can use the defective corrugated synthetic
vascular prostheses). Of the modern means of drainage merit biologically active drains.
They are based on material with the drainage properties, such as coal canvas algipor or tube of crosslinked hydrogel. The structure of the drainage material is introduced by immobilizing these or other
drugs that increase the drainage capacity (proteolytic enzymes, antiseptics). Immobilized proteases
(trypsin, kollitin, terrilitin) gradually diffuse into the wound of the drainage material and have necrolytic
action, preparations and chlorhexidine dioxidine have a bactericidal effect. Products of enzymatic
necrolysis and exudation of purulent wound, purulent drainage cavity is actively absorbed by the
material. Such combinations of biologically active drainage materials produced by industry - daltseks
trypsin band "Wave", etc.
~ 20 ~
Fig 7. Drainage: a - in a prepared form, b - corrugated portion placed in the
cavity of the wound, and a smooth segment output from counteropening.
Suturing a wound on purulent
1. Delayed primary suture is used for the first 5-6 days after surgical treatment, until the wound
granulation.
With delayed primary sutures the two surfaces of granulation tissue are reduced in direct contact. This is
the safest way to treat polluted and dirty and infected traumatic wounds with large tissue defects and a
high risk of sepsis. Need to free the wound of devitalized tissue, rinse with antiseptic and keep it open.
Healing wounds in the open state is gradually acquiring a sufficient resistance to infection, which allows
her to take in without further complications. Period of open wound is characterized by the development
of capillary knots.
Technically, for suturing should respect the basic principle that the wound can not be left closed cavities
and pockets adaptation, and the edges of the walls of the wound should be maximum. In the festering
wound is not desirable to leave ligatures of nonabsorbable material - silk, Dacron, etc.
2. Early secondary suture is placed upon the wound covered with granulation with movable edges to the
development of scar tissue in it. Early secondary suture imposed within 2 weeks after surgical treatment.
3. Late secondary suture is placed upon the granulating wound, which has developed scar tissue. Wound
closure is possible in these cases only after prior excision of scar tissue. Wound closure is performed 3-4
weeks after injury and later.
Indications for suturing a wound or purulent on the wound after the opening of a purulent focus in the
soft tissues are:
1. Complete purification of purulent wounds of necrotic and non-life-capable fabrics, achieved surgical
treatment of suppurative focus or proteolytic enzymes.
2. The absence of marked inflammatory changes in skin and soft tissue around the wound.
3. Possibility of an adequate comparison of the wound edges without tension over them.
The condition for sutures in purulent wound is to ensure sufficient drainage of wound, which is achieved
by active drainage and rational antibiotic therapy.
Contraindications to the stitches on a wound purulent are: the impossibility of complete surgical
treatment of purulent wounds and in her presence of necrosis, the presence of sharp inflammatory
changes of the skin and surrounding soft tissues, the inability to adapt the edges and sides of the wound
without excessive tension.
Contraindications to the stitches on a wound purulent are: the impossibility of complete surgical
treatment of purulent wounds and in her presence of necrosis, the presence of sharp inflammatory
changes of the skin and surrounding soft tissues, the inability to adapt the edges and sides of the wound
without excessive tension.
Superimposed on the normal wound suture anchor, conducted through all layers of the wound. Good
contact of the walls and edges of the wound provides a seam-Donati Parin (Fig. 8).
~ 21 ~
b
a
a
Fig. 8 Donati suture - (a, b).
In some cases, when the expected long-term retention of the wound edges by sutures, and there is danger
of the eruption of stitches and wound dehiscence, Gostischevym V.K, 1972 developed a method of
applying secondary-provisory joints (Fig. 10).
a
b
c
Fig. 10. Secondary provisionally seams (a, b, c).
Clinical symptoms of wound cleansing and its willingness to close are:
1. The absence of inflammatory changes in the wound and surrounding tissues;
2. The absence of necrosis and nonviable tissue at the surface and deep layers of the wound;
3. A small amount of fluid (serous type);
4. The formation of fine granulations on the entire surface of the wound (not swollen, bright red).
5. Severe marginal epithelization and (or insula epithelialization).
Close extensive wound surface seams are often not possible. The application allows you to close any
autodermoplasts wound surface in a short time.
If the granulating wound has equal edges and walls of her good contact with each other, deep in their
pockets and no cavities, we can use to bring together the edges with strips of sticky plaster (Fig. 11).
Extensive wound surface and can be closed by dosed tissue stretching. To close the wound in this way
requires the mobilization of its edges, imposing U-shaped sutures. Gradual stretching of joints (avoid
skin ischemia) leads to the gradual closure of the wound.
To restore the integrity of the skin are used localplastic operations, stages in the supply of plastic flap
pedicle and free skin grafts. Localplastic operation permit, using the plastic properties of the skin, move
or close flaps cutted quite extensive wounds. This type of plastic is valid for defects hands, feet, neck and
joint contractures.
~ 22 ~
a
b
Fig. 11. Convergence of the wound edges with strips of adhesive plaster (a, b).
Of local plastic surgery is most commonly used normal approximation of the mobilized skin edges of the
defect, with or without excision of the pre-diseased tissue.
The principles of intensive therapy of purulent-septic diseases
1. Intensive therapy begins immediately on admission to hospital and the patient is carried out in full.
2. Intensive therapy should be coupled with an urgent examination of the patient, but as becoming the
diagnosis of symptomatic total more directional, the pathogenesis.
3. Intensive therapy should be carried out simultaneously in three directions - the impact on the patient's
body, the impact on the organism (antibiotic therapy), the impact on the source of infection.
4. Microbiological surveillance:
- Collection of material (throat swabs, blood, pus, etc.), 2 times per week;
- Rapid analysis, bacterioscopy screening activity of antibiotics.
- Selection of pure culture, identification of microorganisms, antibiotic-otikochuvstvitelnost strains.
5. Empirical antibiotic therapy.
The indications for transfusion therapy in patients with purulent-inflammatory diseases are determined
by intoxication of the organism, metabolic disorders, especially protein, and electrolyte and water
balance, the nature and extent volemicheskih violations, the state of immunological reactivity.
Disintoxication therapy aimed at reducing the absorption of toxins from the lesion, dilution, binding and
elimination of toxins from the bloodstream.
The principles of detoxification therapy.
1. Reduced absorption of toxins from the site of infection:
a) removal of the source or the wide opening, necrectomy, drainage, active aspiration;
b) continuous irrigation with antiseptic solutions;
c) hyperosmotic bandages;
d) antibiotic therapy.
2. Breeding toxins:
a) the introduction of substitutes detoxifying action (protein hydrolysates, polyionic, colloidal solutions
in the total mass of up to 4 - 5 liters per day)
3. Elimination of toxins:
a) forced diuresis after gipervolemicheskoy hemodilution (osmotic and salureticheskie agents - mannitol,
etc.);
b) peritoneal dialysis;
c) hemodialysis;
d) plasmapheresis.
4. The destruction of toxins:
a) oxygen therapy, hyperbaric oxygen therapy;
~ 23 ~
b) Blood Substitutes transfusion;
c) the stimulation of redox processes.
5. The adsorption of toxins:
a) transfusions of plasma, protein hydrolysates, detoxification of drugs act;
b) the hemo-, plasma-, and limfosorbtion;
c) the B vitamins
Antimicrobial chemotherapy of wound infection
The most crucial point in antibiotic therapy is the choice of starting antibiotic therapy, as the first use of
antibiotics has an effect on the development of all stages of the infection process, in which a dynamic
change of the dominant microbiota. With antibiotic treatment can be observed two trends: inadequate or
excessive dose of antibiotics. In the first case, there is persistence and the emergence of mikropatogens
tertiary centers of "opportunistic" infections, the second - the development of severe dysbiosis.
At the initial stage of the etiological factor is the random microbial contamination through the "gates of
infection." The third - seventh day of the overwhelming dominance of endogenous and transferred to the
nosocomial flora.
Principles of rational antibiotic therapy
The term "antimicrobial chemotherapy" means the use of chemicals designated for infectious diseases
and their pathogens causing death without damaging the host tissue.
The tactics of rational antibiotic therapy include:
The correct choice of drug resistance in the light of identified or suspected (before the results of
bacteriological examination) pathogens.
Appointment of optimal doses to achieve therapeutic concentrations in the source of infection.
The best way and the multiplicity of drug administration.
Adequacy of duration of treatment;
Changing the antibiotic and the appointment of their allowable combinations, increasing the therapeutic
effect.
The main factors determining the effectiveness of antibiotic wound infection are shown in (Fig. 18).
Main factors determining the efficiency of wound infection Antibiotic
The choice of antibiotic
including :
- Antibioticograms;
- A dedicated agent
Dosage and
administration method in
view:
- Peculiarities of
pharmacokinetics;
- Course of disease
The choice of
antibiotic:
- The most active;
- The least toxic
Cancel or timely change
in view of the drug:
- Toxicity;
- The frequency of
adverse reactions
A timely fashion:
- Repetition rate up
to stable therapeutic
effect;
- The use of drug
combinations to
enhance the
antibacterial effect
Fig. 18. Factors determining the effectiveness of antibiotic wound infection
~ 24 ~
More than half of all currently used antibiotics in the world are betalaktams (penicillins, cephalosporins,
carbapenems). Many pathogens are resistant to long-term used in the practice of antibiotics (penicillin,
streptomycin, ampicillin, amoxicillin, cefazolin, etc.).
The most important mechanism for the formation of beta-lactam antibiotic resistance is the production of
bacteria betalaktamaz - it involves about 80% of cases of resistance as Gram-positive and gram-negative
microorganisms, which is one of the main reasons for the declining effectiveness of many traditional for
each hospital antibiotics.
Cephalosporins.
Cephalosporins - is bactericidal agents acting on Gram-positive and Gram-negative bacteria that inhibit
the synthesis of bacterial cell wall.
Cephalosporin antibiotics are divided into four generations.
1st generation cephalosporins (cefazolin, cephalothin) are effective for gram-positive cocci - S. aureus, S.
pyogenes, S. pneumoniae (with the exception of enterococci, and coagulase coagulasepositive
staphylococci resistant to methicillin). In most cases, a generation cephalosporins are active against
P. mirabilis, K. pneumoniae, E. coli.
2nd generation cephalosporins (cefmetane, cefotetane, cefamandole, cefuroxime) have an increased
activity against gram-negative bacteria and a broader spectrum of action compared to a generation of
drugs. Preparations are stable to betalaktamazam produced by P. mirabilis, E. Coli. cefmetazole,
cefotetane, cefamandole, cefuroxime have some activity against anaerobic bacteria, including B. fragilis.
3rd generation cephalosporins (cefoperazone, ceftriaxone, ceftazidime) are now considered the core
group for the treatment of severe infections caused by microorganisms of the family Enterobacteriaceae,
Staphylococcus and Streptococcus, Pseudomonas aeruginosa.
4th generation cephalosporins (tsefpirom, cefepime) are characterized by high activity against Gramnegative bacteria, including P. aeruginosa, Staphylococcus methicillin-sensitive and moderately active
against E. faecalis.
Aminoglycosides.
To include aminoglycosides - kanamycin monomitsin, neomycin, gentamicin, sizomitsin, tobramycin,
amikacin, netilmicin.
Among the semi-synthetic aminoglycoside antibiotic amikacin the most widely used and netilmicin. New
aminoglycosides are more rapid than the beta-lactam antibiotics, bactericidal action.
Aminoglycosides are used:
In the empirical treatment of Pseudomonas infections.
In the ICU during the combination therapy of complicated forms of wound infections with semisynthetic
penicillins, penicillin-protected, cephalosporins, clindamycin and metronidazole with.
In the treatment of sepsis, septic endocarditis.
In the treatment of skin and soft tissues.
In the treatment of intra-abdominal infections.
In the treatment of pneumonia.
Fluoroquinolones.
Fluoroquinolones occupy one of the leading antimicrobial chemotherapeutic agents combined single
mechanism of antimicrobial action - inhibition of bacterial DNA gyrase.
Fluoroquinolones are characterized by:
High penetration of a microbial cell.
High bactericidal activity associated with a higher sensitivity of the target enzymes, and high
intracellular concentrations.
Persistence of antimicrobial effect in subbacteriostatic concentrations.
~ 25 ~
Long post antibiotic effect when vital activity of microorganisms is not restored for some time after
removal of the drug from the site of infection and suppressing induction endoenzymes, exotoxins,
reduced adhesion and virulence of microorganisms.
High concentration of drug in the cells of the phagocytic system (polinukleary, macrophages).
Slow development of resistance.
Depending on the number of fluorine atoms emit:
Monofluorinated (ciprofloxacin, ofloxacin, enoksatsin, pefloxacin).
Difluorinated (lomefloksatsin).
ThreeFluorinated (fleur ofloxacin) connection.
Of the four most widely used in the clinic of fluoroquinolones (ofloxacin, ciprofloxacin, pefloxacin,
lomefloksatsin) the greatest activity against gram-negative bacteria possess ciprofloxacin and ofloxacin.
The advantage is ofloksatsilline effect on staphylococci and pneumococci.
2nd generation fluoroquinolones (sparfloxacin, grepafloksatsin, trovafloksatsin, moxifloxacin,
klinafloksatsin, gatifloxacin, levofloxacin, flerofloksatsin) differ from the traditional first higher activity
against pneumococci, staphylococci methicillin (trovafloksatsin, moxifloxacin, klinafloksatsin), as well
as some anaerobes - Clostridium spp. , Bacteroides spp. (trovafloksatsin, moxifloxacin).
Glycopeptides.
The group is represented by two agents glycopeptides - vancomycin and teicoplanin.
Antimicrobial activity of glycopeptides applies only to Gram-positive organisms (staphylococci,
including strains oxacillin-resistant). Drugs act on enterococci, including E. faecium. In the spectrum of
activity of vancomycin and teicoplanin includes various streptococci, anaerobic cocci, clostridia,
including C. difficille.
Empiric antibiotic therapy and causal acute purulent diseases of soft tissues is presented in (Table 12).
Antibacterials for the treatment of anaerobic infections.
Metronidazole is characterized by a rapid bactericidal effect. The disadvantage of this drug is its narrow
spectrum of activity - only anaerobic microbial groups that require additional appointment time of one,
two and sometimes three drugs are active against aerobic bacteria.
Metronidazole is used in combination with antibacterial drugs of different groups. Metronidazole is well
compatible with cephalosporins, aminoglycosides, fluoroquinolones.
Clindamycin - an antibiotic from the group of lincosamides. Clindamycin is active in the identification of
gram-positive associations in the wound aerobic and anaerobic microorganisms. The effectiveness of
clindamycin is increased in combination with the drug dioksidina, or with aminoglycosides 3rd
generation (netilmicin, amikacin, tobramycin), due to the high activity of these agents against gramnegative microorganisms.
Carbapenems.
Imipenem, meropenem have a broad spectrum of antimicrobial activity, and covering aerobic and
anaerobic microorganisms.
A wide range of antimicrobial activity, low toxicity, low-level resistance of hospital strains can be
considered drugs of choice carbapenems for empirical treatment of complicated forms of wound infection
in monotherapy sepsis, severe abdominal and wound infections.
Antifungal drugs.
Patients with wound infection receiving prolonged antibiotic treatment by several drugs are a group of
high risk of mycotic infections.
T A B L E 12
~ 26 ~
Empiric antibiotic therapy and causal patients with wound infection
Funds in 1st line
Disease
Acute purulent
diseases of soft
tissue (mastitis,
boils, carbuncles,
festering
atheroma,
gidradenity,
panaritiums and
others).
Main
Alternative
Cefazolin iv / or / im
1g.h 4times day
Gentamicin iv/ or
/im x 80 mg twice
daily
Doxycycline 100
mg by mouth x 1
time per day
Metronidazole / 100
mg twice a day x3
Nystatin vnutr1g 3
times a day
Topical: Ointment
on polyethylene
glycol (PEG)-based:
0.5% ointment
hinifurila,
levomekol, levosin,
solutions: 0.01% pp
miramistin
Fuzidin inside
h3times 0.5 g per
day
Clindamycin iv 600
mg 3 times a day
Nizoral inside 1t,
x2 times a day
Topical: Ointment
on the basis of PEG:
10% ointment
mafenidaatsetata,
dioksikol, nitatsid 1% iodine
Solutions: 1% 0.1%
dioxidine furagin
soluble
Funds in 2nd line
Reserve funds
Amoxicillin
clavulanic acid iv
to 1.2 x 3 times a
day
Ampicillin
sulbactam iv, im
1.5 x 4 times a day
Cefotaxime iv, im
2r x 4 times a day
Topical: Ointment:
Metildi-oksilin,
streptonitol.
Ciprofloxacin iv
the 200 mg x 2
times a day (after
blowing a
transition to a
tablet form).
Ofloxacin iv 400
mg x 2 times per
day. (after
blowing a
transition to a
tablet form).
Amikacin iv / im
500 mg 3 times a
day.
Netilmicin iv /
im 200 mg x 2
times per day.
Piperacillin
tazobactam iv
4.5 g 3 times a
day
Ceftriaxone iv /
im 1g x 2
T A B L E 13
~ 27 ~
Empiric antibiotic therapy and causal patients with wound infection
Funds in 1st line
Disease
Postoperative
purulent wounds
of soft tissues
(cellulitis
anterior
abdominal wall
after
appendectomy,
laparotomy,
bowel surgery,
after plastic
reconstructive
surgery, etc.
Main
Alternative
Cefotaxime iv/im
2r x4 times a day.
Amikacin iv 500
mg 3 times a day.
Fuzidin 0.5gh
3raza a day inside.
Carbenicillin iv x4
5g twice a day.
Metronidazole
iv 100mg x3 times
a day.
Nystatin inside 1d
x3 times a day.
Topical: Ointment
for polyethyleneglycol (PEG)
basis: levomekol,
levosin,
Solutions:
iodophors, 0.01%
Miramistin.
Amoxicillin/
clavulanic acid / g
to 1.2 x 3 times a
day.
Ampicillin/
sulbactam iv/im
1.5 x 4s per day.
Ceftazidime iv / h
x 1g twice daily.
Clindamyc iv/im
600 mg 3 times a
day.
Nizoral inside of
1t * 2 times a day.
Topical: Ointment
on the basis of
PEG: 5%
dioksidinovaya,
dioksikol, nitatsid,
1%
yodopironovaya.
