Drug changes are the most common thing for surgeons, yet they are also the easiest to neglect. A sterile incision can become infected due to improper dressing changes; skin flaps can become necrotic due to alcohol irritation; more headaches are some skin necrosis wounds that take a long time to heal through dressing changes; and bone outgrowth often takes a skin flap to fix. There is a lot to be said for changing the medication, and the right medication can often be turned into a miracle.
I have witnessed a patient with skin necrosis due to plate and bone exposure after internal fixation surgery, who was miraculously healed in less than a month by changing the medicine with the secret recipe of Chinese medicine. There is also a case of open fracture of finger bone, after cross*knuckle surgery, the skin necrosis due to rubbing injury, resulting in the extension tendon exposed, two weeks after the herbal medicine change, healed. It is significant: “grass can grow on rocks”. From then on, we pay more and more attention to the medicine exchange and are impressed by the profoundness of the motherland’s medicine. Now let’s take a look at the techniques of medicine change in each of the major schools.
The principle is: sterile. Clean. Remove inactivated necrotic, tissue. Maintain, promote the growth of granulation. Prevent wound exposure and cover exposed wounds. Promote wound healing.
As for saline, it is generally used in mucous membranes with rich blood supply, little chance of infection and acute sensation.
The combination of glucose and insulin has the effect of stimulating the growth of granulation
First of all, I will talk about the more suitable scope of application of iodophor and alcohol. Iodophor is a complex iodine, which is ineffective or inefficient for greasy wounds or areas with well-developed sebaceous glands. Alcohol or iodine, on the other hand, is able to degrease and better immobilize bacterial proteins, while being more penetrating in areas with abundant sebaceous glands. This is why they are used around wounds on the scalp. However, both of these are irritating. Therefore, they cannot be applied to open wounds.
Physiological saline is applied mainly for flushing and wetting, because it may be an extensive wound or a combined uneven wound, and it is hoped that flushing will remove some impurities and infections.
Insulin is mainly used for non-healing wounds in diabetic patients.
The purpose of hypertonic salts is that the local swelling of the wounds is not healed, but can achieve local dehydration, and some speak of the same effect of honey.
There are also localized gentamicin injections and so on mainly for infected wounds.
It is not a principle, right? Just like before, there is also the use of Neosporin. It is possible that the effectiveness of iodophor is not very confident reason. In the nick of time, it is still necessary to apply iodine and alcohol.
1, surgical change of medicine first of all to follow the principle of aseptic operation. It should be observed from the time of starting to take material until the end of the drug change.
2, when to use alcohol, when to use petroleum jelly gauze, it is learned. It is important to be familiar with the mechanism of action of saline, alcohol, iodophor, yellow gauze and Vaseline gauze so that you can choose appropriately when dealing with different wounds.
3. choice of dressing. Some people like to use a large number of dressings, thinking that this will be good to maintain the sterile state; some people only use a few layers, thinking that they can save costs. In fact, dressing more choice less choice is not appropriate. How much dressing selection is appropriate? This has to be said from the growth of the wound, in the first few days the growth of the wound is mainly the growth of granulation tissue, it needs a more moist environment, so the first few days dressing can be used more layers to keep the wound relatively moist.
In the later stages, 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 under the premise of playing the role of isolation. Why some people always do not see the wound cuticle healing in the late stage, I think it is related to the above.
Remember: the purpose of our surgical dressing change is: two to provide
namely.
1. to provide a relatively sterile environment for the trauma so that it will not be attacked again.
2, to provide a relatively conducive to the growth of the wound, healing environment, so that it heals as soon as possible.
The main purpose of dressing change is: 1. to observe the wound 2. to remove necrotic tissue 3. to clean the wound 4. to drain the wound 5. to promote tissue growth.
3, for serious infected wounds sometimes it is difficult to clean the wound by simply rinsing, you can use the method of “bath”, although the literature reported that there is a possibility of spreading the infection, but I think the possibility of spreading the infection by changing the “bath water” several times is almost impossible. I think the possibility of spreading the infection by changing the bath water several times is almost impossible.
This is the main reason why we usually like to use saline gauze to cover the wound, and saline gauze also has the function of smooth drainage. Many people like to add gentamicin wet dressing to the wound at the same time, the first 1-2 times the effect is very good, long-term effect is not good, and easy to lead to drug-resistant bacteria.
