Delayed treatment of open wounds, soft tissue infection incision and drainage, surgical incision infection, etc. should be treated appropriately due to local histopathological reactions that cause exudate, pus, necrosis or tissue defects on the trauma surface. This treatment includes examination of the wound surface, removal of pus and necrotic tissue, placement or removal of drainage to change dressing and dressing, etc. This process is called dressing change, also known as dressing change or dressing application.
I. Wound classification
1, clean wounds are disinfected with iodophor, which is less stimulating and more effective; for clean, nascent granulation wounds, they can also be covered with petroleum jelly gauze to reduce the pain of patients during dressing changes and to reduce tissue fluid exudation and loss.
2, rich blood supply, small chance of infection of the wound available saline simple wetting, sterile auxiliary material dressing can be.
3, there is a skin defect of the wound defect area with saline repeatedly rinsed, around the available iodine volts routine disinfection, after disinfection, covered with saline gauze or petroleum jelly gauze, saline gauze is conducive to keep the wound fresh, dry, petroleum jelly gauze is conducive to the growth of traumatic granulation.
4, the principle of infected or contaminated wounds is to drain the pus, if necessary chap the sutures, expand the wound, thorough drainage, repeated flushing with hydrogen peroxide and saline in the wound, necrotic tissue should be given for debridement, you can also fill the wound with antibiotic gauze, the wound is best disinfected with iodine twice alcohol three times deiodination around the wound. Of course, infected wounds should be changed every day. In addition, when changing the medication for septic incision, do not mind the bad smell, must carefully wipe off the pus moss at the incision, and do not dare to touch the incision because of the patient’s pain, pus moss removed to have a slight blood oozing out, so as to help the incision heal as soon as possible!
5, decubitus ulcer, septic osteomyelitis and other infected wounds iodophor disinfection around the incision, while the incision to hydrogen peroxide, saline rinse, gentamicin dressing cover.
6, osteomyelitis wounds with bone outgrowth when the first change of medication should be diligent, because there is a lot of exudation, and the dressing should be more. During the dressing change, necrotic tissue should always be removed, and gauze can be placed in the medullary cavity. The empirical method is to first rinse the trauma with saline, then with 0,1% iodophor, then with hydrogen peroxide, and finally with Qingda gauze wet and dressing covered. When the trauma surface has fresh granulation and less exudation, perform surgery to remove the dead and sclerotic bone, use a suitable musculocutaneous flap to cover the trauma surface, external fixation frame for external fixation, and then perform bone lengthening after the flap becomes viable.
7. In patients with open fracture wounds with external fixation, the dressing change follows: firstly, disinfection with iodophor (while cleaning and removing necrotic tissue), secondly, disinfection with hydrogen peroxide, then saline rinsing, and finally, furacilin filling to cover the wound surface. Wait for its granulation growth, line free flap coverage.
8, fat liquefaction wounds are prone to fat liquefaction in fat-rich areas, at which time the incision is widely opened (all areas of fat liquefaction are opened), culture + drug sensitivity, and enhanced dressing changes. Such an incision should be changed for a long time, in order to shorten the time, after the initial disinfection in the local subcutaneous injection of gentamicin, placed glucose powder into the incision, daily change of medication, after the wound exudes less oil gauze to stimulate the growth of granulation, fresh after the second phase of suture or butterfly tape pulled together.
9, long ulcerated wounds to use Chinese herbal medicine change. Chinese medicine drug exchange has its own unique features, but usually there is no sterile concept. For example, for refractory sinus tracts (such as after brain surgery, after heart bypass surgery or sinus tracts caused by chronic osteomyelitis, usually early with eighty-two dan or nine one dan + red oil ointment, lifting rot and removing pus, and late with raw muscle san + red oil ointment closure, the effect is very good, even if the Pseudomonas aeruginosa or drug-resistant Staphylococcus aureus infection can be well cured.
10, for polluted oily wounds with turpentine to wash away the oil stains.
11, old granulation wound such granulation tissue regeneration ability is poor (dark red color, not fresh, uneven height, sometimes old bleeding appearance), the surrounding tissue is not easy to heal, scrape the surface granulation tissue with a scraping spoon to scrape or cut out, so that it bleeds, reveal fresh granulation, external application of rubber ointment (this is the Chinese medicine to decompose the muscle, Western medicine will be flushed with hydrogen peroxide to achieve the purpose of decomposition). If there is pus, attention should be paid to the presence of pus cavities or sinus tracts, and the change in the patient’s body temperature should be noted.
12, Pseudomonas aeruginosa infection of the wound is characterized by pus is light green, there is a special sweet fishy odor, if the wound surface crust, pus accumulation under the scab, there is necrotic tissue, to remove the scab, pus and necrotic tissue. Burn trauma early green pus infection can be cut scab implants. Also available 1% to 2% phenoxyethanol wet dressing, or 0, 1% gentamicin, 1% silver sulfadiazine, 10% methanesulfamilone and other solutions wet dressing. The traumatic surface can be wet dressed with 3% acetic acid and 10% chloral hydrate solution if it is small.
