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RENDERING FIRST AID AND TREATMENT OF FROZEN IN THE DOREACTIVE PERIOD
On the issue of tactics of first aid and treatment of frostbite in the pre-reactive period, there are two points of view. The first, older, theory of "forced warming up" is based on the fact that the earlier it is possible to stop the effect of the damaging factor (cold) on the fabric, the better the results of treatment will be. The second, more modern, concept of “warming from the inside” is based on the fact that the increase in interstitial temperature and, consequently, an increase in the need of tissues for oxygen must be preceded by the restoration of microcirculation; in this case, the warming of tissues occurs "independently", due to the influx of warm blood and the restoration of energy metabolism in the cells. There are also compromise points of view, providing a combination of elements of both tactics.
First, you should try to restore blood circulation and sensitivity with a soft massage in the direction of lymphatic drainage, active and passive movements, careful rubbing with wool fabric. Rubbing with snow is strictly contraindicated, since ice crystals traumatize the skin, and the temperature of the tissues decreases even more. If the skin becomes warm after the massage, and the sensitivity is restored, then there is no irreversible damage to the tissues and no specific treatment is required; if this did not happen, then there is frostbite.
2. First aid
- place the victim in a warm room, remove frozen clothes and shoes;
- to put a heat-insulating cotton-gauze bandage;
- give a hot drink, a little alcohol;
- in the absence of the possibility of emergency hospitalization - place the affected limb in a bath with a water temperature of + 17-18 C and gradually fill up with warm water for an hour, bringing its temperature to 35-36 C (but not higher!), while doing so should be easy massage in the direction of lymphatic drainage. After that, treat the skin of the affected limb with alcohol and apply a bandage with A.V. Vishnevsky ointment.
3. Treatment in the hospital
a) measures aimed at restoring microcirculation and combating hypoxia and intoxication:
- reopoliglyukin 400 ml intravenously, drip;
- Heparin 5 - 10 thousand units intravenously;
- 0.25% solution of novocaine (mixed with 5% glucose in the ratio 1: 1) - 600 - 800 ml intravenously;
- hemodez - 400 ml intravenously, drip;
- Novocain blockade - sheath, cross-section, perirephral; in addition, they have an analgesic effect;
- vasodilator drugs myotropic action (no-spa, halidor, aminophylline);
- HBO - 1 - 2 sessions after or during the infusion therapy;
- the introduction of drugs is most effective in the form of intra-arterial infusions.
b) measures aimed at restoring the energy, electrolyte and acid-base balance of the tissues and the body as a whole:
- 5% glucose solution (in glucosinovocaine mixture), intravenously;
- intravenous administration of alcohol solutions with a concentration of up to 30% at a dose of not more than 0.1 g of alcohol per 1 kg of the patient’s mass per hour; in addition to energy, alcohol has a pronounced sedative and analgesic effect;
- introduction of potassium preparations - up to 100 ml of 4% solution in the composition of the glucose-novocaine mixture;
c) painkillers and sedatives:
- for pain, non-narcotic or narcotic analgesics may be used; for sleep disorders - tranquilizers and neuroleptics in standard dosages;
- conductive procaine blockade;
d) measures aimed at combating the inflammatory reaction:
- antihistamines in average therapeutic dosages;
- broad-spectrum antibiotics that do not have a nephrotoxic effect in average therapeutic dosages (semi-synthetic penicillins, cephalosporins);
c) local treatment
- physiotherapy: UHF - has a warming, vasodilator, analgesic and anti-inflammatory effect, up to 40 biodoses per session are used; other physiotherapeutic procedures - DDT, Novocain electrophoresis, phonophoresis with hydrocortisone are prescribed less frequently, since they require imposition of electrodes directly on the injured tissue;
- open or closed local management is further determined depending on the integrity of the skin at the time of inspection, the presence and nature of the bubbles. With open reference, the skin is treated with antiseptics (alcohol, 3% alcoholic solution of boric acid, 0.5% alcoholic solution of chlorhexidine) and the dressing is not applied. Frequently used treatment with 5% potassium permanganate solution is less preferable, since discoloration of the skin makes it difficult to visually monitor the further course of the process. With a closed method of treatment, a bandage with an AV Vishnevsky ointment is applied to the affected limb. In both the first and second cases, the limbs should be given an exalted position to improve the venous and lymphatic drainage.
TREATMENT OF THE VICTIMS IN THE REACTIVE PERIOD The strategic objectives of treatment in the reactive period are:
1. To restore blood circulation, first of all, microcirculation in the affected tissues;
2. Eliminate or reduce toxemia and remove dead tissue;
3. To restore, to the extent possible, the function of the limb by means of reconstructive and plastic surgery.
ANTICOAGULANT AND DEAGREGANT THERAPY
Of the available anticoagulants in the early reactive period, preference should be given to the drug of direct action - heparin. The best results are observed when it is used as early as possible - in the first 2-4 hours after the onset of the first symptoms of the reactive period. Its dose is usually 5 thousand. IU intramuscularly or intravenously, after 4-6 hours under the control of blood clotting time, which, when determined by the Mas-Magro method, should not exceed 20 minutes (normally 8-12 minutes).
A highly effective method of administering heparin is to include it in the composition of infusion media for intraarterial administration together with novocaine, glucose, reopoliglukine, myotropic antispasmodics. In this case, 10 to 15 thousand units of heparin are slowly intra-arterially administered.
Along with heparin, preparations activating fibrinolysis and, thereby, causing dissolution of blood clots are used. Fibrinolysin injected by 20 - 30 thousand.