Solutions: 1%
dioxidine
~ 28 ~
Funds in 2nd line
Reserve funds
Ciprofloxacin iv
the 200 mg x 2
times a day (if
necessary - the
transition to a
tablet form)
Ofloxacin iv 400
mg x 2 times a
day (if necessary
- the transition to
a tablet form)
Ceftriaxone in /
1g x 2 times a
day
Cefepime w / 1 g
x 2 times a day
Cefpirom iv 1g x
2 times a day.
Vancomycin iv
x in 1 g 2 times
a day
Teicoplanin iv
400 mg 1 time
a day
Netilmicin
iv/im 200 mg x
2 times a day
Piperacillin /
tazobactam iv
4.5 g 3 times a
day
Imipenem /
cilastatin iv 1g
x 2 times a day
Meropenem iv
1g 3 times a
day
Fluconazole iv
or inside a 200
mg x 2 times a
day
Mortality rates for invasive mycoses caused by, for example, fungi of the genus Candida, reaches 85%.
Candidiasis, as an endogenous infection can occur clinic mushrooms affection of the brain, liver, spleen,
kidneys, heart, lungs, and joints. For the treatment of a doctor's arsenal has only five effective antifungal
drugs: amphotericin B, fluconazole, itraconazole, and liposomal amphotericin flyutsitozin B.
The choice of antibiotic should be justified not only the data of bacteriological research, and clinical
manifestations of the severity of intoxication, the severity of multiple organ failure, the vastness of the
purulent process.
With a limited suppurative process, the absence of clinical and laboratory signs of intoxication should be
preferred oral dosage forms. In complicated wound infection involving internal organs antibiotic therapy
should be based only on injectable forms. In these cases, all antibiotics should be administered only
through catheter into the central vein or an artery in the presence of purulent process in the lower
extremities.
To enhance the antimicrobial activity in the treatment of generalized forms of wound infection or
identification of the association of several microorganisms, when one antibiotic does not cover the
spectrum of microorganisms, shows the assignment of combination antimicrobial therapy required taking
into account their synergy. As a rule, appointed by the bactericidal (penicillins, cephalosporins,
aminoglycosides, rifampin, polymyxins) and bactericidal or bacteriostatic (macrolides, tetracyclines,
lincosamides) with bacteriostatic agents.
Combined antibiotic therapy remains the drug of choice dioxidine.
Dioksidin active infections caused by Gram-negative and gram-positive bacteria (including a group of
opportunistic pathogens), as well as pathogenic anaerobes. For intravenous infusion using 0.5% solution
diluted in 5% glucose solution or isotonic sodium chloride solution to a concentration of 0.3%. Daily dose
(600 - 700 mg) was administered in two - three steps. In severe septic states in the introduction, each
using 150 ml 0.3% solution dioksidina, 1% solution dioksidina used for washing wounds.
The route of administration of antibiotic.
When the local nature of purulent infection in order to relieve an acute suppurative process enough to use
one antibiotic with mandatory local treatment of purulent wounds with ointment under the bandage on the
basis of polyethylene glycol with a broad spectrum of antimicrobial activity, or modern iodophors,
dioksidina that increase the antimicrobial effects of drugs designated for general antibiotic therapy.
With extensive purulent foci of sepsis is necessary to increase doses of antibiotics to the maximum. It is
advisable to use a combination of 2.3 drugs. Drugs should be administered through catheters installed in
the central veins, which allows the treatment of generalized forms to create and maintain long-term at the
right level of concentration of the antibiotic, not only in the lesion focus, but all over the patient.
With the localization of a purulent focus on the lower extremities effectively intra-arterial injection of
drugs into the lower epigastric artery infusion method using clock perfuzorov.
Continuous intraarterial infusion allows you to create and maintain a sufficiently high concentration of
drug in the tissue while leaving the concentration of antibiotics in the general blood stream at a lower
level. This enhances the effectiveness of antibiotic therapy and reduces the possibility of a general toxic
effects of antibiotics.
Duration of antibiotic therapy.
When the local suppurative process enough antibiotics for 3 - 5 days. Longer therapy is conducted in
groups of patients with acute purulent diseases of soft tissues, with the generalization of the infectious
process. The criterion necessary to continue therapy or drug withdrawal should be the data of
bacteriological monitoring, as well as the dynamics of clinical indicators.
The main criteria for discontinuation are the disappearance of pathogenic microorganisms from
suppurative focus or reducing the number of bacteria in 1 g of tissue injury, a distinct positive dynamics
of clinical and laboratory parameters of wound healing, normalization of temperature, improving the
overall condition of the patient.
Early withdrawal of antibiotic therapy to achieve a stable clinical effect may lead to a relapse or a
prolonged course of the disease and significantly complicate further treatment.
~ 29 ~
complications of antibiotic therapy
1. Allergic reactions - a pathological condition caused by sensitization of the organism with antibiotics.
Their character is varied:
a) The reaction of allergic-type (shock, serum sickness);
b) skin reactions;
c) the effect of antibiotics organotropnoe by allergization.
Anaphylaxis manifested loss of consciousness, a sharp drop in blood pressure, the disappearance of the
pulse. Conducted in anaphylactic shock resuscitation. Sometimes there collaptoid state.
Serum disease - often manifested in the form of true allergic reactions (urticaria), as one of the
symptoms. In addition, these patients expressed the common symptoms: fever, swollen lymph nodes,
splenomegaly, joint pain. Skin reactions: urticaria, erythematous, bullous rash. Angioneurotic
angioneurotic edema and inflammatory-necrotic lesions (Arthus phenomenon) occur less frequently.
II. The toxic effect of antibiotics is manifested in several forms:
1. The neurotoxic effects (effects on the CNS, polyneuritis, neuromuscular block).
2. Toxic effects on internal organs and blood system.
3. Teratogenic effects of antibiotics.
III. Adverse reactions caused by the direct pharmacodynamic action of antibiotics: 1. Toxic shock
2. Dysbacterioses 3. Superinfection.
For errors of antibiotics include: 1) widely used without evidence, and 2) the use of low or unjustifiably
high doses without evidence, and 3) use of antibiotics without the sensitivity of the microflora, and 4)
failure to comply with the rules of sound combination;
5) lack of knowledge of contraindications, and 6) use of antibiotics without prior trial on the body's
sensitivity to a particular antibiotic.
THE SPECIFIC ISSUE OF SURGICAL INFECTION.
Surgical infection of soft tissue
Surgical infections are the leading soft-tissue pathology in the primary structure of the uptake of surgical
patients in the outpatient management, and in the hospital - post-operative nosocomial infections of soft
tissues accounted for 40% of all nosocomial infections.
However, the classification of infections in surgery not fully edited. Its division into purulent, putrid,
anaerobic (clostridial and non-clostridial) and specific does not meet modern requirements (S.A.
Shlyapnikov, 2003).
It is therefore advisable to introduce students and young surgeons to the classification proposed by D. N.
Ahzenholz in 1991, which is widely used by foreign experts. We are talking about levels cheryreh soft
tissue surgical infections.
Level I - the affection of the own skin.
Level II - the affection of the subcutaneous tissue.
Level III - damage to the superficial fascia.
Level IV - the affection of the muscles and deep fascial structures.
The affection of the skin
Many of the special concept that refers to infection of the skin - impetigo, ecthyma, and others are
discussed in the national medical literature in the course of dermatology. In this regard, we consider the
following diseases at the I level, boil and erysipelas.
~ 30 ~
Furuncle (Fig. 19) - an acute purulent necrotic
inflammation of the follicle and surrounding tissues.
Called the golden bowl (Staphylococcus aureus), rarely
white (Staphylococcus pyogenes albus) staphylococci.
Contamination of the skin, micro predispose to disease.
Significant role in the occurrence of boils and boils the
development has weakened body defenses caused by
debilitating chronic disease, vitamin deficiency, diabetes,
etc.
Boils do not develop on the skin, hairless (palms and
palmar surface of fingers, soles). Most often they are
observed in skin areas exposed to pollution (forearm, wrist
rear) and friction (back of the neck, lower back, gluteal
femoral region).
Infection is introduced into the body through broken skin (cracks, scratches), and therefore of particular
importance in the prevention of disease assumes compliance with hygiene standards at home and at work.
The clinical picture. Around the hair is formed by a small pustule with a slight inflammatory infiltrate in
the form of nodules. During this period the patient feels a slight itching and tingling. By the end of the 1-2
days produced inflammatory infiltrate, which acts conically above the skin. The skin over the infiltration
of red and becomes painful when touched. At the top of the infiltrate has been a slight accumulation of
pus with a black dot (necrosis) in the center. Later pustule dries and breaks often, and the 3-7th day of
purulent infiltration and necrotic tissue is melted in the form of a rod with the remains of hair stand out
from the pus. The resulting purulent wound is cleaned, filled with granulation tissue and healing.
At the site of inflammation is a small whitish, somewhat sunken scar.
Multiple lesions boils called furunculosis. The appearance of many boils in a limited area of the body is
called the local furunculosis. Sometimes the occurrence of boils in the form of multiple eruptions
continued with little remission for several years. This process is called chronic, recurrent furunculosis.
Furuncle usually does not cause significant changes in the general condition of the patient, but in some
locales ulcer patient's condition may be severe.
Severe clinical course observed in boils face (upper lip, nasolabial fold, nose and suborbital region).
Significant development of venous and lymphatic network on the face contributes to the rapid spread of
infection. Progressive vein thrombophlebitis can move on to the venous sinuses anastomoses of the dura
mater, which leads to their thrombosis, threatening severe complications - a purulent basal meningitis.
Quickly there is swelling of the face, tight painful palpable veins, rapidly deteriorating general condition
of the patient's body temperature reaches a high level (40 - 41 ° C), there are severe neck stiffness,
impaired vision. Progressive venous thrombosis and sepsis with boils were often result from attempts to
~ 31 ~
squeeze out the contents of the boil, remove
(cut) it while shaving, massage. The
prognosis of these complications are very
serious. Lethality varies, according to
different authors, from 9 to 65%.
Furuncle may be complicated by
lymphangitis, regional lymphadenitis.
Especially dangerous is progressing acute
thrombophlebitis and sepsis. Acute
thrombophlebitis develops in boils, which
erythematous haemorrhagic form
are located near the large saphenous vein,
and sepsis is more common in boils, which
are located in the facial area. Abscess may also develop the surrounding tissue. If such an abscess appears
near the joint (articular abscess), the infection can pass to him and give rise to purulent arthritis.
Forecast. In uncomplicated furunculosis prognosis is quite favorable. Boils and abrasions should be
differentiated from gidradenitom, anthrax, pseudofurunculosis infants and some infectious granulomas
(tuberculosis, actinomycosis, syphilis).
Treatment.
When boils and abrasions use local and general treatment.
Local treatment:
1) careful toilet of skin inflammation around the hearth - 70% rubbing alcohol, 2% salicylic alcohol;
2) lubrication of 1-3% alcoholic solution of methylene blue, brilliant green, and others;
3) on the scalp and neck hairs around infiltrate carefully cut off;
4) early in the process has a positive effect sometimes boil tincture of iodine lubrication;
5) which revealed the presence and empty boil ointment
applied to various antiseptics;
6) In the presence of necrotic mass necessary to create
conditions that are aimed at accelerating a discharge of
purulent-necrotic core. Used for this treatment ointment to
soften the skin over the necrotic core. In the protracted
process of applying nadsechenie skin in the area of the rod
with a sharp scalpel, removing the necrotic core. It is
recommended to provide peace of the affected extremity
furuncles.
It is strictly forbidden squeezing the contents boil and
massage in the inflammatory focus.
For pain relief apply dry heat (heating pad, solux), as well as
UHF.
With the localization of boils on body, neck and limbs must
be applied labels, protecting the skin in the area of
inflammation from mechanical impact.
The indications for hospitalization is the localization process
in the face of the risk of complications.
gangrenous necrotizing form
Necessary as soon as possible to begin vigorous treatment
with antibiotics. If a patient with boils, abrasions or heat, it is
prescribed strict bed rest and antibiotics in combination with sulfanilamides, detoxication therapy.
Surgery is rarely used, only the development of suppurative complications (eg, cellulitis).
In chronic furunculosis effective subcutaneous staphylococcal vaccine, immunization with staphylococcal
toxoid y-globulin.
~ 32 ~
Erysipelas. Erysipelas inflammation is an infectious disease characterized by acute serous, rapidly
spreading inflammation of the skin, at least - the mucous membrane in which the zone of inflammation
sharply demarcated from the surrounding tissue unaltered.
Classification form of erysipelas.
• erythematosus.
• erythematous-bullous.
• erythematous-hemorrhagic.
• haemorrhagic bullosa.
• bullosa necrotic.
• abscess.
• gangrenosum.
Erysipelas contagious and can lead to nosocomial diseases.
More often localized erysipelas of the face, head and lower extremities. Very rarely it affects the mucous
membranes of the lips, mouth, pharynx.
Erysipelas is caused by different types of strep, L-forms of bacteria. In the development of the disease
plays an important role local and general predisposition of the body, an allergic condition.
Pathogenic streptococci from exogenous sources (usually) falls into the skin at microtraumas or other
damage. When the endogenous source of streptococcus enters the skin lymphogenous or hematogenous
route.
Pathologic anatomy. The disease onset is characterized by the appearance of sharply hyperemic, clearly
demarcated lesions in the form of plaques. There is serous inflammation localized in the reticular layer
and along the lymphatic vessels of the subcutaneous tissue. There is a plethora of blood vessels and
lymph vessels overflow lymph containing large amounts of streptococci. In the affected area marked
desquamation and parakeratosis of the epidermis. Inflammatory exudate detach the epidermis, forming
bubbles of various sizes that contain clear, yellowish fluid, which is typical for bullous form of erysipelas.
In the exudate of bubbles may accumulate a large number of neutrophils and content becomes purulent
character. In rare cases, the exudate becomes hemorrhagic in nature (hemorrhagic erysipelas).
When suppuration of fluid in the subcutaneous tissue abscess develops, typical forms of phlegmonous
erysipelas.
In debilitated patients exudate and toxins streptococcus blood circulation, tissue trophism of the skin,
which leads to extensive necrosis and the development of necrotic (gangrenous) faces.
Pathogenesis. In the development of erysipelas note the following sequence: acute or latent infection,
endo-or exogenous factor permitting, allergic reactions, skin disorder trophism.
Primary erysipelas develops in contact with streptococci in the skin of the exo - or endogenous sources.
Streptococcus introduced through scratches, wounds, scrapes, scratches, scrapes, diaper rash of the skin.
Secondary erysipelas develops as a complication of local purulent process (furuncle, carbuncle, infected
wound, etc.). Secondary erysipelas affects the skin, directly adjacent to the purulent focus and is subjected
to infection.
The clinical picture. The disease manifests marked general and local manifestations. Violations of the
general state precede the development of local symptoms. There may be a prodromal period of malaise,
weakness, headache. Then there are terrific chills, severe headache, nausea, vomiting, tachycardia,
breathing quickens, the temperature quickly rises to 40 - 41 ° C. There is severe intoxication, which may
be accompanied by delirium. Appetite disappears, there insomnia, constipation, decreased amount of
urine, which defines the content of protein, erythrocytes, leukocytes, hyaline and granular cylinders.
In the blood - moderate normochromic anemia, leukocytosis and neutrophilia pronounced, decrease in
eosinophils. The liver and spleen in most patients is increasing.
To form erythematous erysipelas characterized by local symptoms: swelling, burning pain, heat sensation
in the affected area, hyperesthesia of the skin, the appearance of a bright red with sharp edges, serrated
edges. As the outlines of the affected area is similar to a map.
~ 33 ~
In the bullous form as a result of detachment
of the epidermis exudate formed of different
size bubbles. The contents of the bubbles,
which are contagious streptococcus, may
facilitate the transport of faces by contact.
Exudate is serous blisters, haemorrhagic and
purulent (Fig. 20). Bullous disease of
erysipelas usually lasts 1-2 weeks.
In the phlegmonous erysipelas changes on the
skin surface can be Just noticeable, but in the
subcutaneous tissue is noted seropurulent
soaking tissue accumulation of pus. The
In Fig. 20. Erythematous-bullous form of
general condition of the patient more difficult.
erysipelas
In the phlegmonous erysipelas inflammation
of the inflammatory process begins with skin
lesions. Symptoms of subcutaneous phlegmon and intramuscular fat are the same as symptoms of an
ordinary phlegmon.
In malnourished, debilitated and elderly patients, as well as the presence of hypovitaminosis and heavy
neutron crystallographic disorders bullous form of erysipelas and abscess may become necrotic.
Form of erysipelas (erythematous, bullous, abscess, etc.), correct to consider the phases of the process.
Erythematous erysipelas may form under the influence of adequate treatment in this phase to end in
recovery, and the weakness of the immune-forces or late begun and inferior treatment may develop the
following phases of the disease (bullous, abscess, necrotic).
Mug on the trunk is often wandering, migrating. When migrating inflammation may occur again in the
previously affected areas.
Erysipelas is a creeping, if it is gradually spreading over the surface of the skin. If the process consistently
affects various parts of the body, the face is called migrating.
Relapse of erysipelas leads to sclerosis of tissues, lymphatic disorder, and therefore there are swelling,
sharply breaking form and function of the organ.
Complications of erysipelas of the process:
The spread of infection from the skin of the surrounding tissue.
Metastasis of streptococcal infection, adherence of secondary infection and the development of severe
toxemia.
Purulent lesions joint capsules, tendon sheaths, joints, muscles in their tendinous part, the affection of the
veins (thrombophlebitis).
Infectious psychoses, etc.
Differential diagnosis. Differentiate from erythema should face, dermatitis, phlegmon, lymphangites,
pseudoerysipelas, cutaneous anthrax.
When lymphangites marked red bands or reddening of the skin in a grid according to the location of
lymph vessels.
If you suspect a bullous erysipelas and gangrenous forms, especially when in contact with sick animals, to
conduct a differential diagnosis of cutaneous anthrax, which is characterized by the presence of lesions in
the center section of necrotic tissue with associated vesicles at the periphery, and extensive soft tissue
edema (anthrax carbuncle) , an increase in regional lymph nodes.