Vaseline gauze can provide a moist environment conducive to the growth of granulation and reduce the exudation of tissue fluid, and can stop bleeding in early wounds.
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 with poor or ineffective effect after changing with other drugs, varicose veins on the lower extremities with skin erosion and ulcers and difficult healing of wounds, small burns with obvious edema and slow healing of wounds from superficial degree II to deep degree II, and decubitus ulcers.
Hypertonic glucose can be evenly distributed on the trauma surface, causing a hypertonic environment, causing dehydration of bacterial cells, loss of bacterial reproduction capacity and death of the bacteria, and dehydrating the local cells of the body, reducing the edema of the trauma surface and granulation tissue, and forming a protective film to prevent the cells from continuing to invade the infection, improving local blood circulation, improving the nutrition around the trauma surface, and promoting the healing of the trauma surface. In addition, glucose has a myogenic effect, which can reduce trauma pain and facilitate wound healing.
Treatment of septic wounds. Generally, if there is pus flowing out of the wound or a sense of fluctuation can be palpated, it should be opened and drained in time. Then fill with diluted PVP-I gauze, fully drainage, should not fill too tightly affect the blood supply and unfavorable drainage. Of course, saline gauze can also be used. Or apply topical antibiotics, such as penicillin, gentamicin, etc.
We use alcohol and strong iodine to close the wound in the first stage.
open wounds with saline and strong iodine
Hypertonic saline is used when the wound is heavily edematous
Glucose and insulin, mostly used when the wound is malnourished, when growth is slow
Principles of dressing change 1 aseptic 2 protect the wound 3 promote growth
When changing the dressing, you can properly scrape away the surface edema or lack of fresh granulation, and then use chymotrypsin wet dressing, which can promote local tissue healing
Infected wounds or postoperative fat liquefaction wounds should be promptly and intermittently removed and drained, after disinfecting around the wound with iodine and alcohol, squeeze out as much pus as possible from the wound by hand and extract gentamicin (for mild cases) or vancomycin (for heavy cases) with a 20ml syringe to remove the needle and directly bluntly tie the drainage port to directly flush and back pump the flushing fluid. Gauze drainage strips may be left in place, usually two or three times to remove infection and seal.
In fat-rich areas where fat liquefaction is likely to occur, our experience is to open the incision widely (open all areas of fat liquefaction), culture + drug sensitivity, and intensify dressing changes. If the culture is positive, it is an infection.
As we all know that such an incision needs to be changed for a long time, in order to shorten the time and reduce the financial burden of the patient, we inject gentamicin under the skin locally after the initial disinfection, @@@@@ and place glucose powder into the incision @@@@@. Change the medication daily, and oil gauze will be used to stimulate the growth of granulation after the wound exudes less. After the freshness, the second stage suture or butterfly tape can be pulled together. We did a control and it significantly reduced the time.
Talk about the lower extremity vasculitis after amputation, the incision does not heal in a little experience in changing medication.
Generally such patients due to poor skin blood flow, although the painful, necrotic limb was amputated, but the incision after amputation is still very difficult to heal, and often easy to accompany infection!
Such an incision change is very important, first of all, when changing medication to closely observe the incision, if septic, must immediately cut the sutures of the septic area, remove necrotic tissue, open the incision, unobstructed drainage, generally put a small drainage strip on!
In addition, when changing medication for a septic incision, do not mind the bad smell, be sure to carefully wipe off the pus moss at the incision, and do not dare to touch the incision because of the patient’s pain, there should be a slight blood oozing after the pus moss is removed, so as to help the incision heal soon!
It is best not to let alcohol seep into the wound when changing an open wound, alcohol is not good for wound healing (this is the viewpoint taught by my doctor during my internship)
Another iodine 2 wine 3 is the classic orthopedic disinfection method, when we first arrived at the orthopedic department, our leaders asked us newcomers outpatient debridement must strictly comply.
For contaminated oily wounds, we use turpentine here to wash away the oil stains
For 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 scraper or cut out, so that it bleeds, reveal fresh granulation, external rubber high (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 to the change in the patient’s body temperature.
For Pseudomonas aeruginosa infected wounds.
Characteristically, the pus is light green and has a special sweet fishy odor. If the wound is crusted, pus accumulates under the scab and there is necrotic tissue, the scab, pus and necrotic tissue should be removed. 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. Traumatic surface such as small available 3% acetic acid, 10% chloral hydrate solution wet dressing.
