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Государственное бюджетное образовательное учреждение высшего

профессионального образования
«Курский государственный медицинский университет»
Министерства здравоохранения Российской Федерации

ИНВАЗИВНЫЕ И НЕ ИНВАЗИВНЫЕ ТЕХНОЛОГИИ


В ОБЩЕЙ ХИРУРГИИ

УЧЕБНОЕ ПОСОБИЕ ДЛЯ СТУДЕНТОВ МЕДИЦИНСКИХ ВУЗОВ

КУРСК – 2019

1
УДК 617-089(075.8) Печатается по решению
ББК 54.5я73 редакционно-издательского
И 58 совета ФГБОУ ВО КГМУ
Минздрава России

Инвазивные и неинвазивные технологии в общей хирургии:


Учебное пособие для студентов медицинских вузов / Под редакцией
Б.С. Суковатых. – Курск: КГМУ, 2019. – 208 с.

Авторы:
Б.С. Суковатых, О.В. Алименко, Е.Г. Андрюхина, Ю.Ю. Блинков,
Н.М. Валуйская, И.И. Гуреев, А.Ю. Орлова, Л.Н. Беликов, М.Б.
Суковатых.

Инвазивные и неинвазивные технологии, к которым относятся


наложение различных видов повязок, транспортная и лечебная
иммобилизация, инъекции, инфузии, гемотрансфузии, зондирование полых
органов через естественные отверстия, пункции полостей, суставов,
поверхностно расположенных гематом и абсцессов, технология остановки
наружного кровотечения, сердечно-легочная реанимация, правила
перевязок больных, хирургическая обработка ран, оказание первой
медицинской помощи при неотложных состояниях, приобрели особое
значение именно в хирургии, хотя широко применяются и в других
клинических дисциплинах. Поэтому знание и умение выполнения данных
манипуляций является необходимым для врача любой специальности.
Особое значение эти манипуляции приобретают при оказании первой
медицинской помощи больным и пострадавшим.

ISBN ББК 54.5 я73

© Коллектив авторов, КГМУ, 2019


2
© ФГБОУ ВО КГМУ Минздрава России, 2019
FEDERAL STATE BUDGETARY EDUCATIONAL ESTABLISHMENT
OF
HIGHER EDUCATION
«KURSK STATE MEDICAL UNIVERSITY»
MINISTRY OF PUBLIC HEALTH OF THE RUSSIAN FEDERATION

General Surgery Department

INVASIVE AND NONINVASIVE TECHNIQUES


IN GENERAL SURGERY

Education manual for international faculty students

Kursk – 2019
3
УДК 617-089(075.8) Printed according to the
ББК 54.5 я73 decision of the Editorial –
I 58 publishing council
of Kursk State Medical University

Invasive and noninvasive techniques in general surgery. Education


manual for international faculty students. // under edition of professor
B.S. Sukovatykh. – Kursk: KSMU, 2019. – 208 р.

Authors:
Professor Dr. B.S. Sukovatykh MD, PhD
Professor Dr. Yu.Yu. Blinkov, MD, PhD
Assistant professor M.B. Sukovatykh MD
Assistant E.G. Andryuhina, MD
Assistant N.M. Valuyskaya, MD
Assistant O.V. Alymenko, MD
Assistant A.Yu. Orlova, MD
Assistant I.I. Gureev, MD
Professor Dr. Belikov L.N.

Invasive and noninvasive techniques include procedures such as dressing,


bandaging, transport stabilization, injections, infusion and transfusion methods,
catheterization of organs, punctures of tissues, joints, abscesses, and cavities,
control of bleeding, CPR, surgical debridement, and first aid. They have gained
the importance in surgical practice and other medical fields. Therefore a doctor
of any specialty must have sufficient knowledge of these topics. These skills
find particular importance in situations requiring the first aid.

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Оглавление
1. CHAPTER 1. BANDAGES AND MODERN BANDAGING MATERIALS IN MEDICAL
PRACTICE ........................................................................................................................................... 1
1.1. Classification of bandage: ......................................................................................................... 9
1.2. Bandaging materials and wound bandages .............................................................................. 10
1.3. Fixative bandage ..................................................................................................................... 13
1.4. Types of bandaging techniques ............................................................................................... 19
1.5. Different types of bandages on the body area .......................................................................... 24
1.5.1. Headbands ........................................................................................................................... 24
1.5.2. Bandages on upper limbs ..................................................................................................... 29
1.6. Pressing, sealing and compression bandages ........................................................................... 39
2. CHAPTER 2. TRANSPORT STABILIZATION ........................................................................ 43
2.1. General principles of transport stabilization ............................................................................ 44
2.2. Types of splints used in transportation .................................................................................... 46
2.3. Transport stabilization of the upper extremity ......................................................................... 49
2.4. Transport stabilization of the lower extremity ......................................................................... 54
2.5. Transport stabilization of the neck and head ........................................................................... 59
2.6. Transport stabilization of the spine and pelvic injuries ............................................................ 61
2.7. Modern methods of transport immobilization ......................................................................... 63
2.8. Medical immobilization and plaster bandages ......................................................................... 69
2.9. Plaster bandages ...................................................................................................................... 69
3. CHAPTER 3. PARENTERAL INJECTIONS AND INTRAVENOUS INFUSION.
TRANSFUSION THERAPY .............................................................................................................. 90
3.1. Intracutaneous and subcutaneous injections ............................................................................ 90
3.2. Technique of intradermal injection of drugs includes: ............................................................. 91
3.3. Intravenous injection and infusion ........................................................................................... 93
3.4. Filling a disposable intravenous infusion drip ....................................................................... 95
3.5. Connecting the system to the vein ........................................................................................... 96
3.6. Taking blood from a vein for lab analysis ............................................................................... 97
3.7. Bloodletting ............................................................................................................................. 98
3.8. Setting the peripheral venous catheter ..................................................................................... 99
3.9. The technique of venesection. ............................................................................................... 100
3.10. Intra-arterial injection ........................................................................................................ 101
3.11. Determination (typing) of blood group, Rh- factor by express method, individual and
biological compatibility (cross-mutching), the suitability of blood for transfusion. .......................... 103
3.12. Blood transfusion .............................................................................................................. 106

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4. CHAPTER 4. CATHETERIZATION OF HOLLOW ORGANS AND SEROUS CAVITIES .. 109
4.1. Urethral catheterization ......................................................................................................... 109
4.1.1. Female urethral catheterization .......................................................................................... 109
4.1.2. Male urethral catheterization ............................................................................................. 109
4.2. Gastric lavage ........................................................................................................................ 110
4.3. Cleansing enema .................................................................................................................... 111
4.4. Siphon enema (colon lavage) ................................................................................................. 112
4.5. Medication enema ................................................................................................................. 112
4.6. An abdominal cavity puncture ............................................................................................... 113
4.7. Laparocentesis ....................................................................................................................... 113
4.8. Puncture of the abdominal cavity through the posterior vaginal fornix in women ................. 115
4.9. Puncture and drainage of the Douglas pouch in men ............................................................. 115
4.10. Puncture of the pericardium cavity .................................................................................... 116
4.11. Pleural puncture ................................................................................................................. 116
4.12. Pleural cavity drainage according to Bulau........................................................................ 118
4.13. Capillary suprapubic bladder puncture .............................................................................. 120
4.14. Trocar epicystomy ............................................................................................................. 120
4.15. Lumbar puncture ............................................................................................................... 121
4.16. Puncture of the joints of the upper limbs ........................................................................... 123
4.16.1. The shoulder joint puncture ............................................................................................... 123
4.16.2. The elbow joint puncture ................................................................................................... 124
4.16.3. The wrist joint puncture ..................................................................................................... 124
4.17. Puncture of the joints of the lower limbs ........................................................................... 124
4.17.1. The knee joint puncture ..................................................................................................... 124
4.17.2. The hip joint puncture ........................................................................................................ 125
4.17.3. The ankle joint puncture .................................................................................................... 126
4.18. Puncture of soft tissues hematoma and superficial abscesses ............................................ 126
5. CHAPTER 5. HEMOSTASIS (CONTROL OF BLEEDING) .................................................. 127
5.1. The finger pressing vessel method ......................................................................................... 127
5.2. Bleeding control by joint hyperflexion. ................................................................................. 129
5.3. Compressive bandage. ........................................................................................................... 130
5.4. The tourniquet ....................................................................................................................... 131
5.5. Tamponade wounds ............................................................................................................... 134
5.6. Local application of hemostatic agents .................................................................................. 135
5.7. The imposition of styptic clamp ............................................................................................ 136

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5.8. Emergency treatment of acute gastrointestinal bleeding ........................................................ 138
5.9. Emergency treatment of pulmonary bleeding ........................................................................ 139
5.10. Technique of postural drainage of the bronchial tree ......................................................... 140
6. CHAPTER 6. SURGICAL TREATMENT OF WOUNDS ....................................................... 143
6.1. Preparation of dressing and surgical linen ............................................................................. 143
6.1.1. The technique of the dressing material preparation. .......................................................... 143
6.1.2. Preparation of surgical linen .............................................................................................. 143
6.1.3. Stowage of sterilization chamber and their preparation for sterilization ............................ 144
6.2. Methods of sterilization of surgical linen, dressings and suture material and surgical
instruments ........................................................................................................................................ 145
6.3. Quality control of sterilization and pre-sterilization process ................................................. 146
6.4. Sterilization in the dry heat oven ........................................................................................... 148
6.5. Preparation of sterile tables in the dressing and operating room. ........................................... 148
6.6. Methods of the surgeon's hands preparation (scrubbing) before a surgery. ........................... 149
6.6.1. Preparation of hands with 0.5% solution of chlorhexidine digluconate ............................. 150
6.6.2. Hands preparation with pervomur solution ........................................................................ 151
6.6.3. Hands preparation with cerigelum ..................................................................................... 152
6.6.4. Preparation of hands by Spasokukotsky-Kochergin’s method ........................................... 153
6.7. Putting on sterile clothes and sterile gloves (gowning and gloving). ..................................... 154
6.8. Preparation of the surgical field (prepping). .......................................................................... 155
6.8.1. Prepping of operating fields with iodonate and iodopiron. ................................................ 156
6.8.2. Prepping with the solution of chlorhexidine ...................................................................... 158
6.9. Primary surgical debridement of wounds .............................................................................. 158
6.10. Dressing of clean wounds .................................................................................................. 160
6.11. Dressing of purulent wounds ............................................................................................. 161
6.12. Application of bactericidal dressings ................................................................................. 163
6.13. Care of patients with colostomy or ileostomy.................................................................... 165
6.14. Treatment of bedsores ....................................................................................................... 170
7. CHAPTER 7. CARDIO-PULMONARY RESUSCITATION AND ANESTHESIA ................ 172
7.1. Indications to CPR ................................................................................................................ 172
7.2. The sequence of the basic resuscitative measures .................................................................. 172
7.3. The establishment of the absence of consciousness in a victim. ............................................ 172
7.4. Restoration and the guarantee of the respiratory tract patency. ............................................ 173
7.5. Introduction of the oropharyngeal airway through the mouth................................................ 176
7.5.1. The introduction of the nasopharyngeal airway through the nose. ..................................... 177
7.5.2. The estimation of respiration effectiveness in the victim. .................................................. 180
7.6. Artificial respiration .............................................................................................................. 180

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7.7. Obstruction of the upper respiratory tract by foreign bodies. ................................................. 183
7.8. The estimation of blood circulation. ...................................................................................... 186
7.8.1. The procedure of the indirect massage............................................................................... 187
7.8.2. The procedure of the indirect massage of the heart without artificial respiration. .............. 189
7.8.3. The typical errors and complications in conducting indirect massage of the heart. ........... 189
7.8.4. The medicines, used with specialized (extended) CPR. ..................................................... 189
7.8.5. The ways of administering of medicines with the CPR. .................................................... 191
7.9. Universal algorithm of actions with sudden death of the adult .............................................. 192
7.10. Local and regional methods of anesthesia; ........................................................................ 192
7.11. The regional methods of anesthesia ................................................................................... 193
7.11.1. Conducting anesthesia according to Lukashevich-Oberst. ................................................. 193
7.11.2. Circular blockade. .............................................................................................................. 194
7.11.3. Paravertebral novocain blockade. ...................................................................................... 194
7.11.4. The blockade of intercostal nerves..................................................................................... 195
8. CHAPTER 8. RESPONDING TO AN EMERGENCY. BASIC TYPES OF EMERGENCIES
AND THE FIRST AID...................................................................................................................... 197
8.1. Emergency Medical Services (EMS). .................................................................................... 197
8.2. First Aid ................................................................................................................................ 197
8.2.1. Evaluating the Situation ..................................................................................................... 197
8.2.2. Emergency care ................................................................................................................. 198
8.2.3. Other emergencies ............................................................................................................. 198
8.2.4. Non-Cardiac Facility Emergencies .................................................................................... 198
8.2.5. Bleeding ............................................................................................................................ 199
8.2.6. Shock ................................................................................................................................. 200
8.2.7. Fainting.............................................................................................................................. 201
8.2.8. Heart Attack ...................................................................................................................... 201
8.2.9. Stroke ................................................................................................................................ 202
8.2.10. Seizures ............................................................................................................................. 203
8.2.11. Vomiting and aspiration .................................................................................................... 203
8.2.12. Electric shock .................................................................................................................... 204
8.2.13. Burns ................................................................................................................................. 204
8.2.14. Orthopedic injuries ............................................................................................................ 205
8.2.15. Head injury ........................................................................................................................ 205
8.2.16. Accidental poisoning ......................................................................................................... 206
8.3. Action in an Emergency ........................................................................................................ 206
8.3.1. In the health care facility ................................................................................................... 206
8.3.2. In the community ............................................................................................................... 206

8
1. CHAPTER 1. BANDAGES AND MODERN BANDAGING MATERIALS
IN MEDICAL PRACTICE

The existing variety of bandages requires classification in order to better


understand their purpose. Currently, there is no single generally accepted classification
of dressings. From our point of view, the following classification of bandage is one of
the rational options.

a. Classification of bandage:
I. By the type of material used:
1. Soft:
A) Dressing,
B) Without bandage (glutinous, kerchief, sling, sticking plaster, T-shaped,
coatings).
2. Solid (splint, starch, gypsum).
II. Depending on the purpose:
1. Wound bandages:
A) sorptive; B) protective.
2. Fixing - designed to fix the dressing on the wound.
3. Pressing bandages - creating a constant pressure on any part of the body (to
stop bleeding).
4. Occlusive bandages - preventing the penetration of air into the pleural cavity
from the external environment and the interfering with the act of breathing.
5. Compressive bandages - designed to improve the venous outflow of blood
from the lower limbs.
6. Immobilizing bandages:
A) transportive; B) medical - providing immobility of the damaged part of the
body.
7. Corrective bandages - correcting the wrong position of any part of the body.
Soft bandages are bandages imposed by bandage, gauze, elastic, mesh-tubular
bandages, cotton fabric. Soft bandages are extremely diverse. Most often bandages are
imposed to hold the dressing material (gauze, cotton wool) and medicinal substances
in the wound, and also to carry out immobilization for the period of transportation of
the victim to the medical institution. Most often, bandages are used to apply soft
dressings. More rarely other means (without bandage) - glutinous, kerchief, sinister,
T-shaped, contoured bandages; Mesh-tubular bandages.
In hard bandages uses a hard material (wood, metal) or a material that can
harden: gypsum, special plastics and starch, glue, etc.
Most often in desmurgy, bandages are used to fix the dressing in the wound to
create optimal conditions for tissue healing.
It is necessary to clearly understand the difference between various dressing
materials and the methods of fixing it.
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b. Bandaging materials and wound bandages
The bandaging materials used during operations and for bandaging must meet
the following requirements: biologically and chemically intact; have capillarity and
good hygroscopicity; minimally free-flowing; soft, elastic, should not injure soft
tissues; easy to sterilize and not lose its qualities; and cheap to produce.
By properties, modern bandages are divided into two main groups:
• protective;
• sorptive.
The choice of bandaging depends on the condition of the wound and the phase
of the wound process. Basically, all wounds can be divided into: a) primarily closed
wounds (operating), epithelial sterile and donor; B) wounds with minimal exudation;
C) moderate exudation; D) marked exudation.
Protective bandages are used for the treatment of primarily closed or sterile
superficial wounds, for all other groups, sorptive.
A classic material that can be classified as protective and sorption, which has
found wide application, is cellulose and its derivatives - cotton wool, gauze. The most
common material used in surgical practice is gauze.
Medicinal bleached hygroscopic gauze can be of two kinds - pure cotton and
with a mixture of viscose (cellulose xanthate). The difference is that gauze with a
mixture of viscose, is cheaper in production, has 10 times less hygroscopicity, so its
use is undesirable for superimposing on wounds. It can be successfully used as a lining
or fixing material. The advantage of cotton gauze is its high hygroscopicity and
relative cheapness. Disadvantages include rapid impregnation with discharge from the
wound, which requires frequent dressings and significant adhesion to the wound
surface, which, with changing dressings, makes reparative processes difficult. Medical
gauze is made of large and small napkins, pads, turundas (narrow swab), cotton wool
and bandages, cotton-gauze bandages, dressing packets.
A very valuable dressing material is prepared from cotton, which is of two
kinds - simple (non-lean) and hygroscopic. The latter has a high absorption capacity.
Simple cotton wool is not hygroscopic and is used in surgery as a soft lining, for
example, when applying tires, gypsum dressings, and also as a material that delays
heat (warming compresses, etc.). The disadvantage of cotton wool is its relative high
cost.
In extreme conditions, it is possible to use absolutely clean cotton cloth as a
dressing material. However, it is absolutely unacceptable to use artificial fibres for
these purposes. In order to enhance the sorption properties, synthetic nonwoven
materials are sometimes used with immobilization of cellulose sorbents on them,
which increases the absorption capacity to 3,400% cellulosic gauze Pehacell
(Germany),"Biatravm" (Russia). Their advantage is their low cost and ease of
sterilization. All textile materials, despite the ubiquity have a number of serious
shortcomings, namely quick impregnation of the exudate and practically unable to
connect, have high adhesion properties to the wound, and are not able to maintain an
adequate microclimate in the wound. All this complicates wound healing, leading to
need for frequent dressings, pain and disruption of reparative processes at dressing
changes, the possibilities of formation of secondary infectious cavities.
10
Given the above shortcomings, in recent years there is a large number of new
dressings that must meet the following requirements: irreversibly bind excess wound
exudate and microbial body, to protect the wound from drying out; contribute to the
development of reparative processes in the wound, protect the wound from mechanical
and chemical irritation and secondary infection. In addition, the use of in-patient
practice of ready-to-use sterile and individually packaged modern wound dressings is
very convenient, often requires daily dressing, which facilitates wound care dressings
and simplifies the process.
As noted above in the case of primary closure or superficial wounds with sterile
dressings using protective bandages, the main function of which is to isolate and
prevent the penetration of microorganisms into the wound. They are permeable to
water vapour and provide a moist environment for epithelialization. The main, and
sometimes only one structural element of such coatings is an elastic polymer film.
Protective dressings are conditionally divided into two groups:
• coating applied as a finished product;
• coating formed directly on the wound.
the first group of coatings - transparent film, attached to the healthy part of the
body with the help of adhesives (Hydrofilm or Hydrofilm plus).
The insulating coating of the second group are formed directly on the surface of
the wound. For this purpose, we proposed aerosol composition, when applied to the
wound in 1-2 minutes will create a coating film due to the evaporation of the solvent.
Film forming aerosols are glue BF-6, furoplast "Lifuzol" (Russia) and others. The
advantages of the coatings of this group is the ease and speed of application that do not
require highly skilled medical staff, economic material, the ability to monitor the
condition of the wound without changing the dressing and water-resistant film that
allows you to wash patients.
As sorption dressings for wounds with minimal exudation mainly used are
hydrogels (Hydrosorb, Hydrosorb gel, Hydrosorb comfort) are made of silicone or of
natural rubber, polyvinyl chloride, polyurethane, polyamides, polyethylene,
polystyrene, polypropylene and silicone. They limit the evaporation of tissue fluid that
instantly creates a moist environment, are able to absorb a small amount of wound,
promote rehydration and prevent necrosis, reduce pain, do not stick to wounds. In
recent years, it received a coating of chitosan wound - «Chitosan» (United Kingdom,
Taiwan), "Kollahit" (Russia). This coating consists of a chitin derivative from lobster
and is biologically a semipermeable membrane.
For the treatment of pressure ulcers, donor skin and other skin wounds in the
epithelization phase of wound healing process, wound with minimal exudation uses
absorbable wound dressings of collagen, which is associated with its properties to
stimulate fibroblastogenesis, lysis and replacement by connective tissue. On the basis
of the soluble collagen coating, was developed "Kombutek-2"; "Oblekol" - collagen
film with sea buckthorn oil; "Gentatsikol" - combination product containing
gentamicin sulfate. Absorbable dressings can also be made of synthetic polymers:
polyglucolid, polylactide, and others.
For wounds with moderate exudation we use hydrocolloids, atraumatic mesh
bandages and dressings with activated drugs.
11
Hydrocolloids (Hydrocol, Hydrosorb, Medisorb, Gelepran) absorb the liquid,
are hypoallergenic, well-protect and stimulate granulation, self-fixing the wound.
Atraumatic mesh bandages (Atrauman, Grazolind, Branolind H, Voskopran,
Parapran) have good permeability, maintain the moist environment, easily modelled in
the wound, and do not adhere to the granulation. This type of bandage requires a
secondary covering, usually in the form of banal gauze. Polymer materials are widely
used to create these bandages. The principle of construction is that the surface of the
cellulosic or synthetic material facing the wound, is coated with a thin film of a
hydrophobic polymer, and to wound dressings the sorption activity is not lost, as is the
case in perforated films. As materials for the hydrophobic layer, we use polyethylene,
polyvinyl chloride, polyamides, silicone, polypropylene. To increase the rate of
absorption of exudate by the sorbent, the perforated film is suggested to be coated with
surfactants, such as in the Aseplen bandage. Another method of manufacturing
nonadherent dressings is to cover the surface facing the wound, a thin metal layer
sputtered in vacuum impregnation or acrylic silicone resin containing ZnO powder,
silver or aluminum. To the same group of bandages can be attributed the simplest and
long-used gauze bandages with hydrophilic ointments (levomikol, levosin). To
enhance the therapeutic effects when used to moderately exudative wound bandages,
we use activated drugs. As carriers for the immobilization of medicinal substances,
non-woven materials are used from polyvinyl alcohol fibers, activated with sodium
dichloroisocyanurate or hydrogen peroxide, cotton dressings, fluorine compounds,
oxidized cellulose and viscose fibers, various sponges and films. With the introduction
of drugs in bandages we often use their combination. To combat infection, wound
bandages include antiseptics (Dioxydin, Chlorhexidine, Capatol, Miramistin) -
Aseplen-K and Aseplen-D, sulfonamides, antibiotics, Lincocele (Belarus), nitrofurans
- Coletex, iodine "Aserlen-I." Also silver ions, xeroform, are used.
As a result of immobilization of proteolytic enzymes on a polymer coating
material, it is possible not only to extend the enzyme's duration and to reduce its
therapeutic concentration, but also to limit the possibility of absorption of the drug into
the bloodstream. To this end, enzymes - trypsin, chymotrypsin, Lysozyme, terrylitin,
etc. are used. To this group of wound coverings are: "Polypor" - polyurethane foam
composition with immobilized trypsin; "Dalcex-trypsin" - trypsin, immobilized on
medical gauze; "Pextrisin" - trypsin, immobilized on kapron knitted fabric;
"Theralgin" is a porous sponge containing an enzyme terrylitin; "FERANZEL"
(Belarus) - contains chymotrypsin immobilized on monocarboxycellulose.
As for wounds with pronounced exudation, in the overwhelming majority of
cases, this pathology is an indication for treatment in a surgical hospital. To treat such
wounds, modern bandages are used: super absorbents, spongy bandages and alginates.
Superabsorbents (TenderVet24) absorb the liquid well, promote rapid wound
cleansing, stimulate proliferation processes, and have low adhesion. Spongy bandages
(PemaFoam, Pemafom comfort) also absorb the liquid well, stimulate granulation,
promote the prevention of maceration of the skin. Alginate bandages (Algipor,
Sorbalgon,) are resorbable natural polymers obtained from seaweed. This type of
bandage irreversibly binds the fluid, cleans wounds, promotes drainage and
hemostasis, stimulates the growth of granulations.
12
c. Fixative bandage
The wound bandage should be applied so that it does not stray and does not
squeeze the damaged part of the body, providing, at certain indications, rest to the
damaged organ, the most advantageous functional position and free outflow of the
wound discharge.
There is a rather large number of ways of fixing the bandage, each method
having its own specific indications.
Adhesive bandages.
Adhesive (Glue) bandages are applied to the area of the postoperative wound
and for small injuries. Their advantages: 1) closing directly the area of the wound, you
can observe the state of the surrounding skin; 2) are simply and quickly superimposed;
3) do not restrict the movements of the patient; 4) are economical.
The following different types of adhesives are used.
Adhesive Plasters.
The simplest form of a firming bandage is an adhesive plaster. They are in the
form of rolls of tape of different widths. It adheres well to dry skin and is used to fix
various dressings and to seal small wounds. Apply adhesive plaster and then, when
you need to pull together the edges of the granulating wound and keep them in this
position to accelerate the healing process. Adhesive plaster is used to treat fractures by
the method of constant traction, especially in children. Of great importance is the
adhesive plaster, when it is necessary to eliminate the communication of any cavity
with the atmosphere, for example, with penetrating wounds of the chest. To apply this
dressing, take a piece of adhesive plaster, exceeding the size of the wound. The first
strip is placed at the lower edge of the wound, bringing its edges together. The second
strip of adhesive tape and each subsequent so that they glue the previous one 1/3 of the
width, like the roof tiles, hence the name "tile" bandage. Plaster bandages when wet,
get off, irritate the skin, and requires large amounts of labour and are expensive.
Gluing bandage
Currently, for glue-stickers we apply glue, which does not tighten and less
irritating to the skin. Its composition: rosin - 40 parts, alcohol 96 - 33 parts, ether -
15 parts, sunflower oil - 1 part. The order of application of the adhesive bandage:
wound dressing is applied to the wound, and a thin layer of glue is applied to the skin
around the wound with cotton wool. After 30-60 seconds, when the glue begins to dry
a little, glue a gauze napkin of the necessary shape and size, tightly pressing it against
the skin and stretching at the edges. The free edges of the gauze napkin, not adhering
to the skin, are cut.
Colloidal bandage
Collodion is a solution of colloxylin in ether and alcohol. The solution is
applied with a brush to the edges of the gauze pad applied over the dressing material.
When evaporation of solvents freezes, the bandage adheres tightly to the skin.
Disadvantages of this dressing are skin irritation and unpleasant sensations as a result
of contraction of the skin at the place of lubrication with collodion and collodion is
easily ignited. Currently, collodion bandages are used rarely.

13
Handkerchief bandage
The scarf dressing is a common bandage for first aid, since it does not require
complex adaptations, can be quickly applied using a headscarf, sheets, gauze, canvas,
etc. Under the kerchief is meant a piece of triangular-shaped cloth in which the base is
distinguished (the long side), the top (the angle lying against the base) and the ends -
the other two corners.
In first aid, a scarf made of a headscarf can serve to apply a dressing and fix the
dressing on almost any part of the body. However, most often it is used to suspend the
upper limb, especially with injuries to the forearm and hand.
To fix the hand (Fig. 1.1), the latter is folded to the right angle, and the scarf is
brought in such a way that the upper end is placed under the clavicle from the side of
the affected arm, and the second end hangs downward, the apex of the scarf comes out
from under the elbow. Wrapping the upper end up in front of the forearm of the sick
arm, it is carried on the shoulder of the healthy side and behind the neck, where it is
tied to the other end of the scarf. The top of the scarf is bent around the elbow and
fastened to the front of the elbow by a pin.

Fig. 1.1. Stabilization of a shoulder and upper limb using triangular bandage.

Using a scarf, you can apply bandages to the mammary gland (Fig. 1.2), the
foot and the hand (Fig. 1.3). With a head bandage, the scarf is put on the back of the
head and the crown, the top is lowered on the face, the ends are tied on the forehead,
then the tip is bent in front of the tied ends and fastened with a pin.

14
Fig. 1.2. Supporting a mammary gland using triangular bandage.

Fig. 1.3. Applying a triangular bandage to the wrist.

Slings and four-tail bandages (sling bandage)


A simple sling can be made with a piece of gauze of almost length of 50-60 cm,
both ends of which are incised in the longitudinal direction so that the middle of the
length of 10-15 cm is uncut (see Fig. 1.4). In such dressings formed 4 end; the middle
part is intended to cover the damage to the site over the dressing and secure the latter.
It is most often used on the face in the region of the nose, forehead, occiput, chin, as a
temporary measure to retain tampons and temporary immobilization. Like the scarf
bandage, it does not cover the hermetically damaged area and is fragile.

15
Fig. 1.4. Four-tail bandage.

In Fig. 1.5. The technique of imposing a four-tail bandage on the nose


(Figure 1.5.a), on the chin (Figure 1.5.b), the back of the head (Fig.1.5.c) and the
crown (Fig. 1.5.d) is shown. An obligatory condition for imposing a sling is the cross
of its ends before tying.

а b

c d

Fig. 1.5. Variants of the applying of a four-tail bandage.

T-bandages
This dressing is convenient for keeping the bandaging material on the
perineum, scrotum and anus. Easy to manufacture, if necessary, can be quickly
superimposed and removed. It consists of horizontal and vertical (wider) stripes of
bandage, the horizontal part around the waist in the form of a belt, and the vertical part
- from the waist through the crotch forward and is attached to the same belt
(Fig. 1.6). The T-bandage can successfully replace the so-called suspensions used to
maintain the scrotum, for example, after surgery for hydrocele, for orchitis, orchid
epididymitis, etc.
16
Fig. 1.6. T-shaped bandage on the perineum.

Bandages with the use of elastic mesh-tube bandages (tubular bandages)


To keep the sterile material on large wounds, tubular knitted bandages and
elastic reticular bandages "Retilast" are widely used, which, having great extensibility,
tightly fit any part of the body, do not dissolve during incision and at the same time do
not restrict movements in the joints. They look like a tube of different diameters
woven from a cotton and rubber thread. Depending on the size, there are five numbers
of tubular bandages: No. 1 on the finger, No. 2 on the forearm or drumstick, No. 3 on
the shoulder, No. 4 on the thigh and head, No. 5 can stretch so much that it can be put
on Chest or stomach. Having a mesh structure, elastic mesh-tubular bandages provide
the possibility of aeration and observation of the condition near wound tissues.

Roller bandages
Roller bandages are the most common, as they meet the requirements for
modern rational dressing (strength, elasticity, porosity, creating the right pressure,
etc.). Currently, for bandaging is always used soft gauze, which has good elasticity.
Gauze bandages do not prevent evaporation of moisture from the bandage. Bandages
from a denser fabric (flannel, canvas, calico) are not currently applied. The use of soft
bandage remains to this day one of the most common ways of strengthening dressings,
despite the widespread use of adhesive plasters, glue, polymerized plastics, synthetics,
etc. This is due to the versatility of bandage dressings, their adaptability to any
variations of the body surface and any pathological processes. If to add to this the
possibility of their combination with other methods of fixation, then the scope of their
application becomes unlimited.
The rolled part of the bandage is called the head, and the beginning of it is the
free end. Bandages can be single-headed and double-headed (rolled from two ends to
the middle), the latter used in exceptional cases (head bandage). The back of the

17
bandage, i.e. The surface facing the bandaged part of the body is called the back, and
the opposite side by the belly, and with the bandage the abdomen should be turned
outward so that the bandage can easily and freely roll out on the surface of the
bandaged body section. The bandage is narrow (up to 5 cm), medium (7-10 cm) and
wide (12 cm or more). Each part of the body requires its width bandage
The basic requirements for this kind of bandage are as follows:
• cover the affected area of the body;
• not to violate blood and lymph circulation;
• hold securely on the body area;
• have a neat appearance if possible.

Rules for the imposition of a soft bandage


Despite the high prevalence of these bandages, their imposition requires a
certain skill, knowledge and skill. Correctly applied bandage does not disturb the
patient, neat, firmly and permanently fixes the dressing. In order for the dressing to lie
properly, you should use bandages of the appropriate width, depending on the size of
the anatomical area being bandaged. So, for a trunk wide bandages are necessary, for a
head - average, for a hand and fingers - narrow. Bandage consists of the following
stages: 1) the imposition of the initial part of the bandage; 2) superposition of the
actual dressings; 3) securing the dressing.

Bandaging rules
1. At the start of Bandage, care should be taken to ensure that the patient is in a
position convenient for him, and the bandaged part of the body is accessible from all
sides.
2. An obligatory condition is the application of a dressing in the horizontal
position of the patient in order to prevent complications (shock, fainting). The
exception is a minor damage.
3. The dressing is applied in that position of the limb, which is the most
profitable in the functional sense, especially applying the dressing for a long period of
time.
4. It is very important that the application of the dressing, as well as the
bandage itself, does not cause the patient unpleasant sensations, which largely depends
on the skill of the bandage. During bandaging, the person who provides the aid, must
face the patient to constantly monitor his/her condition.
5. Bandage is very tiring and inconvenient, if the medical worker has to tilt or
lift his hands, so it is best to place the bandaged part of the body at the level of the
lower part of the breast of the patient.
6. The dressing should be applied from the peripheral parts, gradually covering
the central regions of the body with bandages. The exception is bandages on the hand,
foot and fingers of the hand and foot, when the bandage turns are located from the
center to the periphery.
7. Bandage begins with the first two fixing turns of the bandage.
8. The head of the bandage is held in the right hand, the beginning of the
bandage is in the left, the bandage is rolled from left to right with a backboard on the
18
bandaged body surface, without lifting your hands from it and stretching the bandage
in the air. In some cases, right-to-left bandages can be done, for example, when
bandages are applied to the right side of the face and chest.
9. Bandage should roll smoothly, do not form wrinkles; its edges should not lag
behind the surface and form "pockets".
10. The dressing should not be applied very tightly (if a pressure bandage is not
needed) so that it does not disturb the blood circulation, but it should also be not too
weak so that it does not slip off the wound.
11. The hand of the patient should follow the course of the bandage, and not
vice versa.
12. While bandaging (except creeping bandaging) each subsequent round has to
cover the previous one by 1/3 or 1/2 the width of the bandage.
13. To fix the bandage after the end of bandaging, the end of the bandage is torn
or (better) cut with scissors in the longitudinal direction; Both ends are crossed and
tied, and neither the cross nor the knot should lie on the wound surface. Sometimes the
end of the bandage is bent during the last circular move or pinned to the previous
rounds by a pin.
14. When bandage is removed, the bandage is either cut or unwound. Cut the
bandage starting away from the damaged area or with the opposite side wound. During
unwinding, the bandage is collected in a bundle, shifting it from one hand to the other
at a close distance from the wound.

Errors in the application of soft bandages


1. If the dressing is tightly applied, cyanosis, edema, the temperature of the
distal part of the limb decreases, and throbbing pains appear. When transporting a
patient with a tightly applied bandage in winter, frostbite of the distal limb may occur.
In case of appearance of the described symptoms, the injured limb is elevated. If after
5-10 minutes there is no improvement, the dressing should be loosened or replaced.
2. With a weak bandage tension bandage quickly slips. In this case, it is better
to replace it, ensuring that when the bandage is completely passive, the damaged limb
is damaged.
3. The integrity of the dressing is easily broken if the first fixing turns are not
made. To correct the error, the bandage should be tied up, reinforced with a glue and
adhesive plaster.

d. Types of bandaging techniques


To properly apply any bandage, you need to know the anatomical features of
this or that part of the body and the so-called physiological positions in the joints.
Different parts of the limbs have a different shape (cylindrical - shoulder, conical -
forearm, shin), which must be taken into account when applying bandages. The nature
of bandaging (more amount of bandages) can also be affected by more expressed
muscles in men and greater roundness of the forms in women. In view of these
provisions, various types of bandage dressings have been developed.

19
A circular dressing or a circular bandage (fascia circularis) is the simplest
form of a bandage dressing, in which all the tours of the bandage fall on the same
place, completely covering each other. It begins and ends at the same place, so less
often it is used as an independent on the parts of the body of a cylindrical shape. In this
case, the bandage moves going from left to right ring each other completely. At the
beginning of bandaging, the first move of the bandage can be given an oblique
direction, bending off its edge, which is then fixed with the second stroke (Figure 1.7).
A circular bandage is convenient for bandaging small wounds and is often
superimposed on the shoulder, wrist joint, lower third of the shin, abdomen, neck,
forehead.

Fig. 1.7. Circular bandage.

A spiral bandage (fascia spiralis), is used if it is necessary to bandage a


significant part of the body. It, like any other bandage, is started with circular
bandages (2-3 layers), then the bandage is led from the periphery to the center. In this
case, the bandage tours go somewhat obliquely from the bottom upwards and each
subsequent tour closes 2/3 of the width of the previous one. The result is a steep spiral
(Fig. 1.8).
Creeping or serpentine bandage (fascia serpences). This bandage is used mainly
for fast and temporary strengthening of the dressing material over a considerable
length of the limb. The cervical bandage is started by the circular movements of the
bandage, which are then converted into helical formations, from the periphery to the
center and back. So that the rotation of the bandage is not in contact (Fig. 1.9).

20
Fig. 1.8. Spiral bandage.

Fig. 1.9. Creeping bandage.

Cross or eight-shaped bandage is when the bandage tours are superimposed in


the form of the number 8 (Fig. 1.10). At the same time, the bandages are repeated
several times, and the cross is usually located above the affected area. This bandage is
convenient for bandaging parts of the body with an irregular surface shape (ankle,
shoulder, hand, occipital region, perineum, thorax).

21
Fig. 1.10. Cross bandage: а – occipital, b – chest, c – perineum, d – hand,
e – foot.

Varieties of Figure-of-eight bandages are spicate (fascia spica). Its difference


from the cruciate is that crossing is not on the
same level, and gradually moving up (rising
dressing) or down (descending). Place chiasm
bandage in appearance resembles an ear, hence
the name of the dressing (Fig. 1.11). Usually
spica is applied to the area of the joints.

Fig. 1.11. A spicate bandage on the hip joint.

Various types of 8-shaped bandage are


turtle bandage, converging and diverging (fascia
testudo inversa or reversa) bandages. Such a dressing is applied to the area of large
joints (elbow, knee). It consists of a bandage moves, crossed to the side flexion of the
joint and diverging in a fan on the extensor side. Divergent bandage begins with a
circular course through the center (the most protruding part) of the joint. Subsequent
moves are bandage above and below the previous ones, crossing over to the side
flexion of the joint and covering 2/3 of the previous moves to the complete closure of
22
the lesion (Fig. 1.12.a). Converging turtle bandage begin circular strokes bandage
above and below the joint and also crossed in the flexor side of the latter. Further
moves pull together to each other to the convex part of the joint until it is shut down
the affected area (Fig. 1.12.b).

b
b

Fig. 1.12. Turtle bandage: a – divergent, b – convergent.

Returning bandage (fascia reccurens). It is usually applied to rounded surfaces


(head, stump of limbs). This dressing is reduced to the alternation of the circular
movements of the bandage with the longitudinal, going successively and returning
back to the complete closure of the stump (Figure 1.13).

Fig. 1.13. Returning bandage on stump.


