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FIRST AID AND TREATMENT OF DEFECTS IN THE DORECATIVE PERIOD

On the question of the tactics of providing first aid and treating frostbites in the pre-active period, there are two points of view. The first, the older, theory of "forced warming" is based on the fact that the earlier it will be possible to stop the effect of the damaging factor (cold) on the tissue, the better the treatment results will be. The second, more modern concept of "warming from within" proceeds from the premise that the increase in the interstitial temperature and, consequently, the increase in tissue requirements in oxygen should be preceded by the restoration of microcirculation; warming of tissues in this case occurs "independently", due to the influx of warm blood and the restoration of energy metabolism in cells. There are also compromise points of view, providing for a combination of elements of that and other tactics.

First, you should try to restore blood circulation and sensitivity with a gentle massage in the direction of the lymph drainage, active and passive movements, careful rubbing with woolen cloth. Rinsing with snow is strictly contraindicated, as ice crystals injure the skin, and the temperature of the tissues is further lowered. If after the massage the skin becomes warm and the sensitivity is restored, then irreversible tissue damage has not occurred and no specific treatment is required; If this did not happen, then there is frostbite.

2. Provision of first aid

- put the victim in a warm room, remove frozen clothes and shoes;

- impose a heat-insulating cotton-gauze dressing;

- Give a hot drink, a little alcohol;

- if there is no possibility of emergency hospitalization - put the affected limb in a bath with a water temperature of + 17-18 ° C and gradually add warm water to the hour, bringing its temperature to 35-36 ° C (but not higher!), massage in the direction of the lymphatic drainage. After that, treat the skin of the affected limb with alcohol and apply a bandage with the ointment of A.Vishnevsky.

3. Treatment in hospital

a) measures aimed at restoring microcirculation and combating hypoxia and intoxication:

- reopolyglucin 400 ml intravenously, drip;

- Heparin 5 - 10 thousand ED intravenously;

- 0.25% solution of novocaine (in a mixture with 5% glucose in the ratio 1: 1) - 600-800 ml intravenously;

- gemodez - 400 ml intravenously, drip;

- Novocain blockades - case, cross section, paranephric; in addition, they have an analgesic effect;

- vasodilator preparations of myotropic action (no-shpa, halidor, eufillin);

- 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 tissues and the organism as a whole:

- 5% glucose solution (in the glucose caffeine mixture), intravenously;

- intravenous injection of alcohol solutions with a concentration of up to 30% in a dose of not more than 0.1 g of alcohol per 1 kg of patient per hour; except for energy alcohol has a pronounced sedative and analgesic effect;

- administration of potassium preparations - up to 100 ml of a 4% solution in the composition of a glucosaccharide-novocaine mixture;

c) analgesics and sedatives:

- pain can be treated with non-narcotic or narcotic analgesics; with sleep disorders - tranquilizers and antipsychotics in conventional dosages;

- Conducting Novocain blockades;

d) measures aimed at combating the inflammatory reaction:

- antihistamines in the average therapeutic dosages;

- broad-spectrum antibiotics that do not have a nephrotoxic effect in the average therapeutic dosages (semisynthetic penicillins, cephalosporins);

c) topical treatment

- physiotherapy: UHF - has a warming, vasodilating, analgesic and anti-inflammatory effect, up to 40 biodosides per session; other physiotherapeutic procedures - DDT, electrophoresis with novocaine, phonophoresis with hydrocortisone are prescribed less often, since they require the application of electrodes directly to injured tissues;

- open or closed local management is further defined depending on the integrity of the skin at the time of examination, the presence and nature of the blisters. When open, the skin is treated with antiseptics (alcohol, 3% alcohol solution of boric acid, 0.5% alcohol solution of chlorhexidine) and the dressing is not superimposed. Frequently applied treatment with a 5% solution of potassium permanganate is less preferable, as changing the color of the skin makes it difficult to visually control the further course of the process. With the closed method of treatment, a bandage with AV Vishnevsky ointment is applied to the affected limb. And in the first and second cases, the limb should be elevated to improve venous and lymphatic drainage.

TREATMENT OF VICTIMS IN THE REACTIVE PERIOD The strategic objectives of treatment in the reactive period are:

1. Restore blood circulation, first of all, microcirculation in affected tissues;

2. Eliminate or reduce toxemia and remove dead tissue;

3. Restore, to the extent possible, the function of the limb with the help of reconstructive and plastic surgeries.

ANTICOAGULANT AND DESIGREGANT 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 noted with its earliest possible application - in the first 2-4 hours from the time of the onset of the first symptoms of the reactive period. The dose is usually 5 thousand ED intramuscularly or intravenously, after 4-6 hours under the control of the time of blood clotting, which, when determined by the method of Mac Magro, should not exceed 20 minutes (normally 8-12 minutes).

A highly effective way of introducing heparin is to include it in the infusion medium for intra-arterial administration, along with solutions of novocaine, glucose, rheopolyglucin, myotropic antispasmodics. In this case 10 to 15 thousand units of heparin are intraarterially injected slowly.