1.Alcohol: decubitus ulcer protection (50%), skin and instrument disinfection (70%)
2.Hydrogen peroxide (3%): cleaning wounds, ulcers, pus sinuses, loosening necrotic tissues and removing adherent dressings.
3.Gentamicin solution (0.2-0.5%): local flushing for Pseudomonas aeruginosa and Staphylococcus infection wounds.
4.Saline (0.9%): wet dressing for washing of wounds.
5.Furacilin (0.02%) solution: surface disinfection of ulcers, purulent wounds, etc.
6.Zinc oxide gelatin: long-lasting calf ulcers.
7.Red mercury (2%): disinfection of skin mucous membrane, still used in the countryside.
8.Cod liver oil: local application for promoting the formation of epithelium on traumatic surfaces.
9.Acetic acid (0.5-2%): for scalding and burn infected wounds.
10, chlorhexidine (0.05%): traumatic surface, wound rinse.
11, magnesium sulfate (50%) solution: for contusions, cellulitis, dermatitis and other anti-inflammatory swelling. Local wet and hot compresses.
12, boric acid ointment (5%): burns, abrasions, skin ulcers and bedsores.
13, Band-Aid: Apply to small wounds.
For osteomyelitis with bone outgrowth when the dressing change should first be diligent, because there is a lot of exudation, you can QD, and the dressing should be more, in the process of dressing change, necrotic tissue should be removed at any time (very important!) , (oil) gauze can be placed in the medullary cavity. My experience is to first rinse the trauma with saline, then with 0.1% iodine, then with hydrogen peroxide, and finally with QD gauze wet and covered with a dressing.
When the trauma is fresh and the granulation is less exuding, surgery is performed to remove the dead and sclerotic bone, and a suitable myocutaneous flap is used to cover the trauma with external fixation frame, and then bone lengthening is performed after the flap becomes viable. However, sometimes multiple surgeries may be required to achieve the treatment goal.
For refractory sinus tracts such as after brain surgery, after heart bypass surgery or sinus tracts caused by chronic osteomyelitis, usually the early stage is treated with 8.2 dan or 9.1 dan + red oil ointment to lift the rot and remove the pus, and the later stage is closed with raw muscle mass + red oil ointment, which is very effective, even if the infection is Pseudomonas aeruginosa or drug-resistant Staphylococcus aureus.
Reimplantation surgery or anastomosis of the flap surgery can best be changed with furacilin solution similar to body temperature, change with alcohol can be scolded; finger change gauze should avoid ring wrapping, local best to fill with shredded gauze.
On the use of oil gauze 1. for abscess after incision to play a role in drainage, while the abscess just cut open to have a hemostatic effect of compression. 2 it can be placed directly on the wound to facilitate the growth of granulation. 3 it depends on the replacement cycle of the wound, such as wound exudation should be more daily replacement, exudation can be less depending on the situation. 4 implantation area packed fixed should be replaced for the first time in 5 — 7 days, and later depending on the situation. 5 oil gauze and The wound is not stained so as to protect the skin pieces that do not grow firmly from being removed.
To sum up.
Change of dressing: deferred open wounds, soft tissue infections incision and drainage, surgical incision infections, 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 trauma, removal of pus and necrotic tissue, placement or removal of drainage to replace dressings and dressings, etc. This process is called dressing change, also known as dressing change or drug application.
A. Preparation before dressing change
1, fully understand the wound, the size and depth of the wound site, the number of gauze filled in the wound cavity, the presence or absence of drainage and whether to remove or replace, the need to expand or flush, whether to remove 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 process of drug exchange may occur, should be fully prepared to understand in detail.
2, aseptic preparation: general drug exchange requirements in the morning care or drug change room cleaning work after half an hour, preferably in the drug change room change. Wear a mask and hat, invite the patient to the dressing change room, observe the wound situation (uncover the gauze should be uncovered in the direction of the wound, vertical uncovering easy to make the wound open again), assess the number of instruments needed, and dressings, types, and then go to wash hands after the preparation of the items for the dressing change.
Generally need two sterile bending tray, two forceps, alcohol cotton balls, 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 balls after clip alcohol cotton balls (if first clip alcohol, residual forceps of alcohol clip iodine cotton balls dilute the iodine, affecting the disinfection effect).