23
It should be emphasized that the bandage on any part of the body can not only
be circular or spiral, because such a dressing can easily be displaced, so it should
definitely be supported by 8-shaped passages, to adhere to the surface of the body.
When bandaging limbs of unequal thickness, such as the forearm, it is advisable to use
a technique called - bend. The bending is carried out in several rounds and the steeper,
sharper pronounced difference in the diameters of the bandaging part.
It is possible to improvise and combine different types of dressings when
bandaging large areas of the body. So, when bandaging the entire lower limb, all 7
basic bandages can be used.

e. Different types of bandages on the body area

i.Headbands
To apply a bandage to the head, bandages of width 5-7 cm are used. The most
commonly used are "cap", "Hippocrates cap", "cap", "bridle", bandage on one eye, on
both eyes, on the ear, crosswise on the back of the head.
Simple bandage (cap) This is a returning bandage covering the cranial vault
(Figure 1.14). Two circular strokes lead around the head, grasping the overhead region
and the occipital region (1). Then a bend is made from the front, and the bandage is led
along the lateral surface of the head obliquely, somewhat higher than the circular (2).
Go to the back of the head, make a second kink and cover the side of the head on the
other side (3). After that, the last two oblique strokes are fixed by the circular
movement of the bandage and then again the two oblique turns (5 and 6) are made
slightly higher than the previous ones (2 and 3) and again fix it. This relatively simple
bandage requires little time for its overlap, but at the same time a very good technique
of superposition. It is important that the excesses of the bandage lies as low as possible
and be better fixed by circular strokes. Due to its small strength, it is not applicable for
superposition in severe patients.

Fig. 1.14. Headband "cap".

24
The cap of Hippocrates (Fig. 1.15). Standing facing the struck person, the
bandage takes in each hand one head of a double-headed bandage and, deploying
them, puts one or two circular strokes around the head.

Fig. 1.15. Headband "Hippocrates cap".

Bringing both heads of the bandage to the back of the head, the left head is
brought under the right and makes a bend, the right head continues its circular motion,
and the left head proceeds in the sagittal direction through the crown to the forehead
after the bend (Fig. 1.15.a). In the forehead area, both heads meet: the right head,
going horizontally, the left head again returns through the crown to the back of the
head, where it again crosses with the horizontal course of the right head, etc.
(Fig. 1.15.b). Longitudinal recurring passages gradually cover the entire head
(Fig. 1.15.c). Thus, one part of the bandage is done by the anteroposterior courses, and
the other is circular. The bandage is fixed in circular motions of both heads around the
head.
Cap (Fig. 1.16). A piece of bandage 50-75 cm long is placed in the transverse
direction on the crown so that the ends descend vertically down in front of the auricles,
where the assistant holds them in a tightened position (sometimes the patient himself
does it). On top of this bandage, the first horizontal moves are carried around the head
so that the lower edge of them goes over the eyebrows, over the auricles and over the
occipital hillock. Having reached the vertical bandage on one side, the bandage is
wrapped around it (make a loop) and further to the forehead area somewhat in an
oblique direction, covering half the circular stroke.

25
Fig. 1.16. Cap bandage.

After reaching the opposite string, again make a loop and again lead in an
oblique direction to the occipital region, half covering the underlying course, etc. So
every time, throwing a bandage through a vertical tape, lead it more and more
obliquely, until they cover the entire head. The bandage is terminated by the circular
movements of the bandage, tying the knot in front. The ends of the vertical tape are
tied under the chin for a firm fixation of the entire bandage.
Bandage of the bridle type. It is used when the lower jaw is damaged, after the
dislocation is adjusted, etc. (Fig. 1.17). First, two horizontal circular strokes are placed
around the head from left to right. Further a bandage goes above the ear of the left side
obliquely upwards through the back of the head under the right ear and under the
lower jaw in order to grasp the jaw from below and exits from the left side in front of
the left ear upward on the crown. Then the bandage behind the right ear leads again
under the lower jaw, covering the front half of the previous stroke. After making three
such vertical strokes, the bandage is led from the right ear forward to the neck, then
obliquely upwards through the back of the head and makes a circular motion around
the head, strengthening the previous tours. Then again they go behind the right ear,
then almost horizontally they cover the whole lower jaw with the bandage and, after
coming to the nape, again repeat this move. Then go under the right ear under the
lower jaw oblique, but closer to the front, then along the left cheek upward on the
crown and behind the right ear. Repeat the previous move, and then, circling the front
of the neck, go to the back of the head over the right ear and finish the bandage with
the circular horizontal movement of the bandage.

26
Fig. 1.17. "Bridle" bandage.

The bandage on one eye. The bandage begins circular strokes around the head,
and for the right eye bandage is left, to right, and for the right side, vice versa
(Fig. 1.18). Having strengthened horizontal strokes a bandage goes back down on the
back of the head and lead it in the ear with a sore hand obliquely upward through the
cheek, closing the patient’s eye. Oblique circular course is fixed, then re-make an
oblique course, covering half of the previous one. So alternating, oblique and circular
moves, cover the entire eye area.

Fig. 1.18. The bandage on one eye.

Bandage both eyes. After fixing bandage circular strokes (Fig. 1.19), it leads
from the back of the neck under the ear and make a bottom-up oblique stroke, closing
his eyes with one hand. Next, continue to lead the bandage around the occipital region
of the head and across the forehead obliquely downward, closing his eyes on the other
side, and then bend the bandage below the ear and across the back of the head through
the other side of the ear and make another upward slash move. Thus, alternating with
each other, oblique strokes bandage gradually close both eyes. Secure the bandage
with circular strokes bandage.

27
Fig. 1.19. Bandage on both eyes.

Bandage on the ear area (Neapolitan bandage). It begins with circular rounds
around the head (Fig. 1.20). On the patient side, the bandage is lowered lower and
lower, covering the ear area and the mastoid process. The last move is located in front
on the lower part of the forehead, and behind the back of the neck. Finish the bandage
with circular bandages.

Fig. 1.20. The bandage on the ear is a Neapolitan cap.

Eight-piece bandage on the back of the head. It begins with round turns around
the head (forehead), then goes over the left ear to the back of the head, then goes under
the right ear to the front surface of the neck from under the left corner of the lower jaw
up through the back of the right ear to the forehead (Fig. 1.21). Repeating these turns,
they cover the back of the head.

28
Fig. 1.21. Figure-of-eight on the back of the head.

Suffice often used "sling-like bandages" on the chin and nose, as well as
harness bandages technique overlap which can be viewed in the relevant sections.

ii. Bandages on upper limbs

Most often the following bandages are superimposed on the upper limb: spiral
on one finger, spicate on the first finger, gloved, returning and crosswise on the wrist,
spiral on the forearm, turtle bandages on the elbow joint, spiral on the shoulder, spiky
on the shoulder joint, bandgages “Dezo” And “Velpo”.
A spiral bandage on one finger (Fig. 1.22) is used for a single finger injury.
First reinforce the bandage with two or three circular strokes in the area of the wrist.
Then the bandage leads obliquely through the rear of the hand (2) to the end of the
diseased finger, from where the whole finger is banded to the base with spiral strokes.
Then (8) the bandage is carried back to the wrist, where it is fixed.

Fig. 1.22. Spiral bandage on one finger.

29
The bandage on the thumb is made spiky (eight-shaped) (Fig. 1.23). It begins
the same way as described above. Next, a bandage on the back surface of the thumb to
its apex (2) and a semicircular stroke encompass the palmar surface of this finger (3).
Then the bandage is led along the rear of the wrist to the wrist and again the eight-
shaped stroke is repeated, each time going down to the base of the finger (4 and 5),
(6 and 7). Attach a bandage to your wrist.

Fig. 1.23. A spicate bandage on the thumb.

The bandage on all fingers (knight's glove) is


done when you need to bandage a few fingers or all
fingers separately. It begins as a bandage on one finger
(see above). After bandaging a spiral one, a finger
bandage is led along the back surface through the wrist and bandages, thus, the next
until all the fingers are bandaged (Fig. 1.24). On the left hand, begin to bandage with
the little finger, and on the right - with a thumb. Finish the bandage with a circular
motion around the wrist.

Fig. 1.24. Bandage on all fingers "knight's


glove".

Returning bandage on the hand (glove). It is


applied when it is necessary to bandage the brush
(Fig. 1.25) together with the fingers (with extensive
burns and frostbites). The dressing begins with circular strokes around the wrist
(turn 1). Then the bandage is carried along the back of the hand (2) on the fingers and

30
all fingers on the palm and the back are covered with vertical strokes (3, 4, 5). Then by
horizontal circular strokes, starting with the ends of the bandage on the wrist.

Fig. 1.25. Bandage on the hand "glove".

The turtle bandage is superimposed on the area of the joints with a bent position
(Fig. 1.26). They are divided into divergent and
convergent. The convergent dressing begins with
peripheral rounds above and below the joint
(1 and 2), crossing at the ulnar fossa. Subsequent
strokes go like the previous ones, gradually
converging to the center of the joint (4, 5, 6, 7,
8, 9). Finish the bandage with a circular stroke at
the midpoint of the joint.

Fig. 1.26. Tortoise bandage on the elbow joint.

The divergent bandage in the area of the elbow joint begins with a circular
motion through its middle, then makes similar moves higher and lower than the
previous one. The subsequent moves increasingly diverge, gradually closing the entire
area of the joint. Strokes cross in the ulnar fossa. Secure the bandage around the
forearm.
The spiral bandage (Fig. 1.27) can be performed with bend and without bends.
The second is convenient for bandaging uniform parts of the body (shoulder, shin,
thigh, etc.). Begin the bandage with two or three circular moves, and then the bandage

31
turns go, partly spiraling two-thirds covering the previous rounds. Depending on the
direction of bandaging, the dressing can be ascending and descending.
Bandage with bends are applied to the conical shape of the body. After two -
three circular strokes begin to bandage with bends, this bandage is made obliquely
upwards, thumb pressing down its lower edge, and bending the bandage so that its
upper end was the bottom, then goes obliquely downward, tracing around the limb and
reiterate the bend. The greater the degree of expansion of the limb, the steeper make
excesses. All bends are done on one side and on the same line. In the future, as needed,
or make a simple spiral bandage or continue to bend the bandage.

Fig. 1.27. Spiral bandage on the forearm.

The spicate bandage (Fig. 1.28) is a variation of


the eight. On the shoulder joint area, it is applied as
follows. The bandage is led from the side of the healthy
axillary cavity along the front surface of the chest and
further to the shoulder (stroke 1). Going around the
shoulder in front, outside and behind, the bandage is led
through the armpit and lifted obliquely over the
shoulder (stroke 2), cross the previous round on the
front surface of the chest and shoulder. Then the bandage goes along the back surface
of the back to the healthy axillary cavity. From here begins the repetition of moves
1 and 2 (3 and 4). In this case, each new move lies slightly higher than the previous
one, forming the appearance of the ear in the cross-over.

Fig. 1.28. A spicate bandage on the shoulder joint.

The Desault’s bandage is superimposed on fractures


of the humerus and clavicle. The patient is seated, the arm is
bent at the elbow at a right angle (Fig. 1.29). The first point
is to bind the shoulder to the body, which is achieved by
imposing a number of circular spiral moves from the
healthy hand to the patient (1). Then, with the same
bandage, the second part of the bandage begins: from the
armpit area of the healthy side, on the front surface of the
32
breast, the bandage is carried on the shoulder of the diseased side (2), from here
vertically down the back side of the shoulder to the elbows, catching the elbow with a
bandage, obliquely through the forearm into the armpit of the healthy side (3). From
here on the back on the injured shoulder strap down the front side of the shoulder (4).
Walking along the elbow from the front, the bandage is led across the back obliquely
into the healthy armpit, where the repetition of the moves begins (2, 3, 4). Such moves
are repeated several times to obtain a good fixation. Then hang a hand, a piece of
bandage of sufficient width, fixing it to the back.

Fig. 1.29. The Desault’s bandage.

The Velpeau’s bandage (Fig. 1.30).


Applied for temporary immobilization in
fractures of the clavicle, after the adjustment of
the dislocations of the shoulder joint. The hand of the damaged side is bent at the
elbow joint to form an acute angle and the palm is located in the deltoid region from
the healthy side. In this position, the limbs are bandaged. First, the hand is fixed by the
circular movement of the bandage from the sick arm to the healthy one (1), which
covers the shoulder and forearm of the diseased side, goes through the healthy axillary
fossa back. From here, a bandage is lifted along the back from the damaged deltoid
area, it is bent around from the rear to the front, a bandage is dropped down the
shoulder (2) and, picking up the elbow from below, is directed to the armpit from the
healthy side (3).

Fig. 1.30. Velpeau’s bandage.

33
Movements are repeated several times, with each vertical stroke of a bandage
medially from the previous one, and each horizontal below it.
1.5.3. Bandages on the trunk and pelvis.
When applying bandages to the area of the trunk and pelvis, the following are
most often used: spiral on the chest and stomach; Bandage on one and both mammary
glands; "T-shaped" on the perineum; Spicate on the gluteal, inguinal area, hip joint.
A spiral bandage on the chest (Fig. 1.31) is used for chest injuries. The dressing
is applied so that it does not slip off the chest. To do this, use an additional bandage
tape, which, before applying the bandages, is laid obliquely across the chest on the left
shoulder and from there in an oblique direction through the back. Then, from the
bottom of the breast, with spiral circular strokes, climbing up, bandage the entire
thorax to the armpits, where they fix circular motions. Loose hanging the initial part of
the tape is thrown over the right shoulder and from the rear is connected with another
loose end of the bandage.

Fig. 1.31. Spiral bandage on the chest.

Mammary gland bandage. It is used both for traumatic injuries, and as a


compression, for the cessation of lactation. The bandage is in front of the patient. The
gland is slightly raised and held in this position. The bandage starts from the circular
motions below the breast (Fig. 1.32), lead to the right side of the chest, from where,
covering the lower and inner part of the breast, they lead bandage to the left shoulder
and descend obliquely from the back to the right axillary cavity. Here, covering the
lower part of the mammary gland in a circular motion, fix the previous stroke, lead the
bandage again obliquely upward through the gland to the left shoulder and repeat the
previous moves. Gradually, the bandage rises upward and closes the entire mammary
gland. Secure the dressing with horizontal strides.

34
Fig. 1.32. Mammary gland bandage.

Bandage on both mammary glands (Fig. 1.33). The beginning of the bandage is
fixed with two horizontal circular rounds under the mammary glands. The third round
is conducted from the lateral surface of the thorax to the right under the right gland,
raising it to the left deltoid region. Thus, the first 3 rounds are the same as when
applying bandages to the right mammary gland.

Fig. 1.33. Bandage on both mammary glands.

On the side of the back, the bandage is carried to


the right axillary fossa, under the right breast, then -
under the left and on the back - it is raised obliquely to
the right deltoid region. From the right deltoid area, the
bandage is lowered under the left breast, supporting it
from the inside and from the bottom. On the left side of the chest, the bandage is
guided to the back in the horizontal direction. So, the third round fixes the right
mammary gland, the fourth one - the left breast. Then the turn of the bandage
alternates, repeating the third and fourth rounds each time placing a bandage above the
previous round, until both breasts are closed by the bandage.
T-shaped Bandage. This type of bandage is used for injuries and diseases in the
perineum and anus. Such a bandage consists of a strip of cloth or bandage, to the
middle of which the end of another strip or the strip is sewn, through the middle of
which another strip is thrown. The technique of their superposition is shown in the
section T-shaped bandages.
A spicate bandage closes the lower abdomen, the upper part of the thigh, as
well as the buttock area and the groin area. Depending on the location of the bandage
35
intersection, the bandage may be inguinal, lateral and posterior. The inguinal spicate
bandage (Fig. 1.34) begins with circular movements around the abdomen, then the
bandage is led from behind in front of the lateral, and then along the front and inner
surface of the thigh. After that, the bandage is led along the posterior half-circle of the
thigh, coming out from its lateral side obliquely into the groin area, where the previous
round is crossed. Rising up and to the left, they bypass the posterior semicircle of the
trunk and again repeat the described eight-shaped moves. A dressing can be ascending
if each subsequent tour is higher than the previous one, or downward. Secure the
bandage with circular strokes around the abdomen.

Fig. 1.34. Inguinal spicate bandage.

The lateral spicate bandage (Fig. 1.35.) is imposed


similarly to the inguinal, but the cross-passages of the
bandage are carried out along the lateral surface of the hip
joint.

Fig. 1.35. Side spicate bandage on the hip joint.

Rear spicate, like previous ones, starts with a circular turn around the abdomen.
Bandaging the patient through the buttock sides on the inner thighs, it is raised again
on the trunk, crossing the previous turn of the bandage on the back surface. Having
finished a semi-circular course around the belly, the previous rounds are repeated
several times, gradually shifting them to the bottom. The bandage ends by circular turn
around the belly.
1.5.4. Bandages on the lower limbs
When bandaging the lower extremities, the following types of dressings are
most often used: spiral and spicate on the finger; Cross-shaped and returning to the
foot; Bandage on the entire foot, on the entire foot without fingers, spiral on the shin,
turtle bandages on the knee joint; Spiral on the thigh.

36
Spiral bandage on the finger is used for diseases and injuries of the 1st toe of
the foot (Fig. 1.36). Bandage is fixed by circular turns in the ankle area. Then a
bandage to the distal phalange of the 1st finger is passed through the back surface of
the foot. From here, spiral rounds cover the entire finger to the base and again, through
the rear of the foot, a bandage is returned to the ankle, where the dressing ends with
fixing circular turns.

Fig. 1.36. Spiral bandage on 1 finger.

A spicate bandage on the finger is applied less


often. It is applied the same way as on the finger of the
hand.
Bandage on the entire foot. Begin with circular
moves around the ankles. Further, several times the foot
is traversed along its lateral surfaces, covering the fingers
and the heel (Fig. 1.37). These turns are done loosely
without tension, so as not to cause bending of the fingers.
Next, starting from the fingertips, bandage the foot circularly, spiral rounds cover the
entire foot to the ankle joint.

Fig. 1.37. Bandage on the entire foot.

Bandage on the entire foot without toes (Fig. 1.38). On the right foot the
bandage starts from the outside of the foot, on the left - from the inside. Along the
edge of the right foot from the heel towards the fingers reaching the level of the base
of the toes. On the rear of the foot, the bandage is directed to the inner edge of the foot
and makes a circular motion, wrapping it on the sole. Then the bandage is lifted again
to the rear, skewing the previous tour. After the cross, the bandage is guided along the
inner edge of the foot, imposing it as low as possible, reaching the heel that is
37
traversed from behind and repeating a turn similar to the one described. Each new turn
in the area of the heel is placed above the previous one, the crosses make it closer and
closer to the ankle joint. The bandage is fixed around the ankles.

Fig. 1.38. Bandage on the entire foot without toes.

Cross-shaped bandage on the ankle joint (Fig. 1.39): when applying a cruciform
bandage, the bandage is fixed around the shin, then they are led obliquely through the
rear of the foot and after a semicircular course on the plantar surface they again return
to the rear of the foot, where they make a cross through the previous course of the
bandage. Having finished this eight-shaped move, gradually reaching the base of the
foot, where they fasten the bandage.

Fig. 1.39. A cruciform bandage on the ankle joint.

Bandage on the heel area is commonly achieved by


turtle diverging bandage. Begin bandaging with circular
rounds through the heel. Further tours are imposed above
and below the first round. These strokes are strengthened
by a slanting, running from the side of the heel going
behind from the front with the transition to the plantar
surface and the rear of the foot, the ankle joint area and down to the foot, making
crossovers on the back of the fold.
Turtle bandage on the knee joint is done with the joint in flexed position. It may
be divergent (Fig. 1.40.a) and convergent (Fig. 1.40.b). Divergent bandage around the
knee begins to move through the circular center of the joint (1), then make these
passages above and below the previous (2 and 3). Subsequent turns gradually cover the
entire joint area (4, 5, 6, 7, 8, 9). The bandage is crossed in the popliteal cavity. Secure
the bandage around the thighs. Converging bandage begins with peripheral tours above
and below the joint, intersecting in the popliteal fossa. Subsequent moves are similar
to the previous one, gradually converging to the center of the joint. Complete bandage
turns at the centre of the joint.
38
a b

Fig. 1.40. Turtle bandage: a diverging-b-converging.

f. Pressing, sealing and compression bandages


Pressing bandage
A pressing bandage is applied to reduce the size of haemorrhage in the tissues
at the site of injury to reduce swelling and the value of creating peace in the affected
limb, to stop all types of bleeding (capillary, venous and arterial) of compression
sclerotherapy for varicose veins and to reduce lactation. Pressing is performed by tight
bandaging damaged or interested places by imposing circular, spiral or cross-shaped
bandage. Using latex or cotton-gauze pads under the bandage increases the degree of
compression of 4 times.

Sealing bandage
The imposition of an occlusive (sealing) bandage with a penetrating wound of
the chest is a means of providing first aid to the injured person, since it excludes the
ingress of air into the pleural cavity.
For these purposes, an individual bandaging packet (IBP) is used. It consists of
a bandage and attached to it one or two cotton-gauze pads. One cushion is fixedly
fixed to the free end of the bandage, and the other can move along the bandage
(Fig. 1.41).

Fig. 1.41. Individual bandage packet.

39
The sterilized bandage is wrapped in parchment paper and covered with a
rubberized or cellophane coating on the outside. The rubberized sheath is torn along
the notch and removed, then the paper sheath is unfolded. The inner side of the
rubberized sheath is used as a sealing material which is applied to the wound of the
edge of which is pre-treated with an iodine solution. With your right hand take the roll,
the left - the end of the bandage, unfold the pads and place on the wound with the side
to which the hands (the inside) do not touch. With gunshot wounds, one pad is placed
on the entrance, the other on the outlet, after which the pads are bandaged, and the end
of the bandage is fixed with a pin. The pin is located under the outer envelope of the
bag. In this case it is important not to touch the inner, superimposed on the wound side
of the pads. The outside is stitched with a colored thread. If there is one wound inlet,
the pads are superimposed one on top of or next to each other.
In the absence of a dressing bag, air-impermeable material (rubber,
polyethylene film, oilcloth, etc.) can be used for sealing. In extreme cases, you can use
a cotton-gauze dressing, densely greased with ointment. Before applying a sealing
dressing, the edges of the wound are treated with iodine, then greased with any fat
(petrolatum, cream, vegetable fat, etc.), preferably sterile. After that, the wound and
the skin around it are impregnated with air impermeable material, and over - the usual
tight bandage bandage, the turns of which run around the chest. For the bandage, you
can use a towel, a sheet that wraps the chest of the victim and tightly tied on a healthy
side.
Sealing the wound can be strips of adhesive plaster applied in the form of a tile
dressing, so that the edges of the wound become close, and the strips of the patch
overlap.
Compression bandages
Treatment with compression dressings takes a key place in the complex
treatment of patients with pathology of the veins of the lower extremities.
Compression therapy is indicated for all, both acute and chronic diseases of the
veins of the lower extremities. The only contraindication to compression treatment are
chronic obliterating diseases of the arteries of the lower extremities. The therapeutic
effect of compression means is realized mainly by reducing the diameter of the veins,
which leads to an improvement in the functioning of the valvular apparatus and an
increase in the rate of venous return. It was found that a decrease in the diameter of the
vein by a factor of 2 leads to an increase in the linear velocity of the blood flow along
it by a factor of 5. Along with macrohemodynamic effects, elastic compression
improves the function of the microcirculatory bed.
For compression treatment, elastic bandages are most often used, which,
depending on the degree of stretching, are divided into 3 classes: short (the
lengthening of the bandage is not more than 70% of the original length), medium
(70-140%) and high or long (more than 140%) extensibility. This characteristic is
indicated on the packing of the bandage, and it is necessary for the correct choice of
the product.
When applying a compression bandage, the following basic principles must be
followed:

40
1) the foot at the time of application of the bandage should be in the supination
and back bending position, preventing the formation of bandage folds in the area of the
ankles, which can damage the skin during movement; 2) it always starts from the
proximal joints of the toes with the heel engraved in the form of a "hammock"; 3) the
roll of bandage must be untwisted outward in the immediate vicinity of the skin; 4) the
bandage must follow the shape of the limb, that is, the bandage tours must be
alternately applied in the ascending and descending directions, which will ensure its
firm fixation; 5) The bandage should be applied with slight tension at the beginning of
each round, with each subsequent turn overlapping the previous one by 2/3 of the
width. The most important is that as the elastic bandage is applied, the degree of
compression gradually decreases from the level of the ankles to the popliteal fossa,
creating a feeling of a tightly seated shaft in the patient. As for the upper level of the
elastic band, ideally it should be 5-10 cm above the affected venous segment.
However, practically its reliable fixation on the thigh is possible only with the use of
special, adhesive bandages. Therefore, the upper limit should be just below the knee
joint, and the tail of the bandage should be fixed to the bandage with a special pin or
an English pin (Fig. 1.42).
With the correct application of the compression bandage, the tips of the toes at
rest become slightly blue, and when the movement begins, they restore their normal
color. However, disruptions of the arterial blood supply (numbness of the toes,
paresthesias) should not be present. It is important to emphasize that failure to comply
with these simple requirements, in particular the over tightness in the upper third of the
shin, the creation of "strikers" to fix the dressing not only does not improve blood
circulation in the limb, but can significantly worsen it.

Fig. 1.42. Applying elastic bandage on the lower limb.

Along with elastic bandages another kinds of compression products are also
used. These are special medical knitwear (socks, stockings, tights) which are made by
machine knitting on seamless technology. Depending on the degree of compression

41
and their purpose they are sorted into several groups. First group is a prophylactic one
creating pressure at the ankles not more than 18 mm of Hg. The second one is
therapeutic. It may be further subgrouped into several classes of compression pressure
on ankles from 18.5 to 60 mm Hg. Medical compression hosiery is selected by the
physician taking into account the nature and localization of the disease, as well as the
size of the limb.
In addition to the above products (soft compression), in case of chronic venous
insufficiency complicated by trophic ulcers the solid bandage is commonly used. It is
the Kefer-Unna’s zinc-gelatine bandage of a calf. Treatment by zinc-gelatine dressings
along with compression effect eliminates the possibility of skin sensitization, creates a
favourable microclimate conducive to the healing of ulcers. The following ingredients
are commonly mixed up: Gelatina 30.0; Zinc oxide and Glycerine aa 50.0; Distilled
water. 90.0.
Before applying the dressing the patient is placed in a horizontal position, the
affected leg is elevated at an angle of 45-60 ° for 15-20 minutes. The paste prior to the
use is heated in a water bath to liquid state and is applied evenly to the lower leg and
foot. Tape up tight gauze bandage without border in a single layer. The newly applied
layer of paste and bandage is again applied in a single layer. Thus, lubricate and
alternately bandage the limb four times. After about 10 minutes the bandage dries.
After that it is sprinkled with talcum powder and now is covered with a common
bandage which can be changed if gets dirty. The bandage stays for 3 weeks. After this
period it may be again repeated if the ulcer has not healed yet.

42
2. CHAPTER 2. TRANSPORT STABILIZATION

Transport immobilization in severe trauma is the most important part of the first
aid, provided in many cases for saving the life of a victim.
The main objective of transport immobilization is to ensure immobility of
fragments of the broken bones and damaged part of the body during the period of
transporting the injured to the hospital. It contributes to a significant reduction in pain,
without it, it is almost impossible to prevent the development or deepening of
traumatic shock in severe fractures of limbs, pelvis and spine.
Ensuring immobility of bone fragments and muscles, to a large extent, prevents
the further tissue trauma. In absence or insufficient immobilization of the victim,
during transportation the additional muscle damage at ends of bone fragments may be
observed. Also injuries of blood vessels and nerves, perforation of the skin at the
closed fractures can take place. Proper immobilization helps to relieve spasm of blood
vessels, eliminates compression, thus improving the blood supply to the damaged area
and preventing development of infection in the injured tissues, especially in gunshot
wounds.
This is due to the fact that the stiffness of muscle layers, bone fragments and
other tissues prevents mechanical spread of microbial contamination of interstitial
space. Immobilization provides the immovability of blood clots in damaged blood
vessels and, hence, the prevention of secondary bleeding and embolism.
Immobilization is indicated for transportation of patients with fractures and
injuries of pelvic bones, spine, injuries of major vessels and nerves, extensive soft
tissue injuries, common deep burns, prolonged compression syndrome.
The main methods of immobilization of extremities as the first aid treatment
will be binding of the damaged leg with a healthy one by bandage, taping of the
damaged extremity to the body, and the use of available tools. Standard means of
transport immobilization are applied by ambulance teams.
Conducting transport immobilization must be preceded by anesthesia (injection
of narcotics, and in a medical institution - Novocain blockade). Only the absence of
the necessary resources at the place of an accident during provision of self-help and
mutual aid justifies the rejection of anesthesia.
One of the most frequent mistakes in transport immobilization by materials at
hand is the use of short splints not providing fixation of two adjacent joints, because of
what the immobilization of the damaged limb segment cannot be achieved. Insufficient
fixing of the splint by bandage leads to the same poor results. Another mistake is the
use of standard splints without cotton and gauze pad.
This error leads to a local compression of the limbs, pain, and appearance of
bedsores. Therefore, all of the standard splints used by ambulances, are covered with
cotton and gauze pad.
Improper modeling of ladder splints also causes insufficient fixation of the
fracture. Transportation of victims in winter time requires warming of an extremity
with the imposed splint.

43
The integrity of the dressing is easily broken if the first fixing turns are not
made. To correct the error, the bandage should be tied up, reinforced with a glue and
adhesive plaster.

a. General principles of transport stabilization


There are several general principles of transport immobilization, the violation
of which can lead to a significant reduction in the efficiency of immobilization.
Use of transport immobilization should be as early as possible, i.e. already at
first aid treatment at place of an accident with the available tools.
Clothes and footwear usually do not interfere with the transport immobilization,
moreover, they serve as a soft pad under the splint. Removing clothes and shoes is
made only when it’s absolutely necessary. Taking off clothes and footwear is
necessary only in extreme cases. It should be started with the injured extremity.
Bandage on a wound is possible through opening in the clothes. Before transport
immobilization anesthesia should be provided: introduction of Promedolum or
Pantopon solution intramuscularly or subcutaneously, and in conditions of a medical
first-aid post the novocainic blockade should be administered. It is necessary to
remember that the procedure of applying the transport splint is accompanied by the
displacement of bone fragments and is followed by additional amplification of pain in
the area of damage. In the presence of a wound, it should be covered by aseptic
bandage before applying the splint. Access to the wound is provided by dissection of
clothing, preferably along the seam.
Application of a tourniquet by the appropriate indications must be done before
immobilization. Do not cover the tourniquet by bandage. It is necessary to indicate
tourniquet time (date, hour, and minute) in a separate note.
In open (gunshot) fractures ends of the bone fragments protruding into the
wound, cannot be set, as it will likely lead to microbial contamination of the wound.
Before applying the splint, it should be previously modeled, adjusted to the size and
shape of the damaged extremity. The splint should not cause strong pressure on the
soft tissues, especially in the places of protrusion (to prevent the formation of pressure
sores), compress the large blood vessels and nerves. The splint should be covered with
cotton gauze pad, and if it is not available, with the cotton. In fractures of long tubular
bones at least two joints adjacent to the damaged segment of an extremity must be
fixed. Often it is necessary to fix three joints. Immobilization will be reliable in the
case when fixation of all joints, functioning under the influence of muscle limb
segment, is provided. So, in the fracture of the humerus, shoulder, elbow and wrist
joints should be immobilized; in shin bone fractures due to the presence of
polyarticular muscles (long finger flexors and extensors) it is necessary to fix the knee,
ankle, and all joints of the foot and toes.
The extremity should be immobilized in usual physiological position where the
muscle-antagonists (eg, flexors and extensors) are equally relaxed. Average
physiological abduction of brachium is at 60°, thigh – at 10°; forearm – in a position
44
halfway between pronation and Supination, hands and feet - in the position of palmar
and plantar flexion at 10°. However, the practice of immobilization and conditions of
transportation force to have some deviations from physiological position. In particular,
do not provide so significant shoulder abduction and hip flexion in hip joint, and knee
flexion is limited by 170°.
Reliable immobilization is achieved by overcoming the physiological and
elastic muscle contraction of segment of the damaged extremity. Reliability of
immobilization is achieved by strong fixation of the splint on all extent (by belts,
scarves, shoulder straps). During imposition of splints it is important to be careful with
the damaged extremity to avoid the additional injury.
In winter, the injured extremity is more exposed to freezing injury, especially
when combined with a damage of blood vessels. During transportation of a patient the
extremity with the applied splint should be warmed.
To immobilize the injured extremity various means at hand can be used like
boards, sticks, rods, and others. In their absence, the injured upper extremity can be
bandaged to the body and the broken leg to the healthy one. The best immobilization
can be carried out by the special means: wire ladder splints, Diterichs’ splint, plywood
and others.
Soft fabric dressings may be used as an independent or a complement method
of fixation. Fabric bandages are commonly used in fractures and dislocations of the
clavicle, scapula fractures (Dezo’s bandage, Velpo’s bandage, Delbe’s ring, etc.),
injuries of the cervical segment of the vertebra column (Schantz’s collar).
If there is no other means for fixing, then these bandages and scarves can be
used to immobilize fractures of the upper and lower extremities, even - bandaging the
injured leg to a healthy one. Besides, soft fabric dressings are always supplementary to
all other methods of transport immobilization.
Immobilization by a cotton-gauze collar (Fig. 2.1). Prepared beforehand high
cotton-gauze dressing with a cotton layer with thickness of about 4-5 cm is applied
circularly on the neck of the victim in a lying position. It is fixed by gauze bandage.
Such collar abuts in the top on occipital and chin area, and in the bottom - on the area
of shoulder girdle and chest, creating the rest to the head and neck during
transportation.

45
Fig. 2.1. Soft fabric neck bandage – "Schantz’s collar."

b. Types of splints used in transportation


Splint – is the basic means of transport immobilization, represents any solid
overlay of the sufficient length.
Splints can be improvised (made from any available material) and specially
designed (standard).
Standard splints are manufactured commercially and can be made of wood,
plywood, metal wire (mesh, Kramer’s splints) (Fig. 2.2), plastics, rubber (inflatable
splint), and other materials.

Fig. 2.2. Kramer’s ladder splints.

For immobilization bandages are also needed, the splint is fixed to the
extremity using a bandage; cotton is put as the gasket under the extremity.
Bandages can be replaced with any material at hand - strap, a strip of cloth,
rope, etc. Instead of cotton cloth napkins, bundles of hay, grass, straw, etc. can also be
used.
46
In 1932, Professor Diterichs offered the wooden splint for immobilization of
the lower extremity in injuries of a thigh, hip, knee and upper third of the leg. This
splint is still used in practice and is the most reliable method of transport
immobilization (Fig. 2.3).

Fig. 2.3. Diterichs’ splint.

The splint consists of two wooden outer and inner crutches, a sole, and a twist
with the cord. Crutches are sliding, consist of two branches - top and bottom. Top parts
of branches end with terminate stops for the armpits and perineum.
They also have slots and holes for fixing them to the extremities and the body
by the belt, strap or bandage. Internal crutch on the lower branch has a folding bar with
a round window for the cord and a groove for the protrusion of the lower branch of the
crutch. There are two eyelets in the sole designed for crutches and two loops for secure
fixation of the cord.
Kramer’s splint. It is a long frame of thick wire with cross bars. It can be easily
bent in any direction. In each case, the splint is made individually, depending on the
damaged segment and the nature of the trauma. It can be used as a single one, as well
as two or three splints simultaneously can be applied.
Fig. 2.4 shows the fixation of the shoulder by the wire Kramer’s splint.

Fig. 2.4. Kramer’s splint with cotton-gauze pads. Fixing the shoulder by Kramer’s
splint.

47
Chin splint. It looks as a gutter-shaped plastic plate bent in the longitudinal and
transverse directions. It is used in mandibular fractures (Fig. 2.5).

Fig. 2.5. Chin splint.

Holes in the splint are designed to drain saliva and blood, and to fix the sinking-
down tongue by ligature. The lateral end openings have three hooks for fixing the head
cap loops.
Pneumatic splints are the most modern method of transport immobilization.
These splints have some advantages: being inflated they are automatically almost
perfectly modeled according to the extremity, the pressure on the tissues is even that
eliminates pressure sores. The splint itself may be transparent, allowing you to control
the condition of the extremity and bandage. Particularly noticeable advantages of this
splint in case of crush syndrome when you apply the tight bandaging of the extremity
with immobilization. However, it is impossible to immobilize the thigh, shoulder by
this splint because it is not intended to fix the hip and shoulder joints.
One of the kind of pneumatic splint is vacuum stretchers, which are used in the
fractures of the spine and pelvis.
For immobilization of the upper extremity a standard medical kerchief is often
used of, which is a triangular piece of fabric. It is applied as a separate mean of
immobilization and as an auxiliary one, often is used to maintain in hanging position
the arm and shoulder.
EXTRA FOCAL FIXATION DEVICES
When transporting a patient from one hospital to another, in wartime, transport
immobilization of the damaged segment is provided by using devices for extra focal
osteosynthesis (Fig. 2.6).

Fig. 2.6. Immobilization of the wrist by Volkov-Oganesyan’s splint.

48
This method of fixing is more reliable than the use of a splint. However, it can
be carried out only by a qualified traumatologist in the operating room.

c. Transport stabilization of the upper extremity


At the scene immobilization of the upper extremity can be carried out by the
simplified methods, regardless of the damage localization, using the available
methods. The extremity should be bandaged to the body. The shoulder should be
positioned on the mid-axillary line, forearm bent at right angle, the hand should be
pushed between two closed buttons of a jacket, a coat or a shirt.
Another way is to create a hammock to hang up the upper extremity. The
jacket, coat or overcoat should be rolled up in the form of gutter where the hand
should be placed, bent in elbow joint at an angle of 90°. Coat at the lower edge should
be tied with a string (a rope, a bandage, a wire), strengthened around the neck or
fixed by safety pins. For the same purpose the lower edge of the coat can be pierced
with a knife, and bandage should be passed through the hole for hanging up the coat
around the neck.
Instead of the coat, you can use a towel, piece of cloth, etc. The corners of the
towel are pierced with a knife or a piece of wire. A string (bandage, rope) is passed
through the opening and thus two tapes are made, each of which has two ends - the
front and the back ones. In the gutter made from the towel forearm is placed, the front
tape at the end of the towel is put on a healthy shoulder girdle, and it should be bound
with the back end of the tape from the elbow end of the towel. Back tape at hand is put
horizontally and posteriorly in the lumbar region is bound with the front end of the
tape from the elbow end of the towel.
The standard kerchief is widely used for hanging up the upper extremity. The
patient sits or stands. The kerchief is put on the front surface of the chest with the long
side along of the midline of the body, and the kerchief’s top is put laterally at the level
of elbow joint of the injured extremity. The upper end of the long side of the kerchief
is passed through the shoulder girdle of the injured extremity. The forearm, bent at the
elbow, is bent around by the lower half of the kerchief, its end is placed on the
patient’s side of the shoulder girdle and it should be bound with the other end, held
around the neck. The elbow joint should be bent around by the top of the kerchief in
front and fixed by a safety pin.
IMMOBILIZATION AT INJURIES OF WRIST, HAND AND FINGERS.
For transport immobilization in damages of this localization we use a ladder or
plywood splint beginning from the elbow joint and coming on 3-4 cm beyond the ends
of the fingers. The forearm is placed on the splint in the position of pronation.
A hand should be fixed in the condition of small dorsiflexion, fingers must be
half-bent, fixed with opposition of the first finger. For this purpose cotton-gauze roll is
put under the palm. It is better to bandage the splint starting with a forearm, bandage
should be bent under the splint in order to reduce the pressure on the soft tissues. On
the hand circular tours of bandage take place between I and II fingers. Usually, only
the injured fingers are bandaged to the roller on the splint, other uninjured fingers are
left open. Immobilization is finished by suspending a forearm on a kerchief (Fig. 2.7).