Treatment. In the erythematous form of erysipelas patients admitted to a hospital infection. Patients with
other forms of erysipelas hospitalized in the surgical hospital. In the hospital provide immobilization of
the affected limb. It is desirable to isolate the patient in a private room. Necessary to conduct a
comprehensive therapy with sulfa drugs, antibiotics and ultraviolet radiation. Of antibiotics prescribed
penicillin, semisynthetic penicillins.
When ultraviolet light is used erythemic or sub erythemic dose. At first, usually determine an individual
biodose , ie , the minimal dose of ultraviolet rays, which is obtained when a weak erythema reaction in the
~ 34 ~
skin region located symmetrically affected. After this affection, erythema or bullous erysipelas irradiated
area: limbs - 4-5 biodoses, the person - 3 biodoses
In the phlegmonous erysipelas irradiation should be performed with caution as it may lead to increased
swelling and thrombosis of small vessels in the skin. When gangrenous erysipelas irradiation is
contraindicated.
Wet dressings and baths are contraindicated. In the erythematous form of erysipelas the affected area is
treated with alcohol and iodine. In the bullous form of blisters after treatment with alcohol and reveal the
bandage with chlorhexidine, cintomitsine emulsion, suspension or streptotsidis tetracycline ointment, etc.
In the phlegmonous and gangrenous forms additionally produce an autopsy collection of pus, drainage,
removal of necrotic tissue.
Prophylaxis. Activities aimed at preventing disease and infection from a patient with erysipelas, are
reduced to fighting with contact infection. The first group includes measures to prevent and timely
processing of micro traumas, abrasions received in the workplace, at home, strict personal hygiene.
Prevention of infection around the contact is determined by the strict isolation of patients and aseptic
conditions in their care.
The affection of the subcutaneous tissue
The second level of destruction are anthrax, hydradenitis, cellulitis, abscess.
Carbuncle - acute suppurative inflammation of multiple necrotic hair follicles and sebaceous glands in
the transition of the inflammatory process in subcutaneous tissue, causing her death, which applies to the
superficial fascia.
Pathogens - Staphylococcus aureus infection or staphylostrepcoccusis , rarely streptococcus.
Emerald, tends to be single. Its causes are the same and boil. It is more common in diabetic patients.
Pathologic anatomy. In the thick skin and subcutaneous tissue inflammatory infiltrate formed large size, a
few exciting hair follicles. Because of circulatory disorders form necrotic areas, merging in the future in a
common focus.
Around the necrotic area develops pus, necrotic tissue undergo partial melting and gradual rejection. Pus
through multiple holes in the skin stands out on its surface. After sloughing wound granulation tissue and
runs rough massive scar is formed. Necrotic decay and may be subject to the fascia covering the muscles
in the area of inflammatory infiltrate relatively ¬.
The clinical picture. Most often the carbuncle develops on the back of the neck, shoulder and in the
interscapular region, lower back, buttocks, at least - on the limbs.
Initially, there is little inflammatory infiltrate with superficial pustules, which are rapidly increasing.
There is tension fabric, sharp pain on palpation, arching,
tearing pain. The skin in the area of the infiltrate becomes
purple hue, tense, swollen (Fig. 21).. Thinned epidermis over
the fire breaks necrosis in several places, formed a few holes,
of which stands a thick greenish-gray pus. In the future some
holes merge, forming a large defect in the skin, through which
flows a lot of pus and necrotic tissue are rejected. The body
temperature rises to 40 ° C, there is severe toxicity (nausea and
vomiting, appetite loss, severe headache, insomnia, possible
delirium.
Complications: lymphangitis, lymphadenitis, progressive
thrombosis, sepsis, purulent meningitis.
The differential diagnosis should be performed between
conventional and anthrax carbuncle.
In Fig. 21 Carbuncle back of the
Treatment. The patient should be hospitalized in a surgical
ward. At the beginning of carbuncle (stage inflammatory
neck
~ 35 ~
infiltrate) used intramuscular injections of antibiotics
and sulfa drugs into the longer-acting, UHF-therapy.
Carbuncle on the surface imposes a dry bandage or
aseptic bandage with cintomitsine, streptomitsine
emulsion.
General activities of the patient is prescribed rest (bed
rest, immobilization of limbs, and carbuncle prohibit a
person to talk to, give liquid food). Showing
painkillers, drinking plenty of fluids.
Dissection of the infiltrate, failure of conservative
treatment for 2 - 3 days, an increase of intoxication are
the indications for surgical intervention. The operation
In Fig. 22. Carbuncle dissection and
usually performed under general anesthesia. In the
excision of necrotic tissue
presence of carbuncle operation lies in its dissection
and excision of necrotic tissue. (Fig. 22).
Two mutually perpendicular section begins with healthy skin. Cross-cut cut through the skin and necrotic
glubokole-containing tissue (adipose tissue, and sometimes fascia). The resulting patches with necrotic
tissue separated from the fascia or muscle within healthy tissue. Then each of the flaps alternately seized
with forceps and surgical scissors with pointed excised non-viable skin, subcutaneous fat. Wound
copiously washed with 3% hydrogen peroxide and antiseptic solutions, drain its surface. In a wound swab
is introduced with the hypertonic solution of sodium chloride, an antiseptic, a solution of proteolytic
enzymes. Tampons are changed daily.
When a person carbuncle appoint conservative treatment, using all of the funds, and under the
inflammatory infiltrate and locally applied antibiotics UHF therapy.
If anthrax is small, you can use it within the excision of healthy tissue, followed by drainage of the
wound and applying primary suture. In the postoperative period were active aspiration and administration
of proteolytic enzymes (better - terrilitina), antiseptics and antibiotics.
Forecast. With timely treatment of carbuncle favorable prognosis, but malnourished, debilitated patients
with severe diabetes, as well as the carbuncle shall not exclude the
possibility of a bad outcome.
Hydradenitis (Fig. 23) - an acute purulent inflammation of
apocrine sweat glands. Called staphylococcus, golden chalice
(Staphylococcus aureus).
Located in the armpit, much less - in the inguinal and perianal
areas, and women - in the nipple.
Predisposing to the development of its causes dermatitis (eczema,
diaper rash), excessive sweating, uncleanliness.
Infection enters through the ducts of glands on the lymphatic
system or through a small skin injury (bruises, scratches). In sweat
glands occurs inflammatory infiltrate with subsequent purulent
Fig.23 Hydradenitis
fusion of the surrounding tissue. Suppurative process often takes
on the character of subacute, often relapses.
The clinical picture. In the depth of subcutaneous tissue appears dense painful knot. At first, he covered
the skin intact, and then its surface becomes purplish-red, bumpy. When abscess formation infiltrate
appears fluctuation, which is formed through a small hole is allocated creamy pus. Duration of infiltration
- 10 -15 days.
Hydradenitis differentiate from tuberculosis of axillary nodes, Hodgkin's disease and lymphosarcoma.
Treatment. General treatment - antibiotic therapy, sulfonamides. With recurrent forms - specific
immunotherapy (stafiloanatoksin, stafilovaccine , autovaccine) bracing means.
~ 36 ~
Local treatment - treatment of skin lesions in ethanol, 2%
boron and 10% camphor spirit, dry heat, UHF-therapy.
Surgical treatment. When suppuration inflammatory infiltrate
produce autopsy an abscess incision along the skin folds.
With recurrent, persistent current hydrodenitis when the
inflammatory process involved in fatty subcutaneous tissue
armpit, make excision of purulent foci, together with all the
subcutaneous fat that area with the imposition of primary
suture and drainage of purulent wounds. Displaying
ultraviolet irradiation of the skin, UVIS.
An abscess. Abscess is a limited collection of pus in the tissues and organs. Localization and size of
abscesses are the most diverse. The form of the cavity is different - from simple to complex curved with
multiple pockets and blind passages. The cause of the abscess is the penetration of germs into the tissues
through abrasions, punctures, wounds, as well as therapeutic manipulations (injection, subcutaneous
injection) produced without complying with the rules of asepsis.
An abscess may develop abrasions, lymphadenitis, suppuration of the hematoma, with a total of purulent
infection (metastatic abscesses). Metastatic abscesses are located away from the primary site of infection
Feature of the abscess as a purulent process is limited
the presence of pyogenic membrane - the inner wall of the abscess, lined with granulation tissue.
Pyogenic membrane separates the necrotic process and produces exudate.
Abscesses caused by staphylococci, streptococci, at least - Pseudomonas and E. coli, etc.
By the nature of the flow abscess may be acute or chronic.
If the abscess becomes chronic, a pyogenic membrane formed two layers: the inner, facing into the cavity,
and composed of granulations, and the outer formed by mature connective tissue.
In some diseases the pus can spread interstitial
crevices and settle in places remote from the primary
localization of the abscess. An example is the socalled cold abscesses (wandering abscess),
characteristic of tuberculosis, which can be emptied
through the fistulous passages.
The clinical picture. With significant accumulation of
pus is usually expressed in the general reaction: fever,
weakness, loss of appetite, insomnia, changes in the
blood, morning and evening temperature fluctuations.
Over the abscess is noted swelling and redness of the
skin. Only with deep-seated abscess, these symptoms
In Fig. 24. Symptom fluctuation.
are absent.
An important feature of an abscess in the presence of
other signs of acute inflammation is a symptom fluctuation, or fluctuation (Fig. 24).
It is due to the presence of fluid (pus), enclosed in a cavity with elastic walls, which transmits the impulse
in the form of waves from one wall in all directions. This symptom is absent when the wall is very thick,
and a small abscess cavity and in depth. In this case it is necessary to carry out diagnostic puncture of
abscess or ultrasound of soft tissue (Fig. 25)
~ 37 ~
Represents a significant threat to break the
abscess into any cavity (joint, pleural cavity).
In chronic abscess signs of acute inflammation
may be almost entirely absent. In these cases,
swelling, a small pain, symptom fluctuations and
puncture data allow a diagnosis. For the diagnosis
of abscesses is necessary to use ultrasound.
Ultrasound imaging of abscess depends on the
stage of its development. Formed an abscess has
clear irregular contours, heterogeneous liquid
structure with the presence of fine sediment that
settles at rest on the walls of the abscess, or moves
with a change in body position. It can be observed
amplification of the posterior wall of Education.
In Fig. 25. Ultrasound picture of soft tissue
Abscess formed around most of the rim is
abscess.
visualized with various degrees of increased
echogenicity, with an irregular inner contour
(pyogenic capsule). Ultrasonic signs of an abscess formed appear 8-12 days after its formation.
Sign of an abscess is hypoechoic unformed education, often irregularly shaped, with fairly uniform
content, the lack of rim (capsule) increased echogenicity. Around education can be identified hypoechoic
area of varying severity (zone of edema).
Differential diagnosis. Necessary to differentiate normal from cold abscess, ie, migrating abscess
tuberculous origin, characterized by the presence of the main focus of tuberculosis, slow development,
lack of acute inflammation. Abscess should also be differentiated from a hematoma, aneurysm and
vascular tumors.
Treatment. The diagnosis of abscess is an indication for surgical intervention, whose goal regardless of
the localization of the abscess is opening, emptying and draining the cavity.
Puncture aspiration of abscess with pus and subsequent introduction into the cavity of the abscess
antibiotics, enzyme preparations can be used only on strict indications, in some locales abscess.
Operation - opening superficial abscess - is performed under local infiltration anesthesia of 0.25% or
0.5% solution of novocaine or short-term intravenous anesthesia. (Sombrevin, ketamine, etc.). For
opening the abscess choose the shortest line access, taking into account the anatomical and topographical
features of the body above the point of greatest fluctuation. Often reveal an abscess on the needle: the
original puncture the abscess, followed by needle-dissected tissue.
At the opening of an abscess on the possibility of
coming to its lower pole, to create good conditions
for drainage.
In order to reduce exposure of surgical field isolate
gauze area in the center of which is expected to
open the abscess, and making a small hole in the
wall of an abscess, the pus is removed electric
pumps. Aspirated pus, the incision extends
remaining pus and necrotic tissue is removed. If the
abscess cavity is extensive, her finger examined,
dividing the bridge, removing tissue sequesters.
Abscess cavity was washed with an antiseptic
solution (Fig. 26).
Abscess cavity drained by one or more rubber or
In Fig. 26. Abscess of the left tibia. Washing the
plastic tube and injected into her gauze sponges
wound with antiseptics after opening the
soaked in a solution of proteolytic enzymes,
abscess
puncture needle
~ 38 ~
antiseptics and antibiotics. When emptying failure in the main incision is made counteropening.
In chronic abscess excised with its capsule within healthy tissue, sutured the wound and drain for active
aspiration to prevent recurrence of infection.
General treatment includes antibiotics, taking into account the sensitivity of the microflora, the use of
specific treatment (staphylococcal toxoid immunization, the use of specific y-globulin).
Cellulitis (abscess) - an acute purulent inflammation of the subcutaneous fat and cellular spaces
(subcutaneous).
The agents of cellulitis are usually staphylococci and streptococci, which penetrate into the fiber through
the damaged skin, mucous membranes or hematogenous route.
Phlegmon is a distinct disease, but may be a complication of various suppurative processes (carbuncle,
abscess, etc.). The inflammatory exudate fat spreads, moving from one fascial sheath to another through
the holes to neurovascular bundles. Pushing back the cloth, squeezing and destroying the vessels, pus
leads to necrosis of tissue.
When phlegmon distinguish two phases of inflammation - serous and purulent infiltration of melting.
By the nature of the exudate distinguish purulent, purulent, hemorrhagic, and putrefactive forms of
cellulitis. Depending on the location of isolated epi-and subfascial (intermuscular) forms of diffuse
purulent inflammation of the tissue.
In certain locales abscess is a special name. Perinephric tissue inflammation called paranefritom,
perienteric - paracolitis, rectal - paraproctitis.
The clinical picture. The clinical picture of cellulitis characterized by the rapid emergence and spread of
painful swelling, redness poured over it, high temperature (40 ° C and above), pain, dysfunction of the
affected body part. Swelling is a dense infiltration, which then softens. The disease often begins abruptly,
with chills, headache, general malaise, accompanied by severe intoxication, increase in body temperature
to 40 ° C. There is a high leukocytosis and neutrophilia pronounced.
Subcutaneous abscess, developing primary, can lead to several complications (lymphadenitis,
lymphangitis, erysipelas, thrombosis, sepsis, etc.).
In the propagation of cellulitis in the surrounding tissue can occur secondary septic arthritis, and other
tendovaginitis purulent lesions.
Subcutaneous abscess may develop secondarily in diseases such as osteomyelitis, suppurative arthritis,
suppurative pleurisy.
Subcutaneous abscess person may be complicated by progressive thrombophlebitis of the veins of face
and purulent meningitis.
Treatment of patients spend in hospital. In the stage of serous infiltration of cellulitis acceptable
conservative treatment. Assign bed rest, antibiotics, create peace. Locally around phlegmon used UHF-
~ 39 ~
therapy. In the delimitation process and the formation of ulcers (limited cellulitis) are conducting an
autopsy and drainage of cellulitis.
With progressive phlegmon postponement of surgery is not allowed. Under general anesthesia produce
operation. Phlegmon reveal one or several parallel slits. The direction of the cuts is determined by the
localization of cellulitis: the extremities of their conduct on limb, in the gluteal areas - along the lower
gluteal folds on the abdomen - in the course of the muscles of the chest - in the course of the pectoralis
major muscle fibers on the lateral surface of the chest - a hike of edges on the back - along the spine.
The wounds were washed with antiseptic, drain drainage pipes.
In specialist hospitals can apply active debridement, which consists in excision of all nonviable tissue,
evacuation of pus from cellulitis, draining several drainage tubes and the imposition of a primary suture.
After a drainage tube in the postoperative period produces an active aspiration.
Putrid infection. Usually putrid abscess combined with anaerobic staphylococcal infection. More often is
caused by Proteus vulgaris, Escherichia coli.
predisposing factors
1. Traumatic wounds with a lot of crushed, devitalized tissue, bite, gunshot wounds.
2. Urinary phlegmon in fractures of the pelvis.
3. Phlegmon of the anterior abdominal wall after injury to the colon (fecal cellulitis), putrid peritonitis.
Clinical manifestations. According to clinical manifestations of infection are often reminiscent of putrid
gas gangrene, but differs from it on several grounds.
1. The general condition. Picture of intoxication, high body temperature, restlessness, delirium, dry
tongue.
2. Local manifestations. Inflammatory changes, flushing wounds, fever, necrosis of wound edges, pain in
the wound. In the context of discovering the healthy blood supply muscles.
3. The character of discharge. Limited accumulation of gas in the fatty tissue of the wound. Putrid or fetid
purulent fusion of tissues, only a limited area of the wound.
On the radiograph is determined by a significant accumulation of gas in the wound
Treatment. In the putrid infection, as in the anaerobic treatment should be started immediately, be
complex and involve primarily the radical excision of nonviable tissue, eliminating pockets, streaks,
followed by adequate draining and prolonged washing with an antiseptic solution. The principles of
antimicrobial therapy, as well as correction of metabolic and circulatory disorders do not differ from those
used in gas gangrene.
Forecast. The favorable outcome of the disease is possible only in a timely initiated therapy.
Surgical infections brush (panaritiums and phlegmon)
Classification.
I. Purulent diseases of the fingers (panaritiums).
1. Skin felon. 2. Subcutaneous felon. 3. Tendinous whitlow (thecal abscess). 4. Articular whitlow. 5.
Bone felon. 6. Osteo-articular felon. 7. Paronychia. 8. Subungual felon. 9. Pandaktilit. 10. Furuncle
(carbuncle) rear toes.
Superficial forms of felon - cutaneous, subcutaneous, paronychia, hyponychial.
Deep forms of felon - bone (acute and chronic), tendon, bone and joint, pandaktilit.
II. Purulent diseases of the brush
1. Thenar abscess intra-musculature. 2. Intra-musculature of hypo-thenar abscess. 3. Commissural abscess
(helotic abscess). 4. Median palmar space abscess (over-and under-tendinous above and subgaleal). 5.
The cross (U-shaped) abscess. 6. Subcutaneous abscess back of the hand. 7. Subgaleal abscess back of the
hand. 8. Furuncle (carbuncle) back of the hand.
All acute purulent diseases of fingers called felon, paronychia except when the Suppurative process is
located above the nail plate at its base.
~ 40 ~
In order to select a rational therapy appropriate to allocate stage process: initial (sero-infiltrative) and
purulent (pus-necrotic).
