Dressings

DRESSINGS, a therapeutic measure applied mainly to wounds and consisting of the application of aseptic and antiseptic materials to a wound in a known sequence and the fixation of these materials to a specific area of the body to protect it from the harmful influence of the external environment. The objectives pursued in dressings of a given wound are: 1) to soothe wound pain, 2) to stop bleeding, 3) to divert wound exudate, and 4) to protect from infection. The dressing of a wound must prevent both the initially occurring pains in the wound and the subsequent ones associated with infection. Thanks to the covering, the irritation of the wound is eliminated, and the wound with its surroundings is placed in conditions of rest. A well-executed dressing usually eliminates pain, whereas a poorly performed one may cause it. Painful sensations in the wound immediately after a dressing are an indication to change the latter. The second objective of a dressing is to stop bleeding after injury or surgery. As a rule, a dressing should be performed only after careful hemostasis in the wound has been achieved; however, when it is impossible to achieve this, one must resort to tamponade and the application of so-called compressive dressings. Diverting wound secretion is performed by draining the wound, the drain being set up so that the outflow of secretion is more perfect. Suction of secretion is also achieved by using well-absorbing materials. Changing a dressing is directly related to its soaking and to the amount of secreted secretion. To avoid disturbing the rest of the wound, one should change not all layers of the dressing, but only the upper ones. With large accumulations of secretion, it is necessary to resort more widely to open treatment of the wound; with a deficiency of secretion, one should use substances that enhance secretion, for example hypertonic solutions (10% NaCl solution). One of the main objectives of a dressing is to protect the wound from infection. A rationally applied dressing can itself be a source of such infection. Therefore, it is important that the first dressing be performed after the appropriate toilet of the wound (see). Technique of dressings. Dressings must be performed with strict observance of aseptic and antiseptic rules. Before each major dressing, when contact of hands with dressing material and tissues of the wound is anticipated, the hands must be washed according to the methods generally accepted in surgery. If the dressing is not complex, thorough hand washing may not be mandatory, provided instruments are used. Work in rubber gloves is very convenient and practical, especially when dressing purulent wounds. The dressing of the wound itself must be performed carefully and cautiously. Any forced actions—rubbing the edges of the wound, rough manipulations—must be excluded. If the matter concerns an infected wound secreting purulent exudate, it is not necessary to necessarily remove crusts and deposits from the wound with an instrument, nor to scrape pus from granulations until blood appears. It is sufficient to carefully remove pus adhering to the skin around the wound with a gauze ball moistened in gasoline, gently pressing on the tissues adjacent to the wound and striving in this way to reveal the presence of secretion in the pockets and corners of the wound. Any probing should be avoided; it can be resorted to only in case of extreme necessity and preferably performed after the wound is dilated with blunt hooks. The best method is still inspection of the wound ad oculos. If a significant amount of secretion accumulates in the wound, it is necessary to introduce an aspirating tampon into the wound. At present, the use of a tampon is strongly limited, since it has been proven that the absorptive capacity of the tampon is soon lost, since it quickly becomes slimy, gauze loops become clogged, and the tampon instead of absorbing secretion clogs the wound in the form of a plug. The technique of tamponade must be characterized by gentleness. Carefully advancing the tampon into the distant corners of the wound under the control of dilating blunt hooks, excess purulent secretion is carefully removed, avoiding traumatization of the tissues. The introduction of the tampon itself must be performed while observing strict aseptic rules. Under no circumstances is it permissible to crumple strips of gauze in the hand or take them with the hands, even washed. The introduction of a tampon must be performed with instruments—forceps and a probe. The assistant, at the moment of introducing the tampon, stretches the wound with hooks. The tampon should not be driven into the wound too tightly—such tamponade is harmful, as it presses on the walls of the wound and does not sufficiently well suck up the contents. The tampon is introduced with a probe immediately to the deepest place of the wound, and its end remains outside. The introduction of a tampon is irrational and not indicated in the presence of long and narrow wound tracts, especially in the case of gunshot wounds with a long tract. Such a tampon only clogs the wound tract and causes stagnation of secretion in it. The tampon in the wound should be changed carefully. No forcible pulling of the tampon should take place. The tampon is removed only after the introduction of blunt hooks into the wound, carefully pulling not at the end of the tampon, but closer to the place where it adheres to the wound. Remembering the danger of transferring infection from one wound to another and to one's own fingers, one should not examine the circumference of the wound with the bare hand, but should use either a glove or a gauze ball on forceps for this purpose. When a wide outflow of wound secretion is necessary, drainage tubes are introduced. Their thickness varies depending on the character of the pus and the size of the purulent cavity. The rule for introducing drainage is to place it in the lowest corner of the wound for better outflow of secretion. Passing through-drainages blindly without preliminary investigation of the wound tract with a probe and a sound is an unacceptable procedure. The drainage is introduced, like the tampon, after the wound is dilated with hooks. It is better not to pass through-drainages that traumatize tissues, but to use two drainage tubes running towards each other. To facilitate the passage of drainage into the wound, it is sometimes rational to lubricate them with sterile vaseline oil or glycerin. With tortuous wound tracts and the formation of scar tissue along the wound tract, drainage sometimes cannot be introduced immediately—in these cases, the introduction of drainage on a probe or on a sound helps. During the treatment of the wound by tamponade and drainage, as the wound heals and the wound tract narrows, the tampons decrease in caliber, just as the caliber of the introduced drainage decreases, and the latter also gradually shortens with the shortening of the wound tract. One should take drainage with a wide lumen, avoiding thick-walled tubes, which, due to the narrowness of the lumen, can become clogged with pus. When dressing patients, one should observe the principle of sequence in dressings in connection with the character of the wounds. To avoid infection of clean wounds, one should always dress clean patients first—postoperative (removal of sutures, etc.)