49
Fig. 2.7. Immobilization by ladder splint and triangular bandage at fractures of the
bones of the hand and wrist: a – ladder splint; b – fixing the hand; c – splinting
bandage and fixing the splint by bandage; d – suspension of the arm on a kerchief.

Ladder splint of the necessary length can be used in another option, modeling
its distal end in such a way that to give the hand the position of dorsiflexion with
semi-bent fingers. If the 1st finger is not damaged, it is left free out of the splint.
Cotton-gauze pad is bandaged to the splint.
In case of fingers damage only transport immobilization is the same as
described above. You can just bandage the injured fingers to the cotton-gauze ball or
roller and hang up the forearm and hand on the kerchief.
Sometimes forearm and hand with the fixed roller are put on the ladder splint
and then it should be hung up on a kerchief. The damaged first finger should be fixed
on the roller in position opposing other fingers, rather than to be put on a roll of
cylindrical form.
POSSIBLE MISTAKES:
1) Cotton-gauze pad is not placed on the splint, it may lead to the local
squeezing of soft tissues, especially over osteal prominence, causing pain; possible
formation of bedsores;
2) The splint is not modeled, when it is not bent longitudinally in the form of a
gutter;
3) The splint is put on the extensor surface of the forearm and hand;
4) The splint is short and hand hangs down;
5) There is no cotton-gauze roller, on which the hand and fingers in half-bent
position must be fixed;
6) The splint is fixed loosely, so it slides down;
7) Immobilization is not finished by suspension of extremity on a kerchief.
IMMOBILIZATION IN THE FOREARM INJURIES.
In injuries of a forearm the splint must fix the elbow joint and wrist joints – it
should be started in the upper third of the shoulder and ended 3-4 cm distally from the
ends of the fingers. The ladder splint is shortened to the desired length and is bent at a
right angle at the level of elbow joint. Longitudinally the splint is bent in a gutter
shape for providing the better fitting it to the forearm and shoulder, then cotton-gauze
pad is fixed. The assistant takes patient’s arm like a handshake, and produces a
50
moderate extension of the forearm, simultaneously creating antiemphasis by another
hand for about 3 seconds in the lower third of the affected shoulder. The forearm is
placed on the splint in a position halfway between pronation and supination; palm
facing the stomach, cotton-gauze roll with diameter of 8-10 cm is put. On the roll
dorsiflexion of hand should be done, the opposition of the thumb and partial flexion of
other fingers should be performed (Fig. 2.8).

Fig. 2.8. The ladder splint application in fractures of the forearm:


a – preparation of the splint; b – splinting and fixing the splint by bandage; c – hanging
up an arm on a kerchief.

In this position, the splint is bandaged and the extremity is hung on a kerchief.
The use of plywood splint does not provide complete immobilization, because the
elbow joint cannot be permanently fixed. Good immobilization of the forearm and
hand is achieved by using the pneumatic splint.
POSSIBLE ERRORS:
1) Modeling of a splint is made without taking into account the size of the
patient's extremity;
2) Soft pad is not placed under the splint;
3) Two adjacent joints are not fixed (the splint is short);
4) The hand is not fixed in the splint in dorsiflexion position;
5) Fingers are fixed in unbent position, the first finger is not opposed to the
others;
6) The splint is not shaped in gutter position and it does not create a "nest" for
the pad in the olecranon;
7) The hand is not suspended by the kerchief.
IMMOBILIZATION IN INJURIES OF THE SHOULDER, THE SHOULDER
JOINT AND ELBOW JOINT.
In injuries of a shoulder it is necessary to fix the 3 joints - shoulder, elbow and
wrist – and to give the extremities final position, close to physiological, i.e. when the
51
muscles of the shoulder and forearm are in the rest position. To do this, take the
shoulder of the body at 20-30° and bend forward. Measure the length of the patient's
extremity from the olecranon to the end of the fingers and, adding another 5-7 cm bend
the ladder splint across to the angle of 20°. Then, receding by 3 cm in both sides from
the top of the angle, splint is unbent by 30° to provide an additional "nest" at the level
of the olecranon to prevent the splint pressure on the oleocranon. Outside the "nest"
the main branches are set at right angle at the level of elbow joint. Further modeling of
the splint is made by adding 3-4 cm to the length of the arm of the patient on thickness
of cotton-gauze pad and the possible extension of the shoulder. At the level of the
shoulder joint the splint is not simply bent at an angle of about 115°, but also spirally
twisted. In practice, it is easier to do it on the shoulder and back of the person making
immobilization. At the level of the neck the sufficient oval bending of the splint should
be provided to prevent the pressure on the cervical vertebrae. The end of the splint
should reach the scapula of healthy side. At the level of the forearm the splint is bent
in the shape of a gutter (Fig. 2.9).

Fig. 2.9. Application of the ladder splint in fractures of the humerus;


a – preparation of the splint; b – the fixation of the splint; c – fixing the splint by
bandage; d - hanging up the splint by a handkerchief.

Two 70-80 cm long tapes are tied for the subsequent suspension of the distal
end. A cotton-gauze pad is attached for the entire length of the splint. During splinting
the victim sits. The assistant bends the extremity at the elbow joint and produces
extension and retraction of the shoulder. A special cotton-gauze roller is placed in the
armpits, which is strengthened in fixed position by the bandage tours through the
healthy shoulder girdle. The roller has a bean-shaped form. Its size should be
20x10x10 cm. After splinting tapes are pulled on it and tied to the corners of the distal
end. The forward tape is passed on the front surface of a healthy shoulder girdle, the
back one – on the back surface and through the armpit. The required degree of tension
of tapes is determined by providing flexion of the forearm at a right angle at its free
overhang. The forearm is placed in a position in between pronation and supination; the
palm facing the stomach, the hand is fixed on the cotton-gauze roller.

52
Bandaging of the splint should be started with a hand, leaving fingers free to
monitor the state of blood circulation in the extremity. The entire splint is bandaged,
paying special attention to fixation of the shoulder joint, on area of which spike-shape
bandage is applied. The splint is fixed by eight round tours of bandage passing through
the armpit of the healthy side. At the end of bandaging upper extremity with the splint
is additionally hung on a kerchief.

POSSIBLE ERRORS:
1) The ladder splint is not modeled by the size of the affected upper extremity;
2) For a forearm the short site of the splint is bent, so that the hand is not fixed
and is hanging down from the splint;
3) A "nest" for soft pads under the olecranon is not formed in the splint, so the
splint will cause pain and can cause a bedsore;
4) The site of the splint for the shoulder corresponds exactly to the length of the
arm, in the result of which an important element of immobilization is excluded -
traction of shoulder under the effect of gravity of the forearm;
5) The splint in the area of the shoulder joint is only bent at an angle, forgetting
that without twisting spirally there will be not sufficient fixation of the shoulder joint;
6) The proximal part of the splint comes to the end on the scapula of the
damaged side, thereby fixation of the shoulder joint is not achieved. It is bad if the end
of the splint covers the entire scapula on the healthy side, as healthy hand movements
will lead to loosening of the splint and violation of fixation;
7) The splint flexure is not modeled for the prevention of pressure on the
cervical vertebrae;
8) The splint at the forearm level is not bent in a gutter shape, then fixation of
the forearm will be unstable;
9) Splint is applied without pads (cotton-gauze, or other);
10) Cotton-gauze roller is not placed in the armpit for shoulder abduction;
11) Cotton-gauze roller is not placed under the palm;
12) Not entire splint is bandaged;
13) The hand is not bandaged;
14) Fingers are bandaged;
15) The hand is not hung up on the kerchief.
In scapula damages good immobilization is achieved by suspending the upper
extremity on a kerchief and only in case of the scapula neck fractures immobilization
by ladder splint should be applied, as well as in injuries of the shoulder joint and
shoulder. Transport immobilization for fractures of the clavicle can be accomplished
by the oval of the ladder Cramer’s splint covered with cotton. The oval is enclosed in
the armpit and shoulder girdle and is fixed by bandages to the healthy side (Fig. 2.10).
The forearm is suspended on the kerchief.

53
Fig. 2.10. Application of ladder splint in fractures of the clavicle.

In fractures of the clavicle immobilization can be accomplished with a stick of


about 65 cm long positioned horizontally at the bottom corners of the scapulas. The
patient himself presses it behind by his upper extremities in the elbow area; hands are
fixed by the belt. It is necessary to know that prolonged compression of blood vessels
by a stick causes ischemic pain in the forearm.
The immobilization of the clavicle is done by eight shaped bandage from a
wide bandage or kerchief. The assistant rests a knee against interscapular area and by
hands retracts the shoulder joints of the patient. In this position eight shaped bandage
is put. In interscapular region by crossing kerchief the cotton-gauze pad is enclosed.
Cotton-gauze rings are widely used to immobilize the clavicle, they are put on
the upper extremity and shoulder girdle, and pulled together on the back by a rubber
tube, in extreme cases, by a bandage. The inner diameter of the ring should not exceed
more than 2-3 cm in diameter of the upper extremity at the site of its transition in a
shoulder girdle. The thickness of the cotton-gauze tourniquet, from which the ring is
made, should be at least 5 cm. The immobilization by eight shaped bandage or rings is
supplemented by suspending a hand on a kerchief.
POSSIBLE ERRORS:
1) A hand is not suspended by a kerchief in immobilization by rings or eight
shaped bandage and thereby the subsequent displacement of fragments because of
gravity effect of the extremity is not eliminated;
2) Cotton-gauze rings are too large in diameter, so that the necessary traction
and fixation of the shoulder girdle are not provided; rings of a small diameter break
blood circulation in the extremities.

d. Transport stabilization of the lower extremity


The simplest transport immobilization and quite reliable in case of damage of
the lower extremity can be carried out on the spot by bandaging the injured lower
extremity to the healthy one. For this purpose bandages, individual dressing package,
waist belt, kerchief, rope, etc. can be used.

54
IMMOBILIZATION IN INJURIES OF THE FOOT AND TOES.
If foot injuries, its back segment (hind foot), give it the position of plantar
flexion at an angle of 120°; the knee joint is bent to an angle of 150-160°. In damaged
forefoot it is fixed at an angle of 90°, thus we do not need to fix the knee joint. The
height of the splint is limited to the upper third of the leg.
It must be remembered that in foot damages there is always significant
traumatic swelling, as well as the compression of the soft tissues takes place. This can
lead to the development of pressure sores caused by shoe pressure or in tight
bandaging. Therefore, before the splinting it is recommended to remove the shoes by
taking off or cutting.
Immobilization of closed fractures of the toe is made by narrow strips of
adhesive tape, which is applied to the finger and the foot in the longitudinal and
transverse directions, but without much tension (freely) in order to prevent further
compression of soft tissues of the finger. Especially dangerous in this regard is to
apply the closed circular adhesive strips.
POSSIBLE ERRORS:
1) In hind foot damages the knee joint is not fixed;
2) In forefoot damages the foot is fixed in plantar flexion position;
3) Shoes are not removed with the threat of edema development.
IMMOBILIZATION IN DAMAGES OF SHIN AND ANKLE JOINTS.
Besides bandaging to the healthy extremity, any flat solid objects of sufficient
length can be used. They are fixed along the affected extremity by bandages, scarves,
belts, handkerchiefs, ropes, etc. In damages of this localization it is necessary to carry
out the fixation of not only the damaged tibia, but also the knee and ankle joints, so the
splints should be up to the upper thigh and reach the foot, fixed at an angle of 90 ° to
the shin. Reliable immobilization is achieved by using two or three ladder splints. The
back ladder splint is applied on the upper thigh and 7-8 cm in distal direction from the
ends of fingers. Before application the splint must be carefully modeled. The platform
for foot should be perpendicular to the rest of the splint. A "nest" for the heel is formed
and then the splint follows the contours of the gastrocnemius muscle, in the thigh area
it is bent at an angle of 160 °. Side ladder splints are bent in the form of the letter "n"
or "r". They fix the tibia on both sides (Fig. 2.11).

Fig. 2.11. Application of ladder splints in fractures of the shin bone and the ankle: a –
Preparation of the splint; b – splinting; c – fixing of splint by bandage.

55
While splinting shoes are usually not removed. An assistant holding with both
hands the heel area and the back of the foot, holds the extremity, slightly pulling and
lifting it, as when removing the boot, fixing the foot at a right angle. Cotton-gauze pad
is placed on the back splint. As the side splint a plywood splint can be used - from the
mid-thigh and 4-5 cm below the top of the foot. Good immobilization of the leg and
foot is achieved by using pneumatic splints.
POSSIBLE ERRORS:
1) Immobilization is performed only by the back splint, without side splints;
2) The splint is short and does not fix the knee or ankle joints;
3) Osteal prominences are not protected by cotton-gauze pads;
4) The back ladder splint is not modeled.
IMMOBILIZATION IN THE THIGH, HIP AND KNEE JOINTS.
Hip fractures are very common, particularly in road accidents. Fractures of the
femur, regardless of the level are accompanied by traumatic shock and wound
infection. This determines the particular importance of creating an early and reliable
immobilization of the thigh, hip and knee joints, as well as the upper third of the leg.
In such injuries immobilization itself is very difficult, because it is necessary to fix
three joint - the hip, knee and ankle (Fig. 2.12).

Fig. 2.12. Immobilization of the lower extremity by Kramer’s ladder splint.

The best of the available standard splints to immobilize the hip is Diterichs’s
splint (Fig. 2.13). For a more durable fixation of the damaged extremity additionally
back ladder splint is used. An important condition for successful splinting by
Diterichs’s splint is participation of two assistants or, at least, one assistant.
Splinting is started with fitting crutches. Branches of the external crutch are
moved apart so that the head rests against the armpit and the lower branch extends
beyond the edge of the foot by 10-15 cm. The head of the internal crutch should rest
against the perineum, a distal end, excluding the folding bar, comes at the lower edge
of the foot by 10-15 cm. In these positions branches of crutches are fixed by
introducing the wooden rods of the upper branches to the corresponding holes of the
lower branches. Then two branches are bound with each other by a bandage to prevent
the rods sliding out through the holes. The heads of crutches are draped by a layer of
cotton, which is bandaged. Through the upper and lower cuts in the branches trouser
belts, straps or bandages are passed. While preparing the back ladder splint it is
initially modeled following the contours of the buttocks, popliteal fossa (bent at an

56
angle of 170°), the gastrocnemius muscle. Cotton-gauze pad is bandaged to the splint
along the entire length. Footwear from the damaged extremity is not removed.

Fig. 2.13. Immobilization of the lower extremity by Diterichs’s splint (a). Traction of
an extremity by the splint (b).

It is also desirable to bandage cotton-gauze pad to the back of the foot in order
to prevent possible pressure sores.
Application of the splint begins with bandaging plywood sole to the foot.
Fixing of the sole should be sufficient, but the wire loops and eyelets of the sole are
left free from bandages.
The distal end of the external crutch is carried out in the ear of the bandaged
sole, and then a crutch is moved up to the stop in the armpit. Belt or dressing
introduced earlier in the upper cuts of the crutch are bound on the healthy shoulder
girdle above the cotton-gauze pad. Internal crutch is conducted in corresponding ear of
the sole and moved up to then stop in the perineum (the ischial tuberosity). Folding bar
is put on a spike of the outer branch, the ends of the bandage (belt) inserted into the
lower cuts are carried out in the middle of the outer branches and bound with some
tension.
The back ladder splint is put under the extremity and the cords are inserted in
the loops of the sole. Further extension of the extremity is done by holding the foot,
another assistant shifts the entire splint up, creating some pressure by the heads of
crutches in armpit and perineum. The achieved traction is fixed by pulling the sole
with a cord and twisting. It is wrong to produce traction by twisting, because it will be
always limited, and therefore insufficient.
Between crutches and osteal prominences (at the level of the ankle, the femoral
condyles, the greater trochanter, ribs) cotton-gauze pads are placed. Diterichs’s splint
is bandaged together with a back ladder splint from the level of the ankle to the
underarm pit. Bandaging is made quite tight. The area of hip joint is strengthened by
eight rounds shaped bandage. After bandaging the splint is additionally strengthened at
the level of iliac bone wings by a waist belt (strap), under which on the side opposite
the splint, a cotton-gauze mat should be enclosed.
If there is no Diterichs’s splint, immobilization is provided by three long
(120 cm) ladder splints. The back ladder splint is modeled by the lower extremity. The
lower part of the splint must be longer than the foot of the patient by 6-8 cm. Then it is
57
bent at an angle of 30° and, receding by 4 cm from the flexure, the long part is unbent
at an angle of 60°, creating a "nest" for the heel. Then the splint is modeled according
to the shape of the gastrocnemius muscle, in the popliteal area an angle of 160° is
created. Then it is curved along the contour of the gluteal area. All the splint is
longitudinally bent in a form of a gutter and is covered with cotton-gauze pads, which
are fixed by a bandage.
The second ladder splint is placed on the internal surface of a leg, its top rests
on the upper end of the perineum, U-shaped bent at the level of foot with the transition
to the external surface of the tibia. The third ladder splint rests on the armpits, it is
carried on the external surface of the body, the femur and tibia and is bound with the
end of the curved internal splint.
The second and the third splints are also covered by the cotton-gauze pads that
must be bent outwards over the upper ends of the splint, resting on the armpits and
perineum. Osteal prominences in addition should be covered with cotton. All splints
should be bandaged to the extremity and body along the entire length. In the area of
hip the splint is strengthened by eight round-shaped bandage and the external side
splint at waist level is fixed by a trouser belt, a strap or bandage.
POSSIBLE ERRORS:
1) Immobilization is carried out without assistants;
2) Cotton pads are not placed on the osteal prominences;
3) Immobilization is carried out without the back splint;
4) the upper end of the Dietrich’s splint is not fixed to the body or fixed only by
bandage that folds, slides, so that fixation is weakened;
5) Strengthening of the splint by a belt is not provided – immobilization of the
hip joint will be insufficient (the victim can sit or lift the torso);
6) The sole is fixed poorly, it slides off;
7) Dietrich’s splint does not fix crutches with the special cuts in the branches;
8) The extension is provided not by hands holding the foot, but only by
rotating-twist – then traction will be insufficient;
9) Weak traction – heads of crutches do not rest on the armpits and perineum;
10) Excessively strong traction can lead to pressure sores in the area of the
Achilles tendon, ankle and back of foot.
IMMOBILIZATION IN TRAUMATIC AMPUTATION OF AN
EXTREMITY.
This situation occurs, usually in railroad injuries, accidents at work on
woodworking machines and others. Splinting in these cases, is intended to protect the
end of the stump from repeated damages during transportation of the wounded. At the
scene aseptic bandage is applied to the stump, and then immobilization is provided by
available means at hand (board, plywood, stick) or bandaging the lower extremity to
the healthy leg; the upper extremity stump - to the body. Stump of the forearm and
hand can be hung by hollow jacket, coat, shirt, as in the immobilization of the
damaged fingers, hand and forearm. If the torn-off part of the extremity is hanging on
a skin piece, the so-called transport amputation is done and then immobilization of the
stump by U-shaped curved ladder splint, which is put on the aseptic bandage. Cotton-
gauze pads are placed under the splint. The immobilization can be carried out by
wooden boards or two plywood splints which protrude beyond the end of the stump by
5-6 cm. While using any splint, fixation of a joint adjacent to a stump is necessary.

58
e. Transport stabilization of the neck and head
Immobilization in injuries of the skull and the brain.
In injuries of the skull and the brain it is necessary to create conditions for
amortization during transportation. However, to fix the head to the body by splints is
not reasonable since there is another threat - the aspiration with vomited masses may
happen, so if splints are in place it would be impossible to turn the head in order to
prevent such aspiration.
Simple improvised methods of immobilization (laying the head on a soft cloth
in the form of a circle) provide sufficient amortization during transportation but do not
prevent rotation of the head. For this purpose, use the bedroll from clothes, etc. The
ends of the bedroll are bound by a bandage, a belt, a rope. The diameter of the formed
ring should match the size of the head of the victim. To prevent aspiration of vomitive
masses head should be turned to one side. Transportation is possible on a slightly
inflated plastic ring or just a big pillow, a bunch of clothes, hay and straw to form a pit
in the center for the head.
TRANSPORT IMMOBILIZATION IN NECK INJURIES
Immobilization of the neck and head is provided by a soft circle, cotton-gauze
bandage or a special transport Elanskiy’s splint (Fig. 2.14).
1. Providing immobilization by the soft ring the victim is placed on a stretcher
and is bound to prevent movements. Cotton-gauze ring is placed on a soft cloth, and
the back of the victim’s head is put into the opening round.
2. Immobilization by cotton-gauze bandage - "Schantz collar type" - can be
made in case there is no difficulty in breathing, no vomiting, and no excitement. The
collar should rest on the occiput and both mastoid, and the bottom should rest on the
chest, which eliminates lateral movements of the head during transportation.
3. Immobilization by Elanskiy’s splint provides rigid fixation. The splint is
made of plywood and consists of two half-flaps fastened together with loops. In the
expanded state splint reproduces the contours of the head and torso. In the upper part
of the splint there is a notch for the occiput, with two semicircular rollers of oilcloth on
each side. A layer of cotton or soft pad is put on the splint. The splint is fixed to the
body and around the shoulders by tapes.

Fig. 2.14. Immobilization of the victim by Elanskiy’s splint.


59
POSSIBLE ERRORS:
1) Fixing the head by splint, excluding turns sideways;
2) During the transportation the head is not turned to one side;
3) The pad under the head is not massive enough; that is why it does not
provide the necessary amortization during transportation.
IMMOBILIZATION IN JAW INJURIES
Bone fragments and entire jaw are rather fixed by the sling bandage. Fragments
of the mandibula are pushed to the maxilla, which performs the function of the splint.
However sling bandage does not prevent posterior displacement of fragments and
retraction of the tongue. More reliable fixation is achieved by a standard plastic chin
splint (Fig. 2.15). First, a special cap is put on the victim's head, which is included in
the splint set. A cap should be fixed on the head by tightening horizontal tape. Chin-
sling splint from a concave surface should be covered with cotton-gauze pads and
pressed to the chin and mandibula from the bottom. If there is a wound, it is covered
by aseptic dressing and splint is applied for the bandage.

Fig. 2.15. Immobilization by chin splint.

Loops of elastic tape from the head cap are put on the hooks in the shaped cuts
of the lateral parts of the splint. In this way, the splint is fixed to the cap by elastic rod,
then it is tightened and fixed to the broken jaw. Two rubber loops on each side are
usually sufficient for good fixing. Too strong traction increases the pain and leads to
the displacement of fragments to the sides.
Jaw injuries are frequently accompanied by retraction of the tongue and the
development of asphyxia. Tongue is horizontally pierced by a safety pin. Pin is fixed
to the clothing or around the neck by the bandage. A doctor or an ambulance
paramedic, pierce the tongue horizontally by thick ligature, with some tension they tie
it to a special hook in the middle of the chin splint. Thus tongue should not protrude
outward beyond the front teeth to avoid biting the tongue during transportation.
60
The victim with damaged jaws and imposed splint is transported with his face
down, because otherwise there is a risk of aspiration of blood and saliva. A bedroll
must be put under the chest and head (forehead) in order the head is not left hanging,
the nose and mouth are free. This ensures breathing and expiration of blood, saliva. In
satisfactory condition of the victim, he can be transported sitting down (with the head
tilted to one side).
POSSIBLE ERRORS:
1) Sling splint is applied without cotton-gauze pads;
2) Elastic pull of sling splint by rubber loops is too large or asymmetrical;
3) Transportation of the victim in position laying on a stretcher the face up - the
saliva and blood leak into the mouth and can be aspirated into the respiratory tract,
asphyxia is possible;
4) Tongue is not fixed during retraction.

f. Transport stabilization of the spine and pelvic injuries


Immobilization in injuries of spinal column
The purpose of immobilization in injuries of spinal column is to prevent
displacement of the broken vertebrae to prevent compression of the spinal cord or its
re-traumatization during transportation, as well as to prevent damage of blood vessels
of spinal canal and the formation of hematomas. Immobilization of the spine should be
carried out in the position of moderate extension. In contrast, the bending of the spine
on the soft sagging stretcher shifts the damaged vertebrae and leads to compression of
the spinal cord.
Patient with the imposed splint can be transported on a stretcher laying face
down (on the abdomen) or face up (on the back). In injuries of thoracic and lumbar
spine, the patient is placed on a board - any tough non-flexing plane. A board should
be covered by a folded blanket. The victim is placed on his back. Very reliable
immobilization is achieved by using two longitudinal and three transverse short
boards, which are fixed to the back of the body and lower extremities. If it is not
possible to create non-flexing plane or there is a large wound in lumbar region, the
victim is laid on a soft stretcher on the abdomen (Fig. 2.16).
In order to prevent bending of the spine, the rollers from overcoat, haversack,
hay, folded blankets, etc. should be put under the chest and pelvis. If the spinal cord is
also damaged, the victim must be tied to a stretcher in order to prevent passive
movements of the body during transportation and further displacement of the damaged
vertebrae, and the sliding of the patient from the stretcher.

61
Fig. 2.16. Transport immobilization in fractures of the spine: a – face down
(on the abdomen; b – face up (the supine position).

Patients should be moved by three persons (from the stretcher to the stretcher or
from the stretcher on the table): one of them holds the head; the second one brings his
hands under the back and lower back; and the third person brings his hands under the
pelvis and knee joints. Raising the patient is made by all the persons on a signal to
prevent dangerous flexion of the spine and further injury.
POSSIBLE MISTAKES:
1) мoderate extension of the spine is not provided during immobilization and
transportation;
2) сardboard-cotton collar is small and does not prevent the tilting of the head;
3) the imposition of two ladder splints in injuries of the cervical spine is carried
out without an assistant, who, holds the head, makes a moderate extension and
stretching of the cervical spine;
4) ladder or plywood splints are not sewn to the stretcher to create a rigid plane.
When transporting the splints slip out from under the patient, the spine is bent, causing
additional trauma with possible damage of the spinal cord;
5) when laying the victim on a stretcher with his face down, the rollers are not
put under the chest and pelvis;
6) the patient with spinal cord damage is not bound to the stretchers.
IMMOBILIZATION IN CAE OF INJURIES OF THE PELVIS
Transportation of patients with pelvic injuries (especially with damage of the
integrity of the pelvic ring) may be accompanied with bone fragments displacement
and damage of the internal organs, which aggravates the shock which is usually
followed by such injury. At the scene the pelvis should be pulled circularly together by
a wide bandage or towel at the level of the pelvis iliac wing and the greater trochanter.
The victim is laid on a board, like in fractures of the spine and vertebrae. After putting
a wide cotton-gauze pad between the knees both legs are tied with each other; under

62
the knees a high roller should be placed, under the head we put a pillow-like roller
(Fig. 2.17).

Fig. 2.17. Transport immobilization in injuries of the pelvis.

If it is possible to create a rigid litter, we can lay a victim on a stretcher in the


"frog" position. It is important to bind a popliteal roller to a stretcher since it is easily
displaced during transportation. Sufficient conditions for transport immobilization are
created by laying a patient on a stretcher with a rigid litter from 3-4 interconnected
ladder splints. Splints are modeled for creating the position of "frog" for a patient. The
ends of the splint, which is 5-6 cm longer than the foot of a patient, are bent at a right
angle. At the level of the popliteal fossae splints are bent in the opposite direction at an
angle of 90 °. If the proximal parts of the splints are longer than the femur of a patient,
they are again bent parallel to the plane of the stretcher. In order to prevent extension
of the splint under the knee joints a proximal part of the splint is connected with the
distal bandage or tape. Splints are placed on a stretcher, covered with cotton-gauze pad
or blanket, and we should lay a patient, which is desirable to be bound to the
stretchers. It is possible to leave free access to the perineum in order to ensure the
emptying of the bladder and rectum.
POSSIBLE MISTAKES:
1) There is no bandage, that pulls the pelvis together in case of the damage of
integrity of the pelvic ring;
2) The legs are not bent in knee joints and are not tied with each other;
3) Popliteal roller and the victim are not fixed to stretchers;
4) Ladder splints are not connected longitudinally for fixing the right angle
under the knee joints.

g. Modern methods of transport immobilization


Over the last 10 years, thanks to scientific research and development activities,
medicine of catastrophes and emergency situations has been updated with new unique
products for transport immobilization by using new technologies, water-proof
materials and disposable transport splints. A set of disposable transport splints is
represented on the Fig. 2.18.

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Fig. 2.18. Disposable transport splint.

Fig. 2.19. Disposable transport splint in use.

Prescription: immobilization of the cervical spine, shoulder, forearm, shin,


thigh (with traction) (Fig. 2.19).
Features:
Simultaneous provision of medical aid to several patients;
Saves immobilizing properties after imposition at least 10 hours;
Made of environmentally safe materials;
Splint has a long shelf life in a package;
It doesn’t require special methods of utilization.
Structure: four large and two small workpieces with marks indicating the fold
line and line of cuts to get the necessary splint.
Package of folding transport splints
Prescription: immobilization of upper and lower extremities.
A splint is made of plastic sheets, PVC fabric, cellular polypropylene, etc.

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Features: this splint is simple, convenient and reliable in application; folded
splint is rather small that allows to put it in backpack, jackets, TAC vest, etc.;
radiolucent; a splint is equipped with fixing belts; it is water-proof (Fig. 2.20).

Fig. 2.20. Package of folding transport splints.

Package of transport ladder splint


It is designed for immobilization of upper and lower extremities. It doesn’t
require a prior preparation. A splint is equipped with belts with fixing buckles
(Fig. 2.21).

Fig. 2.21. Package of transport ladder splints.

Kerchief bandage.
It is designed for fixation of elbow joint and forearm (Fig. 2.22).

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Fig. 2.22. Kerchief bandage.

Package of transport collar splints


It is designed for immobilization of cervical region of the spine. A splint is made of
lightweight plastic with soft synthetic pad on a patient’s side. A splint is easily washed
with detergents and disinfectants (Fig. 2.23).

Fig. 2.23. Package of transport collar splints.

Folding splint
Prescription: immobilization of the cervical and thoracic spine with fixation of
the head; immobilization of femur and shin (Fig. 2.24).

Fig. 2.24. Immobilization of the cervical and thoracic spine with head fixation.
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Vacuum methods of immobilization
All products consist of vacuum chamber with synthetic granules inside and a
protective cover. Protective covers of chambers are made of durable waterproof
material and equipped with fixing belts. By pumping air, a product receives and saves
the anatomic shape of the body, and provides the necessary rigidity.
Features: radiolucent; have thermal insulation properties. Operating conditions:
temperature from -35°C to +45°C. Current care: washed with detergents and
disinfectants.
Prescription: immobilization of the cervical spine, upper and lower
extremities. Various types of vacuum splint are presented in fig. 2.25.

Fig. 2.25. Vacuum splint for immobilization of the cervical spine, upper and lower
extremities.

Package of transport vacuum splints “Omnimod”


It is designed for immobilization of extremities and cervical spine when it is
fractured. Splints are supplied only in packages.
Features: protective covers of chambers are made of durable and waterproof
material and are equipped with fixing belts. A splint is radiolucent. It also has thermal
insulation properties (Fig. 2.26).

Fig. 2.26. Package of transport vacuum splints “Omnimod”.


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Vacuum immobilization mattress “Kokon”.
Prescription: immobilization in spinal injuries, fractures of the femur, pelvis,
polytrauma, internal bleeding and shock. The scheme of use is shown in fig. 2.27.

Fig. 2.27. Scheme of use of a vacuum mattress.

Features: depending on a kind of injury the mattress allows to immobilize and


move a patient in a necessary position; special sections make it possible to provide
reliable immobilization in case of combined trauma and concomitant injury
(Fig. 2.28).
The kit includes: a mattress, a vacuum pump, repair kit, ribs, linking conveying.
Sectional scoop stretcher.

Fig. 2.28. Vacuum immobilization mattress in use.

Sectional stretchers are designed for gentle shifting of a patient with severe
injuries to transport vehicles during the evacuation. A stretcher helps to reduce
significantly the deformations and pain of a patient during the loading and shifting
(Fig. 2.29).
A distinctive feature of the stretcher is its simplicity and convenience for a
patient. The speed and reliability of fixation allows to raise a patient in a confined
space or move him out without any difficulties.
Material and structure: aluminum alloy. Carabiner-type locks provide fast and
reliable fixation of stretchers in transportation position.

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Fig. 2.29. Transportation of a person with the help of vacuum scoop stretchers.

h. Medical immobilization and plaster bandages


Medical immobilization is a prolonged immobilization of a damaged segment
of the body until recovering its integrity (consolidation of the fracture, healing of the
wound).
For immobilization with treatment purposes the most commonly used bandages
are as follows:
Plaster bandages.
Splints (Kuzminskogo, Shulutko, etc.).
Compression-distraction devices (Volkova-Oganesyana, Ilizarov frame, etc.).

i. Plaster bandages
Plaster bandages were introduced to medical practice in the middle of the last
century, they were tested in the periods of mass injuries (wars, natural disasters) and
up till now remain one of the best methods of fixation.
Gypsum (CaSO4- 2H2O) - a mineral wide-spread in nature, which is pulverized
and baked for removal of water molecules. Plaster used for bandages is soft white fine
powder without lumps. Mixed with water, it turns into a pasty mass, which quickly
becomes hard like a rock with stone density.
Plaster is stored in packages, but loose plaster is stored in hermetic metal boxes
to prevent the penetration of moisture. Damp plaster should be dried in an oven at
temperature not higher than 120°C. For plaster bandages standard gauze dressing 7 to
16 cm in width and more than 3 meters in length are used. These bandages are
impregnated with plaster in advance, it means that they rub dry plaster in a bandage
and prepare for future use. Before applying a plaster bandage it is necessary to take
samples for checking out the quality of the plaster:

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1. Gypsum paste made from five pieces of plaster and three parts water should
solidify for 5-7 minutes.
2. Gypsum paste is pressed into the bead (gypsum ratio: water = 1:1).
In 7-10 minutes it is dropped from a height of 1 m. If the plaster is of a good quality,
the ball is not broken.
Creation of a plaster bandage:
Beforehand a plaster bandage or splint is put into warm water (30-35°C).
Wait for the complete blotting of material that is being checked by the end of
air bubbles discharge. Then bandage is taken out and carefully (from the edges to the
center keeping the gypsum paste) squeezed.
The extremity is oiled by vaseline or wrapped by cotton wool to avoid sticking
to the hair, and then we should start to make a bandage.
Plaster bandages are applied in a special room, where there is a kit of necessary
tools to work with plaster bandages (Fig. 2.30).

Requirements for plaster bandage and methods of its imposition.


The bandage should be made of high-quality plaster.
Bandages can be lining (with a layer of cotton under the plaster) and non-lining
(without cotton layer).
Before imposition of circular plaster bandage all of the most prominent points
of the body subjected for fixation must be protected, i.e. covered with cotton-gauze
pads (Fig. 2.31).

Fig. 2.30. Tools for removing plaster bandages.


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Fig. 2.31. Points of the body subjected for protection during application of plaster
bandages.

The extremity should be immobilized in functionally favorable position unless


the method of treatment involves a deviation from this rule. Remember, that the
outcome of a severe and complicated injury may be contracture or even ancylosis,
that’s why a wrong imposition of the extremity will lead to disability.
The bandage should be sufficient in volume. Short or narrow bandages do not
provide sufficient immobility.
The thickness of the bandage depends on a damaged segment and the type of a
bandage. So, for fingers five or six layers of plaster bandages are enough; bones of the
forearm – seven layers; a shoulder - eight to ten layers; toes – six to eight layers; a shin
– ten layers; a hip – twelve layers.
It is forbidden to impose circular tours of a soft bandage on the wound under
the plaster bandages, because gauze gets wet by discharging ichors or moisture of a
plaster bandage, and when it dries, it creates a "stranglehold", resulting in ischemia of
the extremity.
Tours of plaster bandages should be put freely without tension. After each turn
we should model a bandage by hands, especially in areas with a complex configuration
(ankle, metatarsal tubercle, arch of the foot).
A plaster bandage should be rolled freely on the surface of the body. Each
subsequent tour should be imposed not tighter than the previous one and cover at least
half, or even better - to 2/3 of the volume.
The upper and lower edges of the circular and further lateral surfaces of splint
bandages should be skirted by the gauze pad. The last one should be processed with
plaster and carefully modeled. It makes the sharp edges of the plaster smooth, prevents
71
an edge from breaking and getting small pieces of plaster under the bandage that can
disturb a patient and make him inconvenience.
The bandaged extremity should be held by hands, not by fingers because of
traces left. During plaster bandaging the extremity remains fixed in one elected
position without changes, because in case of vibration the wet plaster bandage can get
broken.
The ends of the fingers of a bandaged extremity must be always left open for
monitoring the circulation of the extremity.
A plaster bandage should not disturb urination and defecation.
A complete bandage is marked. The scheme of a fracture or surgical operation
is put on it. The dates of the injury, imposing and removing the plaster are
recorded. Instead of the last one a specified approximate date of immobilization may
be noted, for example, "bandage is imposed for 2 months". A doctor’s signature is
necessary.
A bandage gets rigid for 7 to 10 minutes and gets dry in a day or two. During
this period a bandage must be handled carefully. Drying can be quickened by blowing
hot air (with the hair-dryer).
For a better drying a plaster bandage is left open without blanket for a day or
two. Fingers are covered with cotton for creating comfort and warmth.
During the first week the extremity is in an elevated position to reduce its
swelling. That is why it is placed on the pillow, on the splint; it is hung up to the frame
or other device. For the purpose of convenience and preventing fracture a wooden
shield is placed under the bed mattress.
Blood-soaked bandage is treated with 5% solution of potassium permanganate.
The last one has disinfecting, tanning, deodorizing properties; it also meets cosmetic
requirements deleting blood stains.
At the end of immobilization a bandage is removed. If the removal of splints is
not difficult, the removal of circular bandages, especially bulky, presents considerable
difficulty. Any bandage is cut along the length by using special scissors, saws, knives,
etc. One branch of the scissors is brought under the bandage edge. The second branch
with a knife at the end, performing oscillations back and forward, is used to cut the
plaster through. As the formation of cracks, the first branch is shifted under the
bandage, having platform parallel to the skin. By moving the first branch without
hesitation and working with the second branch, a bandage is cut along the length.
If a bandage is cut through with a knife or a saw, a cutting line should be
moistened with salt solution. In the slit special tongs are introduced that squeeze the
edge of the bandage. Then with tools and manually we throw the edge of the cutting
bandage to be able to remove the immobilized body part.
Violations of the rules of imposing a bandage can lead to circulatory disorders,
nerve compression, pressure sores, skin maceration.
According to qualitative characteristics there are the following kinds of
bandage:circular, splint, cot (Fig. 2.32).

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Fig. 2.32. Plaster bandage: a – splint, b, d – circular; c – joint-fixed; e – cot.

