Dear readers and friends,
Today I present to you the first article of a series on traditional medicine, at least some notions to better understand our body and medical dialectics. Here we do not want to cure anyone especially with traditional medicine, only for information purposes I will write this series of articles.
Wounds
A wound is defined as a break in the continuity of the skin, caused by a mechanical agent and can affect the dermal-epidermal layer and the subcutaneous layer (superficial), the underlying layers (deep) or even cause lesions to internal organs (penetrating).
The classification of wounds is based on the characteristics of the traumatic agent and the appearance of the lesion, and can be distinguished as follows:
a) Cutting wounds : caused by sharp objects (daggers, knives), they may be linear, involve loss of substance or present flaps; as a rule the margins are clear and bleeding is modest if no vessels of a certain size are involved.
b) Puncture wounds: caused by sharp objects, they present a hole in the skin that in section generally reproduces the shape of the injurious agent with a slightly narrower diameter. The edges of the wound may be jagged and present a fair amount of bleeding; loss of substance is not rare.
c) Lacerated and lacerated-contused wounds: the laceration is caused by a pulling or stretching force as expressed in bites, tearing produced by gears, sliding on rough surfaces, traumas found in road accidents, at work, fights, etc. This type of wound is characterized by irregular edges, frayed and everted, by significant bleeding and by the possible presence of retained foreign bodies. Sometimes this type of lesion or even a simple contusion can be associated with involvement of underlying organs such as, for example, the fracture of the nasal bones due to a contusive trauma to the face.
d) Gunshot wounds: further subdivided into grazing wounds, semi-channel wounds, blind wounds, penetrating wounds and blast wounds, in relation to the weapon used and the type of impact of the bullet on the tissue.
The treatment of wounds varies depending on the type of lesion itself, the time elapsed since the trauma and the degree of destruction and contamination of the tissues. This latter eventuality is usually caused, maintained and aggravated by inadequate treatment in the immediate post-traumatic period, thus favoring the passage to the infectious phase properly speaking. Therefore, the general rules in these cases provide, after an initial emergency approach regarding hemostasis and antibiotic and anti-tetanus protection, that the definitive treatment can be postponed until all the conditions of aseptic are obtained.
In the region of the lesion, the skin must be cleansed and, if possible, shaved. The wound must be cleaned and disinfected with diluted hydrogen peroxide or sterile saline; the skin of the surrounding areas can be treated with iodine tincture. Tetanus seroprophylaxis is mandatory in anfractuous wounds, especially if they contain retained foreign bodies, and in all conditions that raise concerns about the presence of spores: contamination with garden soil, street dust, manure, etc. Contaminated wounds must also be monitored for the possible onset of gas gangrene. In any case, treatment with general antibiotics is essential and is aimed, above all, at reducing the risk of superinfection by pyogenic germs.
Suturing a wound is indicated in the presence of conditions suitable for healing by primary intention: scrupulous asepsis and hemostasis and correct approach to the edges are then indispensable. For the dermis, the use of catgut is preferable, as it is absorbable; the skin edges, on the other hand, are approached with non-absorbable threads, generally silk or nylon, to be removed after about a week.
It is important to remember that the more oblique the wound margin is and the greater the depth of the lesion in the underlying planes, the more imperfect the scar will be.
To facilitate the approach maneuver, the edges must be modeled as a flap by detaching from the underlying tissues, which becomes more extensive the more the wound involves the platysma region. Detaching is performed by lifting the edge of the lesion with surgical forceps, cutting with the scalpel in the thickness of the skin above the platysma and deepening the incision with scissors, taking care never to compromise the vitality of the skin flaps with a course that is too superficial or too deep.
In the suture technique it is good to follow some rules whose purpose is to obtain, once healing is achieved, a scar that is barely visible and located at the same level as the skin level. For example, it is more correct to always insert the needle from the edge of the most mobile and thin flap of the wound to the most stable and thick one and not vice versa; in the suture of the subcutaneous tissue it is good to move from the bottom to the top so as to leave the knots in depth; in tying the threads of a superficial suture it is good practice to encourage the eversion of the skin upwards and outwards, which guarantees the best aesthetic results.
In lacerated-contused wounds, after careful inspection and cleansing, the devitalized parts and those predisposed to infectious complications must be removed. If little time has passed since the trauma and there is no doubt of significant bacterial contamination, the suture can be performed under massive antibiotic protection; otherwise the wound must be left open in order to promote, after repeated dressings, healing by secondary intention.
In gunshot wounds, the priority of the intervention is the extraction of the bullet and foreign bodies present in the lesion; this procedure not only reduces the risk of acute infectious complications, but also avoids any compression disorders or the chronicization of abscesses and fistulous tracts. It is good practice not to delay the removal of the stitches too much: a prolonged stay can cause microwounds with fistulous tracts: the result could lead to irregular healing with poor aesthetic results.