The reasons are various felon finger injuries: cuts, punctures, bites, burrs, abrasions through which
penetrates pyogenic microflora. Occurrence of acute purulent processes in the fingers and hands most
often caused by Staphylococcus aureus, which dominates in 69-90% of cases, at least - in a monoculture,
often - in associations. For the bite of infected wounds as one of the causes of whitlow and phlegmon,
especially characteristic of anaerobic microflora.
The clinical picture.
The predominant symptom is pain - from gnawing at ways to pulsating sinus and abscess formation in
unbearable. In most cases, patients reported fever and deterioration of general condition. Pretty soon
edema of the affected phalanx or just your finger. The intensity of the flare depends on the depth of
purulent process, and its absence in no way does not indicate the absence of purulent process. Impaired
function of the finger is almost always observed. Point palpation bellied probe reveals the zone of
maximum pain, lesions typical of a joint or tendon.
Skin felon.
The most common cause is a felon mikrotrauma
manufacturing, consumer injury.
In skin exudate felon is under the epidermis and
detach it in a bubble, the content of which is serous,
purulent or hemorrhagic in nature (Fig. 30). There
have been moderate pain.
Sometimes the disease is accompanied by significant
increases in body temperature, severe regional
lymphadenitis and lymphangitis.
In Fig. 30. skin felon
Subcutaneous felon. This disease belongs to the most common type of suppurative inflammation of the
brush.
Subcutaneous panaritiums pains are
gradually increasing, jerking,
pulsating character. Pain patients are
deprived of rest and sleep. On
examination, the finger of tension
fabric, sometimes flattening
interphalangeal flexion furrow.
Flushing of the skin expressed mild.
In Fig. 31. Subcutaneous felon.
With a significant swelling of the
a - subcutaneous felon;
phalanges is determined by the pallor
b - in the form of subcutaneous whitlow "cufflinks"
of the skin, which arose due to
compression of vascular interstitial
fluid.
Subcutaneous panaritiums pus tends to spread in depth, since the connective bridge, going perpendicular
to the thumb, limit the spread of the periphery, are natural barriers, channels, guide the transition of
infection to tendons, joints and bone phalanx (Fig. 31).
Paronychia. When the superficial paronychia occurs painful swelling around the nail shaft, hyperemia of
the surrounding tissues, the overhang of the affected nail roll around on the nail plate.
~ 41 ~
In some cases the pus penetrates deep paronychia under the nail plate, left it. In this purulent exudate
appears through the detached edge of the nail. "Saped" pus-edge nail plate loses contact with the nail bed.
There is a nail peeling all over, ie, a felon hyponychial (Fig. 32).
In Fig. 32. a) felon b) hyponychial felon
Subungual felon. Inflammatory purulent exudate accumulates under the nail plate, detaches from the last
nail bed and a few lifts it. On palpation marked fluctuation nail plate. Commit it to the box disappears, but
remains a strong attachment to the proximal nail in the matrix.
Swelling and redness of the skin with subungual felon is not expressed. The main symptom is a
throbbing, arching pain in the ungual phalanx. Complete "sequestration," or removal of the nail plate
surgically create the necessary prerequisites to recovery.
Articular panaritium. The disease occurs after injury to
the interphalangeal or metacarpophalangeal finger
domains with their dorsal surface, where the joints are
covered with a thin layer of soft tissue. Infection of
wound channels can easily penetrate into the joint gap
(Fig. 33). Inflamed joint becomes spindle-shaped, dorsal
interphalangeal furrows are smoothed. Flexor-extensor
movements a finger leads to a sharp increase in pain in
In Fig.33. Articular panaritium
the affected joint. With involvement in the inflammatory
process ligament, cartilage and bone apparatus of the
finger there is abnormal mobility, a sense of crepitations,
"laxity" of the articular surfaces. Radiographically at 12-14 day determined joint space narrowing.
Bone felon. Bone felon developing in the transition of the pathological process of soft tissue finger to the
bone, ie, this process is secondary. In general, developing bone felon from running or non-radical cured
subcutaneous whitlow (Fig. 34).
Pains are dull, constant. From the wound through the fistula scant purulent discharge, sometimes with
small bone sequestration. Phalanx clavate thickened. Function of the brush is considerably reduced.
In Fig. 34. Bone felon
(sequestration of the diaphysis of
the middle phalanx).
Be aware that the X-ray only after 10-14 days can be found
destruction of bone tissue that is not a ground for postponing
the operation. Surgical treatment is indicated in severe
clinical picture of the felon, the patient complained of
persistent pain or reported on a sleepless night because of
pain in the finger.
~ 42 ~
Tendinous panaritium(thecal abscess). Subcutaneous
whitlow is sometimes the cause tendovaginitis. The
infection spreads to the tendon sheath and the flexor
tendon of fingers (Fig. 35). Deterioration of general
condition, appearance jerking, throbbing pain around the
finger, even with the swelling of the tissues
In Fig. 35 Tendon felon. Accumulation
interphalangeal smoothed the furrows - the symptoms of
of pus in the tendon sheath
tendon felon. Finger becomes hot dogs and is in a state of
light bending. Extension finger leads to a sharp increase in
pain while bending significantly reduces its severity. This
symptom is one of the main tendon in panaritiums.
Pandaktilit - it - suppurative inflammation of tissues of the finger. Pandaktilit - usually the result of
improper treatment of purulent process or running a finger (Fig. 36).
Pandaktilit accompanied by severe intoxication
(headache, fever), regional lymphangitis, and axillary
lymphadenitis cubital. In the blood, expressed as changes
characteristic of acute suppurative inflammation.
The clinical picture consists of a set of pandaktilita all
purulent lesions thumb
The disease develops gradually. The reason it is a
virulent infection, incorporating finger as a result of
In Fig.36 Pandaktilit
tissue injury. You may experience pandaktilita and
simple forms of felon.
When pandaktilite pain gradually intensified and become an intense, painful, arching nature, swollen
finger is blue-purple. The inflammatory process is developing according to the type of wet or dry
necrosis. Of fistulas or postoperative wounds scant secretions. Granulation gray, lifeless.
Forecast. When the function hand pandaktilite much suffering. Usually develop contracture finger. Often,
especially when pandaktilite II - V finger, to prevent the generalization of infection, and rapid elimination
of the purulent process in the failure of other therapies operation of choice is complete amputation thumb.
Phlegmon of the brush are the name, depending on the localization of infection (see classification). The
clinic is manifested by edema, hyperemia and tissue soreness in the affected area cells space. Function
suffers from purulent foci adjacent to the fingers. The intensity of pain during passive movements in them
to a large extent depends on the involvement in the process of tendon sheaths. Practically all the brush
phlegmon develops swelling of the tissues back surface. General health is suffering, it is possible fever,
the development limfangoitis of body temperature can rise to 40 0C.
The principles of treatment.
The primary method of treatment - surgery. Treatment of inflammatory diseases of the fingers and wrist
involves several steps, neglecting any of them inevitably complicates the course of the inflammatory
process. Before the operation, the brush should be washed several times with running water and soap and,
if necessary, shaved. The most common surgery performed under anesthesia wires outside the focus of
inflammation 1-2% solution of novocaine, or 1.5% sodium trimekaina, including the localization process
in the nail or middle phalanx of a finger - on-Lukashevich Oberst. In the propagation process proximal to
- carry out the blockade of the nerves in the lower third of the forearm or anesthesia on Usoltsev. In the
space phlegmon Pirogov - Paron regional anesthesia is advisable to make the top third of the forearm or in
the armpit. With known contraindications to local anesthesia operation carried out under general
anesthesia.
Incision, while ensuring optimal choice of the direction of an adequate volume of transactions should be
spared as "workers" of the hand, respectively, the scheme Metzgeg J.T. (1955). Scalpel should cut only
the skin, and all further manipulations in the tissues is carried out by their "moving apart" under the
control eyes.
~ 43 ~
The next step is a careful necrectomy operations, where abscess should focus on the type of excised
primary surgical treatment. Necrectomy for bone and joint structures involves removing only the
sequestered sites.
Immobilization of the thumb in a functionally advantageous position in the postoperative period is
mandatory regardless of the form of the disease. The duration of immobilization determine the terms of
relief of acute inflammation.
Early development of the active movements of the fingers and hands (after removal of drains and sutures)
contributes to a full recovery ¬ NIJ hand function.
Treatment of certain forms of felon.
The incision is carried out with paronychia on the back surface, parallel to the edges of the nail bed
towards the base of a finger phalanx with exposed roots nail.
Hyponychial reveal felon from the same incision and remove the nail plate, after dissecting it into two
halves to the ground. Remove necrotic tissue, and further treatment is carried out with a water-soluble
ointment on the basis of. Ointment is placed on the tissue flap, formed after the cut.
Subcutaneous whitlow terminal phalanx of the oval reveal or semi-oval section, conducted at the lateral
and anterior surface of the terminal phalanx. If the suppurative process is not in the terminal phalanx,
produce lateral incisions with preservation of the skin in the joint.
Surgery for bone felon involves removing the affected area of bone within the healthy tissue (removal of
produce sharp spoon). If the disease is fairly long and has formed fistula, the inflammation in the skin and
subcutaneous tissue, usually not pronounced. In this situation, carry out a radical necrosequestrectomy,
remove the abnormal granulation in the soft tissues and the wound closed by primary suture with the
imposition of drainage and flushing of the system. Bone tissue is gently scrape acute bone spoon. In the
case of sequestration of the phalanx is removed only sequesters freely behind keeping the main body of
the bone.
Surgical intervention for tendon panaritiums determined by the state adjacent to the tendon sheath
subcutaneous tissue. In the intact tissue (in the case of tenosynovitis after injection directly into the
vagina) limit the operational manual dissection of the distal tendon sheath (on the middle phalanx) and
proximal (in the projection of the corresponding head of the metacarpal bone) departments. After the
evacuation of fluid and vaginal lavage with an antiseptic solution to the cavity to drain the entire length of
perforated with microirrigator whose ends we derive through the slits, and the skin sutures. When the
subcutaneous tissue is also involved in pyo-destructive process, perform longitudinal incision on the
lateral surface of the finger with the palm arched extension in the projection of the "blind sac" tendon
sheath. Dermal-subcutaneous flap separate from the vagina, which tends to be partially or completely
necrotic, be sure to retain the palmar neurovascular bundle and perform a thorough necrectomy
subcutaneous tissue excised sections of nonviable necrotic tendon sheath and tendon fibers. Completely
excised tendon only with explicit its necrosis, when it presented a structureless mass.
When the articular or osteoarticular panaritiums usually perform Z-shaped incision on the dorsum of the
finger in the projection of the corresponding joint. Arthrotomy is carried out audit of the joint cavity and
remove the purulent exudate. In the absence of lesions in bone destruction reorganize the joint cavity with
an antiseptic solution and a perforated drainage with
microirrigator (Figure 37).
In identifying bone destruction scrape the affected area
of periosteum and bone of acute bone spoon, and drain
the joint cavity. An extremely important point is further
decompression of the joint, otherwise perhaps the
progression of degradation. Decompression reduces joint
intraarticular pressure is achieved diastasis between the
In Fig. 37. Drainage at the articular
joint ends, which contributes to inflammation and
panaritiums.
cupping prevents the formation of intra-articular
adhesions. The imposition of compression-distraction
~ 44 ~
device or traction metalloplaster design using a modified needle Kirchner is possible only when there is
no inflammation in the soft tissues of articulated phalanges.
Often when a finger believe pandaktilite preservation hopeless and amputated his or affected phalanx.
However, with proper surgical treatment may preserve the finger. Even the flexor-extensor lost motion,
the finger remains a very important function of the confrontation and capture, without which greatly
reduced the practical activity of man.
Perform incision on the lateral surface of the finger with an arched extension to the palmar surface of the
brush head in the projection of the corresponding metacarpal bone. Palmar skin and subcutaneous flap
separate of the flexor tendons with preservation of neurovascular bundles in the same way separate rear
flap. Both flaps are deploying, which provides good access to all structures of the finger. Under
conditions of acute inflammation of the wound with gauze strips filled with the ointment on the basis of
water-soluble and is left open. Later, during the dressings, if necessary, perform the landmark event
necrectomy. Complete surgical drainage and guide the imposition of the wash system and primary sutures
only with full confidence in adequately performed necrectomy.
As the inflammation subsided and wound cleansing skin defects
can be closed by secondary sutures.
Рис. In
38.Fig.Дренирование
38. Drainage of
флегмоны тенара и
cellulitis thenar and
гипотенара
hypothenar
Treatment phlegmon brush
At various locations on the hand of a purulent focus, there are
some on-line access, which should be the most short and gentle. It
should be noted that the implementation of large longitudinal cuts
is unacceptable. Creating access is possible by modifying the
incision on the type of S-shaped, arched or broken, mindful of the
fact that the scar tissue contracts in length.
Phlegmon of thenar reveal arcuate incision parallel to the fold of
skin thenar and outwards away from her with a cut on
contraperturnym back of the hand in the first interdigital area of
the gap.
The incision in phlegmon of hypothenar spend on the inner edge
elevation with hypothenar muscles counteropening on back of the
hand on the outer edge of V metacarpal bone (Fig. 38).
For opening phlegmon median palmar space is advisable to make the cut on the distal palm crease of skin
from IV to II interdigital gap with its further continuation in the skin fold of thenar (fig. 39).
In Fig. 39. The incisions used for opening the
phlegmon median palmar space.
~ 45 ~
Drainage ways in phlegmon of the median palmar space are presented in Figure 40.
In Fig. 40. Drainage of phlegmon in the median palmar space. a - subgaleal
(over tendinous) abscess b-ongaleal abscess, c- under the tendinous
Phlegmon back of the hand of the arcuate sections operate performed taking into account the lines of
Langer. For the opening of the U-shaped cellulitis perform lateral cuts on the middle phalanx of the
thumb and V main phalanx of finger I, of which reveal the corresponding tendon sheath. Lateral
longitudinal incisions on the forearm reveal space Pirogov - Paron (Fig. 41).
In Fig. 41. Flow-flushing drainage at the U-shaped brush with phlegmon
breakthrough in space Pirogov - Paron.
a - the cut, b-synovial drainage sheaths of fingers I and V and the space
Pirogov - Paron.
Upon completion of the operation should be preferred drainage and leaching systems with primary suture,
which reduces the duration of the postoperative period and early rehabilitation of patients.
~ 46 ~
Diabetes mellitus and purulent infection.
During the surgical diseases, developing or occurring with diabetes mellitus, is one of the important
issues of modern surgery.
Background to a large extent due to the fact that the incidence of diabetes progressively increases and
reaches 2-3%, while in older age groups increased to 5-9%. Accordingly, increases the number of surgical
patients with diabetes mellitus.
Surgery for acute purulent diseases in diabetic patients ranged from 6 to 25% of the total number of
surgical operations. Suppurative processes (abscess, abscess, furuncle, carbuncle) develops in 10-25% of
patients with diabetes.
Mortality in diabetic patients when combined with its purulent surgical diseases reaches 20% of cases.
Surgical infection and diabetes, runs at the same time, different number of features. On the one hand, any,
even minor, purulent focus is a violation of all metabolic processes, leading to insulin deficiency,
progression of diabetes and its decompensation. On the other hand, metabolic disorders, slowing
regeneration and repair of tissues complicate and worsen during the inflammatory process, contribute to
its spread and generalization. Every third patient was a diabetic coma triggered by various infectious toxic diseases.
The emergence of infectious disease depends not only on the amount and properties of the pathogen, but
also on the initial state of the microorganism, the endocrine glands, and physiological characteristics
associated diseases and other factors. It is known that disturbances of carbohydrate, protein, fat
metabolism, changes in electrolyte and acid-base balance water exchange, the suppression of regenerative
- reparative ability of the organism - the inevitable companions of diabetes. They are the backdrop for the
adverse flow of purulent-necrotic processes.
Diabetic Foot
The term "diabetic foot" syndrome indicate the anatomical and functional changes of the foot in various
combinations, associated with diabetic neuropathy, micro-and macroangiopathy, osteoarthropathy, against
which there are severe purulent-necrotic lesions.
According to the World Health Organization, worldwide there are over 120 million patients with diabetes
mellitus (DM). Experts predict by 2010 the number of patients will increase to 239.4 million.
Changes in the vascular, nervous and skeletal systems in diabetes, the most pronounced in the peripheral
regions of the lower limbs, frequently contribute to the development of necrotic processes in the foot. The
main factors contributing to the affection of the lower extremities, are peripheral neuropathy, and
atherosclerotic changes in arteries of the lower extremities.
Purulent infection of the lower extremities is a leading cause of hospitalization in the surgical separation
of patients with diabetes mellitus.
Various purulent and purulent necrotic lesions feet (phlegmon, gangrene of fingers and feet, ulcers,
osteomyelitis, etc.) have been reported in 64.8% of patients with diabetes mellitus (Mokhov E.M, et al.,
2005).
Classification of diabetic foot
At the present time have identified a number of classifications of diabetic foot syndrome: etiological and
pathogenetic on the principle of clinical and morphological principle of clinical and diagnostic principle
and combined classification.
A.P. Kalinin, D.S.Rafibekov et al. (2000) on the etiological and pathogenetic principle there are three
main types of diabetic foot:
Type I- diabetic foot with the predominant development of diabetic neuropathy: a) complicated and b)
uncomplicated.
Type II - diabetic foot with a primary ischemic syndrome due to severe micro-and macroangiopathy:
~ 47 ~
a) complicated and b) uncomplicated.
Type III - diabetic foot with associated symptoms of neuropathy and arterial hypoxemia at the same time:
a) complicated and b) uncomplicated.
Wagner F. classifies the lesion stop diabetes, depending on the depth of tissue destruction:
Classification of diabetic ulcers on feet (Wagner F., 1981):
0-th stage - skin intact, can be bone deformation. At this stage the group is at high risk (dry skin, flat feet,
deformation).
Stage 1 - superficial, noninfected ulcers.
Stage 2 - infected ulcer penetrates through all layers of the skin and it is located on the bottom of the
tendon, bone and joint;
Stage 3 - a deep ulcer that penetrates to the muscles, with a massive bacterial contamination, the
development of the abscess and the possible accession of osteomyelitis;
Stage 4- gangrene of the foot or a single finger (local gangrene);
Stage 5 - spread gangrene, requiring a "large" amputations.