Splint (Fig. 2.32.a). It is made of prepared beforehand layer of gauze or


bandages (6 to 10 layers). A wrung splint is put on a table, and is carefully smoothed
to eliminate wrinkles and particulates. This procedure can be performed in a different
way: taking a narrow edge of a splint keep on weight and an assistant clamps it
between the palms and iron from top to bottom. Then a splint on one side is coated
with a thin layer of cotton, which prevents sticking it to the hairline and only after all it
is imposed on a damaged part of the body. When bandages are without a pad, they are
greased with Vaseline for the same purpose. A plaster bandage should cover at least
2/3 of the area of the extremity. In places of bends a splint is cut to avoid wrinkles and
projections, several times we squeeze all edges, preventing them from plunging, and
fix to the body with a gauze bandage. Pay attention to the roundness of the splints’
edges. That’s why the edges are slightly folded outwards, bordered with gauze, and
carefully modeled.
If conditions permit, a splint can be made of plaster bandages directly on the
body of a patient. Such a bandage is much better, as it repeats body reliefs. It is not
necessary to close natural bone prominences (ankle, condyles), because well-modeled
bandage does not lead to compression.
The circular (Fig. 2.32.b, g) (solid, blank) bandage better immobilizes the
injured part of the body. At length it can be different, for example, can cover the
forearm and wrist, or the entire upper extremity and chest at the same time (chest-
formbandage) or the pelvis and lower extremity (hip bandage). When circular
bandages are imposed, parts of the body should be closed by soft pads (cotton),
particularly in cases when bandage is out of pad. An extremity is bandaged from

73
periphery to the center with the expectation that the subsequent tour of a bandage is
covered half prior. The ends of the fingers are necessarily left open.
The circular bandage should be applied in a hospital or a day care ward in out-
patient clinic where it is possible to monitor the status of immobilized extremity
dynamically. It can’t be done in an outpatient setting, because in the case of
compression ischemic contracture and necrosis may develop.
A stage plaster bandage (Fig. 2.33.a). It is used to prevent a contracture. A
circular bandage is imposed above and below the damaged joint. After drying them we
forcibly perform bending or unbending of the joint (depending on the type of
contraction), and fix the position with a plaster muff. In 7-10 days the muff is removed
and corrected with fixation as for the first time. Manipulation is repeated until the
vicious pose of the extremity is eliminated.
Treatment of contractures is also possible by a plaster bandage with a twist like
the mechanism of a stage bandage.
Fenestrated bandage (Fig. 2.33.b). It is a circular plaster bandage with cutting
holes ("window") which is to be inspected or for procedures. If you have a wound,
through this "window" we can perform a ligation, blockade, physiotherapy and other
procedures. The size of a "window" should not exceed half the circumference,
otherwise it loses strength.
Articulated-plaster bandage (Fig. 2.33.v). It has the same form as circular
bandage, but instead of a muff, two parts are fixed by metal hinge around the joint.
The bandage is imposed, when prolonged immobilization is assumed, and there is a
threat of contractures. The best prevention of their occurrence is the early movement,
which is made possible by the use of articulated-plaster bandage.
Bridge-like bandage (Fig. 2.33.g). When the fracture is accompanied with
wounds, which are located on one level and the circumference of the extremity, we
impose a bridge-like bandage, which consists of two circular, fixing with twisted
bandage (sometimes - metal), which provides access to the wound surface.

Fig. 2.33. Plaster bandage: a – stage bandage (the first and the second stage);
b – fenestrated bandage; v – articulated-plaster; g – bridge-like.
74
Corset. It is a circular bandage for the trunk, and sometimes the neck, used in
spinal fractures. Mostly corset is imposed after stage reclination. For this, with the help
of a special device (Hoff frame) in a patient in standing position a stretching is made
by using Glisson loop so that the patient would barely touch the floor with his heels. It
is imposed on the trunk from the symphysis with a support on the wings of the iliac
bone to armpits or neck in a certain position hyperlordosis - hyperextension anteriorly
(Fig. 2.34).

Fig. 2.34. Hoff frame (a); Plaster corset (b).

According to the method of application there are permanent and intermittent


immobilizations.
Permanent (stable) immobilization is used when a rigid fixation of the damaged
segment of the body is required, but its early elimination leads to the defects in the
treatment - it means the displacement of bone fragments, recurrence dislocation, etc.
The size of a plaster bandage in injuries of the upper extremity is shown in Fig. 2.35,
and lower extremity – in Fig. 2.36.

Fig. 2.35. Size of the plaster bandage in injuries of the upper extremity.

75
Fig. 2.36. Size of the plaster bandage in injuries of the lower extremity.

Intermittent (removable) immobilization. In some cases, where immobilization


is urgently needed, it is also an obstacle in the treatment. For example, if a wound or
suppuration is extensive, it is needed in frequent bandaging; when a fracture is intra-
articular, it is prohibited to load the extremity for 3-6 months, but the lack of
movement in the joint during that period will result in stiffness or
ankylosis. Compromise in these cases will be intermittent immobilization. A plaster
bandage is removed at the time of bandaging. For the fractures of bones forming the
joint, stable immobilization is continued until the formation of fibrous adhesions
between the fragments (3-4 weeks) is achieved, and then it is transferred to
intermittent. The doctor assigns gymnastics, starting with careful passive movements,
and physiotherapy. After the end of these procedures the plaster bandage is imposed
again. In the final stages of the treatment an intermittent plaster immobilization is used
only at night.
Thus, a plaster is a fast setting material which is relatively cheap, whereby in all
conditions stable immobilization can be made without any complicated devices. Its
plasticity allows to fix any segment of the human body, and gives the possibility to
combine different devices, gives greater variability in the methods of treatment. The
plaster is hygroscopic and good in absorbing discharges of the wounds. It is a good
conductor of heat. According to a local increase in temperature (determined by touch),
color and smell of discharge which is soaked by a bandage, you can judge about the
wound inflammation.
An important role of a plaster bandage is valuable during a war, when victims
should be transported over long distances. Stable immobilization makes them
movable, it allows the victims to maintain themselves and to take part in defensive
actions in extreme situations. An invaluable contribution was made by the great

76
surgeon N.I. Pirogov, who first applied a plaster bandage in war conditions and
improved its use on the damaged and sick people.

2.7.4. Plaster immobilization with the fracture of the shoulder girdle and upper
extremity
Plaster immobilization with the fracture of the clavicle.
Area of bandaging: immobilization of shoulder and forearm on the side of the
damage. Smirnov-Vayshtein’ bandage is commonly used (Fig. 2.37).

Fig. 2.37. Smirnov-Vayshtein’ bandage.

Plaster immobilization with the fractures of the scapula


Area of bandaging: immobilization of shoulder and forearm on the side of the
damage (Fig. 2.38).

Fig. 2.38. Immobilization of the shoulder girdle Plaster immobilization with the
fractures of humerus.

77
Area of bandaging: immobilization of shoulder and forearm on the side of the
damage (Fig. 2.39).

Fig. 2.39. Immobilization of humerus with thoracobrahilis bandage.

Plaster immobilization with the fracture of forearm.


Area of bandaging: immobilization of the shoulder and forearm on the side of
the damage (Fig. 2.40).

Fig. 2.40. Plaster bandage of forearm.

Plaster immobilization with the fractures of a wrist joint


Area of bandaging: immobilization of forearm and wrist joint on the side of the
damage (Fig. 2.41).

Fig. 2.41. Immobilization of the wrist with circular bandage and plaster splint.
78
Plaster immobilization with in the fracture of hand and fingers
Area of bandaging: immobilization of forearm, a wrist joint and fingers on the
side of the damage (Fig. 2.42).

a) b)
Fig. 2.42. Immobilization in the fracture of fingers of the hand: a – with a circular
bandage; b – with a bandage with stretching.

Plaster immobilization in the fracture of the lower extremity


Plaster immobilization in the fracture of femur
Area of bandaging: immobilization of lumbar region, pelvis, femur, shin and
feet on the side of the damage (Fig. 2.43).

Fig. 2.43. Immobilization of femur

Plaster immobilization in the fracture of shin


Area of bandaging: immobilization of femur, shin and feet on the side of the
damage (Fig. 2.44).

Fig. 2.44. Immobilization in the fracture of shin.


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Plaster immobilization in the fracture of feet.
Area of bandaging: immobilization of shin and feet on the side of the damage
(Fig. 2.45).

Fig. 2.45. Immobilization for the fractures of the foot with skeletal traction.

Plaster immobilization for the fractures of the cervical spine


Extent of the bandage: immobilization of the head, neck with reliance on
the shoulder girdle (Fig. 2.46.а).

а b
Fig. 2.46. Immobilization for the fractures: а – of the vertebral bodies of the cervical
spine; b – of the bodies of the thoracic and lumbar spine.

Plaster immobilization for the fractures of the thoracic and lumbar spine Extent
of the bandage: immobilization of the vertebral bodies of the thoracic and lumbar
spine. (Fig. 2.46 b).
Immobilization for the pelvic fractures
Extent of the bandage: immobilization for the pelvis with hammock (Fig. 2.47).

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Fig. 2.47. Immobilization for the pelvic fractures with skeletal tractionand hammock.

Applying a bandage plaster in children


For treatment of damages in children (fractures, dislocations, wounds) different
kinds of a plaster dressing are successfully used (Fig. 2.48).

Fig. 2.48. Applying a bandage plaster in children.

The rules for the imposition of bandage plaster in children should be stricter,
supervision and care about them require increased attention. The dressing plaster is
called ‘the queen’ of conservative treatment of fractures.
But in spite of the enormous significance of the bandage plaster, all of its
positive features manifest only with proper application.

81
Complications, which may arise when treating the fractures by a bandage
plaster.
In compression of the major arterial trunks - leg pain, loss of sensation more
distally to the compression, pale, cold fingers of the extremities.
In compression of the veins there may appear considerable cyanosis of the
fingers, extremity coldness, pain and increasing edema of the segment of an extremity
more distally to the compression.
The compression of nerves leads to the loss of mobility of active fingers and
their sensitivity under normal skin color and temperature.
Prolonged compression of large vessels and nerves by a bandage plaster can
cause necrosis of the extremity segment more distally to the compression or can lead
to severe and irreversible changes in muscles subsequent to form contractures.
Contracture – is a sharply limiting joint mobility due to persistent changes in the soft
tissues surrounding the joint, leading to the forced attitude of it. With the signs of
arterial, venous compression or nerve trunk the bandage plaster is immediately cut all
over and only after the elimination of all the symptoms a plaster bandage is
strengthened again.
Frequent complications when using bandage plaster are bedsores and skin
maceration. They develop in the field of bone protrusions, which is the highest
pressure of a bandage plaster. The main clinical features of the pressure sores forming
under the bandage are local burning pain at the site of the pressure, sometimes it is of
intolerable character, as well as soaking bandage in the place of pressure. If you have
pain under the bandage it is also necessary to cut it lengthwise and fold the edges to
release the tension.
2.9. Modern solidified dressings, bandages, splints and corsets
For the last two decades a bandage made of synthetic materials (CELLACAST)
is used for the treatment of spine and limb injuries. Modern solidified bandage is
made of synthetic materials so it is much lighter and stronger than conventional
plaster bandage (Fig. 2.49).

Fig. 2.49. New materials for the immobilization of extremities.

Bandages of cellacast are easier applied to any areas of the body, because the
synthetic bandage is easily stretches in all directions, that allows to model the bandage
quickly and adjust it easily to the limb segment.
82
Fig. 2.50. Immobilization of the ankle joint with the bandage of cellacast.

This bandage has a cellular structure, passes air. It can be moistened, it is easily
dried with a hairdryer and doesn't lose its properties. More than that, they are x-ray
transparent and do not impair the quality of the X-ray pictures. It is effective for the
treatment, lightweight and aesthetic (Fig. 2.51).

Fig. 2.51. New materials for the immobilization of extremities.

Fig. 2.52. Immobilization with the use of new materials.


83
«Cellona» is used as a lining. In the fig. 2.53 the lining is shown, on top of
which immobilizing bandage of cellacast is applied.

Fig. 2.53. New lining.

The use of dressings made of synthetic materials requires to follow some rules:
When working with synthetic bandages it is necessary to wear gloves, а
patient's skin is carefully insulated from possible contacts with them.
Synthetic bandage polymerizes and becomes solid, 30 minutes after its
extraction from the hermetic package. If necessary to accelerate polymerization
bandage it should be moistened with water.
The edges of the dressing should be soft due to the protruding interlining. Bony
protrusions under the bandage should also be protected by soft lining.
Observation and care of the bandage made of synthetic materials is carried out
as in case with bandage plaster.
The therapy with corsets
Many modern designs of vertebrate corsets are used as a means of conservative
therapy mainly in juvenile idiopathic scoliosis. The most widely used are 2 categories
of corsets:
 cervical-thoracolumbar-sacral apparatus, orcervico-thoraco-lumbo-
sacralorthoses (CTLSO);
 thoraco-lumbo-sacralapparatus, orthoraco-lumbo-sacralorthoses (TLSO).

84
Fig. 2.54. The corset by Milvoki (CTLSO), back view: lateral tractions are at different
levels; vertical stands connect pelvic support and the cervical ring.

CTLSO – these are variants, copying the corset by Milvoki, but TLSO –are of
other constructions.

Fig. 2.55. Types of Boston’s corsets.

The variants of TLSO are divided into highly- and low-profile constructions.
Standard Boston's thoracolumbar corset and plastic jacket by Wilmington are
examples of low-profile corsets, but TLSO Boston’s corsets with axillary straightening
(Standard Boston's thoracal corset) are examples of highly-profile corsets.
Modern prosthetic and orthopedic immobilization (bandages, orthoses, corsets)
Modern prosthetic and orthopedic products firmly gained its right place in the
treatment and rehabilitation of patients with injuries, consequences of injuries and
diseases of the musculoskeletal system. Prosthetic and orthopedic products are
effectively and widely used to prevent the development of diseases and damage to the
muscles, tendons and joints when the musculoskeletal system experiences constant
load, or single overload (in athletes). Products are simple, easy and convenient in use.
It is easy to give a high-quality processing at home. It is easy to adapt to the anatomy
of a patient.
85
Neck collars.
Purpose: torticollis, overload, injuries, stretching, rheumatoid syndrome,
providing thermal comfort for injuries, stretching, myositis, rigidity, osteochondrosis,
functional instability, support and unloading for the cervical spine (Fig. 2.56, 2.57).

Fig. 2.56. Shans’splint – soft bandage for moderate fixation of the cervical region of
the spine in adults and children.

Fig. 2.57. Shans’splint (orthoses) from polyurethane foam for the entire fixation of the
cervical spine in adults and children.

Orthoses with entire fixation of the cervical region of the spine in adults and
children are used in injuries of the cervical spine, they are put on the cervical spine
after operations. Orthoses are effective in radicular syndrome and in cases of increased
mobility of the cervical vertebrae without displacement. Orthoses are also used in
dislocation of cervical vertebrae for limiting the mobility of the head and neck,
including transport stages of evacuation.
Thoracic spine.
A posture corrector is a strong fixation with 2 metal ribs designed for the
treatment of disorders of posture (slouch) and curvatures thoracic spine (kyphosis,
slouch 1-11 degrees), for rehabilitation after injury of the thoracic spine. Effective use
of the corrector is in combination with massage, manual therapy and physiotherapy
(Fig. 2.58).

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Fig. 2.58. Corset – posture corrector for fixation of thoracic spine in adults and
children.

Lumbar spine.
Purpose: spine support with pain radiating and without; ensuring the stability of
the spine and muscle unloading, light spine support with pain radiating and without;
preventive measures; ensuring the stability of the lumbar spine in sports to warm and
ease the pain (Fig. 2.58).

Fig. 2.59. Stabilizing orthosis for fixation of the lumbar spine in adults and children.

Shoulder girdle and the shoulder joint.


Purpose: damage to the ligament-muscular system, during the early
rehabilitation, after injuries and operations in the area of the shoulder joint; habitual
shoulder dislocation, osteoarthritis; overload, requiring moderate fixation and limiting
the mobility of the joint; immobilization of the upper limb in acute cases, rehabilitation
after surgery (Fig. 2.60).

Fig. 2.60. Soft bandage for the shoulder for moderate fixation of the shoulder girdle
and the shoulder joint in adults and children.
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Contraindications: the need for rigid fixation.
Elbow.
Purpose: Prevention of excessive extension of the elbow joint with injuries,
dislocations and pathological mobility, posttraumatic instability, bursitis, epicondylitis
("tennis elbow "), synovitis, during the early rehabilitation after bone fractures and
dislocations of the elbow joint, bony ankylosis (Fig. 2.61).

Fig. 2.61. Soft bandage for moderate fixation of the elbow joint in adults and children.

Wrist joint.
Purpose:overload, inflammation of the capsule-ligament and tendon apparatus,
epicondylitis, rehabilitation after trauma (Fig. 2.62).

Fig. 2.62. Soft bandage for moderate fixation of the wrist joint in adults and children.

Knee-joint
Purpose: acute and chronic pain due to the injury, operations on the knee joint,
damage and inflammation of the ligament apparatus, pain in the kneecap, rheumatoid
arthritis, degenerative changes, subluxation of the knee joint (рiс. 2.63).

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Fig. 2.63. Soft bandage for moderate fixation of the knee joint in adults and children.

Ankle joint
Purpose: prevention of injuries in sporting activities, mild instability of the
ankle joint, condition after injury in early rehabilitation, light damage ligamentous
apparatus, osteoarthritis, arthritis, inflammation of the Achilles tendon, sprains and
ankle instability (Fig. 2.64).

Fig. 2.64. Soft bandage for moderate fixation for ankle joint in adults and children.

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3. CHAPTER 3. PARENTERAL INJECTIONS AND INTRAVENOUS
INFUSION. TRANSFUSION THERAPY

Medicines may be administered through the digestive tract (enterally) or avoiding


it (parenteral). There are many alternative ways of parenteral injection that may
include:
 injection: subcutaneous, intradermal, intramuscular, intravenous;
 applying to the skin, mucous membranes;
 inhalations;
 rectal and vaginal introduction and others.

There are many alternative ways of parenteral injection that may include:
The subcutaneous, intradermal, intramuscular and intravenous injection techniques
vary. The Fig. 3.0. shows the mentioned techniques.

Fig. 3.0. Techniques of injections.

3.1. Intracutaneous and subcutaneous injections


For the intradermal injection short needles of small diameter are used, but for
subcutaneous injections the medium sized needles of a larger diameter are applied.
Preparation of the hands of medical staff is done the following way. Hands are
washed with sterile brush with soap for 3-5 minutes. Then they are rubbed with a
sterile gauze napkin and treated with gauze pad or a sterile cotton swab impregnated
with 70-degree alcohol.
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The skin on the spot of the prospective injection is thoroughly wiped with
alcohol or ether and then is treated by iodine. In injections the rules of aseptic and
antiseptic should be strictly followed. Preparation for the procedure should be made in
the absence of a patient.
Intradermal injections are usually used at making skin incisions, as well as in
applying different probes and tests or Katsoni reaction. The adequacy of injection of
the drug is determined by eye (the appearance of the so-called lemon peel) (Fig. 3.1).

Fig. 3.1. Technique of the intradermal injection.

3.2. Technique of intradermal injection of drugs includes:


1. Washing hands.
2. Assemble the syringe and take medicine.
3. Put a small needle and release the air.
4. Treat the inner surface of the middle third of the forearm with alcohol.
5. Wait until the skin gets dry.
6. Keep the needle cut up, stretch the skin at the injection site.
7. Slowly insert the needle into the skin by 0.3mm parallel to its surface.
8. Inject the drug.
9. If the injection is done correctly, «a button» is formed.
10. Remove the needle.
In subcutaneous injections a solution of different drugs is injected into those
places where subcutaneous fat layer is the most developed: into the external surface of
a hip, in infero-lateral sections of the abdominal wall below the angle of the scapula,
the outer surface of the shoulder, etc. If the patient has to get frequent injections the
locations should be changed, following the certain order (shoulder, abdomen, hip,
etc.). And avoiding those places, where there are major nerves or subcutaneous veins.
The skin for the planned site of injection is treated well with disinfectant
solutions and smeared with iodine. The drug is taken by 2- or 5-gram syringe with a
needle chosen according to the size and the air is released from the syringe. With
fingers of the left hand you need to take the skin of the patient in the fold, and by the
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right supinated hand with the syringe lying on the second and third fingers and thumb
supported, quickly make a puncture at the base of the fold where the contents of the
syringe is slowly injected by lowering the left arm. It is more convenient to inject from
the top down or bottom up.
Because the needle is free in the subcutaneous fat, it can be easily and carefully
moved in different directions as it’s sometimes necessary when introducing the
significant quantities of drug (Fig. 3.2).
Technique of subcutaneous injection
1. Wash your hands, take the syringe (1, 2, 5 mL), put the needle and inject the
medicine.
2. Remove the needle, let the air out, take with the forceps a cotton ball from the sterile
table, moisten it with 96% alcohol, shift this ball in the arm.
3. Apply alcohol for the middle third of the external surface of the shoulder.
4. Hold the needle with the second finger of the right hand, hold the piston – with the
5th finger, and with the rest fingers hold the cylinder.
5. With the left hand take the skin fold in a triangular shape with the base downwards.
6. With a quick motion insert the needle into the base of the triangle at the angle of
45° to a depth of 1cm between the first and the second fingers of the left hand.
7. Inject the drug.
8. Remove the needle with the fast motion.
9. Apply a cotton ball moistened with alcohol.

Fig. 3.2. Technique of subcutaneous injection.


The most convenient place for intramuscular injection is the gluteal area. To
avoid falling into the nerve or blood vessels in this area one should use the point of
Gallo. This point is formed by the intersection of two lines: the horizontal line,
passing two fingers above the lateral femoral large tube, and the vertical one,
separating the inner third of the buttocks from its two outer thirds.
After preparation of the injection site and the syringe, quickly remove the
needle , directed perpendicular to the injection site, holding the skin at the injection
site with the left hand finger (Fig. 3.3).
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Fig. 3.3. Technique of the intramuscular injection.
Algorithm for the intramuscular injection.
1. Washing hands.
2. Ask the patient to lie down on the couch.
3. Assemble the syringe, take 5-10 ml of the drug, change the needle, let the air out.
4. Process the skin with cotton wool moistened with alcohol, beginning from the
large area of the upper quadrant of the buttocks, then directly the injection site.
5. Take the syringe with the right hand.
6. Stretch the skin with the first and second fingers.
7. The syringe must be kept perpendicular to the skin at the angle of 90°, insert the
needle into the muscle.
8. Inject the drug.
9. Remove the needle with the quick motion. Make a light massage of the injection site
without lifting the cotton wool from the skin surface.
Making injection from the drug ampoules, first shake them, then cut off the cap.
With a cotton ball soaked with alcohol break off the narrow end of the ampoule. The
ampoule with an oil solution should be preliminary warmed in a water bath to 380C,
and then the warm solution is injected.

3.3. Intravenous injection and infusion


Intravenous infusion is carried out by the method of venipuncture or
venesection.

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Technique of intravenous injection (Fig. 3.4)
1. Wear a mask.
2. Wash your hands by the algorithm.
3. Assemble a sterile syringe (10-20 g) according to the algorithm, put on the needle
with a wide lumen.
4. Check the name, dose, drug release date.
5. Take medication into the syringe.
6. Change the needle, let the air out, put the syringe on the tray and wear the gloves.
7. Ask the patient to sit down on the chair.
8. Ask the patient to straighten the right (left) arm at the elbow.
9. Put the rubber pillow under the arm.
10. On the middle part of the arm make the compression of the subcutaneous veins.
11. Choose the highest caliber vein, ask the patient to work by hand.
12. Wipe the injection site with alcohol.
13. Ask the patient to compress his fingers into the fist.
14. With the left hand fix the vein.
15. Take the syringe so that the needle would be cut up and puncture the skin parallel
to the vein.
16. Enter the needle into the vein.
17. Pull the plunger.
18. If there is blood in the syringe, ask the patient to unclench his fist.
19. Remove the tourniquet.
20. Slowly inject the drug, taking care of the patient’s condition.
21. As the needle is removed, press the injection site with an alcohol cotton wool, and
bend the patient's arm at the elbow.

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Fig. 3.4. Technique of intravenous injection.

3.4. Filling a disposable intravenous infusion drip


Algorithm for the intravenous infusion
1. Wipe the surface of the desktop with 1% solution of chlorine bleach.
2. Check the package’s integrity, as well as the shelf life (air does not come out of
packet under its compression with arms).
3. Check the expiry date of the vial.
4. Open the central part of the sterile vial stopper with the metal scissors.
5. Open the package with sterile scissors.
6. Wear a mask.
7. Wash the hands by the algorithm.
8. Open the sterile table holding the desk handles. Take a tray from a sterile table with
the tweezers, put 3 towels, 3 balls, 2 needles, syringe, forceps in the tray.
9. Close the sterile table.
10. Take the balls from the sterile tray with the tweezers, put them in your hand,
moisten them with 96% alcohol, treat the exposed portion of the vial. Put the used
bead in the working tray.
11. Moisten the remaining beads at the sterile tray with 96% alcohol.
12. Take a drip with the hand from the bag. Holding it in the hand, remove the cap
from the air duct and enter the vial.
13. Close the clamp and remove the cap from the needle on the short end of the system
to enter the needle on the way into the vial.
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14. Turn the bottle and place it on a tripod.
15. Remove the needle with a long tube with a cap, holding it in the hand. Put the drip
into horizontal position. Open the clamp. Slowly fill the dropper to the full volume.
16. Close the clamp and return the drip to the upright position. The filter must be
submerged in the liquid by 2/3.
17. Open the clip to fill the system until all the air displacement and the appearance of
the droplets from the cannula. Close the clamp.
18. Fasten the injection needle in the cap adjacent to the cannula.
19. Take the gloves on.
20. Prepare the harness, pad, band-aid.
21. Go to the patient, cover the sterile tray with sterile cloth.
The sequence for preparing of the intravenous infusion system is depicted in the
Fig. 3.5.

.
Fig. 3.5. The sequence of system of preparation for the intravenous infusion of the
drugs.

3.5. Connecting the system to the vein


Algorithm of making an intravenous infusion
1. Place the patient comfortably, put the pad under the elbow.
2. Apply the harness to the middle of the shoulder for the compression of the
saphenous veins.
3. Make the patient bend and unbend fingers of the hand.
4. Take the ball soaked in 96% alcohol with the tweezers from the sterile tray, treat the
surface of the elbow by the ball. Put the ball on the working tray.

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5. Take the sterile towel from a sterile tray, put it in the right hand.
6. Take a sterile needle from the table with the tweezers, put it on a sterile towel.
7. Fix the vein with the finger of the left hand, pulling the skin of the elbow.
8. Puncture the needle into the vein and remove the blood from the cannula
tourniquet. Leave the napkin under the cannula.
9. Quickly open the clamp, releasing a small amount of liquid rubber tube, pinch your
finger and connect the system to the needle cannula.
10. Attach the needle to the cannula and plaster in the rubber tube.
11. Adjust the number of drops (usually 60 drops per 1 min.).
12. Cover the needle with a sterile cloth.
Intravenous infusion is shown in the Fig. 3.6.

Fig. 3.6. Intravenous infusion and fixation of the needle by adhesive plaster.

3.6. Taking blood from a vein for lab analysis


Technique of taking blood from a vein
1. Prepare the dry glass test tubes and a tripod.
2. Put on a mask.
3. Wash your hands by the algorithm.
4. Put a sterile tray, sterile forceps, two needles, two sterile wipes, two sterile balls
with the tweezers on a sterile table.
5. Put on the gloves.
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6. Seat the patient, put the pillow under his elbow.
7. Apply a tourniquet on the middle third of the shoulder. Ask the patient to bend and
unbend fingers for several times.
8. Take the cloth from the sterile tray with sterile tweezers , put a sterile needle on it.
9. Puncture the vein like in the intravenous injections.
10. When the blood comes up from the cannula, use the tube to collect it (do not
remove tourniquet).
11. Take 5-10 ml of blood, remove the tourniquet, apply the ball with alcohol and
remove the needle with the tube.

3.7. Bloodletting
Curative phlebotomy technology is illustrated in the Fig. 3.7.
1. Apply a tourniquet on the middle third of the shoulder;
2. Apply sequently one by one two cotton balls moistened with alcohol to the elbow
bend area, and find the most filled vein (the patient clenches and unclenches his fist);
3. Tighten the skin of the elbow with your left hand and fix the vein.
4. Puncture the vein like in case of the intravenous injection: a needle cannula for
holding up the cut parallel to the skin near the target vein. Under the needle it is
possible to put a sterile towel not to stain the hands with blood of the patient.
5. Place a tube to the needle cannula (if you take blood for analysis) or to connect to it
the connection pipe, lowering its free end in a bottle (if blood letting is produced ).
Release the necessary amount of blood.
6. Remove the tourniquet, ask the patient to unclench his fist;
7. Remove the needle, closing the puncture site with cotton wool moistened by
alcohol.

Fig 3.7. Technology of curative phlebotomy.


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Remember! Puncture the vein for blood sampling for analysis and bloodletting
is done without the syringe, with the needle only.
Tourniquet is removed after the procedure, before removing the needle.

3.8. Setting the peripheral venous catheter


If long infusion of drugs is required, in emergency conditions, with the purpose
of parenteral nutrition, massive fluid therapy is preferable to perform transcutaneous
catheterization of the peripheral veins by vascular catheters of various diameters.
There are several ways of setting the peripheral venous catheter. However, they
all mean the vein needle puncture, and, depending on the technology of the
catheterization, there may be few options.
1. "through the needle catheters" - if a diameter of the needle is greater than a
diameter of the catheter. In this case, the catheter is immediately introduced through a
needle into a vein, but since the needle’s diameter is larger than the catheter after its
removal in the site of venipuncture space, bleeding can start. Therefore, this method is
rarely used.
2. "The catheter on a needle" - after successful puncture the needle from the
catheter is removed and the catheter is carefully moved into a vein.
3. "Catheterization through the cannula" - the needle gets a strung expander.
The needle is removed, the expander remains in the lumen of the vein and the catheter
is inserted through it.
4. "Catheterization by Seldinger" - needle puncture of the vein, when a
conductor is inserted into a vein through a needle, the needle is removed, and the
conductor (by the conductor) catheter is inserted, after which the conductor is
removed. The catheter is inserted by rotational movements.
Currently, the most common and preferrable method is a "catheter on a needle".
The considerable importance is the material from which the catheter is made. In
Russia most of catheters are made from polyethylene. This is the easiest material to
process but it possesses the property of high thrombogenicity, causes irritation of the
inner lining of the vessels, because of its hardness it can perforate them. Preference is
given to Teflon or polyurethane catheters. Their application causes significantly less
complications; if you handle them carefully, their lifespan is much longer than that of
plastic ones.
The choice of the vein for catheterization is made in favour of distal vessels,
soft and elastic by touch, large diameter veins, corresponding to the length of a
catheter. Catheter is put into a vein in "non-working" hand in order not to cause
patient's self-care difficulties in case of complications.
The following peripheral veins are dangerous for catheterization and should be
used as the last choice: hard by touch and sclerotic veins (they can have damaged inner

99
shell); veins of the flexor surfaces of the joints (high risk of mechanical damage);
veins located close to the arteries or their projections (high risk of accidental
puncture); the veins of the lower extremities; previously catheterized veins (damage to
the inner wall of the vessel is possible); veins of the fractured extremities (damage to
the veins is possible); small visible but nonpalpable veins (of unknown status); veins
of the palmar surface of the hands (there is a danger of damage); median cubital veins
(usually they are used for the collection of blood for laboratory tests); veins in the
extremity that has undergone surgery or chemotherapy.
Most frequently catheterized are lateral and medial saphenous veins of the
hands, intermediate veins of the elbow and intermediate veins of the forearm.
Sometimes in case of impossibility of their catheterization, metacarpal and finger
veins are used.
When choosing a catheter one should conside the following: the diameter of the
vein; the required speed of infusion; the potential duration of time, which catheter is
used in the vein; properties of infused solution.
The main thing is to take the smallest catheter providing the necessary speed of
infusion in the largest peripheric vein available.

3.9. The technique of venesection


Operational area is treated with the tincture of iodine and draped with sterile
sheets. Incision is anesthetized with 0.25-0.5% solution of novocaine (Fig. 3.8).

Step 1 – incision along the vein;


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Step 2 – identification of the vein and and putting on ligatures;

Step 3 – inserting needle into the vein;


Fig. 3.8. The technique of venesection.

Skin incision is made along the vein by scalpel. The vein, isolated from
subcutaneous fat tissue, is raised by two ligatures. The vein is fixed and pierced by the
needle. Instead of the puncture it is allowed to open the lumen of the vein with
scissors, into which the needle or, more often - a sterile polyethylene catheter is
introduced. The catheter is fixed to the vein by two ligatures. The wound is sutured in
layers.

3.10. Intra-arterial injection


Intra-arterial infusion takes a special place in anti-shock therapy and intensive
care.
For arterial injection a conventional vial, jar or bottle with preserved blood,
attached to the system of blood transfusion is used.
Transfusion of blood, blood substitutes and medicines in the artery is very
responsible and serious procedure, requiring strict compliance with technical
regulations. Usually this method is used in cardiovascular surgery using a heart-lung
machine during the heart surgery. Catheterization of the femoral artery and the vena
cava is produced. In vascular surgery infusion is performed with intra-arterial
introduction of drugs for the treatment of critical ischemia of the affected lower
extremity. For this make the puncture after catheterization of femoral artery by
Seldinger method. The skin of the groin of the affected limb is treated twice with
antiseptic. In the middle and just below the inguinal ligament pulsation of the femoral
artery is determined. Make the puncture of the femoral artery with the needle with
stylet. After removal of the mandrel in case of a successful puncture of the needle red

101
pulsating blood begins to enter. Conductor, which is a metal string, must be introduced
along the needle in the lumen of the artery. The needle is removed, and through the
conductor polyethylene catheter is introduced into the artery by rotational movements.
After removing the conductor, catheter is fixed to the skin by a ligature, and then is
connected to the system for intra-arterial injection of drugs.
With this method, under the control of the electronic-optical converter in the
X-ray room catheter can be introduced to any artery interesting for a doctor with the
following radiological diagnostic study and introduction of different drugs. The most
common method of treatment is the introduction of artificial emboli (synthetic fabrics)
into the artery of organs affected by a malignant tumor to reduce the flow of blood.
With this purpose at lung and gastroduodenal bleeding, embolization of arteries
(bronchial, gastric) is made. Intra-arterial injection allows to create high concentration
of the substance (anti-tumor agents, radiopaque agents) in the area supplied with blood
of the given artery, that enables to determine the location of the tumor, blood clot,
vascular narrowing, aneurysms accurately.
In other areas of surgery intra-arterial injection of drugs is sometimes used in
shock conditions of different genesis, in cases when catheterization of central veins is
impossible.
One of the most important requirements in this respect is the right choice of
arteries for infusion. Usually it is assumed that the heavier the patient is, the larger and
the more centrally allocated artery should be selected for infusion. However, puncture
of the large artery always presents a danger due to the possibility of developing blood
clots, followed by blood circulatory disturbance in large anatomical areas. It is
reasonable not to use main and single vessel, but peripheral, paired vessels, of which
the most available and least dangerous are radial and posterior tibia arteries. Exposure
of these arteries is made surgically. Under local anesthesia, the incision is performed
by the projection line of the corresponding arteries: behind the medial malleolus to
expose the posterior tibia artery and at the inner edge of the lower third of the distal
radius bone to expose the radial artery. The artery is exposed and is arisen on the
ligature. Arteriotomy is produced with the following introduction of the catheter in the
lumen of artery in a distal direction. The catheter is fixed by two ligatures to the skin
and arteries. The wound is sutured in layers.
The most gentle and economical in time is the closed puncture method of
arterial infusion (Fig. 3.9).
Contraindications for arterial infusions are the following: satisfactory heart
function, arterial blood is pressure above 60 mm. of mercury, venous pressure is not
above 250 mm of water.

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Fig. 3.9. Injection in an artery.

3.11. Determination (typing) of blood group, Rh-factor by express method,


individual and biological compatibility (cross-mutching), the suitability of
blood for transfusion
Nowadays, due to the increase in the number of complications related to blood
transfusions, the indications for its use have been sharply decreased. However,
transfusion of blood and its components is still a highly effective medical treatment,
which allows to save the lives of many patients, that a general practitioner should be
able to perform in case of emergency. To make it, at a minimum, we need to know the
technology of determining the blood group and Rh factor, to check the samples for
individual and biological compatibility, to know the signs of blood medium suitability
for transfusion.
AB0 blood typing
Two drops (0.1 ml) of reagent and one drop of erythrocyte pellet (0.01-0.02 ml
if serum hemagglutinating serum is used; 0.02-0.03 ml if Colyclons are used) are put
in the plate at three points under the designations anti-A, anti-B, anti-AB. The serum
and erythrocytes are mixed with a glass rod. The plate must be periodically shaked,
watching the progress of the reaction for 3 minutes in case of using colyclons; for 5
minutes if hemagglutinating serum is used. After 5 min. 1-2 drops (0.05-0.1 ml) of
saline can be added in the reactive mixture to remove possible non-specific
aggregation of red blood cells.
Interpretation of the results is made according to the table.
Table of summarizing the results of the determination of blood groups AB0 using
Colyclons.
Agglutination of erythrocytes with Colyclons Blood belongs to the group
Аnti-А Аnti-В Аnti-АВ
- - - 0(I)
+ - + A(II)
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- + + B(III)
+ + + AB(IV)
Note: The sign (+) denotes agglutination, sign (-) - no agglutination.
Table summarizing the results of the determination of blood groups AB0 using
hemagglutinating serum
Agglutination of erythrocytes with a Blood belongs to the group
hemagglutinating serum
Аnti-0 Аnti-А Аnti-В Аnti-АВ
- - - - 0(I)
+ - + - A(II)
- + + - B(III)
+ + + - AB(IV)

If there is agglutination with all three reagents it is necessary to exclude non-


specific agglutination of the tested erythrocytes. To make it a drop of saline serum is
added to a drop of erythrocytes instead of Colyclons; and instead of hemagglutinating
serum the serum of AB (IV) group is added. Blood can be attributed to the group AB
(IV) only in the absence of agglutination of erythrocytes in saline or AB (IV) serum.
Determination of Rh- factor by express method
There are two ways of doing it with the use of specific anti- Rh serum.
1. Reaction of agglutination on the plate with the help of anti-D super Colyclons.

Apply a large drop (about 0.1 mL) of reagent to the plate or tablet. Apply near the first
drop a small drop (0.02-0.03 mL) of the tested erythrocytes. Mix well the reagent with
the erythrocytes with a glass rod.
In 10-20 seconds, gently shake the plate. Despite the fact that a clear
agglutination occurs in the first 30 seconds, results of the reaction must be interpreted
in 3 minutes after mixing.
In the presence of agglutination, the studied blood is labeled as Rh positive, in
the absence - as the Rh negative.
2. Method of conglutination with 10% gelatin.

Use the reagents containing incomplete polyclonal antibodies (anti-D serum) or partial
monoclonal antibodies (anti-D Colyclons).
0.02-0.03 ml of erythrocyte sediment is introduced in two tubes, to do it a small
drop of erythrocytes is extruded from the pipette, that must touch the bottom of a tube.
Then 2 drops (0.1 mL) of gelatin and 2 drops (0.1 ml) of reagent must be added to the
first tube, then 2 drops of gelatin (0.1 ml) and 2 drops (0.1 ml) of saline are added to
the second (control) tube.

104
The contents of tubes is mixed by shaking, after which they are placed in a
water bath for 15 min. or thermostat for 30 minutes at + 46-48 C˚ temperature. After
the given time 5-8 ml of saline is added to the tubes and the contents is mixed by tube
inverting.
The results are interpreted by watching the tubes in the light with the eye or by
a loupe. Agglutination of erythrocytes indicates that the tested sample of blood is
Rhesus positive blood, no agglutination proves that the tested blood is Rh negative
blood. In the control tube agglutination of erythrocytes must be absent.
Assessment of suitability of blood for transfusion
Before proceeding with the transfusion of blood components, verify their suitability
for transfusion. The tightness of packing, correct certification are visually checked by
the doctor, providing blood transfusion, quality of blood or blood components is
macroscopically evaluated. It is necessary to determine the suitability of blood for
transfusion is necessary with sufficient lighting at place of storage, preventing shaking.
The criteria for suitability of blood for transfusion are the following: for the whole
blood - plasma transparency, uniformity of the top layer of red blood cells, the
presence of a clear boundary between the plasma and red blood cells; for the fresh
frozen plasma - transparency at the room temperature. When bacterial contamination
of whole blood is possible, the color of plasma is dull with gray-brown shade, it loses
its transparency, the suspended particles in the form of flakes or membranes appear.
Such transfusion medium is not suitable for transfusion.
It is forbidden to transfuse the blood components without labeling results of
testing them on HIV, hepatitis B and C, syphilis.
Conducting tests for the individual and biological compatibility
Test for the individual compatibility enables to ensure that there are no
antibodies in the recipient against the donor's erythrocytes and thus the transfusion of
erythrocytes that are not compatible with the patient's blood is prevented. To assess the
individual compatibility it is compulsory to use a combination of two tests.
1. Test for compatibility on the plate at room temperature

2-3 drops of the recipient serum are placed on the plate and a small amount of
erythrocytes is added in such a way that the ratio of erythrocytes and serum is 1:10.
Stir erythrocytes with serum, the plate must be rocked gently for 5 min., watching the
progress of the reaction.
The presence of agglutination of erythrocytes means that the donor’s blood is
incompatible with the blood of the recipient, and it should not be transfused. If there is
no agglutination, it is an evidence of compatibility for the group agglutinogens.
2. Test for compatibility with the use of 33% poliglukins.