Second, the purpose of the drug change
1, observation of the wound.
2, removal of necrotic tissue.
3, clean trauma.
4.Drainage flow.
5.Promote tissue growth.
Three, the principle of drug exchange
1. the principle of asepsis
2, removal of inactivated necrotic tissue.
3. maintaining and promoting the growth of granulation.
4, to promote wound healing.
Four, the basic techniques of drug exchange
1.Fully understand the size and depth of the wound site, the amount of gauze filled in the wound cavity, the presence or absence of drainage and whether to remove or replace it, whether to expand the wound or flush it, whether to remove the stitches or sutures, etc. Check whether the required dressings, instruments and drugs are available first, and special supplies should be prepared, such as antibiotic solution for wound surface, local anesthetic blade for dilation, long vascular clamp probe for deep wounds, special drainage tube for suprapubic cystostomy replacement, etc. The patient’s mental state, general condition and the possible occurrence of the drug change process should be fully prepared with detailed understanding.
2, aseptic preparation general drug change requirements in the morning care or drug change room cleaning work after half an hour, it is best to change drugs in the drug change room. Wear a mask and hat, invite the patient to the dressing room, observe the wound situation (uncover the gauze should be uncovered in the direction of the wound, vertical uncovering is easy to make the wound open again), assess the number and type of instruments and dressings needed, and then go to wash your hands and then prepare the items for the dressing change. Generally need two sterile bending tray, two forceps, alcohol cotton ball, etc., clip take instruments, forceps must be head down, not cocked up, clip order first clip forceps, put the middle of the bending tray, clip gauze cover on top, iodine, alcohol divided on both sides of the bending tray, first clip iodine cotton ball after clip alcohol cotton ball (if first clip alcohol, residual forceps of alcohol clip iodine cotton ball will dilute the iodine, affecting the disinfection effect).
3, the operating hand to take the outer dressing, and then forceps to take the inner layer, if the dressing sticks with saline cotton ball wetting and then uncovered. Two tweezers, one touching the skin and one touching the dressing (the two should always not touch). Disinfection along the wound and suture mouth gently dip, and then (clean wound) from the inside out zigzag elimination, alcohol two or more times, the range to exceed the cover gauze. Cover gauze light side down, cover more than eight layers of gauze (generally a gauze block four layers). Sticky tape to follow the direction of the skin pattern and vertical gauze sticky, generally three, two sides of the pressure side sticky, the middle one. Finally wash your hands (to protect yourself).
4, the order first clean and then contaminated, first simple and then complex. This is also true for multiple wounds of a patient.
5, the frequency of drug change in principle, auxiliary material wet that should be changed
(1) general wounds : the first time within 24h, after every 2-3 days / times.
(2) special wounds: after mastectomy, 3-5 days/time; 3. after implantation: 7-9 days/time; 4. digestive tract fistula: 2-3 days/time.
V. Commonly used dressings
Choose the growth of the wound in the first few days is mainly the growth of granulation tissue, it needs a more moist environment, so the dressing can be used in several layers in the first few days to keep the wound relatively moist. In the later days, the growth of the wound is mainly the growth of keratin, and at this time the wound needs a relatively dry environment, so the dressing should be as thin as possible while playing a role of isolation. In addition to the role of protecting the wound from external contamination, the dressing also has a certain drainage effect, so dressing changes should ensure that the dressing is closely attached to the wound, especially when the wound is more depressed than the surrounding area.
1. Alcohol decubitus protection (50% alcohol), skin and instrument disinfection (70% alcohol) Wounds with intact epidermis can be changed with alcohol, but if the epidermis is broken, alcohol cannot be used, and iodophor is generally chosen. The classic disinfection method is 2% iodine two times alcohol three times deiodination disinfection.
2, iodophor is less irritating to mucous membranes, does not require deiodination with ethanol, has no corrosive effect and has low toxicity. Iodophor is better than iodine in terms of application (mucous membrane, skin, etc.) and disinfection effect (less allergic reactions), but it also has a range of application, which is not good for wounds with a lot of bleeding, and is not suitable for wounds that are too large. Some hospitals have eliminated iodine because of the many allergic reactions, the need for deiodination, and the corrosive effect. The application of iodophor and alcohol has a more adapted scope. Iodophor is complex iodine, which is ineffective or inefficient on greasy wounds or areas with well-developed sebaceous glands. Alcohol or iodine, on the other hand, is able to degrease and better fix bacterial proteins, and is more penetrating in places rich in sebaceous glands, so it is often used around wounds on the scalp.
3, saline (0, 9%) wound washing wet dressing. Generally used in the rich blood supply, more traumatic secretions, small chance of infection, and sensitive mucous membrane. The application of physiological saline is mainly for flushing and wetting, because for an extensive area of wounds or uneven wounds, flushing can remove some impurities and infectious materials.