0, 1, 2, 3 stages - neuropathic, and 4, 5 stages - neuro-ischemic.
Malum perforans on stage (Arlt Bernhard., 2005)
Degree 1. Skin necrosis
Degree 2. Ulcer without the involvement of bones and joints
Degree 3. Ulcer involving bone and joint
Degree 4. The spread of infection from Malum perforans (lack of clear boundaries).
M.I. Ahunbaev, A.P. Kalinin, D.S. Rafibekov (1997) proposed clinical diagnostic classification of lesions
of the lower extremities in diabetes mellitus:
I. Diabetic hyperkeratosis of the lower extremities.
II. Diabetic neuropathy of the lower extremities.
III. Diabetic osteoarthropathy of the lower extremities.
IV. Diabetic angiopathy of lower extremities.
V. Diabetic ulcers: 1) finger, and 2) feet, and 3) leg.
VI. Diabetic abscess: 1) finger, and 2) feet, and 3) leg, and 4) femur.
VII. Diabetic phlegmon 1) the fingers, and 2) feet, and 3) leg, and 4) femur.
VIII. Dry diabetic gangrene: 1) finger, and 2) feet, and 3) leg; 4) the lower extremity.
IX. Diabetic gangrene moist: 1) finger, and 2) feet, and 3) leg; 4) the lower extremity.
On clinical and morphological principle B.M. Newspapers and A.P. Kalinin (1991) identify six major
clinical variants of necrotic lesions of the foot in diabetes:
1. Specific damage to the skin and nails of the foot in diabetes.
2. Local gangrenous changes in the foot:
a) gangrene of the fingers;
b) the local gangrene of the skin on the foot.
3. Gangrene in combination with advanced infection.
a) progressive atherosclerotic gangrene
b) local gangrene of the foot with a good blood supply.
4. Ulcers:
a) ulcer on the plantar surface of the foot;
b) ulcers on the toes.
5. Nonspecific suppurative-necrotic processes cells spaces of the foot in diabetes:
a) the central plantar space abscess;
b) the lateral plantar phlegmon space;
c) the medial plantar phlegmon space;
~ 48 ~
g) dorsal foot abscess.
6. Anaerobic surgical infection of the foot in diabetes:
a) clostridial gangrene;
b) non-clostridial gangrene.
The pathogenesis of diabetic angiopathy of lower extremities
The pathogenesis of lesions of the lower extremities in diabetes mellitus includes typical changes:
microangiopathy, macroangiopathy, polyneuropathy, osteoarthropathy caused by disturbances in the
immune system, hormonal status, metabolic changes (disorders of protein, fat and carbohydrate
metabolism), genetic shifts, hemorheological disorders. The major pathogenetic processes that lead to the
development of diabetic angiopathy of lower extremities include: 1 - a violation of glucose metabolism in
nervous tissue, and 2 - Damage to microvessels feeding the nerves of 3 - glycation of neural structures, 4 accelerated aging. Nervous tissue contains the enzymes aldose reductase and polioldegidrogenazis that
provide polyol path of glucose utilization. A characteristic of diabetes excessive activation of this
pathway is accompanied by accumulation of sorbitol in the nerve tissue and other polyols, which leads to
swelling of the nerve structures and a lack of mioinozitolis - an intermediate product of glucose
utilization, which is a necessary intracellular substance. Disturbed metabolism of phospholipids,
decreases the activity of K-Na-ATPase, the sodium content increases with a simultaneous decrease in the
concentration of calcium and cAMP. The result is a destruction of nerve cells, demyelination and axonal
degeneration of nerves, degeneration of Schwann cells, perineural and endosclerosis neural vessels.
Microangiopathy is characterized by lesions only small vascular network. In the basal membrane of
capillaries accumulated PAS-positive substances, including mucopolysaccharides, glycoproteins, and
lipids. Membrane thickening of capillaries in 2-5, sometimes 8-10 times, it gradually split into layers,
between which the collagen fibers. These changes of the membrane and the endothelium violate election
filtration of biological fluids and exchange diffusion, which makes it difficult or impossible to remove
metabolic products, providing nutrients and oxygen. Hypoxia causes destruction of the tissues, contribute
to the development of necrotic gangrenous process.
Macrovascular atherosclerotic lesions of arteries shows medium and small-caliber arterioles. Most often
these changes are detected in the popliteal, tibial arteries and the arteries of the foot.
Lipid peroxidation, one of the mechanisms of atherogenesis, plays an important role in the development
of diabetic foot. Lipid peroxides have toxicity and membranotropic violate the permeability of cell
membranes and lysosomal contribute to their degradation, release of lysosomal enzymes and autolysis of
cells. In the damaged epithelium, blood vessels deposited protein-lipid complexes, and peroxides of
polyunsaturated fatty acids may be the reason for the accelerated development of thrombogenesis and
hyperagulatisis syndrome.
Somatic and autonomic neuropathy contribute to the development of foot ulcer. Sensory neuropathy in
diabetic patients manifested reduced pain, tactile, temperature, vibration and proprioceptive sensitivity. In
the foot, deprived of an adequate response to mechanical, thermal or chemical injury, often develop
necrotic process. Osteoarthropathy in diabetes are caused by neuropathy and calcium therapy .
In patients with diabetes decreases the activity of cellular and humoral immunity, increases the viscosity
of blood with a tendency to thrombosis, and thrombosis with obliteration of the vessels of the foot and a
violation of collateral circulation, slows down the process of tissue regeneration and increase the healing
time of wounds.
~ 49 ~
Diabetic Clinic of the lower extremities.
Diabetic neuropathy
Neuropathy can lead to the following types of lesions stop:
1. Neyropaticheskoi ulcer,
2. Osteoarthropathy (with the subsequent development of Charcot joints)
3. Neuropathic edema.
Neuropathic ulcers - a sore spot in high blood pressure or mechanical irritation occurring against a
background of peripheral neuropathy, manifested distal, symmetric sensory, autonomic neuropathic
disorders. By manifestations of diabetic neuropathy include paresthesias, disturbances of various kinds of
sensitivity. For diabetic neuropathy is characterized by changes in pain and tactile sensitivity of the type
"ragged socks," with "holes" indicate areas with relatively fewer violations. Pain in the feet during the
night, disappearing when walking indicate deep frustration and vibration sensitivity.
Violation of motor innervation is characterized by atrophy of the muscles of the foot. Interphalangeal
joints quickly fixed in a bent position (prominent claw
toes). Damage to the autonomic innervation of the foot
is characterized by impaired thermoregulation its "auto
sympathectomy 'and degeneration of the sweat glands.
Foot Skin becomes thin, dry and thin-skinned. As a
result, often formed blisters and cracks, which are the
portal of entry.
Ulcers on the foot are the typical manifestations of
neuropathy in diabetic patients (Fig. 50).
Pain syndrome is not expressed. Typical location of
the ulcers are areas protruding metatarsal heads,
medial surface of the I toe, heel, cushions 'clawed'
toes. Sizes are small ulcers. Their diameter is 1-2 cm,
but they are deep down they are the tendon, or bone
joint area.
Neuropathic edema as a manifestation of diabetic
In Fig. .50. Neuropathic form of diabetic
neuropathy is associated with the violation of
foot (plantar surface of the trophic ulcer
vasomotor functions, such as arteriovenous shunting.
of the foot).
At the same foot and lower leg cold to the touch,
painless. On palpation of tissue swelling in the area of
dense and remain under pressure "pit."
Patients with neuropathy do not feel the spatial arrangement of "anesthetized" stop and therefore often
receive mechanical, chemical or thermal injury, not noting that. Injuries to the skin may be in contact with
foreign objects footwear, wearing footwear improperly selected, the processing of nails, corns. Repetitive
mechanical stress at first leads to an inflammatory autolysis and subepidermal hematoma, which opened
to the skin surface, forming an ulcer.
Diabetic osteoarthropathy
Diabetic osteoarthropathy - a combined lesion of bone and articular organs, ligaments and tendons due to
diabetic micro-and macroangiopathy neuropathy.
Changes in the bones and joints of the foot in diabetes manifested by three main processes: 1) lesions of
bones and joints with diabetic neuropathy;
2) Infectious arthropathies, and 3) bone and articular changes caused by endocrine and metabolic
disorders.
~ 50 ~
Diabetic neuro-osteoarthropathy - a syndromecomplex of aseptic destruction of bones and joints of the
foot in diabetes (Charcot foot). Diabetic osteoarthropathy is characterized by destructive and lytic changes
in the bones and joints mainly on foot. The most pronounced changes in bony structures and ligaments of
the foot are called joint or Charcot foot. It is this form at the clinic is called "diabetic foot". Clinical
symptoms of undifferentiated osteoarthropathy in the early stages of (Arlt Bernhard, 2005):
1. Swelling.
2. The absence of pain.
3. Redness.
4. An increase in temperature.
5. Good pulsation according to sonography.
6. Increased scintigraphic activity
Charcot foot is characterized for: increasing the transverse size of the foot, transverse and longitudinal
arches, an increase of strain and ankle joint, the coracoid and hammer toes deformity, acting head of
metatarsal bones of the foot.
Stage of diabetic osteoarthropathy (Charcot foot).
Stage 1 - the presence of edema of the foot, hyperthermia and congestion;
Stage 2 - the formation of foot deformities, radiographically determined bone changes in the form of
osteoporosis, bone destruction, fragmentation of bone structures;
Stage 3 - severe foot deformity, pathological fractures and dislocations;
Stage 4 - the formation of ulcers, infection with which it is possible the rapid development of gangrene.
S. Forgacs (1987) distinguishes three stages in the bones of radiographic abnormalities in diabetes
mellitus:
Stage I (initial manifestation) - limited osteoporosis, subluxation,
cortical bone defect;
Stage II (progression) - osteolysis, fragmentation, fracture and periosteal reaction;
Stage III (healing) - filling in the cortical defect, spikes, ankylosis, arthrosis.
Changes in bones and joints in diabetes identified in the metatarsal and tarsal bones in the ankle joints and
the joints of the big toe. Patients significantly reduced footprint, which is why the most prominent areas
of the foot have high blood pressure and are the source for the formation of deep ulcers and necrosis.
Develop a variety of bending and deformation, resulting in a broken joint mobility and gait changes.
In cases of infectious complications in diabetic arthropathy appearance of ulcers, sores and fistulas, in
which leave the bone sequester.
Diabetic angiopathy
In patients with diabetes affects the blood vessels - Diabetic angiopathy. It is divided into
microangiopathy and macroangiopathy. Microangiopathy may occur before clinical signs of diabetes. The
frequency of these lesions in patients with diabetes is 97% or more. In the genesis of angiopathy major
role for lipid metabolism disorders, and systemic arterial hypertension. Atherosclerosis in diabetes is
different early-onset, rapid development, more severe. Atherosclerosis has a distal direction and character
multisegmentarny affection. The process develops in about 10 years earlier compared with a similar
group of people without diabetes.
A characteristic feature of diabetes, arteriosclerosis is Menkeberga - calcification of tunica media of
arteries of different diameters in the absence of lesions inside and outside of the envelope.
B.M.Gazetov and A.P. Kalinin (1991) distinguish three types of angiopathies:
1. Microangiopathy is one manifestation of neuropathy and is characterized by lesions of the arterioles
and capillaries;
2. Macroangiopathy - atherosclerosis of large arteries and less leg femoral and iliac arteries, where blood
flow is greatly disturbed the feet;
~ 51 ~
3. The combination of microangiopathy and
atherosclerosis of arteries of lower extremities.
Clinical manifestations of diabetic micro - or
macroangiopathy are: fatigue when walking,
unusual sensitivity to cold (coldness, paresthesias,
and sensations as burning, creeping, "chills",
numbness of various parts of the foot), leg pain
during walking or rest, intermittent claudication.
Complaints of the patient on intermittent
claudication is a characteristic feature of
macroangiopathy. One manifestation of ischemic
gangrene of the foot is finger and development of
necrosis (Fig. 51).
When microangiopathy may occur a paradoxical
phenomenon: the presence of deep venous
disorders, up to the necrotizing process, while
maintaining ripple a.dorsalis pedis et a. tibialis
posterior and the absence of any significant pain.
In Fig. 51. Ischemic form of diabetic foot
(disarticulation I finger the development of
secondary necrosis in the surgical wound).
Features of necrotic lesions in diabetes
The clinical picture of purulent-necrotic complications of diabetic angiopathy is characterized by atypical
course. Wound healing of any type of diabetes dramatically impaired. Feature of the disease is a
significant backlog of local changes of the general symptoms. The spread of purulent-necrotic process
goes on tendon sheath, ligament, aponeurosis at a relatively well-preserved skin. The disease can be
protracted relapsing character with the extension phase of exudation, and destruction, and an extremely
slow onset phase of proliferation.
The features of wound healing in diabetes are:
1) violation of the chemotaxis of phagocytes and functional decline in their activity, and 2) slowing down
of collagen synthesis, and 3) lethargy granulations and delay their appearance in the wound, and 4) the
timing delay of epithelialization.
In diabetes, immunologic changes abruptly reaction. Damage to phagocytosis against violations of
humoral immunity leading to increased susceptibility to various infections.
In 90% of patients with portal of entry are localized in the ungual phalanx or the interdigital spaces.
Frequently observed in skin lesions haircut nails, minor mechanical damage. Paronychia develops first,
then the infectious process extends to the foot. Other sources of pyo-necrotic lesions of the foot are the
wounds and diabetic ulcers of fingers, feet and legs with the development of phlegmon of the central,
medial and lateral cells spaces of the foot.
Skin lesions and paronychia of foot - the most common cause local gangrene in the foot.
Gangrene of one or more fingers may be dry, with a clear line of demarcation, and moist.
Typical of diabetes is the development of gangrene in the foot with a well-developed blood supply. Due
to the fact that such an option arises because of gangrene, severe neuropathy, pain is virtually absent, sick
late to seek medical care, despite the fact that the necrotic process spread over a considerable part of the
foot. The infection is often putrid character, dominated by the processes of necrosis, with a scanty
accumulation of pus.
Patients with diabetes are more likely than in the main population, there are different clinical variants of
anaerobic infections. Non-clostridial gas gangrene occurs almost exclusively in diabetes mellitus. The
~ 52 ~
anaerobic process is accompanied by severe diabetes necrolysis with blistering with serous-hemorrhagic
content.
Treatment
Current combined treatment of purulent-necrotic lesions of the lower limbs is in the recovery of diabetes,
reducing vascular trophic disorders, intoxication, withdrawal and inflammation sparing surgery.
The first determining factor in successful treatment is adequate correction of blood glucose. Are optimal
normoglycemia or blood glucose levels within 7.2 m mol / l fasting and no more than 10 m mol / l in 1.5 2 hours after meals.
Principles of complex surgical treatment of neuropathic diabetic foot infected form:
• Compensation for diabetes
• Unloading of the affected limb
• Targeted Antibiotic
• Anticoagulation, antiplatelet therapy
• Treatment of Neuropathy
• Surgical treatment of purulent focus
• Local medical treatment injuries
• Additional methods of treatment of a wound
• The plastic closure of the wound defect
The main condition for ulcer healing is the elimination of high pressure on this area, which is achieved by
imposing a special plaster cast for 3 - 4 weeks or wearing orthopedic shoes.
The use of antibiotics is shown in the presence of necrotic lesions, given the nature of the pathogen and
its sensitivity, the severity of the process and speed healing. Antibiotic therapy based on the type of
sequential therapy. When antibiotic therapy until the sensitivity of microflora to Assign broad-spectrum
antibiotics and antibacterials (metrogil) taking into account the possible presence in the focus of anaerobic
microorganisms. The duration of parenteral antibiotic therapy in patients with deep necrosis or gangrene
in the background of an adequate surgical treatment should be an average of 4 weeks, and in combination
with enteral administration through - up to 10 weeks with high doses of the drug.
Drugs of choice in antibiotic clindamycin are, amoksiklaf, imipinem, ciprofloxacin. In addition to the
intramuscular, intravenous antibiotics should use the techniques of regional infusion - intra-arterial,
intraosseous route of administration.
At the Department of General Surgery VPO "Mordovia State University of Mordovia" was first
developed and applied the method of intraosseous injection of drugs in the synthesis of Ph.D. thesis
Rygina E.A (2000). This method combines the advantages of not only regional but also tissue therapy,
which significantly increases the therapeutic efficacy of drugs administered.
Of great importance in ensuring the regional blood flow is given antiplatelet, angioprotectors,
antihypoxants and other means. For drugs with antiplatelet effects, include aspirin, chimes, trental, tiklid.
Anticoagulant effect is heparin, flogilin. Rheological properties improve blood reopolyglukine,
reoglyuman, polidez. To vasoactive drugs include nicotinic acid, derivatives of pentoxifylline (trental,
agapurin) Sermion.
For the treatment of patients with ischemic diabetic foot used intravenous prostaglandin E1 (vazaprostan).
The drug is injected at a dose of 60 mg / day to 250 ml of saline solution for 10-14 days. Pathogenetically
justified is the use of drugs with antioxidant effect: mexidol, dimefosfon, aevit, α-tocopherol, retinol
acetate.
In the pathogenetic therapy of neuropathy used drugs of alpha lipoic acid (tiotaktsid). Tiotaktsid 600 T
assigned 1 per day for 3 weeks. The drug is introduced into the I / O, slow, pre-diluted in 200 ml 0.9%
saline solution of sodium chloride. Then designate maintenance oral therapy 600 mg tiotaktsidous 1 per
day.
Used vitamins containing benfotiamine (milgama). Sugar Plum "milgama-100" (Germany) 100 mg and
100 mg of benfotiamine pyridoxine hydrochloride. The drug injection "milgama - N» 2 ml administered
~ 53 ~
daily i/v. In the future do for 2-3 injections per week, then go to the reception "milgamap -100» 1 tablet
daily.
To normalize the exchange of all kinds, neurovascular regulation of blood coagulation properties,
suppressing overproduction of hormones important to use countresular angioprotectors, anabolic
hormones (nerabol, retabolil, silabolin), cholesterol-lowering drugs (miskleron, diosporin, tribusponin,
lipostabil), preparations of nicotinic acid (teonikol, Nikoshpan , komplamin), vitamins (askorutin, B1 and
B6).