2 drops (0.1 mL) of the recipient’s serum, 1 drop (0.05 ml) of the donor’s
erythrocytes are put in the tube, then 1 drop (0.1 ml) of 33% poliglukins is added. The
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test tube is tilted to the horizontal position, slightly shaking, then slowly rotated in
such a way that its contents spreads out on the walls with a thin layer. Such spreading
on the walls of the tube makes the reaction stronger. Contact of the patient’s serum
with erythrocytes with tube rotation should be continued for at least 3 minutes.
In 3-5 min. 2-3 ml of saline is added in the test tube, the contents are mixed by
inverting the tube 2-3 times without shaking.
The result is assessed by watching the tubes in the light with the eye or through
a loupe. Agglutination of erythrocytes indicates that the blood of the donor and of the
recipient is incompatible, the absence of agglutination is indicative of the donor’s and
recipient’s blood compatibility.
Biological test
The biological test is carried out irrespective of the amount of blood transfusion
medium and speed of its transfusion. If it is necessary to provide transfusion of several
doses of blood components, biological test is carried out before the start of transfusion
of each new dose. Before making a test, the container with transfusion medium should
be kept at the room temperature for 30 min. or warmed on a water bath at the
temperature of 37 C˚ under the thermometer control.
The technique of the biological test is the following: 10 ml of blood transfusion
medium is infused with the rate of 2-3 ml (40-60 drops) per a minute, then transfusion
is stopped and within 3 min. the recipient should be under control: a physician must
check pulse, respiration, blood pressure, general condition, skin color and body
temperature. This procedure is repeated twice more. If one clinical sign or symptom
such as chills, back pain, a burning sensation and tightness in the chest, headache,
nausea or vomiting is noticed, the transfusion must be aborted.

3.12. Blood transfusion


Blood transfusion is a therapeutic method comprising introduction of
erythrocyte-containing blood components into the patient’s (recipient’s) intravascular
space. The blood is donated by a donor in blood banks. Sometime recipient’s blood
(autologous transfusion) is used, such as reinfusion or preoperative blood salvage
techniques.
Blood components include red blood cell mass, erythrocyte suspension,
defrosted and washed erythrocyte mass. The aim of transfusion is to compensate the
circulating volume of red blood cells and to maintain the normal blood oxygen content
in anemia.
Nowadays the principle of compensation of specific blood components, missing
in the patient’s body, is used in various pathological conditions. There are no
indications for transfusion of whole preserved blood, except for the cases of acute
massive blood loss when there are no blood substitutes, no fresh frozen plasma, no
packed red blood cells nor erythrocyte suspension.

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Blood components should be transfused only of such group of the ABO system
and Rh-factor, that is compatible to the recipient.
By vital indications and if there are no blood components of the patient’s group
compatible in the ABO system it is possible to transfuse blood of Rh-negative donors
of blood group 0 (I) to the recipient with any other blood group in the amount up to
500 ml (except for the children). Rh-negative packed red blood cells or erythrocyte
suspension of donors with group A (II) or B (III) by vital indications can be transfused
to a recipient with AB (IV) group, regardless of its Rh-factor.
Patients with blood loss of 1000-1200 ml (up to 20% of the volume of the
circulating blood) rarely require the transfusion of blood gas carriers. Transfusion of
saline solutions and colloids fully ensures their replenishment and normovolemiс
maintenance, especially because the inevitable decrease in the muscle activity is
accompanied by the decrease in the body's need for oxygen.
The indication for transfusion of blood gas carriers in acute anemia due to the
massive blood loss is the loss of 25-30% of volume circulating blood, accompanied by
the decrease in hemoglobin level below 70-80 g/l and a hematocrit below 25% and the
occurrence of circulatory disorders.
Even more limited are the indications for transfusion of blood gas carriers in
chronic anemia. For these patients with reduced amount of circulating hemoglobin the
most important is the elimination of the cause of anemia, but not restoration of
hemoglobin level using transfusions of erythrocyte - containing blood components.
The doctor making transfusion of blood and blood components must do all
records, regardless of the tests made before and available records, personally carry out
the following control tests directly at the bed of the recipient:
1. Clarify the recipient's first and second name, date of birth and compare them with
those on the front page of the case history.
2. Get the patient’s informed consent.
3. Recheck the blood group of the recipient by the ABO system, compare the result
with the data in the case history.
4. Recheck the blood group by the ABO system on the donor’s container and compare
the result with the data on the label of container.
5. Compare the blood group and Rh-factor, marked on the container, with the results
of the test, previously recorded in the case history and just received.
6. Carry out the tests on individual compatibility by the ABO systems and the donor’s
Rhesus erythrocytes and the recipient’s serum.
7. Make a biological test.

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Transfusion of blood transfusion mediums is performed by medical staff in the
compliance with the aseptic technique using the disposable devices for the intravenous
administration with the filter.
After transfusion the donor’s container with a small amount of the remaining
blood transfusion medium and test tube with blood of the recipient, used to carry out
tests on individual compatibility, is subjected for mandatory preservation for 48 hours
in the refrigerator.
The doctor making transfusion of blood and blood components, must register
the following items in the patient’s case-history with each transfusion:
- indications for transfusion of blood components;
- before the transfusion: passport data from the label of the donor’s container,
with information about the donor’s code, blood group by ABO systems and
Rhesus factor, the container’s number, date, the name of the blood service
institutions (after transfusion the label is detached from the container with the
blood component and pasted in the patient’s case history);
- the result of the control test of the recipient's blood group by ABO system and
Rh-factor;
- the result of the control test of blood group or erythrocytes, taken from the
container, by ABO and Rh-factor;
- the result of tests of individual blood compatibility of the donor and the
recipient;
- the result of the biological test.
For each recipient, especially if multiple transfusions of blood components are
required, it is recommended to have a transfusion card (diary), with the records of all
transfusions made for the patient, their volume and outcomes in addition to the
medical record of the patient.
After the transfusion the recipient complies for two hours with the bed rest. The
recipient is observed by the attending doctor or doctor on duty. He measures body
temperature, blood pressure, records the figures in the case history of the patient, every
hour.
Hourly urine output and color of urine is controlled. The appearance of the red
color of urine, while maintaining the transparency indicates acute hemolysis. It is
required to make clinical blood and urine tests the day after the transfusion.
At outpatient transfusion recipient must be under medical supervision for at least three
hours after transfusion. Only in the absence of any reaction, the presence of stable
arterial pressure and heart rate, normal diuresis, he can be discharged from the
hospital.

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4. CHAPTER 4. CATHETERIZATION OF HOLLOW ORGANS AND
SEROUS CAVITIES

4.1. Urethral catheterization


Preoperative urethral catheterization is performed to monitor the functional
state of the urinary system. For catheterization it is necessary to prepare a sterile
catheter, two sterile forceps, sterile Vaseline, cotton balls, 0,0002% furatsiline solution
or 2% solution of boric acid, all to be put into a sterile kidney-shaped bowl. Wash
hands thoroughly with tap water and soap and after that keep wiping them with alcohol
swabs for three minutes.

4.1.1. Female urethral catheterization


1. Wash your hands properly.
2. Put on a sterile facial mask.
3. Using the sterile forceps, take 4 cotton balls, the forceps and some
gauze napkins from the sterile table and put the stuff into a sterile bowl.
4. Cover the sterile table.
5. Using the sterile forceps, pull a sterile catheter out of a dressing
box. Put a catheter into the sterile bowl on the working table.
6. Pour sterile solution of furatsiline over the sterile cotton balls,
holding the latter with the forceps.
7. Lubricate the catheter with the Vaseline.
8. Put on sterile gloves.
9. Position the patient lying supine with her knees flexed and her
thighs abducted.
10. Lay an oilcloth under the patient and provide a bedpan.
11. Separate the major and minor labia with the non-dominant hand
and expose the urethral meatus.
12. Using the forceps, take the cotton ball from the sterile table and
clean the external urethral meatus with furatsiline solution. Dispose of the
wasted cotton balls by putting them in the bedpan.
13. Using the forceps, take the catheter out of the sterile kidney dish
and insert it 3-5 cm into the urethra. Then lower the outer end of the catheter
and place it in a bedpan.
14. On decreasing of the amount of the urine draining, withdraw the
catheter so spillages irrigate the urethra.

4.1.2. Male urethral catheterization


Position the patient lying supine with his knees and hip joints flexed. Place a
bedpan or a urinal between the patient’s thighs. Clean the balanum and the urethral
meatus with antiseptic solution. Using the forceps, take the catheter 2-3 cm away from
its inner end and lubricate it with Vaseline. Using the left hand, squeeze the penis in
between the third and fourth fingers and expose the urethral meatus with the first and

109
second fingers. Insert the catheter into the urethral meatus with the forceps and
gradually advance it deeper. Some feeling of resistance may be during the catheter’s
passage through the isthmus. On catheter entering the bladder, urine starts draining. At
that moment, evaluate its transparency, color and amount.
If it is impossible to use a soft catheter, perform catheterization with a metallic
one. Application of the latter requires certain skills as it may cause damage to the
urethra.

4.2. Gastric lavage


Gastric lavage with a thin tube
Insertion of a gastric tube is necessary for prevention from gastric content
aspiration during a process of gastric lavage. Manipulation is performed as follows.
Lubricate the end of the thin tube with Vaseline and introduce it through the nose.
Advance the tube into the esophagus and have a patient to make swallowing
movements. On reaching the first mark (50 cm), the tube end is supposed to be in the
cardiac portion of the stomach. In case the stomach is overfilled, its content starts to
excrete just at once and has to be placed in a basin. Advance the tube deeper into the
stomach up to the second mark (the tube end is supposed to appear in the antrum) and
stick it to the nose with a strip of a sticking plaster.
Gastric lavage with a large diameter tube
Equipment: a large diameter tube, a rubber tube, a funnel of 1 liter in capacity, a
bucket for washing water, a bucket for clean water, a glossotilt, a metallic tip, gloves, a
waterproof apron.
1. Prepare the gastric lavage system.
2. Put aprons on yourself and on a patient, get the patient to sit on a chair
with his hands fixed behind the chair back.
3. Approach the patient either from behind or from a side.
4. Set a gag (alternatively, the left hand second finger with a metallic tip
on) in between the patient’s molars and slightly move his head backwards.
5. Using the right hand, put the blunt tube end on the patient’s tongue
base, have the patient to make swallowing movements and take deep breaths.
6. As the patient performs swallowing movements, advance the tube into
the esophagus (conduct it slowly since doing it hastily may lead to tube
twisting).
TAKE NOTICE: If during the procedure the patient starts coughing and
choking and his face begins growing cyanotic, withdraw the tube immediately
as one proves to get stuck in airways, not the esophagus.
7. On reaching a certain mark stop advancing the tube and connect it to a
funnel. Lower the funnel to the level of the patient’s knees. Discharge of the
gastric content proves the correct position of the tube.
8. Hold the funnel at the level of the patient’s knees, then tilt it slightly
and pour some water into the funnel.

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9. Gradually raise the funnel upwards and as the water level gets to the
funnel mouth, lower it beneath the previous position. As a result, the quantity of
the water instilled should be equal to that of the water discharged.
10. Pour out the funnel content into a basin.
11. Repeat the procedure for 8-10 times until clean washing water is
received.
TAKE NOTICE: In unconscious patients with no coughing and
laryngeal reflexes gastric lavage is performed only after previous tracheal
intubation made by a doctor.

4.3. Cleansing enema


Indications:
1. Preparation for X-ray exploration of the digestive system and organs
of the small pelvis.
2. Preparation for endoscopic exploration of the large intestine.
3. Obstipation, intoxication, preoperative period, periparturient period;
period before medicated enema.
Contraindications:
1. Digestive tract bleeding.
2. Acute inflammatory and ulcerative processes in the large intestine and
the anal area.
3. Malignant neoplasms in the rectum.
4. Period just after a digestive tract surgery.
5. Anal area cracks or rectal prolapse.
The sequence of actions:
1. Fill an Esmarch’s irrigator up with water of room temperature.
2. Open the valve of the rubber pipe and get the latter filled with
water. Then close the valve.
3. Hang the irrigator on the stand and lubricate the tip with Vaseline.
4. Get the patient to lie on the couch on his left side with his knees
flexed and slightly brought toward the abdomen.
5. Using the first and the second fingers of the left hand move the
buttocks apart and introduce the tip into the anus with the right hand. At first,
advance the tip 3-4 cm towards the navel, and then direct it in parallel with the
spine.
6. Loosen the valve so that water starts entering the bowel.
7. After water introduction into the bowel close the valve and get the
tip out.

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4.4. Siphon enema (colon lavage)
Equipment: two gastric catheters of 1 cm in diameter and 1 m in length, a
funnel with capacity of 1 liter, 10-12 liters of warm water, a basin for waste water, an
oilcloth, an apron, Vaseline.

Indications:
1. Getting no result out of cleansing enema and laxatives.
2. Necessity to remove swallowed toxic substances from the bowel.
3. Suspicion of bowel obstruction.
The sequence of actions:
1. Position the patient the same way as for cleansing enema.
2. Lubricate the blunt catheter end with Vaseline over 30-40 cm in
length.
3. Move the patient’s buttocks apart and introduce the blunt end into
the rectum.
4. Connect the funnel to the catheter.
5. Perform bowel lavage the same way as gastric one until lavage
water is clean.
6. Pour out the last portion of lavage water and slowly remove the
catheter.

4.5. Medication enema


Laxative enema
Emollient enema
Equipment: a pear-shaped balloon or a Janet syringe, a flatus tube, Vaseline,
100-200 ml of oil at the temperature of 37-38 C.
The sequence of actions:
1. Warn the patient to stay in bed until morning after receiving an
enema.
2. Fill the balloon up with oil.
3. Lubricate the flatus tube with Vaseline.
4. Get the patient to lie on his left side with his legs flexed and
brought to the abdomen.
5. Move the patient’s buttocks apart and insert the flatus tube into
the rectum 15-20 cm.
6. Connect the balloon to the flatus tube and slowly introduce oil.
7. Remove the flatus tube and put it in disinfectant solution, then
wash the balloon with soap.

Hypertonic enema
Equipment: the same equipment as for emollient enema, plus 50-100 ml of 10%
sodium chloride solution, 20-30% magnesium sulfate solution.

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Contraindications:
Acute inflammatory and ulcerous processes in the lower part of the colon;
cracks in the anal area.
The sequence of actions is similar to the one applied to laxative enema.

Inserting a rectal tube


Administration: flatulence.
The sequence of actions:
1. Get the patient to lie supine with an oilcloth under him.
2. Place a bedpan between the patient’s legs (put some water into the
bedpan).
3. Lubricate the rounded end of the tube with Vaseline.
4. Introduce the tube 20-30 cm into the rectum. (put the outer end of
the tube in the bedpan as there might be feces excretion).
5. In an hour remove the tube carefully and wipe the anus with a
napkin.

4.6. An abdominal cavity puncture


The purpose of the operation: evacuation of ascites fluid in patients with
abdominal dropsy.
The technique: Puncture is to be performed according to the median line of the
abdomen. The puncture point is supposed to be chosen in the middle of the distance
between the navel and the pubis. The bladder has to be emptied preliminarily. Get a
patient to sit on an operating or dressing table. Apply alcohol and 5% iodine solution
on the surgical field. Anesthetize the skin and deep layers of the abdominal wall with
0.5% Novocaine solution. Using the scalpel tip, make an incision on the skin in the
puncture point. Produce the puncture itself with a trocar. The surgeon holds the trocar
in his right hand, shifts the skin slightly, and, keeping the trocar perpendicularly to the
abdomen surface, punctures the abdominal wall; then withdraws the stylet and directs
the fluid jet toward the washbowl. To avoid fast drop of the intra-abdominal pressure
during fluid evacuation, which may lead to collapse, it is necessary to close
periodically the outer opening of the trocar. Moreover, an assistant should tighten the
towel around the abdomen as ascites fluid drains.

4.7. Laparocentesis
Laparocentesis is puncture of the peritoneum with the following insertion of a
drainage tube into an abdominal cavity. The puncture has to be performed by a doctor.
Indications: ascites, peritonitis, intra-abdominal bleeding, application of
pneumoperitoneum.
Contraindications: coagulopathy, thrombocytopenia, iliac passion, pregnancy,
inflammation of the skin and soft tissues of the abdominal wall.
Equipment and instruments: a trocar of 3-4 mm in diameter with a pointed
stylet for puncture of an abdominal wall. A rubber drainage tube of 1 m in length; a
clamp; a syringe of 5-10 ml in capacity; 0.25% Novocaine solution; a dish for
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collecting the ascites fluid; sterile test-tubes; dressing material; sterile cotton swabs;
the sterile forceps; skin needles, sterile sutural material, a scalpel, a sticking-plaster.
The technique: A doctor and an assisting nurse should put on sterile caps and
masks. Their hands need washing the same way as for a surgical operation and then it
is necessary to put on sterile surgical gloves. It is necessary to provide absolute
sterility of the trocar and the tube as well as all the instruments contacting skin.
Implementation of the puncture takes place in the procedure or dressing room in the
mornings, patients coming on an empty stomach. The patient has to empty his bowel
and bladder. The patient should take the sitting position, but if there’s a severe
condition he can be lying on his right side. For pre-medication inject subcutaneously 1
ml of 2% Promedolum solution and 1 ml of 0.1% Atropine solution 30 minutes before
the operation. Perform the puncture of the abdominal wall according to the median line
of the abdomen straight in the middle of the distance between the navel and the pubic
bone or at the edge of the rectus abdominis (before producing the puncture make sure
there’s free fluid in the abdominal cavity). After disinfection of the puncture point
carry out an infiltrative anesthesia of the front abdominal wall and parietal peritoneum.
To avoid damaging the organs of the abdominal cavity, it is expediently to sew the
abdominal wall aponeurosis with a thick ligature, which can be used to stretch the soft
tissues and create some free space between the abdominal wall and the neighboring
organs. Move the skin slightly aside in the puncture point with the left hand and insert
the trocar with the right one (image 4.1). In some cases it is normal to make a small
incision on the skin with a scalpel before inserting the trocar. After the trocar enters
the abdominal cavity, withdraw the stylet and watch the fluid draining freely. Take
several ml of the fluid for analysis and make some smears, then put rubber tube on the
trocar so that the fluid drains into a washbowl.

1
1 – A ligature driven through the
abdominal wall soft tissues.
2 – A trocar inserted into the
abdominal cavity.

Fig. 4.1. Technique of laparocentesis.

Let the fluid out slowly (1 liter per 5 minutes), applying a clamp to the rubber
tube periodically. When the fluid starts running out slowly, place the patient on his left
side. If there are no fluid excretions anymore due to covering the inner opening of the
trocar by intestines, produce some pressure onto the abdominal wall. After that, the

114
intestines may move and the fluid circulation resumes. During the fluid drainage
there’s an abrupt intra-abdominal pressure drop, which leads to redistribution of
circulating blood and in some cases to collapse. To prevent this sort of complications
an assistant should tighten a wide towel around the patient’s abdomen during the
procedure. After the fluid is removed, withdraw the trocar and stitch up the skin in the
puncture site (or just stick it tightly with a sterile cotton swab), then apply an aseptic
bandage, place an ice pack on the patient’s abdomen and administer the strict bed
regimen to the patient. It is necessary to keep looking after a patient after the
procedure of puncture to be able to reveal the possibility of complications as soon as
possible,
Complications:
 Phlegmon of the abdominal wall due to poor observation of the
aseptic and antiseptic rules.
 Damage of the blood vessels of the abdominal wall leading to
hematomas of the abdominal wall or bleeding in the abdominal cavity.
 Subcutaneous emphysema of the abdominal wall due to air
entering into the wall through a puncture point.
 Damaged organs of the abdominal cavity.
 The fluid excretion from the abdominal cavity through the
puncture point which may cause wounding and the abdominal cavity
infiltration.

4.8. Puncture of the abdominal cavity through the posterior vaginal fornix
in women
Indications: clarifying the diagnosis of the abscess of the Douglas pouch,
exudate evacuation with the following drainage of the abscess cavity.
Contraindications: vaginal obliteration, severe uterine retroversion.
The technique: Insert the mirrors into a vagina, after that fix the posterior
labium of the uterine wall with the vulsella. Withdraw the vaginal mirrors and bring
the cervix toward the symphysis. Using a long needle, make the puncture behind from
the borderline between the cervix and the fornix, the patient being under local
anesthesia (0.5% Novocaine solution). Direct the needle in parallel to the pelvis axis to
the depth of 2-3 cm. Suck off the content of the Douglas pouch. If there is some pus
arising in the syringe during suction, produce the puncture of the posterior vaginal
fornix with a scalpel and introduce into the Douglas pouch a PVC drain.

4.9. Puncture and drainage of the Douglas pouch in men


Indications: the abscess of the small pelvis cavity.
Contraindications: rectal atresia and rectal tumors.
Preparation: evacuation of the rectum by means of giving a cleansing or
hypertonic enema.

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The technique: Get the patient sitting in the gynecological chair. Wash the
rectum with an antiseptic solution (5% iodine solution). Insert the rectal mirrors into
an ampoule of the rectum. Using local anesthesia (5% Novocaine solution) perform
the puncture of the rectum’s ampoule anterior wall. If there is some pus arising in the
syringe, make a 0.5 cm long incision of the rectum’s wall using a scalpel and a needle,
then introduce a PVC drain. Insert a swab with Vishnevsky ointment as well as a flatus
tube into the rectum.

4.10. Puncture of the pericardium cavity


Indications: Cardiac tamponade due to wounding, transudate or exudate
accumulation that aggravates heart functions, closed injuries. Puncture of the
pericardium cavity is supposed to be implemented under the US (ultrasonic) control.
The technique: Get the patient lying supine with a roll under hos loin. Wipe the
skin of the epigastric area with alcohol and iodine solution. Perform the puncture with
a long thin needle connected to a syringe filled up with 20 ml of 0.5% Novocaine
solution. Insert the needle to the left from the xiphoid basis, directing it obliquely
upward along the posterior wall of the breastbone to the depth of 2-3 cm (Fig. 4.2).

Fig. 4.2. Pericardiac tamponade.

After that, blood or serous fluid starts dripping and has to be removed with a
syringe. Indicators of the puncture effectiveness are as followings: improvement of the
patient’s general condition, appearance of heart sounds, tachycardia decrease, diastolic
pressure drop and systolic pressure rise.
Complications: heart damaging in case of too deep insertion of the needle,
stomach damaging in case of directing a needle toward the surface of the anterior
abdominal wall at the angle of >30.

4.11. Pleural puncture


Indications: Normal human pleural cavity contains about 50 ml of liquid. If
there is lung or pleura disease, inflammatory or edematous fluid may accumulate in
between visceral and parietal pleura, which deteriorates the patient’s condition. The

116
fluid can be removed by means of pleural puncture. If there’s a small amount of fluid
in the pleural cavity, it is necessary to administer diagnostic puncture to detect the type
of the accumulating fluid and presence of any pathological cells in it. Pleural puncture
has to be performed for diagnosis clarification as well as for removal of liquid content
from the pleural cavity. In patients with pleural empyema and hemothorax pleural
puncture should be administered with a therapeutic purpose.
Equipment and instruments: For this kind of puncture use a syringe of 20 ml
and an abruptly bevel-tipped 7-10 cm long needle of 1-1.2 mm in diameter connected
to the syringe by means of a rubber tube. Put a special clamp on a connecting tube so
that air doesn’t enter the pleural cavity during the puncture. Prepare 2-3 test-tubes for a
laboratory exploration. Apart from that, prepare slides, iodine solution, alcohol,
collodion, a sterile dish with swabs, cotton buds, the forceps, ammonium chloride,
kordiamin for unconscious patients.
The technique: Puncture has to be performed by a doctor. Get the patient sitting
on a chair with his face turned to the back of the chair. Put a pillow on the top of the
chair back so that the patient can lean against it with his elbows flexed. The patient can
slightly lower forward his head or bring one down upon his hands. Also, the patient
should bend his body a little straight opposite the puncture site direction. Sometimes it
is expedient to offer the patient to put his crossed hands on his chest or put his
puncture-side hand on his head or his intact-side shoulder. To remove fluid from the
pleural cavity, make a puncture in the 8 th intercostal space according to the posterior
axillary line. To remove air from the pleural cavity, make a puncture in the 2 nd
intercostal space according to the mid-clavicular line (Fig. 4.3).

Fig. 4.3. Pleural puncture.

If there is free effusion in the pleural cavity, the puncture should be performed
in the lowest point of the cavity or below the fluid level, detected by physical and
X-ray exploration. Make a pleural puncture in the center of percussion blunting, which
is mostly situated in the 7th or 8th intercostal space according to the posterior axillary
line or scapular one. Thoroughly sterilize the skin with ethyl alcohol and iodine
solution. Make a puncture along the upper edge of the rib, which prevents damaging of
the intercostal vessels and nerves. Local anesthesia with Novocaine solution should be
provided preliminarily, a nurse fills up a disposable (one-off) syringe with Novocaine
solution. After giving local anesthesia, puncture the pleura, and that is supposed to feel
like “the needle dip”. By that moment, a nurse has set up a system consisting of a
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triple adapter and two taps, one of which is connected to the syringe and the other one
is connected to the Bobrov apparatus. After the pleural puncture the pleural cavity
content should be sucked off into the syringe. A nurse switches the adapter the way
that provokes closing of the tap, which connects the syringe to the needle. At the same
time it induces opening of the second tap that leads into a tube connected to the
Bobrov apparatus, where liquid from the syringe is discharged into. This procedure has
to be repeated many times. As a doctor commands, a nurse counts both pulse and
frequency of respiratory movements, and measures B.P.
At the end of the pleural puncture, a nurse provides a doctor with an alcohol
cotton ball for disinfection of the puncture point. After that, applies a sterile napkin
and fixes one with a sticking plaster. After the procedure is done, a patient should be
taken to the ward in a wheelchair, and a duty nurse watches his condition as well as the
state of his bandage for twenty-four hours.
The content extracted during the pleural puncture should be put into a test tube
or a Petri dish and sent immediately to the lab.
Send the pleural fluid for analysis and specify the patient’s surname and
exploration purposes. Use the Poten apparatus (pleuroaspirator) if there is large
accumulation of fluid in the pleural cavity. The apparatus includes a glass container of
0.5-2 liters in capacity and a rubber plug that covers the container throat located above.
There is a metallic tube that passes through the plug and divides into two bends with
taps. One bend serves for sucking off air from the container with a vacuum and
creating negative pressure. The other bend should be connected to the needle in the
pleural cavity with a rubber tube. In some cases 2 glass tubes can be inserted into the
pleuroaspirator plug: a short one is connected to a vacuum with a rubber tube, and a
long one is connected to the rubber tube, which is put on the needle.
The peculiarity of carrying out the pleural puncture in patients with
pneumothorax is as following.
Apart from fluid aspiration, the pleural puncture may be needed due to
emergent indications such as pneumothorax. It is worth paying special attention to the
fact that in patients with pneumothorax the pleural puncture has to be performed in the
2nd or 3rd intercostal space along the mid-clavicular line. The technique of the
procedure is exactly the same as the one described above. In case of non-valve
pneumothorax air should be sucked off carefully from the pleural cavity with a syringe
or pleuroaspirator. In case of valve pneumothorax air continually enters the pleural
cavity during inhalation, but there is no return drainage. Therefore after puncture do
not put a clamp on the tube, but set up air drainage and take the patient to the surgical
department as soon as possible.

4.12. Pleural cavity drainage according to Bulau


Indications: Chronic pleural empyema.
Anesthesia: local anesthesia.
The technique: Perform the diagnostic puncture before an operation. In the
point intended for drainage, make a 1-2 cm long incision along an intercostal space.
Using twisting movements, insert a trocar of 0.6-0.8 cm in diameter into this opening

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through soft tissues of the intercostal space. Withdraw the trocar stylet and introduce a
polyethylene drain of an appropriate diameter into the trocar tube to the depth of
2-3 cm instead. Clamp the outer end of the drain with the Kocher’s forceps. Fix the
drain with a left hand and withdraw the trocar tube from the pleural cavity with a right
one. After that, put the second Kocher’s forceps on the polyethylene drain at the skin
surface. Unclasp the first Kocher’s forceps and remove the trocar tube. Fix the drain to
the skin with a sticking plaster (or with a ligature) and attach it to the body with a
bandage. With a glass cannula, connect the loose end of the drain to a polyethylene
tube of 1 m in length.
To create pus drainage from the pleural cavity, submerge the end of the
polyethylene tube into a container with disinfectant solution, and put the container
below the level of the patient’s chest. Besides, in order to prevent air or liquid suction
from the container into the patient’s pleural cavity during inhalation, put a rubber
glove finger with a cut top on the tube end.
To produce negative pressure in the pleural cavity, make a compressed lung
spread out and create more reliable pus drainage, the Pertes-Gartert apparatus can be
used.
It comprises three-bottle system (Fig. 4.4).

а – pleural fluid collection bottle;


b – water-seal bottle with liquid
draining into the 3rd bottle;
c – suction control bottle (water
drainage creates vacuum in the 1st
bottle).

Fig. 4.4. Drainage and aspiration of the pleural cavity content.

Preliminarily fill up the whole tube system with antiseptic solution. Put the
loose end of the tube into a container with disinfectant solution. Nowadays, specially
manufactured machines are used for active pleural cavity aspiration. They create
vacuum suction of 20 mm Hg. The difficulty is that their employment is only
expedient in large multi-profiled hospitals.

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4.13. Capillary suprapubic bladder puncture
Indications: urinary retention with impossibility of catheterization, urethral
injuries, burns of external genitals, and also urine collecting for clinical and
bacteriological exploration.
Contraindications: small bladder capacity, acute cystitis and paracystitis,
bladder tamponade with blood clots, neoplasms of a bladder, big scars and inguinal
hernias dislocating a bladder, considerable obesity.
Procedure conditions: complete filling up of a bladder with urine or
disinfectant solution.
The technique: Perform puncture with a long needle of “Record” syringe or a
Veer’s needle (it is desirable to use the US control). Make a puncture precisely along
the median line of the abdomen 2 cm above the pubic symphysis. Direct the needle
perpendicularly to the skin surface and drive it through all layers of the abdominal wall
and bladder wall to the depth of 6-8 cm. As urine starts draining, stop advancing the
needle (Fig. 4.5).

Fig. 4.5. Bladder puncture.

After bladder content evacuation withdraw the needle and apply iodine solution
to the puncture site. No bladder impermeability is affected during the puncture, so
from this point, the operation is safe enough. The opening in the bladder wall
disappears due to constriction of muscular elements. If necessary, the puncture may be
performed repeatedly.

4.14. Trocar epicystomy


This one is mostly employed as its suprapubic version. There is a large amount
of instruments offered for execution of this method of temporary or constant urine
drainage. According to the way of application, all trocars can be divided into 2 types:
1) ones that require removal of the trocar tube after drainage tube insertion into the
bladder cavity through the trocar tube; 2) ones with a drainage tube situated above the
stylet; in this case, the drainage tube should be left in the bladder cavity after a
puncture and stylet removal.

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Indications for trocar epicystomy are steadily increasing lately as experience is
being gained. Trocar epicystomy has to be done in case of acute or chronic urinary
retention, when there are no indications for bladder revision. Besides, it can be a
method of choice to employ both for durable bladder drainage and temporarily for
urine evacuation during preparation of a patient for a radical surgical operation.
Contraindications for trocar epicystomy are exactly the same as for capillary
puncture.
Preparation for an operation, a patient’s position on a surgical table, an extent
of bladder filling with urine or disinfectant solution are the same as ones for
suprapubic capillary puncture.
Provide local anesthesia of abdominal wall soft tissues 2 cm above a pubic
symphysis with Novocaine solution. After that, carry out epicystomia in 4 steps: the 1 st
step – a puncture of soft tissues and a bladder wall with a trocar; the 2 nd step – bladder
content evacuation; the 3rd step – catheter insertion into the bladder cavity; the 4 th step
– catheter fixing to the skin with a ligature (Fig. 4.6).

a b c d

Fig. 4.6. Steps of trocar epicystomy: a – trocar position after insertion;


b – stylet withdrawal; c – drain insertion and trocar tube removal; d – the tube is
settled and fixed to the skin.

4.15. Lumbar puncture


The subarachnoid space puncture is mostly performed in a lumbar part of a
spinal canal. The lumbar puncture was proposed by Quincke (1891) and is still widely
employed in practice for therapeutic and diagnostic purposes.
Indications: CSF (cerebrospinal fluid) collection for exploration (on the subject
of blood presence, cytosis, etc.); decrease of intracranial pressure in patients with
traumas and indicators of brain swelling; drugs injection (antibiotics, anti-tetanus
serum) and anesthetic solutions in case of spinal anesthesia; air introduction into the
subarachnoid space for execution of pneumoencephalography.
The subarachnoid space puncture is admitted to be performed in any part of a
spine, but the safest points are the 3rd and the 4th intervertebral spaces (Fig. 4.7).

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Fig. 4.7. Lumbar puncture technique: a – a projection of lumbar vertebras,
b – position of the needle in between lumbar vertebras.

Position a patient sitting on a surgical or dressing table with his feet set upon a
backless stool, his elbows placed on his hips and his back highly bent backwards.
If necessary, perform puncture with a patient in a lying position. Get the patient
to lie on his side with his knees flexed (his hips are brought to his abdomen) and his
chin closely brought to his chest.
For a lumbar puncture, use a special thin needle with a bevel-tipped stylet.
Apply local anesthesia with 0.5% Novocaine solution in quantity of 10-12 ml.
The technique: After skin preparation use a cotton ball with iodine solution on
to draw a straight line joining the highest points of iliac crests, which improves
orientation. This line crosses the spine at the level of the 4 th intervertebral space. In
addition to it, using the pointer finger of the left hand, find the space between spinous
processes located in the intersection point of the line mentioned above and the spine
midline. Apply alcohol on the skin one more time and find the upper edge of the
spinous process of the 5th lumbar vertebra. Just accurately above, make a puncture
precisely along the spine midline using a needle with a stylet. After that, keep
advancing the needle perpendicularly to the loin surface, slightly inclining it in cranial
direction. Motion of the needle should be smooth and strictly directed. In case of even
the slightest veering off, the needle end may run into either a spinous process or a
vertebral arch. Advance the needle up to the depth of 4-6 cm (it depends on the
patient’s age and soft tissues layer thickness). The needle goes through the following
layers: skin and subcutaneous fat, lig. supraspinale, lig. interspinale, lig. flavum and
dura mater. As the needle enters the subdural space, which is followed by a peculiar
crunch, it is necessary to stop advancing the needle and withdraw the stylet. Then
advance the needle 1-2 mm further and CSF starts dripping from the cannula (in some
cases blood traces may appear, which happens as a result of damaging the small blood
vessels of the brain tunic with a needle). If there is no fluid dripping out, insert the
stylet back into the needle and carefully introduce the latter some deeper or rotate it

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around its axis right and left. Fig. 4.8 shows localization of the needle in the epidural
and subdural spaces.

Fig. 4.8. Localization of the needle in the epidural and subdural spaces.

In case distinct and considerable blood traces become visible, withdraw the
needle and make a puncture once again, one vertebra higher or lower. Collect the
dripping out CSF into a calibrated glass or a test-tube. Connect a Clod’s manometer to
a puncture needle for CSF pressure detection. Fast fluid evacuation may cause damage
to the cerebral blood flow. After needle withdrawal apply iodine solution to the
puncture site and attach a sticking plaster.

4.16. Puncture of the joints of the upper limbs


Indications: Joint puncture is performed with diagnostic and therapeutic
purposes for Figuring out the joint cavity content (such as effusion, blood); removal of
the content from the joint cavity; and injection of antiseptic solutions or antibiotics.
For a puncture use a syringe of 10-20 ml in capacity with a thick needle. In some cases
(for a knee joint) a thin trocar can be used, but it is less popular. Before performing
joint puncture, fulfill preparation of instruments, the surgeon’s hands and the surgical
field the same way as for any surgical operation.
Provide local anesthesia with Novocaine solution. When making a puncture it is
desirable to move the skin slightly aside with a finger before a needle is inserted. It
creates a curvature of a wound channel (the way of the needle) when the needle is
withdrawn and the skin is back to its place. Such a curvature of the wound channel
prevents the joint cavity content from flowing out after needle withdrawal. Advance
the needle slowly until there is a sense indicating that the joint capsule is punctured.
After the operation is performed, withdraw the needle promptly and apply collodion or
an adhesive plaster to the puncture site. Immobilize the affected limb with a splint or a
gypsum bandage.

4.16.1. The shoulder joint puncture


If appropriate indications are the case, the shoulder joint puncture can be
performed both on the front side and the back one. To make a joint puncture from the
front side, find the shoulder blade coracoid and insert a needle precisely below it.
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Drive the needle forward between the coracoid and the capitellum to the depth of
3-4 cm. If the shoulder joint puncture is going to be made from the back side, the
puncture point is situated below the rear edge of the acromion process top,
specifically, in the fossa formed by the rear edge of the deltoid and the lower edge of
the supraspinatus muscle. Drive the needle forward towards the coracoid to the depth
of 4-5 cm (image 4.9.a).

4.16.2. The elbow joint puncture


Bend the patient’s arm at the elbow at the angle of 90 ̊. Insert the needle from
the back side between the lateral edge of the olecranon and the lower edge of the
lateral epicondyle of the humerus, just above the radial head. Puncture the upper part
of the joint precisely above the olecranon top, advancing the needle simultaneously
downward and forward. The elbow joint puncture along the medial olecranon edge is
not used as it may cause damage to the ulnar nerve (image 4.9.b).

4.16.3. The wrist joint puncture


Since the joint capsule is separated from the palmar surface skin by two layers
of flexor tendons, back and radial surfaces turn out to be the most available puncture
site. Make a puncture on the back surface of the joint in the intersection point of two
lines. The 1st line joins styloid processes of the ulna and the radius and the 2 nd one is
continuation of the second metacarpal bone. Thus, the puncture point is situated
exactly in the place where the space between the tendons of m. extensor policis longus
and m. extensor indicis is (Fig.4.9.c).

Fig. 4.9. a – shoulder joint puncture; b – elbow joint puncture, c – wrist joint puncture.

4.17. Puncture of the joints of the lower limbs

4.17.1. The knee joint puncture


Indications: hemarthrosis, intra-articular fractures.
The technique: Apply alcohol and iodine solution to the skin. Anesthetize the
skin of the kneecap lateral side with 0.5% Novocaine solution. Direct the needle in
parallel to the kneecap back surface and get into the joint cavity. Suck off blood from
the joint cavity with a syringe. If intra-articular fractures are the case, after blood
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evacuation inject 20 ml of 1% Novocaine solution to anesthetize the fracture site.
Puncture of the knee joint upper part tends to be made at the lateral edge of the
kneecap base (Fig. 4.10).