3, operation: hands to take the outer auxiliary material, and then tweezers to take the inner layer, if stuck with saline cotton balls to moisten and uncover. Two tweezers, one touching the skin, one touching the excipient (the two always do not touch). Disinfection along the wound and suture mouth gently dip, and then (clean wound) from the inside out back to eliminate, 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 grain 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: clean first after the pollution, first simple after complex. This is also true for multiple wounds of a patient.
Second, the frequency of dressing change
In principle, the 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.Post-implantation: 7-9 days/time;
4.Gastrointestinal fistula: 2-3 days/time;
5.Summer, change daily and apply alcohol gauze;
Third, how much dressing is appropriate to choose? The growth of the wound in the first few days is mainly the growth of granulation tissue, which needs a more moist environment, so the dressing can be used more layers in the first few days to keep the trauma 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 the dressing should be closely attached to the wound during dressing changes, especially when the wound is more concave than the surrounding area.
IV. Commonly used dressings selection
1.Alcohol: decubitus ulcer protection (50%), skin and instrument disinfection (70%). 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: less irritation to mucous membranes, no need to use ethanol deiodination, no corrosive effect, and low toxicity. Iodophor is better than iodine in terms of application (mucous membranes, skin, etc.) and disinfection (less allergic reactions), but it also has a range of application. Wounds that bleed a lot are not effective, and wounds that are too large should not be applied. 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 immobilize bacterial proteins, while being more penetrating in areas with abundant sebaceous glands. So it will be applied around the wounds of the scalp.
3.Saline (0.9%): wet dressing for wound washing. It is generally used on the mucous membranes with rich blood supply, more traumatic secretions, less chance of infection, and sensitive sensation. The application of physiological saline is mainly for flushing and wetting, because for an extensive area of wounds or combined and uneven wounds, flushing can remove some impurities and infectious materials.
4.Hypertonic saline: used when the wound is heavily edematous. The purpose of hypertonic saline is that the local swelling of the wound is not healed, but can achieve local dehydration effect. 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 cleared and thoroughly applied.
5, hypertonic glucose: a dehydrating drug, can enhance the plasma osmolarity and produce dehydration, for infected wounds with poor local nutrition, large wounds, poor or ineffective after changing with other drugs, varicose veins on the lower extremities with skin erosion and ulceration, difficult healing of the wound, shallow Ⅱ to deep Ⅱ small area burns with obvious edema, slow healing of the wound, and decubitus ulcers are more effective.
Hypertonic glucose can be evenly distributed on the trauma surface, causing a hypertonic environment, causing dehydration of bacterial cells, loss of bacterial reproduction capacity and death of the bacteria, and dehydrating the local cells of the body, reducing the edema of the trauma surface and granulation tissue, and forming a protective film to prevent the cells from continuing to invade the infection, improving local blood circulation, improving the nutrition around the trauma surface, and promoting the healing of the trauma surface. 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%): cleaning wounds, ulcers and pus sinuses, loosening necrotic tissues and removing adherent dressings.
7.Gentamicin solution (0.2-0.5%): local flushing, used for Pseudomonas aeruginosa and Staphylococcus infection wounds.
8.Furacillin (0.02%) solution: surface disinfection of ulcers, purulent wounds, etc.
9.Zinc oxide gelatin: long-lasting calf ulcers.
10.Insulin is mainly applied to non-healing wounds of diabetic patients.
11.Red mercury (2%): disinfection of skin mucous membranes, skin sassafras red mercury is best, coated with ten minutes after drying without bandaging
12, cod liver oil: local application, used to promote the formation of epithelium on the wound.
13.Acetic acid (0.5-2%): burns, burns infected wounds.
14.Chlorhexidine (0.05%): traumatic surface and wound irrigation.
15.Lifanox: the best effect of contraction wounds (direct wet cover).
16, magnesium sulfate (50%) solution: for contusions, cellulitis, dermatitis and other anti-inflammatory 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. The use of raw muscle powder can promote the growth of granulation.
18, the surface of the 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 smooth 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 infection of the trauma, to make diligent change (preferably 3-4 times / day), many people Like trauma at the same time with gentamicin wet dressing, the first 1-2 times the effect is very good, long-term effect is not good, and easy to lead to drug-resistant bacteria produced.
19, 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 wound to be used with caution, because it is easy because of poor drainage, often aggravate the infection.