—and subsequently, patients with granulating infected wounds. Instruments that accidentally come into contact with infected wounds during clean dressings should be set aside and not used on the same day; after the dressing, they should be boiled for an hour in a 5% solution of carbolic acid. Dressings can be divided into: 1) aseptic and 2) antiseptic. Aseptic dressings are indicated for accidental sutured or postoperative wounds. The technique of dressing these wounds usually consists of smearing the circumference of the wound and the suture line with astringent skin antiseptic substances (5% iodine tincture, bromferron, brilliant green) and applying several layers of aseptic white gauze and cotton, secured with a bandage. Much more economical, however, is the application of so-called patches, which are secured to the skin with collodion or mastizol. Patches are indicated mainly for postoperative sutured wounds on the torso (laparotomy wounds). The dressing of surgical wounds with a roll is also common, again in abdominal wall operations, especially in fat subjects. The technique of applying a dressing with a roll is as follows: after suturing the deep layers of the abdominal wall down to the aponeurosis, the skin is sutured through the entire thickness of the adipose tissue, stepping back 2–3 cm from the line of the wound edges, with curved needles, at the same time catching the aponeurosis along the suture line. Usually 3–4 such sutures are applied corresponding to the length of the wound. Suturing the skin in the usual way, a roll is placed and secured with threads. The roll is usually removed on the third day after the operation and protects against the formation of hematomas in the wound. An indication for changing a dressing in clean wounds is the occurrence of darting and pulsating pains in the wound in the days following the application of the dressing, and an increase in temperature. When removing a patch or dressing, the wound is examined along the suture line and its circumference, and based on tenderness or redness, as well as the presence of an infiltrate, one judges on the presence of infection. Redness at the places of needle insertions and extractions of the skin suture is an indication to remove the sutures before term. If one of the removed sutures turns out to be wet, it is better to remove all sutures immediately. The presence of a painful infiltrate around the wound is a reason to open the wound along the suture line. With swellings along the suture line and the absence of sharp pains, one should think of a hematoma. The latter is better to release by removing two or three sutures and then applying a secondary suture to the wound.

In the case of a smooth course of a clean sutured wound, dressings usually coincide with the moment of removing the sutures, which are removed at various times depending on the area of the body, age, and the patient's disease. In children, sutures are generally removed earlier than in adults. Sutures on the integuments of the head are removed as early as the third day after application, with the last sutures removed by the fifth day (cutting through). On the neck, where one should remember about cosmetic scars, sutures are also started to be removed from the third day. On the scrotum, sutures are removed by the sixth day. On the trunk and extremities, removal of sutures is generally performed on the eighth day. Technique of removing sutures. Having smeared the suture line with tincture of iodine, bromferroin, etc., the ends of the tied thread are grasped with forceps closer to the knot; the knot is lifted upward and the thread is cut below it, trying to avoid infection by not passing the part of the thread lying outside the wound into the wound canal. After the sutures are removed, the suture line is smeared again with tincture of iodine and an aseptic adhesive plaster or an aseptic dry dressing is applied. Antisepsis. Dressings are indicated for infected wounds and can in turn be divided into dry and moist. For dry antisepsis dressings, iodoform, viroform, etc. gauze is used and it is introduced into the wound cavities and canals in the form of tampons. Moist antisepsis dressings are applied after wide excision, refreshing the edges of lacerated, more often gunshot wounds, washing the latter with antiseptic liquids using a system of drainage tubes (see Wounds—treatment). How often must dressings be done in the treatment of infected wounds? From clinical observations it is known that any manipulations in an infected wound are associated with pain, deterioration of the general condition and well-being of the patients, and increases in temperature. Hence it follows that dressings must be done only for the indications mentioned above. To ensure rest for the wound and give sufficient drainage of pus from the infected wound, the moist upper layers of the dressing are generally changed daily, leaving the deep layers and tampons introduced into the deepest parts of the wound untouched. If an operative intervention has been performed for a purulent process and tampons and drains have been introduced into the wound, the latter must be removed as early as possible no earlier than the 4th–5th day after their introduction. Further change of drains and tampons, again to avoid traumatization of the tissue, must be performed at intervals of 3–4 days. If we are talking about an infected wound of bones, operated osteomyelitis, then to observe the greatest rest, the limbs laid in a cast or on traction must remain in the same position and during dressings. If during dressings in such patients accumulation of pus with formation of pockets and tracks is detected, the latter must be opened. Since these manipulations are painful, it is necessary to apply especially gentle technique during dressings and widely use painkillers (morphine before dressings, ether anesthesia during incisions). It should be mentioned that dressings with ointments are indicated. They are applied to protect the skin surrounding the wound from irritation by wound secretion in granulating wounds, ulcers, dermatitis, etc. The most common for this purpose are fats and indifferent ointments: lanolin, vaseline, boric vaseline, zinc ointment, etc. Ointment dressings are especially common in the presence of fistulas of hollow organs (gastric fistula, intestinal fistula, anus praeternaturalis), to avoid maceration of the skin by the contents of these organs. It is necessary to point out that ointments and fats protect the skin better if they are applied not directly to the latter but to pieces of gauze.