Fig. 4.10. Knee joint puncture.

Advance the needle perpendicularly to the femoral axis under the quadriceps
tendon to the depth of 3-5 cm. From that point, it is possible to make the knee joint
puncture too. Direct the needle simultaneously downward and medially between the
back kneecap surface and the front surface of the femoral epiphysis.
If the technique and aseptic rules are completely observed, no complications
arise.

4.17.2. The hip joint puncture


The hip joint puncture can be made both on the front surface and from the back
one. For puncture point detection use an established scheme of a joint projection. For
this purpose, draw a straight line from the greater trochanter of the femur to the middle
of the crural arch. The middle point of that line corresponds to location of the femoral
head (Fig. 4.11).

Fig. 4.11. Hip joint puncture: a – a scheme of the hip joint puncture; b – the technique
of the hip joint puncture.
Insert a needle into the found puncture point and keep advancing it
perpendicularly to the femoral surface to the depth of 4-5 cm until it reaches the
femoral neck. After that, turn the needle a little medially and advance it deeper in
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order to get into the joint cavity (image 4.11a). Puncture of the hip joint upper part can
also be made above the greater trochanter top, and in this case the needle should be
positioned perpendicularly to the long femoral axis (image 4.11b). As the needle is
kept on deepening into soft tissues, it runs into the femoral neck. In this situation,
direct the needle a bit cranially (upward) to get into the joint cavity.

4.17.3. The ankle joint puncture


The ankle joint puncture can be performed both on the lateral surface and the
medial one. For puncture point detection use a scheme of a joint projection
(image 4.12). The puncture site on the lateral joint surface is situated 2.5 cm above the
lateral malleolus tip and 1 cm medially from one (in between the lateral malleolus and
m. extensor digitorum longus). The puncture site on the medial joint surface is located
1.5 cm above the medial malleolus and 1 cm medially from one (in between the medial
malleolus and m. extensor halucis longus). After anesthetizing soft tissues, make a
joint puncture in the detected puncture point, introducing the needle between the talus
and the malleolus. Suck off fluid or blood from the joint cavity and inject drugs
(antibiotics, antiseptic solutions) if necessary.

Fig. 4.12. Ankle joint puncture: a – a scheme of the ankle joint projection;
b – the technique of the ankle joint puncture.

4.18. Puncture of soft tissues hematoma and superficial abscesses


For this puncture use syringes of 10-20 ml in capacity with a thick needle or a
thin trocar of 2-3 mm in diameter. Twice apply iodine solution or 96% alcohol to the
surgical field. Perform a puncture in the point of maximal fluctuation, which can be
discovered during hematoma or abscess palpation. Fill the syringe with antiseptic
solution (0.5% Novocaine solution, Lidocaine) and provide layered anesthesia of soft
tissues above the placement of pathological process. The puncture of a hematoma
capsule or an abscess feels like “a needle dip” into the cavity. If blood in the syringe is
the case, fulfill hematoma content aspiration. Remove the needle and put on a
compressive bandage. During pus aspiration remove the needle, make an incision of
soft tissues with a scalpel and open up the abscess cavity. Cut off necrotic tissues,
wash the abscess cavity with antiseptic solution (hydrogen peroxide, furatsiline,
sodium hypochlorite) and drain it with a rubber drain. Apply a bandage with
hydrophilic ointment (Levosin, Levomekol).

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5. CHAPTER 5. HEMOSTASIS (CONTROL OF BLEEDING)

One of the most important compensatory adaptive reaction of the human organism is
the ability to self adapt through hemostasis by activating blood coagulation
(spontaneous hemostasis). Unfortunately, this is not always possible, as the bleeding
from large vessels to stop on their own rarely occur. Ongoing external bleeding is an
indication to use temporary methods to stop bleeding. From how it is done correctly
and in a timely manner, often depends on the life of the victim.
The methods that stop external bleeding are well known. Basically, if you have a
glance at the history of surgery, it’s primarily the development of methods of
controlling blood loss.
A General Doctor needs to acquire the simplest and most effective methods of
temporary hemostasis by finger pressing vessel, by bending limbs in the joint,
imposition of a pressure bandage, tourniquet, hemostatic clips; to be able to produce
tamponade of the wound and use local hemostatic actions.
However, you need to have a clear idea on how to execute the methods to stop the
bleeding because there are certain advantages and disadvantages for each temporary
method indicated. These methods are determined by the nature of the clinical situation,
external bleeding and its intensity. Referring to external bleeding, as it’s known, can
be arterial, venous, capillary and mixed. The intensity depends on the type of the
damaged vessel, the caliber and number.
Arterial bleeding is recognized by the scarlet color of blood and jet pulsing blood.
Such bleeding is the most dangerous.
Venous bleeding is usually not so intense, but the jet may be powerful, not pulsing and
flowing continuously. Although bleeding from the subclavian or jugular vein blood,
the flow is intermittent, and synchronized to the breathing. The color of blood is dark
cherry.
In capillary bleeding the blood is dark red, flows from the entire surface of the wound
and individual bleeding vessels are not visible. There are skin abrasions bleeding with
shallow cuts.
Mixed bleeding usually combines different characteristics of the above mentioned
signs.

5.1. The finger pressing vessel method


It is used to temporarily stop arterial blood bleeding in the extremities, neck or head.
Pressing is performed above the bleeding places where there is a large array of muscle
and where the artery is not very deep and can be pressed down to the bone. The artery
is compressed by the finger, palm, fist at certain points. The most important one is
shown in Fig. 5.1.

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Supraclavicular region (1) - the place of compression of the subclavian artery, it is
pressed to 1 edge in the point located above the collarbone, immediately outward from
the location of attachment of the sternocleidomastoid muscle to the sternum. In the
armpit (2) - where the axillary artery can be squeezed, pressing the head of the
humerus. Inguinal fold (3) - the area to compress the common femoral artery to the
pubic bone. The inner surface of the biceps (4) - for the arteries of the hands. The neck
of the inner edge of the Sternoclavicular muscle near its middle (5) area where the
carotid artery is pressed against the transverse process of VI cervical vertebra. On the
inner thigh (6) in the upper and middle, you can try to press the femoral artery to the
femur. Compress the popliteal artery in the popliteal fossa (7) to the distal part of the
femur in a slightly flexed knee joint. The posterior tibial artery can be compressed just
behind the inner ankle (8).

Fig. 5.1. Temporary control of bleeding by finger pressing: 1 – subclavian artery;


2 – axillary artery; 3 – common femoral artery; 4 – the brachial artery; 5 – carotid
arteries; 6 – femoral artery; 7 – popliteal artery; 8 – the posterior tibial artery;
9 – dorsal artery of the foot; 10 – superficial temporal artery; 11 – facial artery.
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The dorsal artery of the foot is pressed on the front surface of the foot outward from
the tendon of the extensor of the thumb. On the face it's easy to find the superficial
temporal artery (10), by pressing directly on the bone at a point located in front of the
ear canal. Bleeding from the cheek can be easily stopped with compression of the
facial artery (11) to the horizontal part of the mandible.
Indications: first action to stop arterial bleeding .it is used before using other methods.
In some cases, the presence of sterile gloves and a good visualization of the source of
bleeding, digital compression of the vessel can be done directly in the wound
(Fig. 5.2).

Fig. 5.2. Stop bleeding by finger compression of the vessels in the wound.

If there is a wound in veins you can also use the finger pressing method, which is
performed distal to the wound.

5.2. Bleeding control by joint hyperflexion


This type of bleeding control is performed for injuries of the subclavian and/or axillary
artery. The artery is pinched between the clavicle and 1st rib (Fig. 5.3.a). When there
is a wound in the artery of the upper thigh and inguinal region, make flexion in the hip
joint (Fig. 5.3.b). If there is an injury of the popliteal artery: flex the knee joint
(Fig. 5.3). In the elbow joint when there are injuries in the brachial artery in the elbow
crease (Fig. 5.3.g), the usage of this method to stop bleeding from the distal portions of
the limbs is also possible, but not advisable, due to the damage.

129
b
a

Fig. 5.3. Bleeding controlled by joint hyperflexion.


Indications:
1) Stop all types of bleeding from the groin, hamstring and elbow region; 2) First
method to stop bleeding, before applying other methods.

5.3. Compressive bandage


The application of a pressure bandage on the bleeding area causes an increase in the
interstitial pressure and compression of the lumen of damaged vessels, which
contributes to the formation of intraluminal thrombus. A pressure bandage if applied
correctly, can stop the bleeding, even from major blood vessels and difficult areas.
The technique of a pressure bandage: first, check if the wound contains foreign bodies
(glass splinters, pieces of wood or metal), raise the injured limb above the heart level
with the patient supine. After applying sterile gauze, and if there is no clean cloth, we
can use a piece of sheet, etc. Then Tightly press against the edges of the wound, at the
same time, bringing them closer to each other as much as possible. Use the gauze to
enhance compression and definitely put a pad of thick ball of cotton wool or folded
tissue and a tight bandage. The situation is simplified if the available tools are present,
in particular individual dressing package (Fig. 5.4).

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Fig. 5.4. The application of an individual kit of pressure dressing bandage.
Indication: Any injury, mainly on the limbs.

5.4. The tourniquet


Among the various temporary methods to stop bleeding, the tourniquet is the
most reliable and the quickest. The tourniquet is a circular compression of a soft tissue
limb with blood vessels and pressing them together to bones. The tourniquet is used
only when there is a severe arterial bleeding from an arterial limb, in all other
cases the application of this method is not recommended.
The most widely used is Esmarch elastic tourniquet. It’s strong, elastic rubber
tube or a strip with a length of 1.5 m, the ends are attached to a chain and the hook is
used for fastening (Fig. 5.5).

Fig. 5.5. Rubber hemostatic tourniquet Esmarch type.

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In the absence of a standard harness a variety of available devices (twist, burning with
a thick ball of cotton wool, any solid rubber tube with a diameter of 1-1,5 cm, elastic
bandage, belt, scarf, piece of cloth etc.) may be used.

b
a
Fig. 5.6. Stop bleeding with the help of improvised material: a) twist with a bandage;
b) spin a soft cloth without a thick ball of cotton wool.

It is necessary to remember that rough and hard objects, such as wires or ropes which
are not recommended because of the risk of the nerve damage.
Tourniquet technique: to prevent the infringement of the skin under the tourniquet
enclose a towel, clothes, pad, etc. (Fig. 5.7.). Raise the limb and place the tourniquet
underneath the limb (a) Using the tourniquet, wrap the limb several times but without
weakening the tension (b)so as to stop bleeding. Tours tourniquet should lie down next
to each other, without prejudice to the skin (b). The ends of the harness are fixed with
chains and hooks on top of all the stages. Fabrics should only be pulled together to
stop bleeding.

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а б

в г
c

Fig. 5.7. The technique of blending a - rubber harness and the extension harness; б –
the tourniquet with constant stretching; в– harness coils lie one on another; г – note
with the time overlay.

When the tourniquet is applied correctly, the arterial bleeding immediately


stops, over-tightening of the harness can cause the crushing of the soft tissues
(muscles, nerves, vessels) and the paralysis of the limbs. A light tourniquet does not
stop the bleeding, but rather creates venous stasis (the limb does not turn pale and
becomes bluish in color) and increases venous bleeding. A tourniquet should be
applied so that it is conspicuous. After that the tourniquet should carry out
immobilization of the wounded limb. In connection with the complete cessation of
blood circulation in the limbs, applying hemostatic tourniquet creates a direct threat to
immobilization, so the wiring should not compress the limb for more than 2 h.
However, if you have the opportunity, every hour you should remove the harness and
check to see if the bleeding has stopped and whether it is time to replace the tourniquet
pressure bandage or not. If it continues, the bleeding should be pressed and the

133
tourniquet should be re-applied after 15 minutes slightly above or below. Once again
do not leave the tourniquet for more than one hour. It is important to keep track of the
time when it was applied and re-applied. Be very specific about the time (minutes and
hours). If possible, the description of the state of the wound should also be noted.
Typical places of the tourniquet are shown in Fig. 5.8.

Fig. 5.8. Typical tourniquet Esmarch to stop bleeding: 1 – tibia; 2 – on the hip;
3 – forearm; 4 – shoulder; 5 – shoulder (high) fixed to the body; 6 – thigh (high)
fixed to the body.

However, it is believed that the use of a tourniquet on the forearm by some is


considered to be little effective due to the deep location of the vessels between the two
bones of the forearm. In addition, it should be remembered that the tourniquet at the
middle of the shoulder isn’t recommended because of the possibility of compressing
the radial nerve.
Indications:
Traumatic amputation of a limb;
Inability to stop the bleeding by other known methods.

5.5. Tamponade wounds


An effective way to stop bleeding in anatomically difficult areas of the pelvis, neck,
abdomen, Breasts, buttocks, i.e. where the main arteries are located deep enough in the
muscle layer and applying a tourniquet and a pressure bandage are problematic. This is
especially advisable in the presence of narrow wound channels in a large array of
muscular tissue (wounds in subclavian, axillary artery).
In tamponade, the wound with gauze tampon introduces a tool, tightly fill the wounds
with the necessary force to stop the bleeding.
Indications: bleeding from wounds on the trunk and neck.

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5.6. Local application of hemostatic agents
To stop capillary and parenchymatous bleeding or bleeding from the small vessels of
muscles and bones, especially in patients with a tendency to hypocoagulation,
hemostatic effect is enhanced by the application of haemostatic sponge. The use of
sponges to stop bleeding from large vessels is ineffective.
Hemostatic sponge (hemostatic sponge with ambenom, hemostatic collagen sponge
"ТachoСomb") apparently has a view of the plate from the dried foam and is a native
plasma with the addition of thromboplastin and calcium chloride. The modern
modification is made from animal collagen, with an associated clotting factors:
thrombin, fibrinogen and inhibitors of fibrinolysis (Fig. 5.9).

a b
Fig. 5.9. Hemostatic means of local action: a) "ТachoСomb"; b) hemostatic sponge of
collagen.
After the contact with a bleeding wound or other fluids, the coagulation factors
dissolve and create a link between a native collagen and the wound surface. Splitting
peptides, thrombin converts fibrinogen into fibrin. Like a double-component glue, the
wound surface and the collagen stick together during the polymerization. Inhibitors
prevent premature fibrinolysis dissolution of fibrin by plasmin. Components of the
sponge are degraded in the body under the action of enzymes within 3-6 weeks.
The method of application. Using a sterile technique, with scissors open the package
and pull out a plate with a sponge. The dosage depends on the size of the wound,
which should be closed. A plate with the hemostatic needs to close the area, 1-2 cm
larger than the immediate surface of the wound. If this requires a few plates, then it
overlapps each layer with their edges. If the wound is small, the drug can be cut with
sterile scissors to have the required size. Before applying on a wound surface, the
blood should be removed, by applying gauze. Then pieces of gauze sponge are added
to the open surface for 3-5 min. The sponge can fit in a gauze swab for a loose
tamponade of the cavity. The tampon is removed after 24 h. If necessary, the crushed
sponge covers the entire wound surface, it is also common to spray with a syringe or a
sprayer.

135
Indications:
- The capillary and parenchymal bleeding, bleeding from bones, muscles, nasal,
gingival, etc. external hemorrhage;
- the same kinds of bleeding in patients with bleeding disorders
(thrombocytopenic purpura, leukemia, hemorrhagic thrombocytopathy, disease
Rendu-Osler, liver cirrhosis, local increase in blood fibrinolytic activity and
General fibrinolysis, etc.);
- continuous bleeding when using a pressure bandage and tamponade of the
wound.

5.7. The imposition of styptic clamp


As a way to temporarily stop the bleeding, in terms of the first aid, this method is used
in exceptional cases when the bleeding from the deep-lying blood vessels of the pelvis
and abdominal cavity. Although the application of styptic clamp on a damaged vessel,
leaving it in the wound is one of the most reliable ways to stop the bleeding.
The technique of applying. If the source of bleeding is not clearly seen, the edges of
the wound apart with hooks. To apply, preferably sterile, hemostatic clip, we should be
careful, in "dry" wound, as close as possible and perpendicular to the damaged area of
the vessel (Fig. 5.10). This is necessary in order not to switch off collaterals and not to
cause further injury of the artery, which could complicate the performance of
reconstructive operations on vessels. The clamps are left in the wound, and close an
aseptic bandage.
Conditions: a gaping wound with a clear visualization of the source of bleeding in
difficult anatomical zones with the inability and inefficiency of other methods.

Fig. 5.10. The application of hemostatic clamps on the vessel in the wound.

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The application of hemostatic clips in the wound as a method of stopping temporarily
the bleeding damaged blood vessels under the clamp need to be bandaged using a
sterile thin thread. When there is bleeding from small blood vessels and the bleeding
finally stops, sometimes it is enough to impose the clamp and hold for 10-15 minutes
and then, twist a few times along the axis, to remove.
Capillary bleeding is stopped by application of the usual bandage. Hemostatic effect is
enhanced by a loose tamponing of the wound surface with sterile wipes with 3%
hydrogen peroxide, or apply hemostatic sponge on the wound.
Venous bleeding – apply pressure bandage in traumatic area of the extremities, torso
and neck - tamponade of the wound. At the time of preparation of dressings the
bleeding can be reduced, by raising the limb up, pressing using the finger on damaged
wounded vessel (distal to) or, in extreme cases, put distal to the wound "venous
tourniquet" and compressing the veins only, and it will not violate the blood
circulation. The effectiveness of the "venous" tourniquet is judged by the cessation of
bleeding at a distinct pulsation of the artery below the wound.
Arterial bleeding is not stopped from the main vessel, as well as venous pressure
bandage or tamponade. To prepare for dressing,the bleeding vessel is compressed
above (proximal to) the wound (Fig. 5.11).
With arterial bleeding from the main vessel as the first action to make is digital
compression or maximum flexion in the joint, and then a compression bandage. If the
bandage gets wet with blood ("drips") above the wound tourniquet, then we should try
again to implement a hemostasis pressure bandage, increase a local compression of the
damaged area or fixing the limb in a position of maximum flexion. Only the
ineffectiveness of these measures requires the use of the harness. Bleeding from
anatomic areas inaccessible to pressure bandage and tourniquet are stopped by
tamponade, and if it is not effective, use hemostatic clip.

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a

Fig. 5.11. Stages stop arterial bleeding is not from the main vessel: a) arterial bleeding;
b) temporaryily stop bleeding by compression of the artery during proximal to the
wound; с) the imposition of a pressure bandage.
In all cases, after temporary hemostasis, it is necessary to lift the injured limb above
the trunk, which reduces the flow of blood, and improves the opportunity for clot
formation.
The fate of a victim with external bleeding depends primarily on the rapid and correct
actions of persons providing first aid and not to provide vascular surgery.

5.8. Emergency treatment of acute gastrointestinal bleeding. Urgent


measures for bleeding from the digestive tract
As soon as you find that the patient has any hematemesis and/or melena, you should
start to carry out the intensive complex of measures which are aimed at stabilization of
hemodynamics and withdrawal of the victim from the state of decompensation.
In most cases, the nature of bleeding allows for the initial stages of treatment to apply
conservative hemostatic therapy. It can be divided into general and local.
Total conservative hemostatic therapy.
1. The patient is assigned to strict bed rest, he or she mustn’t receive food and water
and ice application on the stomach is recommended.
Note. You should know that the vasoconstrictor effect of ice does not happen,
but has a soothing effect on the patient.
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2. Shown agents have hemostatic properties and angioprotective one. The medicine for
this purpose is dicynone. Hemostatic effects of dicynone (synonyms: etamzilata,
cyclename) at/in the introduction starts in 5-15 min, the maximum effect occurs within
1-2 h, lasts 4-6 hours or more. Introduce 2-4 ml 12.5% solution, then every 4-6 hours
for 2 ml. It can be added into the usual solutions for infusion therapy.
3. A set of general hemostatic measures include injection of traneksam 5.0 i/v every
12 hours; 5% solution of epsilon-aminocaproic acid 100 ml every 4 hours; 10%
solution of ascorbic acid 1-2 ml i/v; 10% solution of calcium chloride (50-60 ml/24
hours), 1% or 0.3% solution vikasol (1-2 and 3-5 ml respectively).
4. When massive blood loss occurs, a large amount of albumin is lost. Infusion therapy
is carried out in accordance with the protocol.
Note.
You should not aim for a quick and complete replenishment of blood loss, so as not to
cause significant increase in BP and resumption of bleeding.
Calcium chloride and ascorbic acid don’t act on ongoing bleeding. They are more
appropriate for preventive purposes.
Menadione starts to have a haemostatic effect after 12-18 hours after injection.
Local conservative hemostatic therapy
1. Simple and accessible, but the ineffective means of local hemostatic
conservative therapy is the intake of ice cubes by mouth.
2. Local hemostatic effect when taken by mouth, have a 10% solution of
calcium chloride, 5% solution of epsilon-aminocaproic acid, 0.2% solution of
thrombin and some other drugs. You can use chopped hemostatic sponge by mouth,
1 tablespoon every 1-2 hours.
3. Endoscopic hemostasis such as a diathermocoagulation, injection of various
drugs into the submucosal layer near the source of bleeding, irrigation of the site of
bleeding with hemostatic solutions, film-forming drugs, and the application of
hemostatic poles to the bleeding vessel are widely used nowadays.
If a patient arrives in critical condition, the physician must provide emergent
assistance and after that simultaneously with the ongoing treatment of a patient it is
necessary to call a surgeon. A patient should avoid medication until the examination
final diagnosis are established.

5.9. Emergency treatment of pulmonary bleeding


All patients with pulmonary hemorrhage need immediate hospitalization and
emergency medical care. Emergency assistance will influence directly the bleeding
vessel, lowers blood volume in the pulmonary circulation and lungs, reduces the
capillary permeability of the lung and increases blood clotting, it is to restore the

139
patency of the airway and prevent aspiration pneumonia, and compensate the blood
loss.
Give a patient semi-sitting position, place tourniquets on the lower limbs, warm the
legs and lower abdomen, periodically turn him on his side, aspiration by the suction of
blood and mucus from the mouth, nose and throat. A patient should breath freely and
speak softly.
Pulmonary hemorrhage can be delayed by intravenous administration of pituitrin -
2 ml or 10 units in 200 ml of saline solution. The main active ingredients are pituitrin
oxytocin and vasopressin, which narrow the capillaries, increase blood pressure,
regulate osmotic pressure of blood.
For unloading of the pulmonary circulation, introduce solution of atropine (1 ml),
camphor (3-4 ml 4 times a day), aminophylline (a 2.4 % solution, 10 ml), regulators of
arterial blood pressure (pentamine, hexon, dimebolin).
Due to hemostatic purpose and in order to reduce the permeability of blood vessels,
use menadione (5 ml 0.3% solution intravenously or intramuscularly, to 0,015 g
4 times per day orally), ascorbic acid (1 g 3 times per day orally), epsilon-
aminocaproic acid (5% solution up to 100 ml of normal saline), pentoxy (0.2 g 3 times
a day) - dicynone - slowly intravenously or intramuscularly (2 ml of a 12.5% solution
with 20 ml of saline); adrokson (2 ml 0.025% solution intramuscularly), calcium and
sodium chloride, calcium gluconate (10ml 10% solution intravenously), vitamin P
(citrin, rutin).
Blood loss is compensated by a single-group blood transfusion of erythrocyte mass
(250-500 ml), introduction of plasma (100-200 ml).
For the prevention of aspiration pneumonia, a patient should also be provided a semi-
sitting position and prescribed antibiotics and sulfonamides.

5.10. Technique of postural drainage of the bronchial tree


It is important for the prevention of pulmonary hemorrhage, it is to ensure sputum
discharge in patients with a lung disease. For these purposes, the method of the
bronchi drainage is to change the body position.
Postural drainage is a medical procedure that facilitates the expectoration of bronchial
secretions and increases cough productivity by giving the body a special drainage
provisions.
In these provisions, the sputum moves under the action of gravity towards the main
bronchi and the trachea, reaches the bifurcation of the trachea, where the sensitivity of
cough receptors is very high, and is removed from the body by coughing.
Postural drainage is indicated for any clinical pathogenetic versions of bronchial
asthma in the period of hyperproduction of mucus.

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Contraindications to postural drainage:
 pulmonary hemorrhage;
 the acute phase of myocardial infarction;
 severe respiratory and heart failure;
 pulmonary embolism;
 hypertensive crisis;
 hypertension in the period of sharp increase in blood pressure.

1st Stage - normalization of rheological properties of sputum:


1) expectorants;
2) aerosol therapy (inhalation);
3) hydration of a patient (a warm drink - 300 ml per 70 kg of body weight,
infusion therapy according to indications).
The duration of this stage is 10-15 minutes.
2nd Stage - Separation of sputum from the bronchial wall:
4) giving a patient drain position for the discharge of phlegm.
5) vibrating massage with the use of intermittent and continuous vibration.
Intermittent vibration or percussion treatment is performed with palms ("boat")
to the chest at a frequency of 40-60 / min for 1 min followed by a pause.
Perform 3-5 cycles. Continuous vibration (manual, hardware) is carried out for
10-30 seconds with short breaks;
6) verbal exercises (the patient pronounces voiced and deaf vowels and
consonants, the sounds of hissing);
7) breathing through the vibrator "Inga" for 2-3 minutes (2-3 times).
The stage duration is 15-25 min.
3rd Stage - The mobilization of sputum and its application in the area of cough reflex:
8) staying in the drainage position (Fig. 5.13);
9) drainage gymnastics;
10) breathing exercises (alternating between a full inhale and a series of short jerky
breaths of diaphragmatic breathing);
11) breathing exercises with the help of an instructor performing an additional
external stress on the lower third of the chest.
This stage duration is 10 min.

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Fig. 5.13. The scheme of the drainage positions in suppurative lung diseases.
4-th Stage - Removing phlegm:
12) apatient coughs;
13) make a smooth deep breath, as you exhale - 2-4 cough push.
This stage duration is 5-10 min.
It fully describes the set of activities performed 2-3 times a day.

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6. CHAPTER 6. SURGICAL TREATMENT OF WOUNDS

6.1. Preparation of dressing and surgical linen


Dressings are used to clean and drying the edges of wounds, for removal of blood and
discharges, clamping of a blood vessel, the drainage of wounds and their protection.
The preparation of the dressing and clothes is done in a special equipment room on a
sterile bench and with clean hands. All dressings (napkins, tampons, gauze balls) are
prepared from soft, absorbent, grease-free white material. The fundamental rule when
folding the material is tucking the cut edge of the gauze inside to prevent the
penetration of threads into the wound.

6.1.1. The technique of the dressing material preparation


A napkin is a piece of gauze folded into 4 layers. When it is used to dress children's
burns and plastic skin surgical wounds a piece of gauze 10 × 15 and 20 × 15 cm size is
used. The endings of the gauze are folded inwards into a depth of 3-4 cm, and then
folded in half of its length and width. A tampon is a different length strip of gauze.
Pieces of 20 cm length and 5-6 cm width are used after plastic skin operations in
children. The endings are folded inwards into a depth of 3-4 cm, and then the strip of
gauze folded in half along its length. Gauze balls are prepared in three sizes: large,
medium and small. In children's surgery they must be slightly less than standardness.
Large balls are prepared from pieces of gauze of 10 × 11 cm, the medium ones of
6×7 cm and small of 5×3 cm in size. Sliced gauze is spread on the table, longer edges
of each piece are folded inwards. The resulting strip of the gauze is folded into a
triangle shape (cornet) and sticking endings are tuck inside. In the skin plastic
operation an average 15-20 m piece gauze is taken. Shaving brushes are wooden rods
with the length of 10 cm long (small) and 14-15 cm (long) and a diameter of 3-4 mm
which at one end are wound tightly with cotton. Before sterilization of 10 pieces of
napkin, they are tied by a gauze strip. 40-50 pieces of gauze balls of the same size are
put into an extended piece of gauze. Their endings are crossed together. 10-15 pieces
of shaving brushes are tied together by their endings with a napkin folded in triangular
shape.

6.1.2. Preparation of surgical linen


The complete set of surgical linen includes - surgical gowns, masks, sheets, towels and
pillow cases. The linen must be clean and intact. Small holes on the laundry must be
immediately sewed as well as the loose threads. For operations only dressing gowns
are used, which are tied up in the back, with long sleeves and strings on the cuffs. A
surgical nurse prepares the zone for the dressing gown from the bandage. Masks sew
from gauze are folded into 4 layers. The size of the mask should be of at least
20×15 cm. In the corners of the mask a drawstring with length of at least 25cm is
sewn. The masks conveniently cover the face and head of the surgeon at the same
time. A piece of gauze of 60×80 cm is stitched and folded into 3 equal parts. At the
boundary between the two parts, at an equal distance from the endings a cut of 12 cm

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long is done. When the mask is worn, it should be at the height of surgeon's eyes. The
edges bent and folded from all the sides and to the ends and strings 20-25 cm long
should be stitched to the sides. This mask must have 4 layers of gauze at the region
covering the mouth and nose. Dressings and linen should be stored into locked
cabinets. After use the linen is soaked into a 0.2% solution of chloramine for 4 hours
and then given for washing. For a single skin plastic surgery 4 robes, 5 sheets, 4 towels
and 2 pillowcases are required.

6.1.3. Stowage of sterilization chamber and their preparation for


sterilization
Sterilization chambers (sterilizers, drums) are designed for the sterilization of surgical
dressing, linen, and gloves by vapor under the pressure and their storage after
sterilization. Sterilization chambers have cylindrical form and are made from a nickel-
plated metal. It is like a drum with a tightly cover lid. The shell of sterilization
chamber has lateral openings, which can be shut with the aid of a belt moved
horizontally.
Large sterilization chambers are intended for the linen; the medium ones- for the
surgical dressings and small ones - for rubber gloves and masks.
Before filling the sterilizer lateral openings are unlocked.
A piece of oilcloth (tally) with the quantity and the form of material written on it is
taken and after tied on the handle located on the cover lid. Sterilization chambers are
filled usually with different materials. The sterilization of material inside cannot occur
if there's an overfilling of the sterilization chambers.
Placement on the sterilization chambers is accomplished in the following order: a
A large pillowcase is placed inside in large sterilization chambers from the walls to its
center and the folded linens: 5 sheets, 3 dressing gowns, 5 pillow cases and 3 towels
are stacked on it. On top they place 4 gowns used by a surgical nurse . Then the edges
of a pillowcase are enclosed and on the top a gauze to wipe the hands of a surgical
nurse is placed. For convenience in use and prevention of the contamination of the
hands during the delimitation of operating field, the sheet is added at first to two
unequal halves, and then a few times up and down.
In closing the surgical field, the long end of the sheet is folded in half and be lowered
to the edge of the table and pulled short, by lying on the table, the sheet can be
completely removed without the risk to contaminate the nurse’s hands. Dressing
gowns sleeves are folded inwards so that the strings won't be left dangling.
Medium sized sterilization chambers are loaded with surgical dressings. Whole
surgical dressings, such as linen, are placed in the pillow case. When filled the
sterilization chambers are closed by their lid. In the average sterilization chambers can
usually support 20 packages of napkins, 10 packages of gauze balls, 2 packages of
swabs and 2 packages of tampons.

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Small sized sterilization chambers are used for the sterilization of rubber gloves or
masks. Clean dry rubber gloves integrity is checked against wholes by inflating them
with air. If a small opening is revealed, through which air passes, it is possible for it to
be glued up using a piece of rubber from another glove. After this, it is necessary to
verify the integrity of the glove one more time. Intact gloves are covered with a thin
layer of talc from both its sides, reversing them in this case. Then gloves are put in
pairs according to their sizes. Each pair of gloves is laid by a gauze strip and wrapped
by a gauze napkin. In the sterilization chambers 6 pairs of gloves or 10-12 masks are
placed simultaneously.
Gloves are sterilized for 30 min at a pressure of 1 atm. Linen and surgical gowns for
45 min at a pressure of 2 atm.
At the end of sterilization, the nurse takes them out of the autoclave and immediately
shuts it by its lateral openings. Afterwards she should register the date of sterilization
and put her signature on the record of the sterilization chambers.
The sterilized linen must always be dry. Sterilization is considered effective for 3 days.
Any sterilization chambers, after opening, must be used immediately.

6.2. Methods of sterilization of surgical linen, dressings and suture material


and surgical instruments
The most currently widely used method is by using pressure of steam sterilization,
they previously were named autoclaves. Usually surgical clothing (gowns, masks,
sheets, towels, pillow cases) and dressings (napkins, tampons, bandages, cotton), as
well as some blunt surgical instruments which do not have an optical system (drum
and support for the skin sutures, the support of apparatus for the performing
transplants, devices for reinforcing electrodermatom’s blades).
The steam sterilizer is a metal drum-like chamber with double walls. Inside of it is a
sterilization chamber. The space between the outer and inner walls of the boiler is
filled with water up to the level indicated on the gauging glass. The water is heated up
to the boiling point and evaporates, resulting in increased pressure and temperature in
the autoclave. These parameters are monitored by a manometer. At a pressure of
0.5 atm. the temperature goes as high as 115°C, at a pressure of 1 atm. at 120°C and at
a pressure of 2 atm. at 134°C. The sterilization of all items is completed in
40-50 minutes at a temperature of 120 to 134°C and a pressure up to 2 atm.
At present there are a variety of steam sterilizers designs, heated by gas, solid or liquid
fuels or electricity with semi-automatic and automatic controls.
Sterilization is carried out in the following order: sterilization chambers filled with
the objects to be sterilized are placed in the inner chamber. The lid of the autoclave is
tightly closed and screwed up. All of the valves except the tap which communicates
with the interior of the autoclave which serves to remove air and steam, are closed.
Then, the heat is turned on. After the appearance of a uniform jet of vapor, which
indicates that air is expelled from the sterilizer, the tap is closed and the pressure is

145
adjusted to 1.5-2 atm. This point is considered the beginning of sterilization process
and written in the log. When the time of exposition (40-50 minutes) is over the heaters
are turned off and the steam is removed from inside the sterilization chamber. The
autoclave lid is unscrewed when the manometer indicator reaches 0. After removing
the sterilization chambers immediately close the gratings. The degree of sterility is
judged by means of indicators placed within the sterilizers. Most often for this purpose
sulfur powder, which must pass from crystalline form to an amorphous state as a result
of its melting point being reached, is used. The melting point of sulfur is + 117°C.
The safety measures required for working with the steam sterilizer:
1. Sterilizers are installed into separate rooms with ventilation and a door that opens
outwards.
2. Operation of the sterilizer steam under high pressure is only allowed after being
tested by inspection representatives. Yearly inspection by specialists is required to be
performed.
3. Only nurses that acquired a certificate through special courses and have the
evidence of its completion are allowed to work with the sterilizers.
4. Sterilizers operating on electric heating should be in contact with the ground.
5. The manometer, which the sterilizer is equipped with, must be sealed. The
admissible pressure is marked on its scale.
6. A working sterilizer must be under constant supervision. Unauthorized persons
aren’t allowed into the sterilization room.

6.3. Quality control of sterilization and pre-sterilization process


Bacteriological quality control of dressings and suture material sterilization is
performed once every 10 days. Each of them containing suture material are taken by
separate sterile pincers separately and put into a sterile test tube. A cotton plug is
placed into the opening of the test tub, shutting it closed, right over the flame of a
burner.
Quality control of disinfection of surgeons hands and surgical instruments is also
performed once every 10 days. It is achieved through taking samples into a solution. A
sterile swab enclosed in the tube is used for this purpose. The test tube is filled with
2-3 ml of a sterile isotonic solution of sodium chloride before using the wet swab to
rub the skin of the surgeon’s hands by sections after the end of their work. Samples of
the walls and furniture of an operating room is taken the same way. After usage of the
swab, it is placed again into the same test tube and shut with a sterile cotton plug over
a burner. Samples of air of the operative room are collected in Petri dishes, filled with
nutrient agar. They leave the Petri dish in the operating room with its lid open for
15 minutes before shutting it down and turning it upside down. The tubes are then sent
to the bacteriological laboratory. Surgical air crops are produced on the Petri dish
filled with nutrient agar. They are left open in the operating for 15 min, then they are

146
closed and turned upside down. All the results of the bacteriological research are
recorded in a special folder.
A surgical nurse using benzidine, orthotolidine or aminopyrine tests must be able to
check the quality of the tools sterilization from blood residues.
Benzidine test. There are two variants of the test:
1. Test with benzidine hydrochloride. A 0.5-1% benzidine hydrochloride solution with
distilled water is mixed with an equal amount of 3% solution of hydrogen peroxide.
2. Test with benzidine sulfate. To a solution of 5 ml 50% of acetic acid dissolved in
0.025 g of benzidine sulfate, 5 ml 3% hydrogen peroxide are added.
Orthotolidine test. There are three variants of the test.
1. Prepare a solution of 4% orthotolidine in 96% ethanol. The solution is stored in a
refrigerator. 5-10 ml is taken for the daily use of the basic alcoholic solution and 50%
of acetic acid is added to it in the same quantity as distilled water. 2-3 drops of
solution and 1-2 drops of 20% hydrogen peroxide are applied to the object being
inspected.
2. To a reagent consisting of 5 ml of 50% acetic acid dissolved into 0.025 g
orthotolidine, 5 ml of 3% hydrogen peroxide solution are added.
3. Mix equal quantities of 1% aqueous solution of orthotolidine preparation in distilled
water and 3% hydrogen peroxide.
Aminopyrine test. Mix equal quantities of 5% amidopyrine alcoholic solution, 30%
acetic acid and 3% of a hydrogen peroxide solution (2-3 ml).
Afterwards the quality of the reagents is checked by dripping them onto blood spots.
The reagent will be suitable for use if it makes the blood spot to turn green. To control
the quality of syringes cleaning the reagent is infused inside of it and displaced
throughout its length with the use of the piston. If the presence of blood residues is
positive in the syringe, the fluid will acquire a greenish-blue coloration in 3 minutes.
Needles are checked by letting the reagent run through them, onto a paper and
observing whether the blue-greenish coloration of the solution appears or not.
Cleaning quality control of surgical instruments, needles, and syringes is carried out by
means of phenolphthalein test.
Phenolphthalein test. 1% alcoholic solution of phenolphthalein is prepared, 1-2 drops
are placed on a clean object. In the presence of residues the reagent acquires pink
color. The syringes quality control should be checked before their sterilization.
Products which give out a positive test for blood or residues are cleansed again until
the control tests come negative.

147
6.4. Sterilization in the dry heat oven
The processing of all instruments has two successive stages: pre-sterilization and
sterilization.
Pre-sterilization consists of the observation, cleansing and drying of objects. At
present, the rules of pre-sterilization preparation are equated with methods for
processing tools that are provided for a complete guarantee of the destruction of
human immunodeficiency virus (HIV infection). All of the procedure must be
performed in rubber gloves.
Immediately after use, the instruments are completely immersed in a container with
disinfectants for their disinfection, such as a 3% solution of chloramine (during
40-60 min.) or a 6% hydrogen peroxide solution (during 90min.). Afterwards the
instruments are rinsed in running water.
Washing of instruments is carried out in a special detergent solution, which includes
detergent (washing powder), hydrogen peroxide and water. Instruments are immersed
in the solution for 20 minutes, at a temperature of 50-60°C. Later they are cleaned with
swabs using the same solution and rinsed, first in running water and then in distilled
water.
Drying can be carried out both naturally and immediately before sterilization in air
sterilizer.
Hot air sterilization (Dry heat) is performed in a special apparatus known as dry heat
ovens. Instruments are placed on the shelf and at first and dried up for 30 minutes at
80°C with the door open. Then the door is closed and the temperature is brought up to
180°C for 60 min. After the heating system has been turned off and the sterilizer
cabinet has cooled down to 60-70°C, the door is slightly opened and, after complete
cooling, the chamber is unloaded with a sterile instruments.
When working with an air sterilizer, safety precautions should be taken: the appliance
must be grounded and the equipment must not be used.
At present, sterilization in an air sterilizer is one of the most reliable methods of
sterilizing surgical instruments.