V. Treatment of common wounds
1, clean wounds disinfected with iodophor, less irritation, good results; for clean, nascent granulation trauma, can also be covered with petroleum jelly gauze to reduce the pain of patients when changing medication, and reduce tissue fluid exudation, loss.
2, rich blood supply, small chance of infection of the wound can be saline simple wetting, sterile auxiliary material dressing can be.
3, for wounds with skin defects, the defect area is repeatedly rinsed with saline, the surrounding area can be routinely disinfected with iodophor, after disinfection, covered with saline gauze or petroleum jelly gauze, saline gauze is good for keeping the wound fresh and dry, petroleum jelly gauze is good for granulation growth of the wound.
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 the septic incision, don’t mind the bad smell, make sure to carefully wipe off the pus moss at the incision, and don’t dare to touch the incision because of the patient’s pain, there should be slight blood oozing after the pus moss is removed, which will help the incision heal soon!
5, decubitus ulcer, septic osteomyelitis and other infected wounds: iodophor disinfects around the incision, while the incision is flushed with hydrogen peroxide, saline, and covered with gentamicin dressing.
6.For osteomyelitis with bone outgrowth the dressing change should first be diligent, because there is a lot of exudation and the dressing should be more. During the dressing change, necrotic tissue should be removed at any time, and gauze can be placed in the medullary cavity. The empirical method is to first rinse the trauma with saline, then with 0.1% iodine, then with hydrogen peroxide, and finally with Qingda gauze wet and covered with a dressing. 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, open fracture external fixation of patients followed by the first iodophor disinfection (while cleaning the removal of necrotic tissue), followed by the use of hydrogen peroxide disinfection, then saline rinse, and finally furacilin filling to cover the wound surface. Wait for its granulation growth and line free flap coverage.
8, fat liquefaction of the incision: fat liquefaction is prone to occur in fat-rich areas, at which time the incision is widely opened (all areas of fat liquefaction are opened), culture + drug sensitivity, and enhanced drug 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, place glucose powder into the incision, change the medication every day, wait for the wound to exude less after oil gauze to stimulate the growth of granulation, fresh after the second phase of suture or butterfly tape pulling.
9, long ulcerated wounds, to use Chinese herbal medicine change. Chinese medicine dressing change has its uniqueness, 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 contaminated oily wounds, we here use turpentine to wash away the oil stains.
11.For 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 scraper or cut out, so that it bleeds, reveal fresh granulation, external 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, for Pseudomonas aeruginosa infected wounds: characterized by pus of light green color, with a special sweet fishy odor, if the wound surface is crusted, pus accumulates under the scab, with 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. Traumatic surface such as small available 3% acetic acid, 10% chloral hydrate solution wet dressing.
VI. Precautions
1.Aseptic one-phase wound dressing change is usually done at 24 hours and 72 hours to routinely observe the local swelling and exudation.
2, open wounds for 24, 48, 72 hours after surgery for three consecutive days of drug changes, with special attention to easy to appear hematoma or drainage situation in a timely manner to exclude the danger is more critical.
3, orthopedic trauma more often seen infected trauma is skin necrosis, decubitus ulcer trauma, hypertonic saline is generally used in a certain period of time, heavy infection, more exudate trauma, can quickly reduce the trauma and granulation tissue edema, reduce exudation.
4, Reimplantation surgery or anastomotic vascular flap surgery can best be changed with furacilin solution similar to body temperature, finger change gauze should avoid ring wrapping, and localized gauze is best filled with shredded gauze.
5, for large area trauma, first of all, pay attention to clear the wound, for the already necrotic tissue including necrotic tendons and vascular tissue do not appease, strive for several times in the change of medicine, the boundary once obvious then decisively removed. Reluctantly left, will only delay the growth of granulation, or even cause infection.
6.For the wound that has cleared most of the necrotic tissues, 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 trauma edge with iodine volts, and cover it with wet saline gauze.
7, oil gauze should not be put on the trauma, it should be on the saline gauze to prevent the saline from evaporating too quickly.
8, there is an infection of the trauma to pay attention to do a bacterial culture + drug sensitivity before changing drugs, so as to avoid later passive.