Along with heparin, drugs that activate fibrinolysis and, thus, cause thrombus dissolution are used. Fibrinolysin is administered in the range of 20-30 thousand.
ED (2 - 3 times for the course of treatment) in the first days after the injury. This drug does not block coagulation, and therefore for every 2 units of injected fibrinolysin, 1 unit of heparin is additionally administered.

An important component of the treatment is intravenous or intra-arterial injection of low molecular weight dextrans (rheopolyukin, 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 fibrinolytic blood activity. For the same purpose, acetylsalicylic acid (aspirin) and its soluble preparations for parenteral administration (aspizol) are used.

APPLICATION OF VASCENTRICULOUS PREPARATIONS

The most widely used myotropic drugs (papaverine, no-shpa, halidor). It is widely used in the treatment of frostbites at all stages of euphyllin.

DESENSIBILIZING VITAMIN AND HORMONOTHERAPY

Apply antihistamines (diphenhydramine, pipolfen, tavegil, suprastin in the average therapeutic dosages); acetylsalicylic acid, sometimes even glucocorticoid hormones in the first 3 to 5 days after frostbite.

To restore metabolic processes in damaged tissue, vitamins C, B1, B6, B12, B15, P, PP, E are used. Of particular importance are vitamins C (ascorbic acid) and E (tocopherol), which have an antioxidant effect, to hypoxia.

DETOXISTIC THERAPY

Detoxification therapy is carried out according to general principles (see chapter 12 of the section "Burns"). Particular attention should be paid to neutralizing the developing metabolic acidosis and recovering potassium losses.

ANTIBACTERIAL THERAPY

1. With any frostbite, emergency specific tetanus prophylaxis is required according to generally accepted rules.

2. With superficial frostbites, if there are no other lesions and complications (pneumonia, thrombophlebitis, etc.), antibacterial drugs are not prescribed.

3. In the presence of deep frostbites of any depth and infectious complications, antibiotics of a wide spectrum of action are prescribed, with the development of suppuration, the choice of antibiotic is corrected in accordance with the data of bacteriological research, antistaphylococcal plasma and other drugs for passive immunization are used.

LOCAL TREATMENT

The main tasks of the place of treatment are:

1. Combating wound infection and preventing purulent-septic complications.

2. Restoration of microcirculation in the zone of reversible degenerative processes.

3. Stimulation of demarcation and reparative regeneration processes.

The first task of local treatment is solved in two ways: by eliminating the entrance gate of the infection and by local application of antiseptics, it is possible to use both open and closed method of treatment.

With a deep uninfected lesion, an open method of treatment is often used. As with the treatment of burns, it is possible to use the tanning method and the drying method. As a tanning agent, 5-10% solution of potassium permanganate is most often used; Drying is done with the help of dry heat (Sollyux lamp, household electric fireplaces, aerotherapeutic installations).

If wet necrosis is not transferred to dry due to the massive necrosis (proximal lesions are plural), late onset of treatment (necolitized tissues autolysis processes started) and development of purulent-septic complications; as well as with frostbite of 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.) on the area proximal to the necrosis zone and reflexogenic zones, which help improve blood circulation (paravertebrally, in the lumbar regions).

The third task of local treatment with frostbite of the third degree is achieved by the use of necrolytic drugs (Iruksol, trypsin, chemopsin) and local regeneration stimulants (solleseril, methyluracil, etc.). With frostbites of the 4th degree, it is advisable to prescribe these drugs only after necrectomy.

OPERATIONAL TREATMENT OF FABRICS

All operations used to treat frostbite can be divided into 7 groups. Indications for 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 it is possible to squeeze the vascular and lymphatic collectors, 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 the mummification of dry necrosis leads to compression of the underlying viable tissues.

3. Primary early amputation is performed before the demarcation line appears within the guaranteed viable tissues. To determine the level of amputation, one can use the method of T. Bilrot: it is necessary to establish a full anesthetic border on the skin; If, within 24 hours, the boundary is determined at the same site and the blood is not extracted from the needle injections, but the hemolyzed liquid, then the anesthetic site is deemed dead, and the anesthesia line is the amputation line.

4. Necrrections are produced at different times as necrosis is verified with the threat of development of moist gangrene. Excision is carried out in the redistribution of dead tissue, so anesthesia and hemostasis is not required.

5. Tangential necrectomy is performed with complete demarcation of necrotic tissues, including bone necrosis, and consists in excision of dead tissues along the plane of demarcation. This type of operation allows you to save a maximum of viable tissues, which creates the prerequisites for the best functional restoration of the limb. After tangential necrectomy, there is a granulating wound, which in the subsequent must be closed with cutaneous plasty.

6. Secondary amputations are performed after complete demarcation of necrosis and differ from tangential necretomies by the primary closure of the stump wound.

7. Various types of dermal plasty for closing granulation wounds after nekectomy and rejection of necrosis. Produced according to the same principles as in the treatment of burn wounds.

8. Reconstructive and restorative operations are performed at a later date in order to improve the functionality of the limb stump after previous operations.
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FIRST AID AND TREATMENT OF DEFECTS IN THE DORECATIVE PERIOD

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