4. Hypertonic saline is used when the oedema of the wound is heavy, and hypertonic saline can achieve local dehydration. Hypertonic saline with petroleum jelly gauze can stimulate the growth of granulation, and is often used clinically for wounds that have not been closed in one phase, or after the infected wounds have been thoroughly cleared.
5, hypertonic glucose is a dehydrating drug, which can enhance plasma osmolarity and produce dehydration. It is effective for infected wounds with poor local nutrition, large wounds, poor or ineffective after changing with other drugs, varicose veins on the lower extremities with surface skin erosion and ulcers, difficult healing of wounds, small burns of superficial degree II to deep degree II with obvious edema and slow healing of wounds, and decubitus ulcers. Hypertonic glucose can evenly distribute on the trauma surface, causing a hypertonic environment, resulting in dehydration of bacterial cells, loss of bacterial reproduction ability and death of the bacteria, and dehydration of local cells of the body, reducing edema of trauma surface and granulation tissue, and forming a protective film to prevent continued invasion of cells into the infection, improving local blood circulation, improving nutrition around the trauma surface, and promoting trauma healing; in addition, glucose also has a myogenic effect, which can reduce In addition, glucose also has a myogenic effect, which can reduce the pain of the wound and facilitate the healing of the wound.
6. Hydrogen peroxide (3%).
Clean wounds, ulcers and pus sinuses, loosen necrotic tissues and remove adherent dressings.
7.Gentamicin solution (0.2-0.5%) is used for local flushing of Pseudomonas aeruginosa and staphylococcal infected wounds.
8.Furacilin (0.02%) solution is used for surface disinfection of ulcers, purulent wounds, etc.
9.Zinc oxide gelatin is used for long-lasting ulcers.
10.Insulin is mainly used for non-healing wounds of diabetic patients.
11.Red mercury (2%) is used for disinfection of skin mucous membrane, and it is best to apply red mercury to skin wounds, which dries without dressing in ten minutes after application. 12.Cod liver oil is applied locally to promote epithelial formation of wounds.
13.Acetic acid (0.5-2%) is used for scald and burn infected wounds.
14.Chlorhexidine (0.05%) is used for trauma and wound irrigation.
15.Lifanos contraction wounds the best effect (direct wet cover).
16, magnesium sulfate (50%) solution for contusions, cellulitis, dermatitis and other anti-inflammatory and swelling. Local wet and hot compresses.
17, boric acid ointment (5%) burns, abrasions, skin ulcers and bedsores. Wet cover with boric acid solution to decay until the flesh buds are fresh, and the use of raw muscle powder can promote the growth of flesh buds.
18, saline gauze surface moist trauma is conducive to tissue growth, which is the main reason we usually like to use saline gauze to cover the trauma, while saline gauze also has the role of unobstructed drainage, but because the moist environment is also a breeding ground for bacterial growth, bacteria will enter the log proliferation period in 6-8 hours, so for serious infected trauma, to make to diligent change (preferably 3-4 times / day), many people like trauma. Many people like to add gentamicin wet dressing to the trauma, the first 1-2 times the effect is very good, long-term effect is not good, and easy to lead to drug-resistant bacteria.
19, Vaseline gauze Vaseline gauze can provide a moist environment conducive to the growth of trauma granulation, and can reduce the exudation of tissue fluid, early trauma can also stop bleeding, but for serious infection of the trauma to be used with caution, because it is easy because of poor drainage, often aggravate the infection.
Six, drug change precautions
1, aseptic phase I wound dressing change is generally in 24 hours, 72 hours routine observation of local swelling and exudation.
2. After open wound surgery, strive for 24, 48 and 72 hours for three consecutive days of drug changes, paying special attention to the easy emergence of hematoma or drainage to deal with abnormal conditions in a timely manner.
3, orthopedic trauma is more often seen infected trauma is skin necrosis, decubitus ulcer trauma, hypertonic saline used in heavy infection, exudation more trauma, can quickly reduce the trauma and granulation tissue edema, reduce exudation.
4. Reimplantation surgery or skin flap surgery with anastomosis of blood vessels can best be changed with furacilin solution similar to body temperature. Finger dressing gauze change should avoid ring wrapping, and it is best to fill with shredded gauze locally.
5, for large trauma, first of all, pay attention to clearing, for the already necrotic tissue including necrotic tendons and vascular tissue do not appease, strive for several times in the drug exchange, once the boundary is obvious then decisively removed. Reluctantly left, will only delay the growth of granulation, or even cause infection.
6. For the wound that has been cleared of necrotic tissue, pay attention to the growth of the granulation, the granulation tissue itself has the ability to resist infection, if there is no obvious exudation, then do not use antibiotics or other medication changes, only disinfect the skin of the wound edge with iodophor and cover it with wet saline gauze.
7. Oil gauze should not be put on the trauma, but on the saline gauze to prevent the saline from evaporating too quickly.
8, there are infected wounds pay attention to do a bacterial culture + drug sensitivity before changing the medication, can guide the anti-infective medication.