Commonly used drugs for medication change
1.Saline
It has the function of enhancing the nutrition of granulation tissue and adsorbing the secretion of planar surface, and has no adverse stimulation to granulation tissue. Isotonic saline cotton balls and gauze are used for cleaning the wound surface, wet dressing of the wound surface and filling the pus cavity; isotonic saline solution is used for flushing the wound cavity; 3% to 10% saline has a strong dehydrating effect and is used for the wound surface with obvious granulation edema.
2.3％ hydrogen peroxide
Released oxygen by decomposition after contact with tissues, with bactericidal effect. Used for flushing trauma wounds, *** or malodorous wounds, especially for anaerobic bacterial infections.
3.0.02% potassium permanganate solution
Decompose and release oxygen slowly, but the effect is long-lasting, with cleaning, deodorizing, antiseptic and sterilizing effect. Used for washing rotten and foul-smelling, infected wounds, especially for suspected anaerobic bacterial infection, anal and perineal wounds. Clinically, 1:5000 solution is often used for wet dressing.
4.0.1% Ravnol
It has antibacterial and bactericidal effects. Used for cleaning and wet dressing of infected trauma.
5.Yaozuo (bleaching powder, boric acid) solution
Has the effect of sterilization, antiseptic and deodorization, dissolving necrotic tissue. Used for cleaning and wet dressing of wounds with much pus and putrefied dead tissue and bad smell. This preparation should be kept airtight and protected from light, and should not be kept for a long time, and the placement time should not exceed one week. Large area wounds should not be applied to avoid absorbing too much chloride ions.
6.Polyvinyl pyridone iodide (PVP-I)
It is a new type of bactericide, effective for bacteria, fungi and budding cells. 0.05%~0.15% solution is used for mucous membrane, wound surface and pus cavity flushing; 1% solution is used for dressing sterile incision; 1%~2% solution is used for wet dressing infected wound, most suitable for chronic lower limb ulcer and cancerous ulcer.
7.Antibiotic solution
Commonly used are 0.5% neomycin solution, 0.16% gentamicin, 0.5% chlortetracycline, 2% bacitracin, 2% ~ 5% chlortetracycline and other solutions, used to wait for the second phase of suture contaminated wounds, larger wounds (such as burns) before the implantation of the wound wet dressing, the dressing should be changed once a day. Chloramphenicol drops are directly implanted on infected wounds, 21 grains per lcm, once daily.
8.1％～2% phenoxyethanol solution
It has bactericidal effect on Pseudomonas aeruginosa and has the best effect, using continuous wet dressing on the traumatic surface.
9.0.01%～0.05% Neosporin and 0.02% chlorhexidine solution
The latter is better than the former in irrigating the incision.
10.10％ garlic solution
It has the effect of sterilization and enhancing the phagocytosis of tissue cells, and has a better effect on Staphylococcus aureus infection.
11.2%～4% methyl violet (gentian violet) solution
It has bactericidal and astringent effects. Used for the disinfection of superficial skin or mucous membrane ulcers, and to promote the healing of nodules.
12.Pure carbolic acid solution
It has corrosion and sterilization effect. Use pure carbolic acid solution swab to cauterize anal fissures and chronic sinus tracts to make the unhealthy granulation tissue necrotic and fall off to promote healing. After using it, you need to wipe with alcohol swab to neutralize it, and then wipe with isotonic saline swab.
13.10％～20% silver nitrate solution
Used to cauterize anal fissures, chronic sinus tracts and corrosive overgrowth of granulation tissues, to be wiped with isotonic saline swabs after use.
14.Oil gauze
It has the functions of drainage, protection of trauma, dressing not easy to dry and prolonging the time of dressing change. If the traumatic discharge is small, it can be changed once in 2 to 3 days. Commonly used are: ① Vaseline gauze; ② cod liver oil gauze: with nutrition and promote the role of granulation, epithelial growth, etc., for slow healing wounds.
15.Powder and ointment
(1) Iodoform gauze: it has the functions of anti-infection, antiseptic, astringent, deodorization and promotion of granulation growth. Used for chronic sinus tracts with glandular secretion, such as anal fistula and wounds after removal of tuberculosis lesions. Iodoform is toxic and should not be used for a long time;
(2) 10%-20% ichthyolite ointment: anti-inflammatory and decongestant effect, used for early abscess;
(3) 10% zinc oxide ointment: applied to the skin surface, has the role of protecting the skin from secretions, commonly used in intestinal fistula, biliary fistula and other surrounding skin;
(4) Streptomycin ointment: applied externally on gauze, used for tuberculous wounds;
(5) 2% polyvinyl pyridone iodine ointment: used for the treatment of burns, chronic ulcers, satisfactory results;
(6) Bactrim ointment: used for infected wounds.
