Expansion

The expansion is to cleanse and decontaminate fresh open contaminated wounds, remove blood clots and foreign bodies, remove dead tissue, suture wounds, minimize pollution, and even become clean wounds, achieving first-stage healing and beneficial wounds. Recovery of function and morphology. Open wounds are generally classified into three categories: cleansing, pollution, and infection. Strictly speaking, there are very few clean wounds. Unexpected wounds are inevitably contaminated with different degrees. For example, the pollution is serious, the amount of bacteria is high and the virulence is strong. After 8 hours, it can become infected wounds. The local blood supply to the head and face wounds is good, and the wounds can be expanded according to the contaminated wounds 12 hours after the injury. Surgery is a basic surgical procedure. The initial treatment of the wound is decisive for the healing of the wound and the restoration of the function and morphology of the injured part. It should be taken seriously. The initial surgical treatment of firearm injuries is mainly the expansion surgery. The expansion surgery is a basic treatment principle for war wound treatment. It is the basic step to prevent infection and repair tissue in the treatment of firearm injuries. It is very important. Due to the damage of high-speed projectiles, there are many necrotic tissues, blood clots, foreign bodies and bacteria in the injured area. The presence of these substances will seriously affect wound healing and tissue repair. Only early debridement can create conditions for follow-up treatment. Treatment of diseases: laryngeal firearm injury Indication Open wounds within 8 hours should be expanded, and wounds with no obvious infection for more than 8 hours. If the wounded are generally in good condition, they should be expanded. If the wound is obviously infected, it will not be debrided. Only the skin around the wound will be wiped clean. After disinfecting the surrounding skin, the drainage will be opened. The expansion is applicable to: 1. All firearm wounds are contaminated. Thorough initial surgical treatment should be performed as soon as possible within 6-8 hours. 2. The visceral injury that has endangered the lives of the wounded has been treated, the shock and water and electrolyte disorders have been corrected, the general condition is stable, and the operation can be tolerated. Contraindications 1. The limbs were injured by firearms, the wounds were large and deep, and the wounded had severe shock and water and electrolyte disturbances, and the general condition was unstable. 2. Suspected major vascular injury to the limb caused by firearm injury, lack of blood supply, and limited technical conditions. 3. Firearm injuries with or suspected of visceral injuries. 4. Export a small soft tissue penetrating injury, or a shallow and small tangential injury. 5. Inflammation of the firearm has occurred, it is not appropriate to carry out excessive debridement operation, and should be fully drained to prevent the spread of infection. Preoperative preparation 1. Before the debridement, the wounded should be fully carried out to eliminate important visceral injuries and determine whether there are blood vessels, nerves and bone injuries. If there is shock, you should first rescue, and wait for the shock to improve and fight for time to debride. 2. If the brain, chest, and abdomen have serious damage, they should be treated first. If there are open injuries in the extremities, attention should be paid to whether or not the fractures are combined at the same time. X-ray films are taken to assist in the diagnosis. 3. Correct shock and water and electrolyte disorders to improve the general condition of the wounded. According to the size of the operation and the possibility of intraoperative bleeding, appropriate blood preparation. 4. Apply analgesic and preoperative analgesic drugs. 5. If the wound is large and the pollution is serious, antibiotics should be used prophylactically. One hour before surgery, a certain amount of antibiotics should be used in the hands. 6. Injecting tetanus antitoxin lightly with 1500u, and severely using 3000u anesthesia. 7. X-ray inspection to determine the location and number of metal foreign objects. Surgical procedure 1. Cleaning and disinfection of skin and wounds Under the inflatable tourniquet, cover the wound with sterile gauze and shave the skin around the wound. If it is greasy, first wipe it off with gasoline or ether, then wash it thoroughly with soapy water, rinse with isotonic saline and dry. . Remove the gauze covering the wound, rinse the wound with a large amount of isotonic saline, and take out the foreign bodies, blood clots and fallen tissue fragments visible in the naked eye. Flushing wounds can be pulsed (oscillating) irrigators, and the number of bacteria in the wound after washing is much lower than in the conventional method. For superficial gunpowder on the face, pick it up with a needle tip. Dry the skin and loosely fill the wound with sterile gauze. After replacing the gloves and instruments, disinfect the skin again aseptically. First, change the sterile gauze in the injured road, disinfect and towel, and order according to the conventional requirements. 