6.5. Preparation of sterile tables in the dressing and operating room


Firstly, the table is wiped with a disinfectant agent recommended for the disinfection
of surfaces in the premises. Sheets, used for the preparation of sterile tables, prior to
sterilization must have their integrity been checked. If a damage is noticed the sheets
should be replaced. An alternative is to use sterile disposable surgical linen or special
use single-use complete sterile sets.
Before the extraction of the sterilized material (napkins, tampons) and instruments
(before opening sterilization boxes/ packages):
- Observe the condition of closure of the sterilization box or the integrity of the single-
use sterilization package;
148
- Check the color of the labels of chemical indicators, including sterilization of the
materials of the package;
- Check the date of sterilization;
- On the label of the package the date, time of opening and signature of the opener are
put.
Before preparing sterile tables, the operating nurse processes her hands with an
alcohol-containing cutaneous antiseptic according to the technology of processing
hands of surgeons, wears a sterile gown and gloves (without a cap and a mask, the
entrance to the operating room is prohibited).
When preparing a large instrument table, two sterile sheets, each of which is folded in
half, are laid out on the left and right half of the table with folding points - to the wall.
Sheets have a "overlap" so that the center of the table edges of one sheet go to another
sheet at least 10 cm, and the edges of the sheets on all sides of the table hung about
15 cm. On the top of these sheets a third one is added and opened so that its edges
hang by not less than 25 cm. The instruments are placed on the table and then they are
covered with a sterile sheet folded in half, or two open sheets.
A large instrument table is covered once a day just before the first operation. During a
surgery instruments and materials from a large instrument table are only permitted to
be taken with the use of sterile gloves and by means of a sterile forceps or pincers.
After an operation, the instruments on a large table are further replenished with sterile
instruments necessary for the next operation.
The preparation of a small operation table is done by covering it with sterile sheets,
which are folded in half, and then by an unfolded sterile sheet which edges hang on the
same length on all the sides of the table. Instruments and materials are put over it and
covered with a sterile sheet folded in half. An alternative is to use a single-use sheet
made of impermeable material.
A small operation table is re-covered every time before a new operation starts.
Individual pilings to each operation are in alternate sterile tables, including the
standard instruments set and individually packed instruments.
The members of a surgical team enter the sterile operation zone through the sanitary
checkpoint, where they shower and they change clothes into the surgical clothes and
cap.

6.6. Methods of the surgeon's hands preparation (scrubbing) before a


surgery
On the hand’s skin surface there are pores and folds with sweat and sebaceous glands
containing many microorganisms, 90% which are part of normal flora and 10% which
are pathogenic.

149
In the pre-operative care of a surgeon's hands his assistant and nurses have a
fundamental role into preventing any infectious process. Preparation of hands before
surgery consists of two obligatory stages: mechanical cleaning, by means of running
water with soap, and chemical using a antiseptic solution.
The use of disinfectants for hands is very important since surgeon must be effectively
protected against infections, but this process should not cause any damage to the skin
of a doctor.
Among many variants of pre-operative hand preparation, there are two main groups of
methods:
1) mechanical cleaning and disinfection;
2) skin tanning in order to prevent infection of the skin through the pores.

6.6.1. Preparation of hands with 0.5% solution of chlorhexidine


digluconate
For preparation of hands 0.5% alcohol’s chlorhexidine solution is used. In the
concentration of 0.5% it should be diluted in a proportion of 1:40 (1 part of 20%
aqueous solution of chlorhexidine diglucol-carbonate and 40 parts of 70% alcohol)
(Fig. 6.1.).

Fig. 6.1. Сhlorhexidine’s bottle.


Purpose: disinfection of hands of medical personnel involved in an operation.
Equipment:
1) a bottle with 0.5% solution of chlorhexidine digluconate;
2) a bottle of ethyl alcohol 70%;
3) sterilization chamber with dressing material and operating linen fixed on the
supports;
4) soap (disposable);
5) hourglass (1-3 minutes).
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Sequence of actions:
1. Prepare a bottle with solution of chlorhexidine diglucol-carbonate 0.5%.
2. Place sterilization chamber with dressing and operating linen on the stand.
3. Turn the hourglass (1 min.), prepare to soap.
4. Wash your hands with water and soap for 1 minute. Wash the hands in the following
sequence: subungual space, fingers, interdigital spaces, thumb, the palm and the dorsal
side of the left hand, then the right hand, left and right wrist, left and right upper arm
up to the elbow.
5. Wash your hands under running water to remove soap scraps from the nails to the
elbow.
6. Dry your hands with a sterile towel thrown over left arm, as it follows: from the nail
of right hand to the base of the fingers; top of the palm of the right hand from the base
of the fingers to the wrist; back of the hand (in the same order); the inner surface of the
right forearm (up to the middle third), then the outer surface of the forearm; the inner
surface of the right forearm (from the middle third to the elbow), then the outer surface
of the middle third of the forearm, including the elbow joint.
7. Put the lower part of the towel on the right hand and dry left in the same sequence.
8. Prepare the hands with small sterile cloth soaked in 0.5% alcoholic chlorhexidine
digluconate, from the nails to the elbow (in the same sequence, like washing of the
hands under running water with soap and water) for 2 minutes.
9. And then with a small sterile cloth soaked in 0.5% alcohol solution of chlorhexidine
digluconate (in the same sequence of action), up to the middle third of the forearm for
1 minute.

6.6.2. Hands preparation with pervomur solution


Hand prepare for a minute is now widely used with a mixture of 85% surfactant and
33% hydrogen peroxide, called "pervomur," also known as the "C-4 system."
Sequence of actions:
1. Prepare the solution (mixing 171 ml of 33% hydrogen peroxide solution, 100 ml of
69% formic acid and then adding distilled water until the volume reaches 1 liter).
2. The solution has to be placed in the fridge for 1.5 hours, being periodically shacked.
3. The stock solution is diluted 10 times (2.4%) for the caring of the hands.
4. The solution is effective for a day.
5. Wash hands with soap, without brushes, for 1 minute.
6. Rinse and wipe your hands with a sterile cloth.
7. Apply pervomur solution on them within 1 minute.
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8. Wipe the hands with sterile cloth.
9. Put on sterile gloves.
10. In the course of an operation the gloves must be washed in every 60 minutes in a
2.4% pervomur solution.

6.6.3. Hands preparation with cerigelum


Purpose: Rapid disinfection of hands during surgery in an outpatient setting.
Equipment:
1. Bottle of cerigelum.
2. Sterilization chamber with surgical sheets.
3. Soap (disposable).
4. The bottle with 70% ethanol.
5. Hourglass (1 min.)
Sequence of action:
1 Place the sterilization chamber with dressing and operating linen on the stand.
2. Prepare a bottle with cerigelum solution, a hourglass and a soap.
3. Wash your hands under running water with the soap for one minute.
4. Dry your hands with a sterile towel (from the nails to the upper third of the
forearm).
5. Pour in the palm of a hand 3-4 ml of cerigelum solution.
6. Rub the solution on the hands and on the middle third of the forearms for
20-30 seconds before the formation of a pellicle (Fig. 6.2).

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Fig. 6.2. Scrubbing with cerigelum solution before surgery.

6.6.4. Preparation of hands by Spasokukotsky-Kochergin’s method


The Spasokukotsky-Kochergin’s method is the most gentle and the one that best
preserves the skin of surgeon´s hands. This is clearly demonstrated with the experience
of thousands of Russian surgeons for a long time. The peculiarity of this method
consists in the fact of using a warm 0.5% solution of ammonia, capable of dissolving
fats. Hands, with this method, are washed in two basins with the solution for 3 minutes
each, on all sides, washing the hands immersed in the solution with gauze. Then, the
hands are wiped during 5 minutes with a sterile cloth and handled to 96% alcohol
solution. Finish the preparation with the lubrication of the fingertips, nail rolls and nail
plates with a 5% iodine solution.
An effective and widely used method of disinfection in Europe is a 3-minute hand
preparation with various iodoforms and hexachlorophene in the form of a special
shampoo.
This method is known for the disinfection of hands in a special ultrasonic chamber
filled with an antiseptic solution.
Frequent use of the same chemical antiseptic by a surgeon, as well as individual tissue
intolerance to active chemical agents, can cause various skin reactions. Therefore,
hand disinfection methods, based on tanning the skin with alcohol solutions, will exist
for a long time in the arsenal of surgical asepsis.
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Currently, numerous bacteriological studies have shown that none of the existing hand
caring methods can provide absolute asepsis. They are only, to some extent, able to
reduce bacterial contamination of the skin the risk of which increases during the
operation due to the exposure to microbes on the skin surface. So, after caring hands,
wearing of sterile rubber gloves was proposed in 1890 (by Halstead), and then it was
introduced in Russia (by V.G. Tsege-Manteyfel) in 1897. The use of rubber gloves
makes it possible to be replaced during the operation with clean gloves or preparation
of any antiseptic solution.
The disadvantage of gloves is that they impair the sense of touch and can be damaged
during operation, posing a threat of infection, especially from the product of the
sebaceous and sweat glands containing microorganisms inside the glove which is
called "glove liquid".
Taking this fact, into account surgeon should always, before putting on gloves,
thoroughly disinfect hands. In case of glove’s damage during a surgery they should be
replaced only after the complete treatment of hands with an antiseptic solution and
more alcohol.

6.7. Putting on sterile clothes and sterile gloves (gowning and gloving)
The purpose of dressing sterile clothing is to prevent entrance of microbial flora into
the sterile objects and the surgical wound.
When putting on sterile clothing, sterility of working conditions is ensured during
operations, bandages, injections and other manipulations.
Equipment: Sterile sterilization chamber with linen and gloves.
Sequence of action.
1. Put on a hat to cover your hair.
2. After the antiseptic preparation of the hands, a nurse or a sterile surgeon pulls the
mask from sterilization chamber, takes the edges ribbon and applies it to the face. An
assistant takes the ribbon from behind, not touching the sterile hands of the surgeon or
the nurse, and guide them over the ears in a similar way from both sides and then ties
the ribbon mask (Fig. 6.3).

Fig. 6.3. Putting on operating masks.


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3. Dressing the surgeon with a sterile gown:
1) take the gown from the sterilization chamber, placing it close to the arms of the
surgeon, with the collar edge close to his hands;
2) surgeon puts his arms into the sleeves of the robe without touching the sterile gown
of the nurse, dropping his hands down; wearing the robe to his hands the surgeon
raises his hands again;
3) a nurse comes from behind to the surgeon to tie the strings of the robe again;
4) the surgeon ties up his sleeves and then asks an assistant to take the tips and tie in a
loop, wrapping his gown.
4. Putting on the surgeon´s gloves:
1) the nurse takes the left glove with both hands to the side. The surgeon takes on his
cuff with four fingers of both his hands pulled apart;
2) the nurse quickly puts on the glove on the hand of the surgeon and bend it at the
elbow level;
3) the nurse pulls the glove up the sleeves;
4) the same procedure is repeated to put on the right glove (Fig. 6.5).
The gloved hands are kept bent at the elbows, hands raised above the waist and apart
from the body.

Fig. 6.4. Putting on sterile gloves with the help of scrub nursr.

6.8. Preparation of the surgical field (prepping)


The surgical field is a surgeon’s place. It is very important to keep it sterile. The
preparation of the surgical field starts in the preoperative period.
The day before a surgery a patient takes a bath or a shower (in case of elective
surgery). On the day of the surgery the field and the surrounding areas are carefully
shaved. The preparation of the field begins immediately (if the operation is under local
anesthesia) or after a patient is anesthetized.
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This process is carried out along the surgical field boundaries to the proposed incision
or wound to the periphery. In the presence of purulent wound it is performed from the
periphery to the center. In vertical or oblique preparation of the surgical field, the
process is started at the top downwards. Due to this downward direction, the antiseptic
solution avoids the contamination of the treated areas by the non-treated ones
(Fig. 6.5).

Fig. 6.5. Preparation of the skin on the surgical field (prepping).

For the treatment of the skin within operating field, various antiseptic solutions are
used: iodonate, iodopyrone. For children, blondes, patients with thyrotoxicosis and in
persons sensitive to iodine, 0.5% of a half-alcohol solution of chlorhexidine
bigluconate should be used.
Jodopiron (povidone-iodine) - is a mixture of iodine with Polyvinylpyrrolidone. It is
soluble in water resistant to storage, non-toxic, odorless. It doesn’t cause allergic skin
manifestations. It is recommended to use 1% solution Iodopiron (free iodine).
Iodonate - is iodophor, in which iodine is a mixture of sodium alkyl sulfates which
exerts bactericidal, fungicidal and sporicid effect. For preparation of fields solution
iodonate is prepared 5 times with sterile water, receiving 1% Iodonate solution.

6.8.1. Prepping of operating fields with iodonate and iodopiron


Purpose: compliance with asepsis in the operating field of a patient.
Equipment:
1) sterile small instrument table;
2) bottle with 1% solution iodinate or 1% solution iodopiron;
156
3) dressings (cotton balls);
4) two tweezers or clips.
Sequence of actions:
1. Аsk the assistant to pour in a sterile cup 1% solution of iodopiron.
2. Prepare the sterile table dressings (cotton balls) and 2 tweezers or clip.
3. Moisten abundantly in 5-7 ml of 1% iodonate solution or 1% iodopyrone solution a
sterile ball with tweezers or forceps
4. Apply tweezers or forceps to the surgeon.
5. Prepare the operational field of a patient.
6. Reset the tweezers or forceps instead of used instruments.
7. Submit your tweezers or forceps with a ball, dipped 1% solution of jodonat or 1%
solution of jodopiron.
8. Process the operational field of a patient again.
9. Cover the patient’s body with sterile sheets of cloths accept the area of future
incision or cut of surgical field.
10. Pin by hoe incision in the area of surgical field.
11. Re-process the patient's operating field with 1% of iodonate solution or 1% of
iodine solution for injection onto the skin (Fig. 6.6).

Fig. 6.6. The stages of operation fields prepping:


а – border zone, b – zone of first lubricating skin with an antiseptic; c – area of second
lubricating skin with an antiseptic, limited to a sterile line, d – оperational field
prepared for surgery.

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6.8.2. Prepping with the solution of chlorhexidine
Chlorhexidine bigluconate (gibitan) is available as a 20% aqueous solution. To process
the operating field, use 0.5% alcohol solution (it is diluted with 70% alcohol in a ratio
of 1:40).
Purpose: adherence to aseptic operative field in a patient.
Equipment:
1) sterile small instrument table;
2) bottle with 0.5% solution of chlorhexidine bigluconate;
3) dressings (cotton balls or napkins);
4) two tweezers or clip.
The sequence of actions.
1. The assistant should pour 0.5% chlorhexidine solution of bigluconate into a sterile
glass.
2. Prepare the sterile table with sterile dressings and 2 tweezers or clip.
3. Give the surgeon a second tweezers with a ball moistened in a glass with a 0.5%
solution of chlorhexidine bigluconate.
4. Clean the operational field of a patient in 1.5 minutes (reset tweezers or forceps into
the waste tool).
5. Give the surgeon a tweezers or forceps with a ball moistened with a 0.5%
chlorhexidine bigluconate solution in the glass to re-process the patient's operating
field for 1, 5 minutes.
6. Cover the patient’s body with sterile sheets by leaving the cut area of surgical field.
7. Pin by hoe incision in the sheet near the area of the surgical field.
8. Re-process the operational field with 0.5% chlorhexidine solution and bigluconate
before suturing on the skin.

6.9. Primary surgical debridement of wounds


The wound is the mechanical integrity of the skin, breaking of the skin or mucous
membrane often with damage of underlying tissue or deeper underlying tissues and
internal organs.
In the course of the wound, the processes are highlighted in the following phases:
1. Phase of inflammation processes, uniting the alteration, exudation, and necrosis.
2. Phase of cell proliferation and maturation of granulation tissue.
3. Phase of scar tissue maturation.

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Currently it is accepted to allocate wounds healing by primary and secondary
intension, as well as healing under eschar.
The first aid at hospital involves stopping bleeding, bandages and (if necessary)
transport immobilization. When expressed arterial or venous bleeding is present, the
place must be pulled with tourniquet.
Clean the skin around wounds, cuticles with solution of iodine; large foreign bodies
are being removed from the wound. In case the site of infection is located in depth of
the wound, it can be reached up with a tool or a finger, but there is a risk of damage of
nerves or blood vessels. Sterile wipes must be imposed on the wound, stack pack of
cotton-gauze pads and remedies depending on the extent of severity of the wound and
its localization. In case of venous and capillary bleeding a bandage should be pressed
on a top to stop the bleeding. When there are open fractured bones, damage to major
blood vessels, nerve trunks, extensive damage to soft tissues, a patient must be
immobilized for transportation. Then a patient is taken to the surgical ward.
There are early primary surgical treatments, performed during the first 24 hours after
injury, lagged two days later, 48 hours after the injury.
Primary surgical treatment must be simultaneous and radical which must be performed
in one step and in the viable tissue should be completely removed. There is a high risk
of anaerobic infections in primarily operated wounded stacked bundles of haemostatic
and extensive shrapnel injuries in which primary surgical treatment is excision of the
edges, the walls and bottom of wounds within healthy tissues with restoration of
anatomic correlations. If the wound is deep and narrow and there are pockets of it
previously extending, the thickness of tissue layer must be removed, (the thickness
varies from 0.5 to 1 cm.) Cut out the skin and subcutaneous tissue around the wound
and prolong the incision of the skin along the axis of the limb along the course of the
neurovascular bundle as long as it is possible to examine all the blind pockets of the
wound and dissect the nonviable tissues. Further the incisions are made through the
fascia and aponeurosis arch. This provides a good inspection of the wound and reduces
the squeezing muscles due to their swelling, which is especially important in case of
gunshot wounds.
After dissecting the wound remove scraps of clothing, blood clots, foreign bodies and
start removing crushed and contaminated tissues.
Muscles are cut out within healthy tissues. Unviable muscles are dark red, dull, do not
bleed on the incision and do not contract with tweezers.
Intact large vessels, nerves, tendons during the treatment of the wound should be
preserved, and contaminated tissues are carefully removed from their surface. Freely
lying in the wound, small bone fragments are removed. Sharp, devoid of the
periosteum, the ends of the bone fragments protruding into the wound are bitten off
with nippers. Upon detection of damaged blood vessels, nerves, and tendons restore
their integrity, when conducting a thorough wound processing of hemostasis. In

159
surgical process if wounds have unsustainable tissue and debris, they must be
completely removed and the wound is sewn up.
Late surgical treatment is performed according to the same rules as early, including
removal of foreign bodies, cleansing wound from dirt, removal of necrotic tissues,
open pockets, stiff hematoma, abscess, to provide good conditions for outflow of
traumatic content. The cutting out of tissues, as a rule, does not occur because of the
danger of generalization of the infection..
The final stage of primary surgical treatment of wounds is the primary suture,
continuity of the regenerative anatomical tissues. Its purpose is to prevent secondary
wounds infection and creating conditions for healing the wounds of primary tension.
The primary suture is applied to the wound in the first 24 hours after injury. It is
usually finished with operational intervention in case of aseptic operations.
Primary-delayed suture is placed in time 5-7 days after primary surgical wounds
treating (before the advent of the granulation), provided that there is no wounds
infection. Deferred seams can be applied provisory as: operation is finished out
loading seams on the wound’s edges and tighten them in a few days, if festering of the
wound is absent.
Secondary sutures are placed after primary surgical treatment, deferred for some time.
It is placed upon the load wound in circumstances where the risk of sepsis in the past
was present. Overlay of secondary seam from several days up to several months after
the injury accelerated healing. An early secondary suture is applied to the granulating
wounds for a period of 8 to 15 days. Edges of the wound are usually mobile, cutting
out isn’t produce.
Late secondary sutures are done in later (in 2 weeks) periods, in case of cicatricle
changes in edges and walls , approximation of the edges, the walls and bottom of the
wounds is impossible, therefore they produce mobilization of edges and excision of a
scar tissue. If there is a greater skin defect, transplantation of the skin must be done.

6.10. Dressing of clean wounds


After removing stickers, doing toilet of the skin around the seam or wounds is
performed. Firstly, soak dry cotton balls in technological ether, cleaning the wound
face. For cleaning you can use traditional alcohol, warm soapy water, 0.5%-s solution
of liquid ammonia. Lassar’s paste is well to be taken off by balls, moistened with
vaseline oil. Skin is rubbed, starting from the edges of the wound to the periphery, not
the other way around. Even the drops of liquid should not enter the wound.
The frequency of dressing phase depends on the nature of the wound and wound’s
discharge quantities. After clean operations with suturing, the first dressing is
performed on the 2nd day to inspect the wound, identify the hematoma, seroma, and
the second - on the 7-9th day, when it is necessary to remove the stitches, or earlier, in
case of a wet dressing and suppuration of the wound.

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Inspection of aseptic wounds with superimposed seams drawing attention to the
emergence of local signs of inflammation (redness, swelling, or ember eruption
seams). In the absence of inflammatory signs and well-lying sutures, the wound along
the seam line is lubricated with 5% alcoholic iodine solution or 1% brilliant green
solution and an aseptic bandage is applied from the gauze pad, which is fixed with a
glue sticker, tubular or usual bandage.

6.11. Dressing of purulent wounds


The dressing of purulent wounds is performed in special rooms for purulent wound
dressings. The frequency of dressing depends on the course of the wound process and
the nature of the discharge. All dressings are done in rubber gloves.
During the wound treatment, painful dressing patient is previously injected 1 ml 1%
solution of morphine or general anesthesia is given. Cut the soiled bandage (bandages)
with scissors away from the wound, unwind the bandage aide, shooting, don’t twist
bandage, since the lower layers may be infected. Do not roll out bandages which are
with blood or pus stains, and cut with scissors which are used for removing bandages
For removal of adhesive plaster strips, they must be moistened, and you should hold
the skin with your hands and then remove them.
Sticker tweezers shoots surgeon performing ligation. In order to do this, a nurse passes
a clip with surgical tweezers. The old sticker is peeled off along the wound from one
end to the other. Removal of the bandages across wounds leads to its hiatus and pain.
While removing the bandage hold the skin by spatula, forceps or gauze ball without
letting it drag on bandage. Firmly attached bandage is contour moistened with
hydrogen peroxide solution or isotonic solution of sodium chloride.
From hand and foot, old adherent dressings should be removed after soaking, if the
condition of the wounds allows you to make a hand or foot bath from a warm solution
of potassium permanganate (1: 4000).
Before the beginning of the procedure, the bath is smeared with alcohol, a solution of
pervomur or washed with hot water with synthetic detergents. Then, warm water is
poured into the bath (38-40°C) and a few drops of a 30% solution of potassium
permanganate are added until a strong pink color is obtained. The limb is immersed for
5 minutes with a bandage on it. After removing the bandage, the limb is taken out of
the water, the bandaging material is picked up by the forceps and dropped into the
washbowl.
The surgeon inspects the wound and processes it. The water from the bath is poured
into sink intended for washing instruments. The bath is washed with hot water with
synthetic detergents, washed with disinfectant and stored in a dry form.
If there is a significant contamination of the skin around the wound, you can protect
the wound surface with a sterile gauze cloth, thoroughly wash the entire limb with

161
soap, and if the wound suppurates, this procedure must be performed during every
dressing.
Clearing the skin of the wound, and then its treatment with iodine and alcohol, iodinol
or other coloring antiseptics. Cleaning the skin around the wound is the first condition
of successful treatment. In addition to cleaning, handling of local hyperemia,
positively affects the trophic of the postoperative seam and accelerates healing.
Treatment of wounds includes removing the wound discharge from it (blood, pus,
serous fluid) or intestinal contents, bile, urine, etc. Balls, tampons, napkins are used to
dry it. The wound is washed with an antiseptic solution with a spray from a syringe, a
bulb, or simply poured into the wound and then dried, wetted with gauze tampons
Antiseptics are used. For these purposes 3% solution of hydrogen peroxide is
preferred, when it comes to contact with a wound discharge, foam is formed that
contribute to removal of discharge from the wound. The foreign materials are removed
from a wound with tweezers or washed away. Such nonviable tissues may be
presented as bone sequesters in osteomyelitis or rejected necrotic tissue.
In case of treatments with the use of physiotherapy, irrigation or insufflating
antibiotics and other drugs, introduction of antibacterial and haemostatic sponges.
Validates the status and effectiveness of the functioning of the drains and tampons, and
if necessary, correct, delete or replace them. Since the gauze pad provides the drainage
function for just a few hours, with a large number of discharges, together with it or
separately a rubber or silicone tube is inserted. Drain tube can be connected to a
vacuum system for drainage.
The period of tampons staying in the wound can be different. The tampon
administered for hemostasis is removed 2 to 4 days after the tamponade. Tampons,
being introduced in the abdomen during the operation, must be removed on the 5-8-th
day after the operation. Indication for immediate removal of a tampon is bleeding from
under it or accumulation of pus underneath. Swabs, wetted with antiseptics,
antibiotics, are removed (or changed) usually within 1-2 days.
Therapeutic measures for dressing wounds with fistulas are of particular importance.
The constant contamination of the skin with intestinal contents, pancreatic juice, bile,
urine, pus leads to its maceration, inflammation (pyoderma, furuncles, erysipelas, etc.)
and ulceration. To reduce the penetration of the skin to be separated from fistulas,
obturators, pelots, ointment dressings, etc. are used.
In the end of treatment and diagnostic procedures produce toilet again the skin around
the wound. When bandaging wounds, complicated fistulas, macerated skin cuticles
make 10% solutions of tannin or 3-5% solution of potassium permanganate, 1%
alcoholic solution of methylene blue and put on it Lascar’s pasta, zinc ointment or
powder its calcined gypsum or chalk powder, talcum powder; treatment of your skin
can also be cerigel, glue WP-6 creating a protective membrane. In severe cases, skin
changes and expressed inability to ensure its protection have resorted to open, without
dressing fistula treatment method.

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Final manipulation is the imposition of dressing. Dry aseptic gauze bandage is placed
on a fresh wound, when providing first aid, after surgical treatment of wounds with dry
swabs or drains, with fistulas. The festering wounds in hydration phase generally
humid-dryings bandages with antiseptic solutions (furacilin, rivanole, chlorhexidine,
iodopiron, hypochloride). In the phase of dehydration applied ointment dressing
(“levomekol”, “levasin”). In epithelialization phase apply ointment dressings that
promote growth of the epithelium (“solcoseryl”, “actovegin”). In case of long-term
bandages, a second layer is often applied on the top of a layer of absorbent cotton to
prevent the bandage from getting wet.
In accordance with the rules of asepsis, first of all, patients after surgery are dressed
with a smooth course of the wound process, then the patients with suspected
inflammation in the wound. Patients with purulent wounds are dressed in special
dressing rooms.

6.12. Application of bactericidal dressings


Treatment and care of chronic wounds, bedsores, trophic and diabetes ulcers is an
important problem in surgery. There are three phases of healing: inflamation phase,
proliferation and remodeling. First phase is characterized by the presence of necrosis,
sites of fibrin and the presence of infection in the wound, which is manifested by pain,
hyperemia, edema and purulent discharge (Fig. 6.7).
For the treatment of wounds in the first phase, the following wound coverings:
“atrauman”, “tenzfervet”, “aquasel”, “algipore”, “algimaf”, “sorbsan” are used.

Fig. 6.7. The picture of the first phase of the wound process.
These coatings have a high sorption and draining ability, turning on contact with the
wound contents in the gel.
Sequence of application:
Open the sterile inner package and remove the dressing.
After removing one layer of protective paper put a bandage on the wound, then
remove the second protective layer of paper (Fig. 6.8).

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Fig. 6.8. Application of bactericidal bandages in the first phase of the wound.
The second phase of the wound process is characterized by decreasing inflammatory
processes, reduced exudation, filling the wound by wound matrix and granulation
tissue (Fig. 6.9).

Fig. 6.9. The picture of the second phase of the wound process.
To cover the wounds, the following coatings are used: “hydrosorb”, “permafoam”,
“intrasite”, “granule” and “terabsorb”. Sorption capacity of hydrocolloidal coatings is
low. The hydrocolloid sorbs the wound secret, passing into a jelly-like state and
preventing secondary infection.
Bandage application technique:
Choose the size of a bandage so that it protrudes beyond the edges of the wound.
Remove the foil, put a bandage on the wound, place and secure the plaster (Fig. 6.10).

Fig. 6.10. Bandages application technique in the second phase of the wound process.
Epithelization of the wound is the next event in the wounds healing by secondary
intention (Fig. 6.11).
164
Fig. 6.11. The picture of the epithelization.
For the treatment of chronic wounds in the third phase of the wound, apply the
following wound coverings: “hydrofim”, ”teraderm”, “nikoderm”, “foliderm”,
“transajt”. Membranous coatings have barrier function against microorganisms and
permeability for water vapor and oxygen.
Application technique:
Select the bandage with the size according to the wound.
Remove the protective layer.
Cover with absorbent wound dressing and secure with a bandage or plaster (Fig. 6.12).

Fig. 6.12. Application technique of bandages in the third phase of the wound process.

6.13. Care of patients with colostomy or ileostomy


Surgical treatment of many diseases of the colon, in spite of the success of
coloproctology and oncology, involves the formation of colostomy. Such operations
are performed to save patients’ lives when it is impossible to do otherwise.
Unfortunately, due to the increasing number of such diseases the number of stomy
patients increases worldwide. According to the statistics of the World Health
Organization for a thousand people, on average, there is one stomy patient. Focusing
on these data, the total number of patients with colostomy in Russia range from
100000 up to 120000.
In order to understand what is colo- and ileostomy, it is necessary to know the
functioning of the digestive tract. The eaten food passes from the stomach into the
small intestine. Here the nutrients are exposed to absorption. Undigested residues pass

165
to the large intestine. As they move to the large intestine active water extraction
process occurs, resulting in a food lump becoming increasingly of dense texture. The
distal part of the colon is the rectum, ending with the anus. Since digestion occurs
before food enters the large intestine, patients can live and eat without colon
(Fig. 6.13).

Fig. 6.13. Anatomic features of the digestive tract.


A colostomy is a surgical procedure in which an opening (stoma) is formed by
drawing the healthy end of the large intestine or colon through an incision in the
anterior abdominal wall and suturing it into place. This opening, in conjunction with
the attached stoma appliance, provides an alternative channel for feces to leave the
body. It may be reversible or irreversible depending on the circumstances. Types of
colo-and ileostomy are shown in Fig. 6.14.

Fig. 6.14. Types of colo-and ileostom.


Immediately after surgery, intestinal stoma may be somewhat edematic or swollen, so
edges will not be visible well. Stoma will diminish in size until the act over the surface
of the skin evenly so that the faeces fall directly into incontinence bag. Stoma has no
nerve endings and therefore a patient is not sensitive to pain, so care must be
undertaken with caution, so that you don't accidentally damage it. Typical colostomy
locations are shown in Fig. 6.15.

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Fig. 6.15. Typical locations of colostomy stomas.
The word “ileostomy” comes from two Greek words "ileum"-ileum and "stoma"-hole.
Ileostomy is an operation in which healthy ileum end is displaced on the surface of the
abdomen and fixed there with the formation of new openings for removing the
contents of the bowel. Ileostomy may be permanent and be established only at a time.
Followed by reconstruction of the digestive system to preserve its ability to work
physiological. Ileostoms are typically positioned in the right lower abdomen, if during
the operation the surgeon decides that a different location stoma is preferred.
Colostoma word comes from two Greek words: "colon"-the colon and "stoma"-hole.
Colostomy is a result of the fact that the open end of the healthy colon appears on the
surface of the abdomen and is fixed there, forming a new outlet for toxins from the
body. After that, the digestive system is reconstructed to preserve its ability to work
physiologically. A colostomy is usually featured on the left side of the abdomen,
however, it may on be right.
Colo-ileostomy or creation requires further care of ostomy with incontinence bag.
Frame of incontinence bag depends on what type of incontinence bag is used. Single
component adhesive incontinence bag is changed when the content level reaches the
level of the half mark, or when the patient starts to feel the inconvenience. You should
avoid permanent and unnecessary necessity shifts, because you can damage the skin
and cause irritation (Fig. 6.16).

Fig. 6.16. Skin irritation around the stoma.


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There are several different types of ostomy applications: single, two-component,
transparent, matte, with filters and without filters (Fig. 6.17).
Single-component ostomy bag have a bag to collect faeces, compactor and external
adhesive ring in a single solid block. Two-component ostomy bags consist of a bag
that is attached to the adhesive plate that runs a function of "second skin".
Incontinence minimal is used for a short time (for example, for sports). Stoma cap,
closes the stoma, but does not have the capacity.
If you use a two-component system, label the plate and leave it for 3-4 days, and close
or change upstream-vented valve bag when it is convenient.
Equipment necessary for ostomy care:
1) new stoma bag (the proper type and size);
2) ruler (stencil) to check if the size of the stoma has changed or not;
One-component system Two-component system

Fig. 6.17. Types of ostomy poach.


3) additional materials: zinc paste, paste of Lassar’s;
4) gauze napkins;
5) package for used ostomy bag;
6) scissors (preferably with one rounded end and the other one sharp);
7) replacement clamp (drained of ostomy applications).
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Technique of changing ostomy bag:
1. Prepare clean incontinence bag. Use scissors to enlarge the center hole of the plate
so that it neatly contain stoma in itself.
2. Carefully separate the used ostomy bag from the top. Trying not to pull the skin
(Fig. 6.18).

Fig. 6.18. The removal of ostomy bag.


3. Put the used incontinence bag in the package.
4. Wipe the skin around the stoma, using dry gauze napkins.
5. After that, using warm water and napkins wash out the skin around the stoma
(Fig. 6.19).

Fig. 6.19. Toilet of colostomy.


6. Get wet wipes to dry the skin around the stoma (do not use cotton wool, it leaves
fluff!).
7. If there is a maceration of the skin around the stoma, apply protective zinc paste or
paste Lassar’s.
8. Using your measurements, check whether there is any change in the size and shape
of the stoma.
9. Fix clean incontinence bag on the stoma, using the manufacturer's instructions
(Fig. 6.20).

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Fig. 6.20. Application of a ostomy bag.
In adhesive (which were glued) ostomy bag you need to remove the wrapping paper,
place the center hole over the ostomy and press evenly, making sure that the plate is
smooth and has no wrinkles. Check the correct location (hole down) of drain hole in
the bag and position the retainer in the closed position (Fig. 6.21).

Fig. 6.21. Fixing the drainage holes of a ostomy bag.


Scissors are used to cut off the lower part of the bag and empty the contents into a
toilet. Next ostomy bag should be washed under water and thrown into a garbage
container.

6.14. Treatment of bedsores


Pressure ulcers (bedsores, decubitus ulcers), are localized damage to the skin and/or
underlying tissue that usually occur over a bony prominence as a result of pressure, or
pressure in combination with shear and/or friction. The most common sites are the skin
overlying the sacrum, coccyx, heels or the hips, but other sites such as the elbows,
knees, ankles, back of shoulders, or the back of the cranium can be affected as well
(Fig. 6.22).

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Fig. 6.22. The most common sites of bedsores.

With a patient lying on the side of the bed sores can develop in the area of the hip joint.
The skin initially turns cyanotic red color without clear boundaries. Then the epidermis
(surface layer of the skin), exfoliates often with the formation of blisters. Further there is
necrosis of tissue that spreads inside and outside, deep bedsores the bare muscles, tendons,
periosteum are affected.
Actions to prevent bedsores:
1. Every 2hrs change the position of a patient, examining the sites of possible bedsore
formation.
2. Re-make the patient´s bed, ensure that his sheet has no crumbs, folds.
3. If a patient has wet clothes or dirty clothes change clothes immediately.
4. Under the sacrum and coccyx, place a rubber circle, placed in the case, and under heels,
elbows, neck-cotton-gauze circles.
5. Use anti-bedsore mattress.
6. In the morning and in the evening, wash the sites where bedsores are most often
formed, with warm water and wipe them with a cotton swab dipped in 10% solution of
camphor alcohol, 0.5% with ammonia solution, or 1-2% with tannin in alcohol, 1% with
salicylic alcohol solution, or diluted table vinegar. Wiping the skin with the same tampon,
you need to do a light massage.
7. When you see bedsores (skin redness) 1-2 times daily lubricate the skin with 5-10%
solution of potassium permanganate.
The formation of bedsores is treated according to the principles of conducting purulent
wounds. The first step is to conduct a partial processing of purulent surgery, which
consists of excision of necrotic tissue. After washing the wound with antiseptic (furacilin,
hydrogen peroxide), napkin with ointment "Levomekol" is placed inside the wound.
Every day, dressings are made with the purging of the purulent wound and the application
of ointment dressings ("Levomekol", dioxydinic, iodopyron ointment). After cleansing the
purulent wound and filling it with granulations, apply gel bandages with 2% fusidin,
"Pronosan", "Appolo", which include iodovidone or miramistin. When epithelization
occurs in the third phase of the wound process, it is advisable to use stimulating ointments
(solcoseryl, actovegin), wound coverings "Algipor", "Digispon", "Collachitis".
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7. CHAPTER 7. CARDIO-PULMONARY RESUSCITATION AND
ANESTHESIA

7.1. Indications to CPR


Cessation of blood circulation: After the heart stops, the blood circulation stops and
vital organs do not receive oxygen. Agonal type ineffective respiration (gasping)
appears early with the stoppage of blood circulation and can lead to error with the
estimation of the effectiveness of respiration. Since non-professional rescuers are
oriented towards the dynamics of respiration during the stoppage of blood circulation,
it is necessary to be trained in differential diagnostics of adequate and inadequate
respiration. The following disturbances in the rhythm of the heart accompanying the
cessation of blood circulation are known: fibrillation of ventricles, ventricular
tachycardia, asystole, electromechanical dissociation.
The cessation of respiration is the result of a number of reasons including; drowning,
stroke, the entry of foreign bodies in the respiratory tract, inhalation of smoke, the
overdose of narcotics, suffocation, injury, myocardial infarction, and the coma of
various etiologies. When the primary cessation of respiration occurs, the heart and
lungs continue to oxygenate the blood for several minutes and the oxygen continues to
enter the brain and other organs. Such patients for a while show the signs of the
presence of blood circulation. In the case of the stoppage of respiration or in
inadequate respiration, resuscitation is the only life saving measure that can prevent
the stopping of the heart.
In adults the sudden death in case of non-traumatogenic etiology, invariably, has
cardiac origin. Basic terminal cardiac rhythm fibrillation of ventricles is present in
80% of cases. For this reason the most significant and determining factor of survival in
adults is the temporary phase, which is passed from the moment of a drop in the
arterial pressure to the recovery of effective cardiac rhythm and pressure. In
accordance with the international recommendations – to the moment of fulfilling the
electrical defibrillation as the leading component in “the chain of survival”. In
addition- to this, the early beginning of conducting of CPR increases the chances of a
victim’s survival.

7.2. The sequence of the basic resuscitative measures


Establishment of the absence of consciousness in a victim.
Restoration and the guarantee of patency of the respiratory tract.
Estimation of the effectiveness of the respiration of a victim.
Estimation of blood circulation.