16.Chinese medicine
Such as red oil ointment, raw muscle, raw muscle yu red ointment, purple flower burn ointment, moist burn ointment, big green ointment, etc., with pain relief, plucking poison and raw muscle, drain pus and decay.
Iodine and alcohol can only be used in places where the epidermis is intact. And iodophor is not suitable to be used in places where sebum is abundant. Glucose plus insulin is to provide nutrition for the wounded granules, hypertonic saline has the effect of dehydrating the edematous granules, saline only plays the role of wet dressing, the granules grow excessively above the skin surface, then we should use silver nitrate or other corrosion. The granulation is protected by petroleum jelly gauze when it grows well.
The principle of changing the medication is to clarify the purpose of the surgical change, for what to change the medication will be determined according to the wound situation.
1. Iodine + alcohol deiodination – disinfectant
2. Vaseline gauze — anti-inflammatory effect is slightly weaker, but promotes the growth of granulation
3. Iodine voltage—-Deep or shallow, moist in nature
4. Uzo — antiseptic
5. Hypertonic glucose + insulin + (growth promoting factor) — Diabetic patients with difficult to heal wounds.
6. Hypertonic salt—reduce granulomatous edema
7. Gentamicin injection — infected wounds; osteomyelitis
8. Neosporin or hydrogen peroxide or metronidazole — rinse coverage are available, anti-anaerobic
9. Antibiotic powder (cephalosporin, etc.) — according to the drug sensitivity test
10. Yunnan Baiyao (capsule) — ancestral medicine
11. Honey, sugar — bias
12. sd-ag,sd-zn—Astringent
13. black ointment plucking scabies — herbal formulas
14. neurovascular tendon outgrowth — avoid using irritating drugs
15. Comfrey oil gauze — decay sound muscle
16. Vaseline gauze — can be used as a carrier of other drugs, oily (can be separated from the fingers and toes, separated from the blood crust, to prevent adjacent wounds and stick together)
17. Iodine + gentamicin — can be used for bedsores
18. Erythromycin ointment, etc.—application to epidermal lesions without dressing
19. Osteomyelitis lotion etc. for wounds with much exudate — dry dressing, elevate the affected limb
20. need to cut when cut, remove stitches rely on experience.
21. Pay attention to whether the patient has any discomfort after the dressing change – any drug-induced pain; any continued leakage of cerebrospinal fluid from the incision; any continued blood leakage from the wound; any dislocation of the joint caused or the shadow of fixation
There is also a clinical situation of eczema-like changes around the incision, with red, rash skin that breaks down easily. Initially, we used various methods to change the medication, such as iodophor gauze, petroleum jelly gauze, erythromycin eye ointment, etc., how can not be changed well. Finally saline cotton balls were lightly rubbed and then covered with dry gauze, and it soon got better. The reason is unknown!
For some sinus tracts, the change can be done with white granulated sugar, don’t be too concerned about the aseptic operation, usually can be changed well. However, some sinus tracts that are connected to the joint are difficult to heal. My method is to scrape the aging meatus in the sinus tract to make it ooze blood, then use cotton balls and other padding in the area of the sinus tract pathway, apply pressure and bandage to close the sinus tract, do not change the medicine for a week, the point is to always maintain a certain pressure, and I believe you will jump with excitement when it opens.
Recipes for treating bone outgrowth.
1, egg yolk oil 100 cooked egg yolks, iron skillet baked over a gentle fire to produce oil, gauze filter.
2, comfrey, angelica, safflower, ground elm 10 grams each, 250 grams of sesame oil, soak 3 to 5 days, the weather is hot, the time is shorter.
Decocted on a gentle fire until the herbs turn black and float, filtered through gauze for 2 times. 60 degrees into egg yolk oil, petroleum jelly blended to a paste, autoclaved and set aside. (Sometimes there is no high-pressure sterilization.) When the bone is exposed more than 2x2cm, use a bone drill to punch a hole until the bone bleeds, apply three layers of external dressing, and change the medicine after the first 4 days, and then every other day. Do not change the medication too diligently, you can refer to Mepore or some of the methods of changing the medication of raw muscle cream.