2. Expanding wounds and expansion Firearm wounds, debridement of skin, subcutaneous tissue and fascia should be expanded to reveal deep tissue. The direction in which the wound is extended should be determined on a case-by-case basis. In the case of limb injuries, it can be cut along the longitudinal axis of the limb, and the incision through the joint should be S-shaped. Debridement should be carried out in shallow and deep order. All subcutaneous tissues and fascia that have lost their vitality should be removed. First, the wound edge of the skin, subcutaneous tissue and fascia should be removed. The resection range is generally 0.5 to 1 cm, but the head, neck and hands should be as careful as possible to avoid dysfunction due to excessive skin defects. Cut the deep fascia into a diamond shape, or cut it in the middle of the deep fascia incision to make a "ten" shape, or make a transverse incision at both ends of the fascial incision to make the incision into a "work" shape to prevent fascia The occurrence of gap syndrome. When deep tissue debridement, the light source should be sufficient and the exposure should be clear. Necrotic tissue, blood clots and metal foreign bodies in the wound should be completely removed, and the wound should be carefully stopped after cleaning the wound. Try to use less thick wire ligation to stop bleeding, so as not to leave too much thread in the wound. In the case of a penetrating injury, debridement should be carried out at both the entrance and exit. For deep blind injuries, sometimes for drainage or removal of foreign bodies, it is necessary to cut from the opposite side. For metal foreign objects that are far away from the injured road, if it is difficult to remove, it may not be taken out temporarily, so as not to aggravate the injury of the injured limb. 3. Debridement of muscles The inactivated muscle should be completely removed, but it is sometimes difficult to judge whether the muscle is inactivated during surgery. Generally, it can be judged according to its color, tension, presence or absence of contraction force, and whether or not the color of the muscle tissue changes. Softening, no tension, no shrinkage after clamping or no bleeding after cutting, should be removed. 4. Treatment of tendon The continuity of the tendon is not interrupted. It should be protected as much as possible during debridement. Do not break it and cover it with subcutaneous tissue or surrounding tissue flaps. Do not expose it. If the tendon is completely broken, it is not suitable for initial suturing or transplantation. It is only necessary to trim the irregular part during debridement, and the broken end is embedded by the nearby soft tissue for later reconstruction. 5. Neurological treatment In addition to the initial anastomosis of the injured nerve endings and the facial acupuncture, the nerves in other parts are not sutured at the initial stage, and the nerve endings should be covered with normal muscles for later treatment. 6. Treatment of blood vessels For the damage of the main arteries, such as the radial artery, the radial artery and the femoral artery, which affect the limb survival, the early anastomosis of the blood vessel should be performed after the expansion. The non-main blood vessels can be ligated without treatment. The main arterial defects are excessive, and the autologous arteries should be used. Repair the saphenous vein graft. After repair, cover it with nearby soft tissue and do not expose it. When the femur fracture is accompanied by major vascular injury of the limb, after the vascular anastomosis, the bone traction brake should be used, and the traction should not be too large. 7. Treatment of fractures After debridement, the fracture should be repositioned, external fixation treatment, no internal fixation, free small bone fragments can be removed during surgery, but large bone fragments and all broken bone fragments connected with soft tissue or periosteum should be retained as much as possible. To prevent bone defects. Even if there is bone defect, it is not suitable for bone grafting. 8. Treatment of wounds Firearm injuries are generally not used for initial sutures, but the exposed parts of important tissues such as blood vessels, nerves, tendons and bones should be covered with soft tissue. The joint capsules should be sutured, and the skin and subcutaneous tissues can be opened without suturing. In the important organization, the skin can only be loosely sutured or covered with a local pedicle flap, but the drainage strip or drainage tube must be left to achieve adequate drainage. Open the unstitched wound, first place a large piece of gauze on the bottom of the wound, then loosely fill the gauze or gauze strip, leaving the second stage suture. complication Wound infection Wound infections are mostly purulent infections, such as more purulent secretions, high fever of the wounded, should be debrided in time, wounds with effective antibiotics wet compress, and systemic application of antibiotics. Therefore, the initial thorough surgical expansion is an important measure to prevent wound infections, especially deep infections. 2. Soft tissue extensive defect Due to the severity of firearm damage, especially high-speed projectiles, tissue defects are severe. If the general condition of the injured person improves after the operation, the wound should be taken at different times to eliminate the wound and strive for complete or partial recovery of the limb function. 3. Joint dysfunction After the expansion, due to pain and tissue scar contracture, sometimes joint function is limited. Therefore, for patients with extensive soft tissue or deep muscle injury, postoperative plastering is used to fix the external fixation. For those who have limited joint function, the wound should be actively treated with reasonable treatment, strengthen active and passive functional exercise, promote joint function recovery, and remove scars for plastic or orthopedic surgery if necessary.

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