Treatment of diabetic neuro-osteoarthropathy include:
1. immobilization for 5-6 months 2. antibiotic therapy;
3. use of orthopedic footwear, 4. surgical techniques.
Principles of complex neuro-surgical treatment of ischemic diabetic foot form:
• Compensation for diabetes
• Unloading of the affected limb
• Targeted Antibiotic
• Anticoagulation, antiplatelet therapy
• Correction of ischemia
• Surgical treatment of purulent focus
• Local medical treatment injuries
• Additional methods of treatment of a wound
• Symptomatic treatment
The basis of surgical treatment of purulent-necrotic complications of diabetic foot put savings principle
(Fig. 52).
Diabetic Foot
Type A
Type B
Type C
(combination of A
and B)
Successful therapy of arterial
circulatory disorders
Treatment of diabetic foot by Bernhard Arlt
Type A - diabetic foot with a primary arterial blood supply to the violation, Type B diabetic foot with associated symptoms of neuropathy and arterial hypoxemia
By Arlt Bernhard only in patients with diabetic foot type B successful local (local) surgery. In patients
with diabetic foot type C primarily needed therapy aimed at restoring blood flow to meet local surgical
treatment.
~ 54 ~
Treatment of neuropathic ulcers carried a medical podiatrists. Treatment includes special handling for
ulcers - removal edges, necrotic tissue, areas of hyperkeratosis, scabs, interfering marginal epithelization.
During the intervention is carried out by inoculation pus breeding ground for verification of the causative
agent and determine its sensitivity to antibiotics. If there is a painless superficial ulcers and no signs of
cellulite are shown dressing in an outpatient setting, oral antibiotics.
Surgical treatment should be gentle and wear, possibly delayed in nature, aimed at conducting local
operations that preserve the limb or its supporting function.
Elective surgery in patients with diabetes should be carried out in the morning and possibly early in the
week, which makes it possible to provide better monitoring of patients in the postoperative period.
Local surgery (necrectomy, amputation finger) is used in the absence of edema, a normal skin condition
and stored in the femoral artery pulsation, good efficacy of antibiotic therapy, a good blood supply of the
foot (according to the Doppler ultrasound).
Surgical treatment of purulent necrotic phlegmon cellulitis is in the showdown, the evacuation of pus as
possible necrectomy, drainage.
For the opening of the foot plantar phlegmon used depending on the location of the abscess medially or
laterally-foot-foot sections of Delorme.
Initially, perform an audit of necrotic suppurative focus, identify and reveal pus formed streaks and
pockets of the fracture of bones and joints. Then excised obviously nonviable tissue and tissue
imbibirovannye pus, remove all the tendons are located in the purulent focus. Leaving only viable tissue.
The spread of necrotic suppurative focus without clear boundaries can not achieve radical surgical
treatment during the same operation, so is suitable necrectomy, landmark necrectomy that allow
distinguish clearly necrosis.
The ongoing necrotic process dramatically worsens diabetes, leading to decompensation of carbohydrate
metabolism, ketoacidosis, and in some cases and hyperglycemic coma. Should not rush to conduct an
amputation. All available means and methods directed to transfer wet gangrene dry.
Indications for surgical interventions in the necrotic lesions of the foot, depending on the urgency of the
operation are presented in Table 3.
Local treatment of wounds is the daily dressings, excision of necrotic tissue. Before the appearance of
granulation after treatment of a wound antiseptic bandage with ointment in a water-soluble base.
Active removal of toxins from the body is achieved by using hemosorption, plasmaeritrosorbtis,
plasmapheresis, and ultraviolet laser irradiation of blood. Bactericidal effect of sodium hypochlorite
solutions possess and ozonized solutions that can be used intravenously as well as locally in the necrotic
focus. In the treatment using hyperbaric oxygen therapy.
The indications for amputation of toes are:
- Dry or moist gangrene or phalanges of fingers
- Dry necrosis of the surfaces of the fingers,
- Suppurative destructive osteoarthropathy and osteomyelitis of bones,
- The development of gangrene of large ulcers.
Performed amputation wedge 2-3-4 toes, amputation 5.1 angulate fingertips. In all cases, the resection is
performed distal metatarsal head.
In patients with coronary and neuro-ischemic CP after failure of medical therapy, or progression of
ischemic preservation, the presence of stenotic atherosclerosis (by angiography) were recommended
reconstructive surgery thrombusarterectum Y, angioplasty, distal bypass surgery. Diabetes is not a
contraindication to bypass surgery, stents and distal tibial and peroneal to the vessels needed to restore
blood flow to the diabetic foot. If through the arterial reconstruction was able to improve blood
circulation, on the ischemic foot amputation may be performed by the finger.
Absolute contraindications for reconstructive surgery for chronic lower limb ischemia are: chronic heart
failure III A of Art., Acute myocardial infarction, acute cerebrovascular accident; total calcification of the
aorta and vessels of the lower limbs, absence of blood flow in the distal vein.
In diabetic gangrene of the foot for limb salvage using amputation of the foot.
~ 55 ~
Trans metatarsal amputation of the foot is shown:
- In patients with good blood supply of the foot against the background of neuropathy, and infection with
a lesion of the distal part of the foot;
- In patients with ischemic diabetic foot shape with limited gangrene of fingers or most of the gangrene of
the distal part of the foot.
In the treatment of diabetic gangrene is necessary to achieve distinguishing necrotic foci, and the
transition to dry wet gangrene.
Indications for high amputation after prolonged conservative treatment, not brought the desired results
are:
- Extensive ischemic necrosis of the anterior and middle part of the foot and heel;
- Wet gangrene of the foot with the spread of proximal extremities, with progressive intoxication;
- Long-existing extensive necrosis of the plantar surface in combination with severe destructive forms of
osteomyelitis of the foot bones;
- Critical limb ischemia with severe pain that can not be a conservative therapy, surgical vascular
impossibility of correction.
- Suppurative destructive arthritis of the foot.
With extensive necrotic lesions of the most favorable position in terms of amputation rehabilitation are
amputated at the lower third of the leg.
Amputation of leg at the level of choice and is indicated for widespread gangrene or in connection with
the loss of the support function (most of plantar necrosis of the skin, including the heel area, extensive
non-healing sores of the foot).
Amputation at the thigh level shows at popular gangrene, the progression of necrotic suppurative process
in the lower leg, which developed as a result of severe ischemia, sepsis. Operation of choice is a skinfascial-muscular method of amputation.
Acute specific surgical infection
Tetanus
Tetanus - a specific acute infectious disease caused by spore-forming anaerobic bacillus B. tetani.
Secreted exotoxin consists of a stick and tetanospazmina tetanogemolizina. Tetanospazmin, acting on the
nervous system, causes the development of tonic and clonic convulsions of striated muscle, and destroys
red blood cells tetanogemolizin. Manifestations of the disease are determined by the action of exotoxin in
the body.
B. tetani is found as a saprophyte in the intestines of many domestic animals (horse, cow, etc.), as well as
humans. Excreted in the feces, the pathogen enters the soil. If any accident contaminated wound is an
immediate risk of the disease tetanus. The highest incidence observed during the wars, as gunshot wounds
are almost always contaminated.
The incubation period of tetanus ranges from 4 to 14 days, but the disease can develop at a later date.
The shorter the incubation period, the heavier the clinical course of tetanus and higher mortality.
Incubation period is determined by: 1) type (rods, spores), the dose and virulence of microorganisms, 2)
the localization, nature and extent of tissue destruction;
3) the state of immune-body forces.
The man is very sensitive to tetanus toxin and has almost no natural immunity to it.
Classification
I. Depending on where the introduction of the pathogen distinguish
The following types of tetanus: the wound, after infection , post-burn, post-operative, after frostbite, after
electric shock.
Allocate as neonatal tetanus and post-natal tetanus, which develops when the penetration of the pathogen
through the lining of the uterus or birth canal. Tetanus can also occur after a miscarriage.
II. The prevalence of isolated:
~ 56 ~
a) The general (common) Tetanus: I) primary common form;
2) the descending form, 3) rising form in which seizures begin with a plot wound up and distributed to
remote areas with the development of lockjaw.
b) local (limited) Tetanus: 1) limbs, 2) head (tetanus cephalicus), developed under the influence of toxin
on the cranial nerves. With the affection of the facial nerve paresis or convulsions observed facial
muscles, with the affection of IX-XI pairs of nerves - a violation of taste. In severe cases, seizures occur
pharyngeal muscle spasm of the glottis - this form resembles the picture of rage and, therefore, called
tetanus hydrophobicus; 3) the body (including viscera tetanus), 4) a combination of limited locations
(arm, torso, etc.).
Local tetanus limited lesion of different muscles in the wound, the disease more easily than with general
tetanus.
It is believed that local tetanus is caused by the uneven distribution of tetanotoksine with maximum
concentration and the effect on the corresponding segments of the spinal cord, which explains the local
symptoms.
Local tetanus is the first phase of general tetanus, but often fails to recognize.
III. On the clinical course are four forms of tetanus:
1) acute, characterized by the rapid flow, 2) chronic, and 3) a pronounced tetanus, and 4) worn form.
Distinguished: the shape of a very severe, moderate, light. The more severe form of the disease, the
shorter the incubation period.
The clinical picture.
In the prodromal period are determined by the initial, Just noticeable symptoms of tetanus - headache,
fatigue, irritability, weakness, profuse sweating, pain, stress and a twitching of the muscles around the
wound area. The most characteristic symptom - the emergence of tonic and clonic spasms of skeletal
muscles. The disease begins acutely. Appears fatigue of masticatory muscles during eating, developed
tonic spasms - lockjaw, which makes opening the mouth. These seizures are sometimes replaced by
clonic. In some patients, there is also muscle cramps in the wound area.
Facial muscles spasmodically contract and give the face a typical expression, known as "sardonic smile"
and characterized the expression of scornful laughter. With the development of the disease quickly spread
to the convulsions muscles of the neck, back, abdomen, extremities and accompanied by excruciating
pain in the muscles.
Tonic and clonic convulsions occur at least, even a slight stimulation (touch, light, etc.). Spastic
contraction of the muscles of back, neck and extremities accompanied by a sharp reextent trunk and
extremities. This situation is called opisthotonos (Fig. 53).
Seizures lasted several minutes. Severe twitching of
muscles can cause ruptures of muscles or broken bones.
At the beginning of the disease increases the
temperature of the patient's body. Sometimes the
temperature reaches 42 ° C or more, there is increased
heart rate to 120 beats per minute, heart sounds - loud
and clear. Perspiration. During the general convulsions,
death can occur as a result of asphyxiation caused by a
In Fig. 53. Opisthotonos of tetanus.
strong reduction of the intercostal muscles, larynx, and
diaphragm. Death from tetanus may occur in 1 - 2 days
(fulminant form), the acute form - for 4 - 5 days.
Subacute form of tetanus is characterized by slow attack symptoms, moderate their expression, in this
form the majority of patients recover within 20 - 30 days. In chronic tetanus muscle tension develops
slowly, clonic convulsions is not marked, temperature is normal or low-grade: the disease lasts several
weeks or months and ends in recovery the patient.
~ 57 ~
Complications of tetanus can be divided into early, associated with tetanus and wound complications, and
late.
Of early complications occur pneumonia. Pneumonias in tetanus – atelektatitis , aspiration, hypostatic.
Asphyxia, together with pneumonia is a major cause of death due to tetanus.
During the tetanus may develop anaerobic or purulent-septic wound complications, which are revealed to
the development of tetanus or during treatment.
Diagnosis of tetanus.
Early symptoms of tetanus are: 1) dragging pain in the wound, muscle twitching this area, 2) excessive
sweating, not corresponding to the height of rise of temperature, 3) sometimes back pain.
Bacteriological study has practical implications for early diagnosis.
In the early stages of the disease and obscure, obliterated the clinical picture of tetanus must be
differentiated from the following diseases: strychnine poisoning, encephalitis, meningitis, basal skull
fracture, tetany, rage, hysteria, myositis, etc.
Prophylaxis.
All preventive measures are divided into two groups.
1.Specific, active-passive antitoxic prevention, aimed at enhancing immunity to tetanus toxin. It is the
active immunization of antitetanus toxoid
(1 ml, after 3 weeks. 1.5 ml and after 3 weeks. Another 1.5 ml of toxoid under the skin) and a mandatory
intramuscular 1500-3000 ME tetanus toxoid after every accidental injury.
Preferred prophylactic agents during
emergency specific prevention of tetanus is presented in Appendix 1.
Previously intradermally into the anterior surface of the lower third of the forearm is introduced from a
specially enclosed vial 0.1 ml of serum diluted 1:100. If after 20 minutes of induration at the injection site
serum does not exceed 0.9 cm, redness around the small, injected subcutaneously with 0.1 ml of undiluted
serum and in 50 - 70 minutes with no response - the entire dose. With the introduction of a positive
reaction test doses of serum should be repeated only with extensive injuries. Administered subcutaneously
at intervals of 20 min - 0.5, 2.5, 5 ml of serum diluted 1:100, and in the absence of reaction - the rest of
the dose. If there is no sample vials of serum, the serum is usually introduced subcutaneously at a dose of
0.1 ml and 30 min - 0.2 ml, and in the absence of reaction in 1 - 1 1 / 2 hours - the rest of the dose.
2.Nonspecific prevention consists of measures aimed at removing bacteria from the wound and the wound
in the creation of conditions unfavorable to their development. These activities are reduced to an early
and complete debridement, which mechanically release it from hitting ¬ Shih bacteria and dead tissue,
blood clots, which are a breeding ground for microorganisms.
Emergency prophylaxis of tetanus includes primary debridement with removal of foreign bodies and
necrotic tissue and specific prevention of tetanus.
Indications for emergency specific prevention of tetanus.
a) Injury to the violation of the integrity of the skin and mucous membranes.
b) frostbite and burns II-IV degree.
c) unsafe abortion.
d) Delivery outside of hospitals.
e) Gangrene or necrosis of any type, abscesses.
f) Transactions related to the opening of the lumen of the gastrointestinal tract.
g) The animal bites.
h) Penetrating wounds of the abdomen.
The main objectives of a comprehensive treatment of tetanus:
1. Reduced income and neutralization again coming from a wound in the body of tetanus toxin.
2. Decrease and total cessation of tonic and clonic convulsions.
3. Improve the overall normalization of cardiac activity, relief of pulmonary ventilation.
4. Prevention and control of secondary complications (pneumonia, sepsis, etc.).
~ 58 ~
Treatment of tetanus is carried out in complex:
1. Produce a broad revision, wound treatment under general anesthesia.
2. Tetanus toxoid is administered by the method of A. Bezredko, intramuscularly, immediately after the
diagnosis of disease. The dose for adults is 100000 - 150000 ME; for newborns 10000 - 20000 ME, for the older children - 20000 - 80000 ME. Before the introduction of the serum is
heated to 36-37 ° C. The introduction of serum repeated within 2 - 3 days in a row, reducing the dose
every time 50 000 ME.
These doses provide adequate protective levels (0,1 ME in 1 ml of serum from patients) needed to
neutralize free circulating toxin in a long time.
Overall course dose of serum is usually 200 000 - 350000 ME. Serum recommend intramuscular
injection, and only in extreme cases, along with intramuscular use on the first day by slow intravenous
administration of 50 000 ME tetanus serum diluted with isotonic sodium chloride solution 5 times.
3. Used drugs, neuroplegic therapies and muscle relaxants to reduce or even stop seizures.
a) Of the anticonvulsants with mild to moderate severity of seizures by intravenous diazepam is used in
combination with hexenal, thiopental sodium and chlorpromazine-(50 mg every 6 hours). In severe
persistent cramps and muscle relaxants are used.
b) From neuroplegic therapies increasingly using chlorpromazine. The drug is used in 2.5% solution of 4
ml intramuscular injection of 4-5 times per day.
Applied also neuroplegic mixture: 1 - 2 ml of 2.5% solution of chlorpromazine, 3 ml of 1% solution of
diphenhydramine on 5 - 6 times a day.
c) Of the curariform resources used hondelfin, diplatsin.
In severe tetanus, involvement of respiratory muscle cramps and threatened asphyxia injected
depolarizing muscle relaxants anti action (tubocurarine) the transfer of the patient on mechanical
ventilation (ALV).
4. In order to improve cardiac used kordiamin, korglikon. To improve breathing produce oxygen
inhalation.
5. For the prevention of wound infection, pneumonia prescribe antibiotics. Tetanus patient must be in an
isolated, dark, remote from the noise chamber. Observation and care is carried out individually.
As a result of suffering a tetanus immunity is not created.
Rabies
Rabies - an acute viral illness that occurs after exposure to damaged skin saliva of infected animals.
Characterized by development of a kind of fatal encephalitis.
The etiology and pathogenesis. The causative agent belongs to the rhabdovirus. Pathogenic for many
warm-blooded animals that are beginning to shed virus in saliva 7 - 8 days prior to the onset of clinical
symptoms. Following the introduction of the virus through broken skin on the nerve trunks reaches the
brain, causing in him swelling, hemorrhage, degeneration of nerve cells. The virus enters also in the
salivary glands and saliva released into the environment.
Symptoms within. The incubation period lasts from 7 days to one year (usually 1 - 3 months). Allocate
the stage warning, excitement and paralysis. Stage lasts for precursors 1 - 3 days.
Under the precursors the patient has discomfort in the area of the bite or spit (burning, pulling sensation,
itching), although the wound healed already, unexplained anxiety, depression, and insomnia.
Excitation stage is characterized by hydrophobia (rabies), aerophobia, subfebrile temperature, increased
salivation, the emergence of hallucinations. I sometimes see rampage attacks from aggressive actions.
After 2 - 3 days excitement turns to paralysis of the muscles of limbs, tongue, or face. After the onset of
clinical symptoms of patients unable to save. Death occurs in 12 - 20 hours after onset of paralysis.
Treatment.
Rabies is help from the local treatment of wounds, scratches and abrasions, the introduction of rabies
vaccine , or simultaneous use of rabies immune globulin and rabies vaccine .
~ 59 ~
Rabies The culture concentrated purified inactivated dry is a vaccine strain of rabies virus Vnukovo-32.
Local treatment of injuries
Local treatment of wounds, scratches and abrasions are extremely important and should be performed
immediately or as soon as possible after the bite or injury: wound surface copiously washed with water
and soap (or detergent), and the wound was treated with 70% alcohol or 5% tincture of iodine. If there are
indications for the use of rabies immunoglobulin, it is used just before suturing.