Burns and Caustications
A burn is defined as the harmful effect produced by a heat source, radiation or contact on organic tissues; lesions caused by a direct chemical action are instead defined as caustications.
Caustics and burning agents can be solid, liquid or gaseous; since they interact with organic matter generating the same biochemical alterations (all of which can be summarised as tissue necrosis) even if with a different mechanism of action, they determine, like the effects of high voltage electrical discharges, the same type of anatomical-pathological lesion.
The classification into degrees is based on the local inflammatory reaction, the presence of necrosis and its extension in depth; we distinguish:
First degree burn (erythematous): it is characterized by active hyperemia due to vasodilation; if not very extensive it regresses in a few days.
2nd degree burn (bullous): in addition to vasodilation, there is marked exudation with sero-hemorrhagic blisters between the epidermal layers or between the dermis and the epidermis. The skin appendages are spared from inflammation: this allows complete restitutio ad integrum if suppurative complications do not occur.
Third degree burn (escharotic): the necrotic action particularly affects the dermis with the formation of an eschar beneath which there is granulation tissue, which is evident after the detachment of the same. In relation to the degree of involvement of the dermis, a full-thickness necrosis is distinguished from partial necrosis: the lesion caused by the latter, although destined to leave a scar area, re-epithelializes due to the presence of both epidermal residues in the interpapillary valleys and skin appendages; full-thickness involvement constitutes an indication for repair with grafting. The presence of tactile sensitivity and pinprick sensitivity generally indicates partial involvement of the dermal layers.
The action of caustics is necrotizing and can be produced in various ways: in fact, we can distinguish dehydrating caustics (soda, lime), oxidizing (silver nitrate, hydrogen peroxide), fluidifying (ammonia, acetic acid), coagulating (mercury salts, copper, lead, zinc). These substances cause extensive and deep necrosis that produce eschars which, after falling, evolve into retracting and deforming sores and scars.
The most minor injuries are similar to those of 1st and 2nd degree burns.
The first therapeutic moment must have as its main objective that of reintegrating the circulatory volume and correcting electrolyte imbalances (in particular metabolic acidosis). Antibiotic prophylaxis is also important because the larger the burned area, the more infectious complications are to be feared. These are due, in the immediate, to the action of streptococcus and staphylococcus, while late sepsis is usually supported by Gram-negative germs, among which Pyocyanus predominates. Finally, it is good to remember that every burned person is exposed to the risk of tetanus infection.
Each therapeutic action carried out with the utmost respect for asepsis promotes either the capacity for spontaneous epidermization or the formation of a suitable terrain to receive the various types of dermo-epidermal grafts.
In 1st and 2nd degree burns or caustications, observed in an outpatient setting, the affected areas should be gently cleansed. The epidermis, although burned, should be left in situ since there is repair tissue underneath; unopened blisters should be evacuated to allow the epidermis to cover the wound.
A treatment called "open", with exposure of the lesion, or "closed" can be performed. In the first, the resolution of skin alterations is favored by the use of a lamp or air conditioning; it is best to limit the use of steroid drugs or antibiotics on the affected area to a minimum in order to avoid skin maceration; in exclusively erythematous lesions (sunburn), hydrating solutions applied locally can prove useful. The pain can be alleviated with aspirin or codeine administered generally.
The “closed” method, on the other hand, is based on the application of a sterile gauze on the affected surface, possibly soaked in a 5 per thousand silver nitrate solution (which, while retaining high bactericidal power, is tolerated by the tissues and in particular by the sores), and protected by a bulky pressure bandage.
For third-degree burns or caustications, emergency hospitalization at a specialized center is mandatory.
A particular type of damage caused by physical agents is that caused by freezing. The cold acts, from a biochemical point of view, by producing a crystallization of intra and extracellular proteins; it also causes capillary vasoconstriction, freezing of red blood cells with microthrombosis, opening of arteriovenous shunts. Clinically, these alterations appear as ischemic and cold areas of the skin, with desquamation and formation of blisters; this is superficial freezing that resolves in a short time with rapid rewarming of the part; slight hypersensitivity to cold may remain. In the most severe lesions caused by damp cold and involving the face and extremities, the parts appear pale, cold, hard and insensitive; hyperesthesia and sweating are often present; instead, they become red, spotted, painful and swollen if reheated (chilblains). Depending on the extent of the lesions and the more or less timely intervention, the symptoms may disappear or gangrene may occur.
The most suitable treatment for cold injuries, unless generalized hypothermia coexists, consists in rapidly warming the area, taking care not to exceed 43 C° since the affected tissues are insensitive and susceptible to burns. The area must be cleaned, disinfected and protected with sterile gauze, always promoting air circulation. It is good practice to keep the injury under observation in order to prevent superinfections or gangrene.
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