U (2 - 3 times per treatment) in the first days after injury. This drug does not block clotting, and therefore for every 2 units of injected fibrinolysin, 1 unit of heparin is additionally administered.
An important component of treatment is intravenous or intraarterial administration of low molecular weight dextrans (reopolygyukin, hemodez, 200-400 ml, 1-2 times a day), which prevent the aggregation of blood cells, reduce its viscosity, reduce the overall peripheral resistance and increase the fibrinolytic activity of the blood. For the same purpose, acetylsalicylic acid (aspirin) and its soluble preparations for parenteral administration (aspizol) are used.
APPLICATION OF VASCULATORY PRODUCTS
The most widespread myotropic drugs (papaverine, no-spa, halidor). It is widely used in the treatment of frostbite at all stages of aminophylline.
Desensitizing vitamins and hormonal therapies
Use antihistamines (diphenhydramine, pipolfen, tavegil, suprastin in the average therapeutic dosages); acetylsalicylic acid, sometimes even glucorticoid hormones in the first 3 - 5 days after frostbite.
Vitamins C, B1, B6, B12, B15, P, PP, E are used to restore metabolic processes in damaged tissue. Vitamins C (ascorbic acid) and E (tocopherol), which have an antioxidant effect, and therefore can increase the resistance of tissues, are of particular importance. to hypoxia.
Detoxification therapy is carried out according to general principles (see chapter 12 of the “Burns” section). Special attention should be paid to neutralizing developing metabolic acidosis and compensating for potassium losses.
1. For any frostbite, urgent specific prevention of tetanus is required according to generally accepted rules.
2. When superficial frostbite, if there are no other lesions and complications (pneumonia, thrombophlebitis, etc.), antibacterial drugs are not prescribed.
3. In the presence of deep frostbite of any depth and infectious complications, broad-spectrum antibiotics are prescribed, with the development of suppuration, the choice of antibiotic is corrected according to the bacteriological data, anti-staphylococcal plasma and other drugs for passive immunization are used.
The main objectives of local treatment are:
1. The fight against wound infection and the prevention of septic complications.
2. Recovery of microcirculation in the zone of reversible degenerative processes.
3. Stimulation of the processes of demarcation and reparative regeneration.
The first task of local treatment is solved in two ways: the elimination of the entrance gate of the infection and the local use of antiseptics, it is possible to use both open and closed treatment methods.
With a deep uninfected lesion, an open treatment method is often used. As in the treatment of burns, it is possible to use a tanning method and a drying method. As a tanning agent, 5–10% potassium permanganate solution is most often used; Drying is performed using dry heat (Sollux lamp, household electric fireplaces, aero-therapeutic installations).
If you translate wet necrosis into a dry one, it is not possible because of the massive necrosis (the lesion is proximal plus), the late start of treatment (the beginning processes of autolysis of necrotic tissues) and the development of septic complications; as well as frostbite 2 degrees, apply a closed method of treatment, the principles of which are the same as in the treatment of burns.
The second task of local treatment is achieved with the help of physiotherapeutic procedures (UHF, DDT, SMT, etc.) in the region proximal to the necrosis zone and the reflexogenic zones contributing to the improvement of blood circulation (paravertebral, in the lumbar region).
The third task of local treatment for frostbite 3rd degree is achieved by the use of necrolithic drugs (iruksol, trypsin, chemopsin) and local regeneration stimulants (solklseril, methyluracil, etc.). For frostbite of the 4th degree, it is advisable to prescribe these drugs only after necrotomy.
OPERATIONAL TREATMENT OF FROZEN
All operations used to treat frostbite can be divided into 7 groups. Indications for the implementation of individual surgical interventions are determined individually.
1. Fasciotomy. It is used in the first 1–3 days after injury, when, due to the increase in edema, compression of vascular and lymphatic collectors is possible, which leads to a further increase in edema and increases the development of moist gangrene.
2. Necrotomies are performed for the same purpose as fasciotomy, but at a later date, when, due to the mummification of dry necrosis, compression of the viable tissues to be produced occurs.
3. Primary early amputation is performed before the appearance of a demarcation line within guaranteed viable tissues. To determine the level of amputation, you can use the method of T. Billroth: it is necessary to establish on the skin the border of complete anesthesia; If in a day the border is determined at the same place and at the same time, not blood but hemolyzed fluid is released from the needle puncture, the anesthesia site is considered dead, and the anesthesia boundary is the line of amputation.
4. Necrectomy is performed at different times as the necrosis is verified with the threat of developing wet gangrene. Excision is carried out in the redistribution of dead tissue, so anesthesia and hemostasis is not required.
5. Tangential necrosectomy is performed with full demarcation of necrotic tissue, including bone tissue, and consists in excision of necrotic tissue along the plane of demarcation. This type of operation allows you to maintain a maximum of viable tissues, which creates the prerequisites for the best functional restoration of the limb. After tangential necrotomy, a granulating wound remains, which must be subsequently closed with skin grafting.
6. Secondary amputations are performed after complete demarcation of necrosis and differ from tangential necroectomy by the primary closure of a stump wound.
7. Various types of skin grafting to close the granulating wounds after nectectomy and rejection of necrosis. Produced by the same principles as in the treatment of burn wounds.
8. Reconstructive surgeries are performed at a later date in order to increase the functionality of the stumps of the extremities after previous operations.
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RENDERING FIRST AID AND TREATMENT OF FROZEN IN THE DOREACTIVE PERIOD
- First Aid
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