If possible, avoid suturing the wound. Suturing is shown only in the following cases:
- With extensive wounds - more suggestive of skin sutures after preliminary treatment of the wound;
- For cosmetic reasons (the imposition of skin sutures to the wound a person);
- Suturing of bleeding vessels in order to stop external bleeding.
After the local treatment of injuries immediately begin treatment and preventive immunization.
Therapeutic and prophylactic immunization
Indications: contact and bites people mad, suspicious for rabies or unknown animals.
Contraindications. Not available.
The scheme of therapeutic and preventive immunization. Detailed scheme of therapeutic and prophylactic
immunization and notes to the scheme presented in Appendix 2.
Rabies immune globulin (RIG) to designate as soon as possible after contact with the disposable,
suspicious for rabies or unknown animals (see Figure therapeutic and prophylactic immunization in
Appendix 2), but no later than 3 days after exposure. RIG does not apply after the administration of rabies
vaccine.
The dose of rabies immune globulin (RIG). Heterologous (horse) rabies immunoglobulin is assigned to a
dose of 40 ME per 1 kg body weight of adult or child. Homologous (human) rabies immunoglobulin is
assigned to a dose of 20 ME per 1 kg of body weight.
Example: The victim's body weight 60 kg, the activity of the immunoglobulin (indicated on the labels and
capsules pack), for example, 200 ME per 1 ml. In order to determine the required dose for administration
of immunoglobulin to the weight of the victim (60 kg) multiplied by 40 ME and divide that number by
the activity of the drug (200 ME), that is:
60 × 40 = 12 ml
200
How can the majority of the calculated dose should be infiltrated with AIG in the tissue around the wound
and deep wounds. If the anatomical location of injury (finger-tips, etc.) can not enter the entire dose in the
tissue around the AIG wounds, the rest of AIG injected intramuscularly (muscle buttocks, upper thigh,
shoulder). Localization of immunoglobulin should be different from the place of vaccination.
Anaerobic surgical infection (gas gangrene)
Anaerobic infection - is one form of wound infection, in which the decisive role played by various types
of anaerobic microorganisms. Anaerobic bacteria are the basis of the normal human microflora.
For an infection to an additional condition: trauma, dysbiosis, the operation - that is, the circumstances
under which the representatives of normal microflora of the fall in unusual circumstances and are
beginning to show its pathogenic properties. If you violate the integrity of organs and various anaerobic
microbes injuries are almost always present. Therefore, any surgery or trauma may be complicated by an
anaerobic infection.
Anaerobic non-clostridial infection, especially self-infection is caused by saprophytic (conditionally
pathogenic microflora).
Clostridial (spore) microbes should be seen as an invasion from outside. In the wound healing process,
usually involving anaerobes and aerobes in different proportions.
Anaerobic wound infection (gas gangrene). This type of wound infections among the most formidable,
life-threatening complications of wounds of any origin. The most commonly causes gas gangrene
~ 60 ~
Clostridium perfringens. Second place belongs to chactote Cl. novyi (Cl. Oedematiens), Cl. septicum, Cl.
histolyticum.
Predisposing factors.
1. Extensive crushing of tissues. Gunshot wounds and comminuted with extensive injuries, contaminated
land and scraps of clothing.
2. Local or general circulatory disorders: tight bandage, bandaging, or thrombosis, severe blood loss.
3. Primary surgical treatment of heavily contaminated wounds, performed within 6 hours after injury.
4. Inadequately performed initial debridement.
5. The reduced reactivity of the organism, fatigue, exhaustion, prolonged starvation, hypothermia,
treatment with glucocorticoids.
Classification. 1. On pathoanatomical classification are the following forms of anaerobic gangrene:
emphysematous, edematous (toxic), mixed, necrotic (putrefactive), abscess and tissue melted.
Emphysematous (classical) form is characterized by predominance tissue gas over the swelling. The
primary agent of her most is Clostridium perfringens.
Edema (toxic) form differs by a sharp toxicity, prevalence of edema on gas production. Pathogen Cl. Oedematiens.
The mixed form is reminiscent of toxic gas-and anaerobes.
Necrotizing form characterized by the disintegration of tissues. Most often it is the causative agent of Cl.
Sporogenes.
Abscess form. Emphysema and edema are less pronounced. Occurs in combination with suppuration.
Tissue melted form, occurs only hard and vigorously.
2. Clinical classification identified two forms: acute and lightning.
3. By anatomical classification there are three most common forms of anaerobic infections.
1. The primary lesion of the muscles (myositis clostridial class-classical form).
2. The primary lesion of subcutaneous fat and connective tissue (clostridial cellulitis or edema-toxic
form).
3. The mixed form, where the pathological process involving all types of soft tissue.
The clinical picture.
The incubation period of 3 - 6 hours to 1 - 2 days. Lightning forms can lead to death within the first two
days.
The main complaint: the increasingly intolerable pressing pain in the affected area. If the patient received
narcotic analgesics, pain may be absent.
Condition of the affected patient progressively deteriorated, as manifested severe weakness, pale skin,
sweating, feeling of anxiety. The pulse rate increases rapidly. Blood pressure drops, the body temperature
remains constant or increases sometimes, confused consciousness, delirium.
At external examination, attention is drawn to the growing soft tissue swelling, pale skin, often with no
other expressed classical signs of inflammation. On palpation of the subcutaneous tissue revealed a dense
infiltrate. Characterized by a gradual increase in swelling of extremities (symptom strings pressing or
dressing).
In diagnosis wounds sharply painful injury, with no redness, and suppuration, typical of other infectious
processes. On the surface of the wound is gray powder, discharge from the wound yellow-brown color
with an unpleasant sweet, putrid odor. On palpation of the wound is determined by a crackling sound.
Marked decrease in hematocrit, an increase of bilirubin due to hemolysis of red blood cells, leukocytosis
with a relative and absolute lymphopenia.
In the smear of the wound determined by large Gram-positive rods.
Classic manifestation of anaerobic infections are cellulitis, fasciitis, myositis.
Differential diagnosis of wound infection aerogenous forms presented in (Table 18).
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T A B L E 18
Differential diagnosis of wound infection forms aerogenous
Symptoms
Clostridial
cellulitis
Clostridial
necrotizing
myositis
Streptococcal
myositis
Wet gangrene of
vascular origin
Incubation period
Beginning
Pain
Edema
More than 3 days
Acute
Strong
Is expressed
3-4 days
Subacute
Expressed
Is expressed
More than 5 days
Gradual
Nonpermanent
Explicit
Color of the skin
less than 3 days
Gradual
No
As a rule, there is
no
Not changed
Marked pallor
Exudates
No
Earthy black with
bubbles
No
The presence of
gas
The smell of
wound
The change of
muscle
The presence of
toxic
Profluvium
Marked, painted in
pink
As a rule, there is
no
Little sweet
Pale with a copper
tint
Pronounced
seroseptic
A light separation
minor
Sour-tart
Minor
Pronounced
necrosis
Easy
Septic
No
Easy
Massive necrotic
changes
Extremely difficult
Gradually
increasing to
severe
Profluvium
Septic
On a radiograph of lesions observed accumulation of gas, the p characteristic caused by the divergence of
the soft tissues (muscles, fat) under the action of gases.
Classic fasciitis is the most common variant of anaerobic non-clostridial cellulitis of the soft tissues.
When fasciitis is usually no loss of skin and muscle. The fascia has a dull color, thick. In later stages,
there is purulent fusion fascia.
If inflammation has spread to the muscle bundles - developing myositis, in which the foreground are the
effects of severe intoxication.
A distinctive feature of clostridial cellulitis is marked flatulence.
Isolation of anaerobic bacteria in the laboratory. Diagnostics. One of the common symptoms of
anaerobic infection is the absence of microflora in the crops with the standard methods of their selection
(without the use of anaerobic culture apparatus).
For rapid diagnosis of native produce smears or fingerprints, followed by Gram stain. By microscopy can
be assumed that in the inflammatory process leading role played by anaerobic microorganisms. Response
obtained after 30 - 40 min. The final bacteriological response with full identification of the microbe can
be obtained after 5 - 7 days.
The most appropriate method in the clinic now - it's cultivation of anaerobes in the anaerobic culture
apparatus. Necessary compliance requirements of 2: 1. Prevent accidental contamination, 2. Prevent loss
of agent from the time of the material.
Easier to protect from the action of anaerobic bacteria in oxygen transport of the material in disposable
syringes, but better - in special seamed bottles, such as penicillin. The material in the bottle is placed in a
~ 62 ~
puncture. Vial - transport medium with or without her, but obligatory filling an oxygen-free mixture
consisting of 80% nitrogen, 10% hydrogen and 10% of carbon dioxide, nitrogen use one.
Gas-liquid chromatography (GLC) allows to obtain reliable information on the involvement of anaerobes
in the inflammatory process as quickly as in the microscopic rapid diagnosis in 30 - 40 min. Volatile fatty
acids (acetic, propionic, butyric, isobutyric, valeric, isovaleric, caproic, phenol and its derivatives) are
specific metabolites of anaerobic microbial activity. Volatile fatty acids are toxic metabolites and their
level can be judged on the severity of intoxication. According to GLC and MS (mass spectrometry) can
be identified not only asporogenous anaerobes, but clostridial microflora (pathogens gas gangrene), which
is characteristic for the presence of 10-hydroxy acids. In the process of diagnosis of anaerobic infections
to clarify the local pathological changes apply all kinds of instrumental examination, including x-rays,
ultrasound, since according to the clinical examination of patients to judge the prevalence of the
pathological process may be difficult.
Treatment. The main condition for successful prevention of gas gangrene - removal of all nonviable tissue
and timely initial debridement.
Surgical treatment consists of a wide incision wounds in combination with excision of necrotic tissue. At
the same time beginning to enter large amounts of semi-synthetic penicillin, tetracycline. The most
common surgical option - the use of broad " trouser stripe" cuts involving dissection of the skin, fascia
and muscle to the bone with a thorough washing of wounds hydrogen peroxide, potassium permanganate.
Excision of the muscles that have, gray color, not bleeding when cut, is mandatory. Loose bone fragments
and splinters of bone viability is questionable, to be removed. Cut through all the muscle fascial sheaths,
as increasing swelling of the muscles leads to compression in their own bed. The wounds are left open for
good aeration, use tampons with hydrogen peroxide and potassium permanganate.
A characteristic feature of non-radical surgery is performed after the operation preserves the fever. So the
question of re-treatment wound (necrectomy) should not be put off, thinking that fever - a reaction to the
surgery.In the most severe cases (with the affection of gas gangrene limb) amputation or disarticulation
perform limb. Amputations performed without tourniquet with finger pressing the vessel by the guillotine
method. Surgical wound is left open.
Apply a bandage with anti-gangrenous bacteriophage, be sure to mobilize the limb. In the presence of
fracture immobilization spend skeletal traction or plaster Longuet. Using a circular plaster cast is not
valid.When choosing antimicrobials used drugs that specifically act on anaerobes (clindamycin
meropinem, thienyl, dioxidine, drugs metronidazole).It is shown that hyperbaric oxygen (HO). The reason
for its use are two factors: an antibacterial effect of hyperoxia and hypoxia, the presence of (circulatory,
fabric, mixed) in clinical illness (especially in a state of shock).
Serotherapy. For the prevention of anaerobic gangrene serum is used anti-gangrenous. Polyvalent serum
contains one ampoule toxoids against three types of agents of gas gangrene (as against 10,000 IU: against
Cl. Perfringens, Cl. Oedematiens, Cl.Septicum). Monovalent serum contains toxoids of only one type of
(50,000 IU each). Before the introduction of the main dose conducting intracutaneous test serum diluted
1:100 in order to identify the sensitivity to the protein.
Specific treatment consists of applying a mixture of anti-gangrenous sera. One therapeutic dose is 150
000 IU (50,000 IU of antiperfringens, antiseptikum, antiedematiens. When installed pathogen is
introduced only serum of the same name).
Delayed treatment of gas gangrene (late diagnosis, watchful waiting) with disastrous consequences.
Forecast. With appropriate treatment promptly initiated a favorable prognosis.
~ 63 ~
Primary prevention of surgical infection
Primary prevention of surgical infection includes prevention of diseases provoking secondary immunity
weakness first and foremost – diabetes mellitus. This kind of prevention implies regular blood sugar tests,
especially in patients with high risk. The following point is the appropriate personal hygiene and
sanitation. Especially high attention must be given to a working facilities and hygiene, preventing thus
microfissures and lesions on the hand. For the types of the surgical infection which seems to be the
complication of an inappropriate surgical treatment, some manipulations for example – postinjection
abscesses, septic complications of the inadequate wound debridement after major wounds. To this point
are the next situations also to be considered – insufficient opening of the purulent focus also leads to a
complicated postoperative course with the elevated body temperature.
Secondary prevention
Secondary prophylaxis implies mainly the prevention of the life-threatening complication of the disease
through the appropriate treatment, wound debridement and openings. For example the face furuncle can
lead to the sinus thrombosis with the intracranial spread of the infection, which is associated with high
mortality and morbidity. For many entities is therefore the prevention of sepsis crucial.
Tertiary prevention
This type of prophylaxis implies mainly the post curative rehabilitation of the patient, aiming first of all to
treat the background disease. Sanatorium-and-spa treatment becomes for this purpose the mainstay of the
follow-up such patients. Many patients with the common suppurative diseases need no prophylaxis. The
diabetic patients on the other hand require appropriate diet and tertiary prophylaxis. The rehabilitation of
the patients with the amputated lower extremities is the most challenging in this setting.
Rehabilitation of patients after hospital treatment
Most patients require outpatient monitoring after hospital treatment. At the same time every day make
shift bandage on the wound, if necessary, measurement of body temperature, blood test for leukocytosis,
etc. Specific rehabilitation measures generally are not required. Good nutrition, antibiotic therapy
significantly accelerated wound healing and patient return to normal work. Some patients who underwent
limb immobilization in the future need for some complex rehabilitation - physical exercise, etc. Require
special attention, patients with concomitant diabetes mellitus. Required are constant monitoring and
correction of blood glucose.
Practical skills
Practical skills needed to be obtained by the students generally include the thorough examination
technique which shortly can be described as following:
- Problems of the patients - patient complaints
- The detailed history of the patient
- Live history, habits, diseases, the problems of the relatives
- The present status – constitutional features, body mass index, obesity or weight lost
- Body temperature
- The respiratory system – with the skills of palpation, percussion and auscultation, breathing behavior
- Cardiovascular – pulse, heart auscultation, blood pressure measurement, edema
- Digestive – complaints, thirst in diabetic patients, appetite
- Urinary tracts – polyuria
- Endocrinology features
- Neural – sensitivity disturbance
- Local examination: with comparison of the lesion with the normal extremity
Fluctuation symptom
Function disorder
The 5 classic inflammation symptoms need to be evaluated by the students.
~ 64 ~
Case studies (10)
1. In a patient with multiple gunshot wounds to the thigh after surgical treatment of the wound sutured
tightly. Longuet superimposed plaster. After a day diagnosed with clostridium infection. Due to the
ineffectiveness of surgery performed under tourniquet amputation stump with the formation of made
flaps. Stump sutured to the abandonment of the glove 2 drainages. In what condition worsened, signs of
clostridial infections detected in the stump with the transition to the abdominal wall.
a) What mistakes were made in the treatment of a patient?
b) How to continue the treatment?
2. At the time of work during the excavation was injured with damage to the integument. After 3 days,
despite debridement, surgical suture appeared around edema, cyanosis, marked crepitus on palpation. The
doctor diagnosed "gas gangrene" and sent the material in the bacteriological laboratory.
Assignment:
a. What material was taken for investigation, collection and transport of feature?
b. Call the methods of laboratory diagnosis of gas gangrene: basic, accelerated, rapid methods. List the
main steps of the method.
c. What are agents of gas gangrene, specify their taxonomic position (family, genus, species), especially
the morphological and tinktorial properties.
d. List the factors that contribute to the development of gas gangrene.
e. Explain the pathogenesis of gas gangrene.
f. Gas gangrene is usually a mixed infection. Explain, in association with which the bacteria are clostridia
in the foci of infection and why?
g. How biologics conducted specific treatment? Its structure and principle of its receipt.
3. In the rural medical post (RMP) at the reception to GPs came the patient C. 59 years old. The patient
with the words of the patient is treated at home during the last week about CHD, hypertension. I took
injections of papaverine with dibazol. For 15 years, suffering from diabetes mellitus (type II), are not
regularly treated. 3 days ago in a patient in the left gluteal painful swollen seal zone of hyperemia. Later
joined by fever and chills notes in the evening. House itself has not taken drugs, about the increasing pain,
worsening of the patient being asked to GPs RMP.
Objective: The patient suffers from morbid obesity, weight is 120 kg with height 160 cm overall
condition of the patient at the time of the inspection of medium gravity, there is a forced situation, the
body temperature at the time of examination 37.0 C at night raises to 38,5-39 S. blood pressure 150/90
mmHg, pulse 88 b in minute.
Locally: the left buttock - especially the skin of the upper outer quadrant of the edematous, hyperemic,
sealed, and hot touch. Symptom fluctuation can not be mentioned because of the subcutaneous adipose
tissue is highly developed. However, in the center of the hyperemic zone is characterized by blanching of
the skin pattern.
Complete Hb - 127 g / l;
blood
Red blood cells - 4.5 x 10 x 12 / l;
count
White blood cell - 14.0 x 10 * 9 / L
- Stab - 12%;
- Segmented -44%;
- Eosinophils - 1% - basophils - (-)-monocytes - 4%;
ESR - 15 mm / hour.
4. Patient C. for about 3 weeks ago was the injury of metal shavings in the projection of the proximal
interphalangeal joint of the 3-finger palmar surface of the left. Chips removed in the medical unit at work,
the wound was treated with 5% alcoholic solution of iodine. Gradually increase the pain in the joint, the
~ 65 ~
finger became spindle-shaped, motion in the joints become painful sharply, and then with abnormal
mobility in it, one day before the treatment the patient noted increased body temperature to 38 C, almost
no sleep because of the intense pain of pulsating character.
The skin over the joint, hyperemic, edematous tissue strongly, finger spindle-shaped, sharp movements
are painful. There is a slight swelling of the dorsum of the left hand.
Your diagnosis? Stage of the process? Kind of a special survey, which helped establish the diagnosis?
View the online help? Postoperative patient follow-up?
Complete
blood
count
Hb - 121 g / l;
Red blood cells - 4.2 x 10 x 12 / l;
White blood cell - 10.1 x 10 * 9 / L
- Stab - 8%;
- Segmented -48%;
- Eosinophils - 1% - basophils - (-)-monocytes - 4%;
ESR - 12 mm / hour.
5. In the RMP at the reception for invited GPs H. patient for 19 years. Patient notes sickly seal the left
breast, fever to 38.5 C, and headaches. The patient has recently (last week) had her first child and breastfeeding, while noting moderate pain during feeding (about which she had stopped to feed this chest).
Home alone to attach ointment bandage with alcohol. After that marks a sharp deterioration in pumping
pyorrhea. The patient grew and developed normally, no bad habits. Birth proceeded without
complications, gave birth to a term vaginal delivery.
Objective: general condition of the patient at the time of the inspection of medium gravity, there is a
slight hyperemia of face, body temperature is 37.5 C at night raises blood pressure to 110/70 S. 38,5-39
mm Hg, pulse 96 b per minute .
Locally: Left breast increased slightly compared to the right, mostly in the upper gland seal and marked
hyperemia. Symptom fluctuation is positive. With light pressure and pumping marked pyorrhea from the
nipple. Axillary lymph nodes increased somewhat, moderately painful. The right breast and lymph nodes
in the opposite side intact.
These surveys, conducted by general clinic
Complete blood
Hb - 119 g / l;
count
Red blood cells - 4.2 x 10 x 12 / l;
White blood cell - 13.1 x 10 * 9 / L
- Stab - 8%;
- Segmented -48%;
- Eosinophils - 1% - basophils - (-)-monocytes - 4%;
ESR - 12 mm / hour.
6. In a patient with localized on face furunculosis person within the last day the temperature increases,
and headache. Increased body temperature to 38 C.
What are the possible complications boil faces?
What is the tactic of GPs in this situation?
7. Patient F, 42 years old, one day before treatment to GPs to receive said increase in temperature to 39 C
with chills and headache. An objective examination revealed a clear-cut and bright zone of hyperemia in
the right leg, with single bubbles in the center of the flare. From the words of 2 years ago noted this
symptomatology. Combined therapy did not receive.
~ 66 ~
Your diagnosis? Spend the differential diagnosis with other diseases with similar events taking place?
The tactics of GPs in this pathology?
Types of prevention of this disease?
8. Patients after 6 months ago hysterectomy with appendages, followed by repeated treatments of
radiation and chemotherapy, there is a vast area of redness and fluctuations in the right buttock, without
clear boundaries, which appeared after intramuscular injection in an outpatient setting. The temperature
increase at the same time moderate. Revealed an abscess cavity, the patient's condition improved
somewhat, but after 3 days and observed similar phenomena on the left.
Your diagnosis?
Your opinion about this case - what is that?
Specify the methods of research?
9. Patient E., aged 17, complaints of pain and redness of the skin on the anterior surface of the forearm,
pain in right armpit during movements of the shoulder joint. The body temperature of the previous night
had risen to 38.5S. 2 days ago when the patient chores injured thumb of his right hand.
Your assumptions at the expense of the underlying disease?
What causes this specific symptoms?
Treatment strategy?
10. In 46 years the tractor on the back of the neck indicated a tight painful infiltrate with extensive
congestion zone. Infiltrate slightly raised above the skin and spontaneously was discovered a few holes.
The general condition of the patient of moderate severity. There is an increase in body temperature to 39
C. Any movement is extremely painful neck.
List the diseases with similar symptoms?
Your final diagnosis?
Tactics of the GP-surgeon?
Explain to the patient primary prevention?
~ 67 ~
CONTROL TEST QUESTIONS (60)
Syndrome of fever in surgical infection
Topic: Characteristics of fever and other clinical manifestations of local surgical infection. Types of fever.
Methods of diagnosis and treatment. The tactics of the general practitioner. Rehabilitation and prevention.
Tests with one correct answer.
1. What factors other than microorganisms, often contribute to the development of anaerobic infections?
a) large, deep wounds contaminated with muscle injury
b) Loss of circulation
c) reducing the body's immune resistance
d) anemia
e) All answers are correct
2. Classification of sepsis in clinical course (specify the wrong answer):
a) fulminant
b) acute
c) subacute
d) chronic
e) a chronic relapsing
3. Choose the acute specific infection:
a) lymphadenitis, parotitis, bursitis
b) whitlow, abscesses, cellulitis
c) diphtheria of wounds, tetanus, anthrax, rabies
d) ulcers, fistulas, gangrene
e) abtsess, carbuncle
4. What types of fever do you know
a) low-grade
b) febrile
c) piretic
d) hyperperetic
e) all answers are correct
5. What type of fever occurs in peri appendiceal abscess
a) low-grade
b) febrile
c) normal
d) hectic
e) hypo febrile
6. What type of fever observed in appendicular infiltrate in a patient
a) normal
b) febrile
c) low-grade
d) hectic
e) hypo febrile
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7. In-hospital infection - this is basically
a) Gram-negative microflora
b) gram-positive microflora
c) both of above mentioned
d) gonorrheal
e) a specific
8. Healing clinic is most pronounced when applied to the purulent wound after surgical treatment
a) The primary joints
b) secondary sutures
c) the significant difference is not determined
d) Tertiary seams
e) without seams
9. Treatment of wound healing in the first phase includes
a) anti-inflammatory therapy
b) stimulating the growth of granulation
c) To promote the process of cleansing the wound, creating a wound rest
d) adaptation of the wound edges
e) the right a) and c)
10. Active drainage of purulent wound - this is
a) the outflow of pus on drainage tube by gravity
b) the outflow of pus on drainage capillary
c) washing the wound extended through the drainage tube
d) long-term drainage of the wound with a constant vacuum aspiration
e) right c) and d)
11. Nosocomial infections in recent years
a) is not observed
b) is rarely observed
c) there is often
d) tends to be more frequent
e) right c) and d)
12. Adverse effects of prolonged use of antibiotics can be explained
a) the weakening of the body
b) the creation of antibiotic-resistant flora
c) and then both
d) flu
e) acute respiratory viral infection
13. Characteristic for pyosepticemia
a) general weakness, exhaustion
b) purulent foci of metastasis in various organs and tissues
c) a sharp pain and inflammation of the stormy surface of purulent metastases
d) hectic temperature
e) the relative subsided by the end of the process of metastasis formation of pyogenic
14. Fever is considered "acute" it lasts
a) no more than 2 weeks
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b.) no more than 70 days
c) Not more than 1 week
d)more than a year
e)2 days
15 Increased body temperature from 37 to 38 C is:
a) subfebrile fever (from Lat. Sub under, below + febris fever)..
b) febrile fever.
c) b) piretic (from the Greek. Pyretos fever) fever.
d) c)is hyperpiretic fever.
e) d)normal temperature
16. Usually, with an increase in body temperature by 1 degree heart rate increases at least
a)8-12 beats a minute.
b) 30 beats per 1 minute.
c)40 beats a minute.
d) 50-54 beats per 1 minute.
e) does not increase
Tests with the issue containing an element of denial.
1. Nosocomial infection include everything except:
a) infection, acquired in a hospital setting
b) infection, hematogenous and lymphogenous spreading paths
c) infection, ranked in the survey
d) infection that hit during the operation
e) All answers
2. Complications of sepsis include all of the above, except
a) The septic bleeding
b) thromboembolism arteries and organs
c) ascites, anasarca
d) a septic endocarditis
e) pneumonia
3. Clinical classification of sepsis includes all of the following forms, except
a) The post-operative
b) recurrent
a) chronic
d) acute
e) fulminant
4. By the actions recommended in sepsis, are all listed, but
a) The opening of a purulent focus
b) the limited administration of the liquid
c) intramuscular injection of antibiotics
d) blood transfusion
e) the introduction of vitamin
5. The conditions favoring the development of the microflora of purulent
in its penetration into the body, are all listed, but
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a) the availability or integrity of the epidermis of the skin epithelium of the mucous
b) the penetration of several microbial species synergist
c) defects of the skin or mucous
d) the presence in the area of tissue injury
e) microbial penetration increased virulence
6. Purulent infiltration of the microflora causes a tissue reaction, expressed all the above, except
a) arterial hyperemia
b) venous stasis
c) the occurrence of pain
d) the local temperature rise
e) loss of sensitivity
7. Specify the major symptoms of anaerobic infection (wrong answer):
a) pain in the wound
b) bloating of the extremities
c) a feeling of tightness dressing
d) a twitch in the wound
e) swelling
Tests with a clinical situation, and several blocks of questions
1. At the reception the doctor asked a man aged 37, he a doctor, who recently returned from Yamana.
Concerned about the increase in body temperature every 48 hours - occurs with a regular increase and
decrease to normal. The minimum temperature below 37 C day. Your first diagnosis:
a) three day malaria
b) Diabetes
c) 4 days malaria
d) Avian influenza
e)fluctuation .
2. What kind of examination is needed:
a) EGDFS
b) Blood sugar
c) Blood on the sterility
d) colonfiberscopy
e) ultrasound
3. Where to send the patient:
a) surgeon
b) GP doctor
c) hospital of infectious diseases
d) therapist
e) urologist
Multiple-choice tests.
1. Signs of inflammation:
a) local temperature rise
b) Diabetes
c) hyperemia
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d swelling, impaired function
e)fluctuation .
f) obesity
g) pain
2. Fever Pale - fever accompanied with pale skin. It is characteristic of (2 answers)
a) sepsis.
b) peritonitis (end stage)
c)Hepatitis
d) influenza
e) mastitis
3. About unclear fever say when (3 answers)
a) fever lasts more than 3 weeks;
b) the temperature is higher 380S;
c) after a week cause surveys temperatures remains unclear.
d) All of fever clear
e) after a year.
5. Associate convulsions with fever may be, if (3 answers)
a) the child's age does not exceed 5 years;
b) there are no diseases that could be the cause of seizures (eg, meningitis);
c) seizures were not observed in the absence of fever.
d) Age of child no more than 2 years
e) There is no convulsions with fever
f) No answers
Subject: fever in patients with furuncles, carbuncles, hydradenitis, subcutaneous and corn abscess,
phlegmon, and lymphadenitis. Differential diagnosis of phlegmon lymphangites and erysipelas. Boil on
the face of danger. The role of diabetes and other metabolic diseases in the development of the carbuncle
and boils. Felon. Features of the flow depending on the surgical anatomy of the wrist. Cutaneous,
subcutaneous, tendon, joint and bone forms felon. Pandaktilitis. Paronychia and ingrown nails. The clinic,
diagnostic techniques, differential diagnosis, complications and treatment. The tactics of the SPM.
Rehabilitation and prevention. Pain and space-occupying lesions in the breast. Classification. Clinical
picture, diagnosis, differential diagnosis. Methods of investigation and treatment. The tactics of the SGs.
Rehabilitation and prevention.
Tests with one correct answer.
1. Burning pain, feeling of heat in the area of reddened, bright redness with sharp edges, high
temperatures typical for a disease?
a)erysipelas
b) phlegmon
c) abscess
d) anthrax
e) gangrene
2. A strong, painful, throbbing, sleep deprivation pain in the finger phalanx and sharply increasing when
lowering arms says:
a) subcutaneous panaritium
b)in erysipelas
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c) in Raynaud's disease
d) cutaneous whitlow
e) Raynaud's syndrome
3. The patient on the back of the neck there is inflammation of formation purple red in color with a lot of
pus in the form of points screens. In the analysis: sugar 12mmol / l, Lake. 11.0 thousand, ESR 20 mm / h.
What disease in a patient?
a) carbuncle
b) Anthrax
c) abscess
d) boil
e) abscess.
4. Deterioration of the general condition, appearance jerking, throbbing pain around the finger, even
swelling of the tissues with a smoothed interphalangeal furrows characteristic:
a) subcutaneous whitlow
b) Bone felon
c) tendinous panaritium
d)Articular felon
e) No answer
5. A sharp pain and swelling in the thenar region and the radial edge of the brush, smoothing of the
palmar creases and sharp pain on palpation characterized for:
a)subgaleal phlegmon brush
b)Interdigital phlegmon .
c) phlegmon of thenar
d) phlegmon of hypothenar
e) hydradenitis
6. Why to make radial and semilunar incisions with mastitis? (Indicate the wrong answer)
a)not to damage the milk ducts
b) not to damage the blood vessels
c) to create good drainage of pus
d) not to damage the nerves
7. The main sign of an abscess:
a)reddening of the skin
b) pain in affection
c) fever
d) dysfunction.
e) fluctuation
8.Furuncle, usually caused by
a) Streptococcus
b) Staphylococcus
c) the gonococcus
d) Pseudomonas aeruginosa
e) Proteus
9. Causative agent of hydradenitis is often
a) Streptococcus
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b) against
c) Staphylococcus aureus
d) Pseudomonas aeruginosa
e) E. coli
10. Abscess of infiltrate characterized by the presence
a) pain
b) hyperthermia
c) the fluctuations
d) flushing of the skin
e) leukocytosis with a shift to the left leukocyte
11. Patients with diabetes mellitus receiving insulin in the treatment of purulent wounds
a) indicated is the use of proteolytic enzymes (trypsin, chymotrypsin)
b) does not show the application of enzymes
c) use of the enzyme solved individually
d) all of the above
e) no answers
Tests with the issue containing an element of denial.
1. In the initial stage of acute serous mastitis is not applied:
a) cutting
b) preventing stagnation of milk
a) antibiotic therapy
d) ultrasound therapy
e) a retromammarial penicillin novocaine blockade
2. Distinguish between all these types of panaritium, except
a) Skin
b) subcutaneous
c) tendon
d) bone
e) palmar
3. Complication of subcutaneous felon third finger left hand
may be all of the following, except
a) tendon felon
b) The bone-felon
c) articular whitlow
g) phlegmon brush
d) forearm phlegmon
4. Danger of hypodermic felon 2nd phalanx of little finger
may be all of the above, except
a) the development of tenosynovitis
b) necrosis of the finger flexor tendon
c) the development of cellulitis of forearm
d) development of a phlegmon of the shoulder
g) fat pulmonary embolism
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5. In the treatment of furuncle in the first phase of inflammation
all of the following is applied, except
a) folding boil antibiotic solution dissolved in novocaine
b) the physiotherapy currents UHF
c) opening the focus of inflammation
d) high-calorie food
e) immunocorrecting therapy
6. Treatment of furuncle includes all of the following, except
a) rubbing the surrounding skin with alcohol 70 °
b) in the presence of necrosis - squeezing and dressing with a hypertonic salt solution
c) folding of penicillin with novocaine around the inflammatory infiltrate
g) sulfa drugs inside
d) UV irradiation
7. Indicated for the neck carbuncle all, except
a) hot compress with ointment Vishnevsky
b) by intramuscular injection of antibiotics
c) sulfanilamide drugs inside
d) vitamin
d) UV irradiation
Tests with a clinical situation, and several blocks of questions
1. At the reception, the doctor turned 59 years old man with complaints: a painful bulge in the occipital
region with a common temperature and a severe general weakness. In this connection became more
liquid to make a little thinner.
I. What is a provisional diagnosis can be assumed:
a)carbuncle
b) tumor
c) hydradenitis
d) lipoma
e) atheroma
II. What laboratory tests necessary for this patient, except:
a) sugar in the urine
b) of anal blood
c) blood sugar
d) of anal urine
e) TORCH infection
III. This patient's blood sugar 5.11 mmol / liter. Sugar in the urine of 4% What type of diabetes, given the
age:
a) diabetes -1 type
b) Type -2 diabetes
c) diabetes - comb type
d) Family diabetes
e) No diabetes
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Multiple-choice tests.
1. What are affected tissues in pandaktilitis:
a) skin
b) cartilage
c) tendon
d) joints, bone
e) mucous
2. What action will be recommended for the patient with mastitis:
a) Early operation with cuts
b) Timely operation
c) anti-inflammatory therapy
d) struggle with milk production
e) struggle with stagnation of milk
3. What are the cuts made during the opening of mastitis:
a) D-Volkovich
b) trouser stripe
c) Cross of Pirogov
d) radial
e) semilunar incision under the breast (according to Bardengeir)
4. What are the associated pathologies predisposing to the formation of furuncle:
a) peritonitis unclear etiology
b) vitamin deficiency
c) immunodeficiency
d) hypertension
e) Diabetes
5. On which areas of the body is often localized hydradenitis:
a) axillary region
b) navel
c) hands
d) face
e) in the crotch
6. The causative agent of erysipelas:
a) gonococcus
b) streptococcus
c) diplococcus
d) enterococcus
7. In the pathogenesis of felon plays a major role:
a) abrasions
b) pricks
c) Cracks
d) obesity
e) cachexia
8. Erysipelas is more often localized:
a) on the lower extremities
b) in the upper extremities
c) On the scalp
d) in small joints
e) in all areas of the body
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References (core)
1. Sepsis at the beginning of the XXI century. Savelev V.S et all.
Practice Manual, Moscow, Littera 2006
2. Essays of purulent surgery, V.F.Voyno-Yasenetskiy, 1946, Medgiz
3. Electronic manual on surgical infection, V.D Fedorov
4. General surgery V.K Gostischev, GEOTAR-MED, 2004
5. Infections in surgery, a guide for doctors, V.K Gostischev., 2007
6. Operational purulent surgery, V.K Gostischev, Medicine, 1996
7. Wounds and wound infection, M.I Kuzin, 1990 Medicine
References(additional)
1. Infection control in surgical practice.
Vivian G.Loo et all. ACS SURGERY. Principles and practice, 2008
2. Acute wound care. 2007 Stephen R.Sullivan et all.
ACS Surgery Principles and practice
3. Prevention of postoperative infection. 2008 Jonatan Meakins.
ACS Surgery Principles and practice
4. Soft tissue infection. 2007 Mark A.Malangoni et all.
ACS Surgery Principles and practice
5. Nosocomial infection
E.Patchen Dellinger 2003, ACS Surgery Principles and practice
6. Lee J.Skandalakis et all.
Surgical anatomy and technique, 2009 pocket manual. Springer
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