7.3. The establishment of the absence of consciousness in a victim


Persistent loss of consciousness is determined by the close examination of a victim
with reference to universal clinical manifestations, which may be different according
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to its etiology and underlying pathology. It is necessary to be convinced of the fact that
if a victim has stably lost consciousness (with the aid of the loud verbal appeal, easy
shaking of the patients shoulders). If consciousness does not return, it is necessary to
undertake fast medical aid quickly (in many countries this point is carried out during
the establishment in the victim of the absence of respiration)

7.4. Restoration and the guarantee of the respiratory tract patency


Introduction of air through the mouth and through the nose. If a victim is without
consciousness, to rescue him it is necessary to estimate the state of his respiratory tract
whether blocked or clear and effectiveness of respiration. For this purpose lie down a
victim in the supine position on a relatively hard surface, which allows effective
compression of the sternum.
The position of a victim for conducting resuscitative measures and increasing
their effectiveness; the victim must be located in the position on the spine on the solid,
flat surface. If the victim lies facing downwards, he must be accurately and with great
care turned onto his back so that then being turned; his head, arms and body seem
unified as a whole, without twisting (preventing additional injury during the turning ,
possibly adding to existing damages).
The position of the rescuer must be positioned with respect to the victim in such
a way that he could conduct artificial respiration, and the indirect massage of the heart
(desirably to the right side from the victim).
The restoration of the respiratory tract patency with the absence of
consciousness in the victim, his muscular tone and body language is reduced;
epiglottis can cause the obstruction of larynx. The retraction of the root of the tongue
is the most frequent reason for the blockage of the respiratory tract in victims without
consciousness (Fig 7.1.a).

Fig. 7.1.a. Airway obstruction by the tongue.

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During the attempting of inhalation, the tongue and epiglottis can cause
obstruction with the creation of vacuum in the victim; the valvular type of obstruction
is created. Since the tongue is anatomically connected with the lower jaw, the
advancement of the latter is accompanied by the forward displacement of tongue from
the anterior wall of the throat and by the opening of the respiratory tract. In the case of
absence of information about the injury of the head or the neck, the method “the
throwback of head - the advancement of lower jaw”, head tilt is used. In this case it is
necessary to remove the visible foreign bodies from the mouth (blood clots, emetic
masses, dental prostheses). To remove liquid from the mouth it is necessary to rapidly
remove it with the aid of your finger wrapped by any cloth (shawl, napkin)
“Head-tilt” method. With one hand, placed in the forehead of the victim, the latter
throws his head back simultaneously with his second hand on the chin of the victim
(the advanced lower jaw), raises it, which completes this method. In this case the head
is retained in the thrown back position with the elevated chin and almost enclosed
teeth. It is necessary to open the mouth of the victim slightly for facilitating his
spontaneous respiration and to prepare for the respiration “from the mouth to the
mouth”. This method (that was previously described as “triple reception of Peter
Safar”) is the method of selection during the restoration of the respiratory tract patency
in victims without the suspicion to the injury of the neck division of the spine
(Fig. 7.1.b).

Fig. 7.1.b. “Head-tilt” method of airway opening.


The “Jaw thrust” method is a limited method, achieved without the throw back of the
head, must be mastered by both the professional rescuers and by professionals. The
method of the advancement of the jaw without “the throwback of the head” of the
victim is the safest initial action with the suspicion to the injury of the neck division of
the spine (divers, persons dropped from a height, have some forms of auto-
injury), since it is carried out without straightening of the neck (Fig. 7.2).

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Fig. 7.2. “Jaw-thrust” method of airway opening.
It is necessary to attentively fix the head without turning to the sides and thereby
affecting flexures in the neck division, if, in case, it happened the real threat is
doubling the damage caused to the spinal cord. If the victim is unconscious after the
guarantee of the respiratory tract patency, the respiration is
restored and the signs of blood circulation appear (pulse, normal respiration, cough or
motion) it is possible to orient the victim to “recovery position” (recovery position) or
steady the victim’s position on the right side (Fig. 7.3).

Fig. 7.3. Recovery position.


Recovery position (steady position on the right side) is used for maintaining the
victims without consciousness (for the period of the expectation when emergency
medical aid arrives), but preserving respiration and signs of blood circulation and in
the absence of suspicions to the injuries of internal organs and damage of extremities.
The position of the victim on the spine is fraught with the repeated disturbance of
respiration and with the danger of aspiration, for example, in stomach contents. The
position of victim on the stomach worsens his independent respiration, since the
mobility of the diaphragm is limited and the compliance of the lung tissue and chest is
decreased.

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Thus, the recovery position is compromised and minimizes the risk of the
complications development described above and simultaneously making it possible to
ensure observation of the victim.

7.5. Introduction of the oropharyngeal airway through the mouth


The types of the air ducts, intended for the introduction through the mouth are
represented in Fig. 7.4.

Fig. 7.4. Types of oral airway.

Indications:
Complete or partial obstruction of the upper respiratory tract.
Compressed jaws in patients in an unconscious state or in intubated patient’s.
Need for aspiration from the oropharynx.
Contraindications:
Breaking of jaws or teeth.
Presence in anamnesis or the sharp episode of bronchospasm.
Anesthesia: local irrigation with 10% solution of Lidocaine for the oppression of
emetic reflex.
Equipment:
Plastic or supplied with soft edge air duct.
Spatula.
Electrical suction pump.
Position: lying on the spine or on the side
Method:
Open mouth and press by the spatula on the base of the tongue; displace the tongue
forward from the throat.

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Introduce the air duct into the mouth by concave side of the chin so that its distal end
would be sent, but it does not reach the rear wall of the oropharynx; the flange of air
duct must protrude 1-2 cm from the incisors.
You will use the method of removal of the lower jaw, ensuring lifting of the tongue
from the wall of the throat.
Press on the air duct and move forward to 2 cm into the mouth so that its bend would
lie on the basis of the tongue.
As convention, airway can be introduced by concave side (Fig. 7.5).

Fig. 7.5. The introduction of airway


through the mouth.

After its end reaches the uvula (in this case the spatula is not used); turn the air duct
to 180° and further move forward on the tongue. This method is not recommended, if
the patient has lost teeth or the injury of the oral cavity, since the turning of the air
duct can cause the displacement of the teeth or strengthening hemorrhage.
Complications and their elimination:
The development of bronchospasmic reaction - support the patency of the respiratory
tract.
Nausea or vomiting - turn the head sideways and conduct aspiration.
The redoubling of the respiratory tract obstruction because of the incorrect
arrangement of the air duct - remove the air duct and introduce it again, if there is a
need in it.

7.5.1. The introduction of the nasopharyngeal airway through the nose


The types of the air ducts, intended for the introduction through the nose are
represented in Fig. 7.6.

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Fig. 7.6. Types of nasal ducts.

Indications:
Obstruction of the upper respiratory tract in patients with preserved consciousness.
Injury of teeth or oropharynx.
Inadequate disclosure of the respiratory tract after the introduction of oral air duct.
Contraindications:
Occlusion of the nasal cavity.
Fracture of nose and base of the skull.
Bend of the nose septum.
Coagulopathy.
Escape of cerebrospinal fluid from the nose.
Transfenoid hypophysectomy in anamnesis.
Forming of rear pharyngeal for closing the defect in anamnesis.
Pregnancy (in connection with the vascular stagnation in the nasal cavity after the first
term).
Anesthesia:
You will visually estimate the degree of the patency of the nostril
(relative size, the presence of hemorrhage or polyps) or conduct the following test.
It is necessary that the patient would breathe out through the nose to the small mirror
or to the blade of laryngoscope. A larger size of the spot of condensation indicates a
more passable nostril.
For guaranteeing of the local anesthesia and vasoconstriction in the nose; a mixture of
the following composition is used: 10 ml of phenylephrine in 10 ml of 2% gel of
Lidocaine.

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Introduce tampon on the rod into the selected nostril and wait for the onset of local
anesthesia
You should carefully consecutively introduce tampons on the rod deeper
into the nostril, until three tampons are located simultaneously on the level of
the rear wall of the nose, without causing significant inconveniences to the patient.
After the use of this procedure; packing of the air duct usually succeeds in conducting
through the cavity of the nose 7.5 mm.
The lidocaine can be introduced by a syringe directly into the nasal cavity when
tampons cannot be used,
Equipment:
Wadded tampons on the rod.
Nose air ducts of different calibers (usually from 6.0 to 8.0 mm), 2% gel of Lidocaine.
Phenylephrine.
Electrical suction pump
Position: lying on the spine, on the side, sitting.
Method:
1. Carefully introduce the air duct into the nose by the concave side to the hard palate.
2. Carry out the air duct into the nose (Fig. 7.7).

Fig. 7.7. The introduction of air through the nose.

3. If it meets with resistance in the posterior pharynx, carefully turn the air duct to
60-90° and continue to introduce it into the opening; turning of the air duct on 90°
counter clockwise may also be useful by its subsequent return to the initial position
after its passage through the opening.
4. If the air duct does not pass with the average effort, use a lesser caliber.
5. If the air duct does not move, extract it on 2 cm, and you will pass through its small
catheter for the aspiration, then attempt to introduce the air duct, using a catheter as the
conductor.
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6. Even if this does not lead to success, repeatedly process the nasal cavity or attempt
to introduce the air duct from the other side after the appropriate work.
Complications and their elimination:
 Nasal haemorrhage - tamponade with the surface hemorrhage, the consultation of
an ENT-doctor for conducting back tamponade.
 The perforation of mucosa with the forming of submucous channel – remove the
air duct. The aid of plastic surgeon can be required by the patient.

7.5.2. The estimation of respiration effectiveness in the victim


To estimate the presence and effectiveness of the independent respiration of the
victim put your the ear near the mouth and the nose of the victim, simultaneously
controlling the excursion of the chest, and listening and perceiving movement of
exhaled air (Fig. 7.8).

Fig. 7.8.
Conducting the estimation of respiration should be done rapidly, no more than for
10 seconds! If the chest is not straightened and does not fall and air is not breathed out
- the victim does not breathe. In such a case if the victim does not breathe, or his
respiration is inadequate (agonal type), or there is no confidence in the effectiveness of
the respiration of the victim, it is necessary to begin conducting artificial respiration.

7.6. Artificial respiration


Respiration “from mouth to mouth”. This type of artificial respiration is a rapid and
effective means of delivering oxygen and replacing the respiration of a victim. Air
exhaled by the rescuer contains sufficient oxygen for maintaining the minimum needs
of the victim (approximately 16-17% of oxygen reaches the victim, in this case the
partial stress of O2 in the alveolar air can reach 80 mm Hg).
Immediately after the restoration of the respiratory tract patency the rescuer must shut
the nasal passages of the victim with two fingers of his hand, which fixes the head of
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the victim in the thrown back position. Having taken a deep inhalation, put lips over
victim’s mouth and breath out (no longer than 2 s) (Fig. 7.9).

Fig. 7.9. Mouth-to-mouth ventilation.


The recommended respiratory volume in the majority of adults is approximately
10 ml/kg (700-1000 ml) with the frequency of 10 per minute (1 cycle each 4-5 s).
From the very beginning of CPR from 2 to 5 breaths in a row should be carried out.
The basic criterion in this case remains on the excursions of the chest, without blowing
off the epigastric region (evidence of air entry into stomach). The latter can cause
serious complications, such as regurgitation and aspiration of stomach contents,
pneumonia. Furthermore, the increased pressure in the stomach, leads to the raising of
the diaphragm, limiting the excursion of lungs that decreases the respiratory system
compliance. The entry of air into the stomach occurs during the exceeding of pressure
in the gullet above the opening pressure of the lower esophageal sphincter. The
probability of air entry into the stomach increases with the stopping of the heart, when
the lower esophageal sphincter relaxes. Furthermore, there are factors, which facilitate
the entry of air into the gullet and stomach: short period of inhalation, large respiratory
volume, and high peak pressure on inhalation.
Thus, to decrease the risk of air entry into the stomach with respiration from the
mouth to mouth is possible to carry out slow inhalation with the recommended
respiratory volume, being guided by the visual stimulation of the excursions of the
chest with each inhalation. The method of respiration “from the mouth to the nose” is
less preferable, since it is even more labor-intensive and less more effective because of
the increased resistance of the inhalation through the nasal passages. It can be an
alternative method with the impossibility (injury) of respiration from the mouth to
mouth.
The essential deficiencies in the method of respiration “from mouth to mouth”
carry the dangerous infections of a man, who conducts the respiratory resuscitation
(HIV-infection, the viruses of hepatitis B and C, cytomegalovirus, pathogenic
bacteria). Although the benefit of the timely rendering aid with the cessation of
respiration and blood circulation considerably exceeds the risk of the second infection
of the rescuer or a patient, this risk will be still less, when conducting CPR or
instructing the basic methods, in the following simple measures of the preventive
maintenance of infections it taken into consideration. To secure oneself from the

181
possible contact of infections; is possible with the aid of devices, which make it
possible to protect the rescuer both from the direct contact with the tissues of the
victim, and from air exhaled. They include different types of simple single-time use
facial masks with the valve of uni-directional (non-reversible type) airflow (“the key
of life” and other), recommended in essence for the non-professional rescuers,
S-shaped air duct, oropharyngeal mask with the facial obturator, esophageal-tracheal
obturator and other professional equipment. Furthermore, there is a specific
psychological barrier for conducting this method of reanimation.
The additional and effective methods of restoration and maintaining the patency of the
respiratory tract is the use of a laryngeal mask and combined tracheal-esophageal tube
(combitube). In particular, the construction of the laryngeal mask (Fig. 7.10.a) makes
it possible to establish it “blindly” and separate the respiratory tract from the throat and
gullet, to conduct artificial respiration, and also to achieve toilet of the trachea-
bronchial tree through its opening.

Fig. 7.10. The laryngeal mask.


Typical errors and complication when conducting artificial respiration.
The most common mistake made by newly trained rescuer or lifeguard maybe
sometimes that they forget to tightly close up the victim’s nose while conducting
respiration from mouth to mouth. This will indicate the absence of excursions of the
chest. The second, most common error is the un-removed retraction of the root of the
tongue in the victim, which can make further benefits impossible and air will begin to
enter the stomach instead of the lungs, it is indicated by the appearance and growth of
buckling in the epigastric region.
Simultaneous air intake into the respiratory tract and stomach is the most frequent
complication when doing artificial respiration. This is as a rule, connected either with
the excess respiratory volume or with rapid (less than 1.5-2 s) inhalation. Blowing into
the stomach can cause regurgitations with the subsequent flowing of the stomach
contents into the upper respiratory tract. Position of the victim on the back and the
attempt to free the stomach from air (especially if a victim’s stomach is full) by the
manual compression in the epigastric region both provoke regurgitation. If blowing
into the stomach has occurred, turn the victim to any side and with a sufficient thrust
remove it from the stomach. The benefits pointed out above must be carried out only
in the side-lying position of the patient and available suction machine.

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7.7. Obstruction of the upper respiratory tract by foreign bodies
The complete obstruction of the respiratory tract by foreign bodies without rendering
to special aid results in lethal outcome during several minutes. The most frequent
“internal” reason for the obstruction of the upper respiratory tract in victims of those
being located without the consciousness is the retraction of the root of the tongue and
closing of epiglottis. “External” reasons for the obstruction can serve foreign bodies,
blood clots with the injury of the head and the face, emetic masses, which now and
then is difficult to diagnose, especially if the patient is unconscious. The most
frequent reason for the development of the obstruction of the respiratory tract in adults
in the consciousness - is the entry of foreign body during food intake. The piece of
food can cause partial or complete obstruction. In this case the timely establishment of
the true reason for sharp respiratory disorders is the key moment, which determines the
outcome of a similar extreme situation. It is necessary to differentiate the entry of
foreign body with fainting, stroke, heart attack, assault of bronchial asthma. In the
West the cases of aspiration in the restaurants, erroneously taken for the heart attack,
even were called “coronary syndrome of cafe”.
Partial obstruction can flow with the satisfactory and disrupted gas exchange. In
the first case the victim has the capability for forcing the cough, without the explicit
signs of hypoxia, and secondly are noted weak, ineffective cough, noisy respiration,
appearance of cyanosis. Such obstruction must be managed as the complete one.
The man is not able to speak, to breathe and to cough with the complete obstruction. In
this case the pose of the victim is sufficiently eloquent for those surrounding
(Fig. 7.11).

Fig. 7.11. Complete airway obstruction.


The refusal of special aid leads to a rapid drop in blood oxygenation , loss of
consciousness with the subsequent cessation of blood circulation. Formerly popular
method of airway clearing by hitting the back of the victim is not advisable. The most
183
popular method is the Heimlich maneuver, known also as “sub-phrenic abdominal
compression” or “abdominal compression” or method of abdominal thrusts.
The essence of this method consists of the following: abdominal compression is
accompanied by the increase in the intra-peritoneal pressure and by lifting diaphragm,
which leads to the pressure increase in the respiratory tract and strengthening of the air
outlet of their lungs, seemingly artificial cough is created which also contributes to the
removal of the foreign body. The method of Heimlich is conducted as follows: The
rescuer must be located with respect to sitting or confronting the victim from the back
side, envelop the victim under his hands and close his hands in such a way that one
arm, assembled into the fist, would be arranged along the center line between the
xiphoid branch and the navel, and the arm of the second hand covering the first
(Fig 7.12).

Fig 7.12. Heimlich’s manoeuvre.


Rapid abdominal compressions (towards yourself and somewhat upward) are
performed until it removes the foreign body or until the victim loses consciousness.
In the case of failure and loss of consciousness of the victim by nonprofessional
rescuers, after patting the victim to the back, one should begin conducting CPR,
accentuating attention to the indirect massage of the heart, the compression of the
chest is accompanied by an increase in the intrapulmonary pressure, which also
contributes to the removal of a foreign body. In this case it is necessary to periodically
visualize, also, with the aid of the index finger to control the presence of foreign body
in the oropharynx of the victim and to attempt to move away by his fingers or by
clamp (Fig. 7.13).

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Fig. 7.13. Airway cleaning.

Professionals, in the case of the victim’s loss of consciousness, must verify the
presence of a foreign body in the oropharynx, by conducting methods on the
restoration of the respiratory tract patency.
In an attempt of artificial respiration, in the case of failure in the Heimlich manoeuvre
it is necessary to perform 5 compressions in the manner that this is shown in
Fig. 7.14, then again to verify the presence of a foreign body in the oropharynx and to
conduct artificial respiration.

Fig. 7.14.
If a foreign body is removed, then it is necessary to continue artificial
respiration before the restoration of free air flow. Thus, for the Heimlich
manoeuvre, they recommend to train non-professional rescuers with rendering aid to
the victim at an early period, beginning from the 1st year.

185
For professional rescuers the method of Heimlich is recommended to be carried out
even if the victim is unconscious. Even with the correct conducting of this method
complications are possible. More frequent ones are connected with the regurgitations
and aspiration of stomach contents, it is thinner with the damage of internal organs. If
Heimlich’s manoeuvre fails a conicotomiya has to be considered. Tracheostomy, even
in the experimental hands, requires the specific time, while conicotomiya can be
executed during several tenths of a seconds.

7.8. The estimation of blood circulation


Beginning from the first recommendations regarding the reanimation dated 1968; “the
gold standard” of the establishment of the heart work was the determination of the
pulse. On the CPR standard of that time, the absence of pulse indicated the stopping of
the heart and required the beginning of indirect massage Since 1992, as a result of
special studies conduction, they made the conclusion that the use of determination of
the pulse as the criterion of the heart stopping has serious limitations exactly,
sensitivities and specificities, especially for the non-professional rescuers. As a result,
the conference of 2000 does not recommend the professional to lose time for the
determination of the pulse on the carotid arteries, to determine cardiac arrest in the
victims during the CPR process. They must be trained to estimate the blood circulation
according to the indirect signs - presence of normal respiration or in the case of its
absence - cough and motions in the victim in response to the artificial respiration
conducted by the rescuer. Professional life-rescuers must continue to be oriented
towards the carotid pulse (spending on this no more than 10 seconds!), in combination
with the evaluation of other signs like respiration, cough, motion (Fig. 7.15).

Fig. 7.15. Checking carotid pulse.


In conduction the heart indirect massage, two methods of the heart massage are
known: opened and closed (indirect, external). The procedure of the open massage of
the heart is not examined, since it is possible only with the opened chest, in particular,
during the cardio-thoracic operations. Ideas about the mechanisms of the indirect

186
massage of the heart in the recent years underwent substantial changes. Studies of the
last 40 years helped to understand the mechanisms of blood circulation with the
compression of the chest. Both in the experiment and in the clinic it was shown that
two mechanisms were responsible: the mechanism of the direct compression of heart
(heart pump) and, the so-called, breast pump. And therefore, it is more right to speak
about the external massage of chest nowadays and not about the closed massage of the
heart. One or another mechanism influences CPR duration. Thus, with a short
duration of the CPR the mechanism of the heart pump predominates. But if the CPR is
conducted for a prolonged time, the heart gradually becomes less yielding and the
mechanism of breast pump begins to pre- dominate. However, the heart emission in
this case is considerably reduced. During the stopping of the heart, with the correctly
conducted external massage, lifting the peak systolic arterial pressure can reach
60-80 mmHg; however, diastolic pressure in this case remains low. The pressure in the
carotid artery rarely exceeds 40mm Hg as a result, the heart emission composes only a
fourth or third from the normal; and on the process CPR is continuously reduced.
Experimental and clinical studies testify in favor of conducting indirect massage in
adults with the frequency of the 100 chest compressions per min. This rate provides
higher level of the coronary and cerebral perfusion in the victim.
Compression/respiration ratio should be 30:2 regardless of one or two rescuers do
CPR. These recommendations are extended to both the non-professionals and to the
professional rescuers while conducting the CPR in adults.
If the endotracheal tube has been inserted, the compressions of the chest can be
constant and independent from the respiratory cycles, in relationship to 100 per minute
without the pauses for the artificial inhalations. In this case the effectiveness of the
CPR grows.

7.8.1. The procedure of the indirect massage


The chest of the victim must be located in the horizontal position on the spine, on the
solid and flat base; his head must not be higher than the level of the breast, as this will
worsen the cerebral blood circulation conducted by the compressions of the chest;
prior to the beginning of the indirect heart massage the victim’s feet should be raised
for the purpose of an increase in the central volume of the blood;
the rescuer can be located from any side of the victim; the position of the hands on the
breastbone – two transversely located fingers upwards from the base of xiphoid branch
(Fig. 7.16), further both hands, one on top of the other (“in the lock”), are arranged in
the lower third of the breast bone;

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Fig. 7.16. Cardiac compression.
The depth of the compressions of the chest is in an average 4-5 cm. Conduct the
calculation support aloud: “one, two, three and four…” to 10, further to 15 without
connecting the union “and”.
Besides the recommended frequency, it is necessary to keep the correct position of the
hands during the entire cycle of 30 compressions, without tearing off and without
changing their position during the pauses for artificial respiration
For a maximally effective indirect massage and decreasing the possibility of the likely
traumatization of the chest, the first chest compression should be conducted smoothly,
trying to determine its elasticity. Do not make jerking motions - this may cause injury
of the chest! The rescuer must be arranged relative to the victim in such a way that the
victim is between his hands, completely straight elbow joints, and the chest of the
victim should be of a right angle (Fig. 7.17).

Fig. 7.17.
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When conducting the massage the body mass of the rescuer is used instead of force of
arms. This will save energy and will increase the effectiveness of the massage. If
everything is done correctly the pulse must appear at the carotid and femoral arteries.

7.8.2. The procedure of the indirect massage of the heart without artificial
respiration
CPR without artificial respiration from “mouth to mouth” is possible in such cases, if
the rescuer conducting CPR is not capable or if he cannot achieve hygienic and other
reasons (absence of shielding respiratory equipment). Experiments to animals and
limited studies in people testify that gasping during CPR can support subnormal
minute ventilation, partial tension of carbon dioxide and oxygen without conducting
ventilation.
The control of the effectiveness of the indirect massage of the heart and artificial
respiration is determined by the following criteria:
 A change in the colour of the skin (it becomes less pale and cyanotic);
 The contraction of pupils, with the absence of reaction to light;
 The appearance of a pulse on the carotid or femoral artery;
 The appearance of independent respiration if possible.
In the last 20 years important studies were carried out, which are concerned with the
development of new methods and equipment for increasing the effectiveness of the
indirect massage of the chest in the CPR course, which includes pneumatic waistcoat
CPR, CPR with the “inserted abdominal compression”, active compression-
decompression (use of a device “Cardiopump”). The contemporary development of
these methods leads to the production of special indications for their application within
the framework of the specialized resuscitative measures.

7.8.3. The typical errors and complications in conducting indirect


massage of the heart
The most common error is an insufficient intensity of the compression of the chest. It
can result from conducting the resuscitation on the soft surface or when compressions
of the chest are weak. The objective indicator of these mistakes is the absence of
pulsation on the large arteries. Interruptions while conducting the massage of the heart
more than 5-10 s (for example, for taking of therapeutic or diagnostic measures) are
also extremely undesirable. The fractures of the bones of the body and chest are the
most frequent complications while conducting of the indirect massage of the heart.
These complications are most typical in persons of old age and it are uncharacteristic
for children. If the damage of the chest nevertheless arose, continue to carry out the
resuscitation to benefit fully.

7.8.4. The medicines, used with specialized (extended) CPR


Medicines in the course of resuscitative measures adapt with the purpose of:
 the optimization of heart emission and vascular tone;
 the normalization of the disturbances of the rhythm and electrical instability of
the heart.

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Adrenaline
Is an indicator for VF, asystole, symptomatic bradycardia. Mainly is used as the
adrenergic action of adrenaline in the dwelling period of blood circulation for an
increase in the myocardial and cerebral blood flow while conducting CPR.
Furthermore, it increases excitability and myocardial contractility; however, this
positive effective action on the heart has a negative side with the overdose of
adrenaline.
The work of the heart sharply grows and it needs oxygen. The recommended dose -
1 ml of 0.1% solution (1mg). Multiple introduction - every 3-5 min of CPR, before
obtaining the clinical effect. Adrenaline must be accompanied by the introduction
20 ml of saline solution.
Noradrenaline
Adrenomimetic is more expressed, than adrenaline in vasoconstrictor action and
smaller stimulating influence on the myocardium. The recommended dose of the
noradrenaline of hydro-tartrate - 2 ml of 0.2% solution, separated in 400 ml of
physiological solution.
Vasopressin
Natural appearing antidiuretic hormone, at the large doses, which considerably
exceeds antidiuretic effect, vasopressin acts as nonadrenergic pheripheral vaso-
constrictor. Today vasopressin is is considered as the possible alternative to adrenaline
in the therapy of refractory electrical defibrillation in adults. Furthermore; it is
effective in patients’ with asystole or ventricular tachycardia without the pulse.
Atropine
Is an indicator in the treatment of symptomatic sinus bradycardia, with asystole in
combination with adrenaline. Atropine is "confirmed” to be effective during the
treatment of hemodynamically significant bradyarrhythmia. In accordance with the
recommendations of the International conference of 2000 with the development of the
cessation of blood circulation through asystole or electromechanical dissociation the
introduction of atropine proposed in adults each 3-5 minutes
on1 ml intravenously to the total dose not more than 0.4 mg/kg.
Amiodarone (kordaron)
It is considered as the preparation of choice in patients for VF and
VT, refractory to three initial discharges of defibrillator. The starting doses 300 ml,
separated in 20 ml of 5% of glucose, introduced intravenously by bolus. The most
possible additional introduction is 150 ml (in the same breeding), if VF/VT are
repeated, reaching to the maximum daily dose - 2 g of amiodarone.
Lidocaine
It is the most effective preventive agent for the frequent ventricular of extra systole
terrible precursor of the appearance of VT and also with developed VT. The
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recommended initial dose is 1 of 1.5 mg/kg (80-120 mg). With refractory VT or
ventricular tachycardia through 3-5 min it is possible to introduce half a dose. During
the concomitant administration of antiarrhythmic drugs there is a real threat of both
involution and weakness of the heart and manifestation of arrhythmia.
Magnesium sulphate
It causes refractory fibrillation of ventricles and prevents the completion of reserves of
intracellular potassium. Magnesium sulphate is recommended with refractory VT,
especially, if hypo magnesia is suspected in patients, patients with prolonged treatment
with thiazide and loop diuretics. Taking the resuscitative measures 1-2 g of
magnesium sulphate, diluted in 100 ml of 5% of glucose, are injected in 1-2 min.
Sodium bicarbonate
Correctly carried out mechanical ventilation of the lungs exerts more effective
influence on acid base balance than the use of buffer solutions. Sodium bicarbonate is
indicated either after the restoration of the heart’s activity or through 10-15 minutes of
the conducted resuscitative measures. The initial dose - 1 ml/kg (2 ml 4% to 1 kg of
body weight), every 10 min subsequently introduces half of the calculated dose under
the control of gases of the blood.
Calcium Chloride
Earlier it was considered that this preparation while conducting the CPR increases the
amplitude of the heart contractions and renders the stimulating effect on the heart;
however, last year’s studies do not confirm this. The application of calcium chloride is
limited to the rare exceptions (initial stage of hypocalcemia, hyperkalemia, the
overdose of the antagonists of calcium).

7.8.5. The ways of administering of medicines with the CPR


The common notion is that the optimum method of the medicine injection while
conducting CPR in the intracardiac way has undergone changes in recent years.
Intracardiac punctures always contain the risk of the conduction system of the heart
and coronary vessels or intramural introduction of medicines.
In a similar situation the preferences are given to the intravenous way of the
introduction of medicines with the cessation of blood circulation. Central venous
access is the most effective and rapid way for medicinal substances into the blood
flow. However, conducting catheterization of the central vein requires time and
significant experience in the doctor; furthermore, this access may lead to severe
complications. The peripheral access is usually more easy to get. However, in this case
the medicine enters central blood flow slowly. For accelerating the entering of
medicine into the central veins it is recommended to catheterize one of the cubital
veins followed by introducing medicine by bolus with subsequent “booster” of its
20 ml of physiological solution.

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7.9. Universal algorithm of actions with sudden death of the adult
The basic resuscitative measures (base CPR):
 To be convinced in the absence of consciousness in the victim;
 to turn for help;
 to restore the possibility of the respiratory tract;
 to verify respiration;·to carry out from 2-5 inhalations (if necessary);
 to verify the presence of blood circulation; to begin the indirect massage of the
heart (in the absence of the signs of blood circulation).
 To deliver the precardial impact (from the indications and with the
impossibility of conducting the defibrillation).
 To connect the defibrillator/monitor.
 To estimate the rhythm of the heart.
 In the case of VT or ventricular tachycardia without the pulse: ·to carry
out attempts and the defibrillation (if it is necessary);
 to renew CPR within 1 min and to estimate the rhythm of the heart again; ·to
repeat the attempt of defibrillation.
 In the absence of the effect to begin the specialization (extended)
CPR (intubation of trachea, venous access, drugs); in the absence of the
effect to analyze and remove the possible reasons:
 Hypovolemia.
 Hypoxia.
 Hyper/hypokalemia..
 Hypothermia.
 Acidosis.
 “Drugs” (narcotics, poisoning).
 Tamponade of the heart.
 Coronary thrombosis.
 Thromboembolism of pulmonary artery.
 Tension pneumothorax.
Forecast
The favourable outcome of CPR under the conditions of the hospital at
present varies from 22% to 57%. Survived rate composes 5-29%, and from this
number 50% depart with neurological disorders. The outcome of CPR in the pre-
hospital stage by an order is given below.

7.10. Local and regional methods of anesthesia


Local infiltration in anaesthesia.
Local anaesthesia is achieved by local anaesthetics via the blockade of nociceptive
pulsation in the zone where the operation is conducted. The types of local aesthetics
are the surface (terminal) and the infiltration aesthetics. It is carried
out by irrigation or application of the local anaesthetics on mucous membranes. The
development of the blockade of nervous terminals occurs as a result of the diffusion of
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the local anaesthesia through the mucous surfaces of the anesthetized zones. The
preparations, which possess high diffusivity, are used for the terminal anaesthesia.
Surface anaesthesia adapts for the anesthetization of the mucous membranes of the
nose, throat, larynx, oesophagus, trachea, conjunctival bag and others, while for the
terminal anesthesia 2% solution of tetracaine solution of 2% lidocaine solution is most
frequently used. Local anesthetics are usually combined with adrenaline 0.1% 1 ml in
ratio of 1 drop each 1 ml of anesthetic. This reduces the risk of systemic toxicity
resulting from resorption of the local anesthetic/
Novocaine causes anesthesia in the place of its introduction. Also it acts as conduction
anesthesia. High pressure inside “the case” ensures closer contact of anesthesia with
the nerve end by which causes rapid development of anesthesia during the application
of weak concentrations of anesthetic.

Fig. 7.17. Infiltration of tissues by the solution of anesthetic.

Although recently the local anesthesia in the classical version is used rarely, the
elements of infiltration anesthesia according to A.V. Viwnyovskiy's method, until
now, is successfully performed by surgeons without conducting of operations inside
body cavities. Local anesthetization technique has its special features depending on the
form of operation and the region of interference.

7.11. The regional methods of anesthesia

7.11.1. Conducting anesthesia according to Lukashevich-Oberst


Indications to conduction anesthesia appear in simple operations on the finger, apropos
of panaritium, grown nail and others. With the heavier damage of several fingers it is
necessary to carry out the blockade of the brachial plexus, or blockade of nerves in the
region of the radiocarpal joint.
A tourniquet is applied to the base of a finger. This keeps anesthesia on the back side
of the skin and subcutaneous fat cellulose in the region of the introduction of the
needle (Fig. 8.18). After that, it is kept perpendicular to the surface of the finger,
anesthesia is introduced into cellulose, in the projection of the passage of nerves. For
the anesthesia we use 5-8 ml of 1% solution of Novocain or Lidocaine, Trimecaine
(without adrenaline). About 3 ml of 1% of solution is needed. Large volumes of
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solution should not be introduced, because this may cause disturbance in the blood
supply of the finger.

Fig. 7.18. Location of finger nerves and the site of injection of the anesthetic solution.

7.11.2. Circular blockade


Novocain blockade is adapted for the anesthetization during the traumatic damages
of extremities, or operations on extremities. First the infiltration of the skin through a
type “of lemon peel” on the front surface of the thigh or arm is conducted. After that,
through a long needle, infiltrating of anesthetic is done till the bone. In this place
0.25% solution of Novocain is introduced in quantity between 150-200 ml.

7.11.3. Paravertebral novocain blockade


Paravertebral blockade is carried out with the traumatic damages of the chest, plural
breakage of the edges, for anesthetization after operations on the thoracic cavity. In its
essence paravertebral blockade is a variety of the blockade of inter-rib nerves. The
execution of paravertebral blockade is conducted at the positions lying on the stomach
or sitting. At the level of the spinous process of vertebra, at a distance of 3-4 cm the
needle is introduced perpendicularly. The surface of the skin moves down and contacts
with the transverse process of the corresponding vertebra. Then the needle is drawn off
a little and another needle of 2 cm is moved, trying to pass along the upper edge of the
transverse process of the vertebra. At this depth an injection of 5 ml of anesthetic
solution causes paresthesia. The deeper introduction of the needles is dangerous
because of the opportunity of the development of pneumothorax (Fig. 7.19).

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Fig. 7.19. Paravertebral blockade: 1) direction of the needle at the beginning of its
introduction; 2) final position of the needle; 3) spinous process; 4) sympathetic
ganglion; 5) connecting branches; 6) inter-rib vessels; 7) lung; 8) pleura.

7.11.4. The blockade of intercostal nerves


Blockade can be executed at the level of angles edge and on the rear or the middle to
armpit lines. In the region where the nerves pass relatively superficially, next to the
extensor of the back. At this level the solution of anesthetic extends its action to
paravertebral nerve plexus. The patient should be in side lying position with legs
pulled to the stomach and bent back.
Standard aseptic technique is used before the manipulation. The needle goes into a
subcutaneous cellular tissue. Then the needle is pushed to the rib’s low edge, after that
forward (about 3 mm) under it. 2-3 ml of anesthetic solution is further injected. In a
similar way other intercostal nerves can be blocked (Fig. 7.20).

Fig. 7.20. Intercostal anaesthesia.


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When intercostal nerves are blocked in middle axillary lines the patient assumes a
supine position. The blockade technique is similar to that described above. Here the
edges are located more superficially, that facilitates access to the inter-rib nerves.
Both the accesses are examined including the potential danger of the puncture of
pleura and the damage of the lungs with the subsequent development of the
pneumothorax. The blockade of the inter-rib nerves is used for the purpose of
anesthetization in case of injury of the chest and after the operations on the organs of
thorax and stomach.

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8. CHAPTER 8. RESPONDING TO AN EMERGENCY. BASIC TYPES OF
EMERGENCIES AND THE FIRST AID

While working in the hospital or long-term care facility, you are always close to
professional medical help. When you witness an accident away from the medical
facility, professional help is not always readily available. Whatever course of action
you choose, the victim should not be further endangered.
Always remember the priorities of any emergency as the ABCs:
 Airway: obstructed or unobstructed?
 Breathing: is the victim able to breathe?
 Circulation: is the heart beating, is there bleeding?
Stay calm. Nothing is accomplished and more problems will result if the people at the
scene of the emergency become upset. If you are calm, you will be a calming influence
on the victim. Know how to summon immediate help. Stay with the victim and call out
for help. If you are out in the community, tell the closest person to call.

8.1. Emergency Medical Services (EMS)


 Do not move the victim unless he or she is in danger.
 Stay with the victim until the person in charge gives you permission to leave.
 Know your limitations. Provide care for which you have been trained and are
qualified to give.
 Know the code names for various emergencies in your facility.
 Know the procedures for activating the Emergency Medical Services (EMS)
system. In most areas, you will dial 1-1-2 Europe, 9-1-1 North America.
 Keep the victim warm. Cover with blankets.
 Do not give the victim any fluids or food.
 If the victim starts to vomit, turn the head to one side to avoid aspiration.
 If the victim is conscious, reassure him or her.
 Protect the victim’s privacy. Keep other people away from the scene unless
they are qualified to assist.
 Apply standard precautions to prevent exposure to blood, body fluids, mucous
membranes, and nonintact skin during the emergency.

8.2. First Aid


First aid includes immediate care for victims of illness or injury. This care is especially
important if medical help is delayed or is not available.

8.2.1. Evaluating the Situation


At the scene of an accident, evaluate the situation and identify the injuries. Quickly
note the number of victims, their injuries, and any dangerous factors at the scene. In
the medical facility, unless there is a fire, you usually will be dealing with a single

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victim. You will be able to focus on the needs of that individual. For example, you
might enter a patient’s room and find the patient lying on the floor, despite the fact that
the bed side rails are up. Quickly evaluate the situation as you signal for help.

8.2.2. Emergency care


Emergency care is care that must be given right away to prevent loss of life. Whether
you are out in the community or in the health care facility, ask someone nearby to
summon help. Do not leave people who need urgent care to get help yourself.
As help is on the way, check, in the following order, for the victim’s:
 Degree of responsiveness
 Airway/breathing capability
 Presence and rate of heartbeat
 Signs of bleeding
 Signs of shock
 Do not move the victim if you do not have to.
 Do not allow the victim to get up and walk around.
 Check for other injuries.

8.2.3. Other emergencies


For some of the emergencies described here, a patient at home or in a long-term care
facility may need to be transported to a hospital emergency room. If the victim is
outside of the hospital, be sure that you know:
 Initial emergency actions to perform
 How and when to notify the EMS system
 How and when to notify the nurse

8.2.4. Non-Cardiac Facility Emergencies


Anticipate and prevent emergencies whenever possible. Think about safety when you
enter and leave a room.
 If you discover a patient who is ill or injured, stay with the patient and call for
help.
 Know facility procedures, phone numbers, and code words for reporting
emergencies.
 Do not move a patient who has fallen to the floor, unless the patient is in
immediate danger or you consider it is not dangerous for the move.
 Stay calm and do not panic. Reassure the patient.
 While you wait for help to arrive, start emergency measures that you are
permitted to do.
 Do not give the patient anything to eat or drink.
 Know the location of emergency equipment and supplies in your unit.
 Many emergencies involve bleeding. Always remember and apply the
principles of standard precautions shown on Fig. 8.1.
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Fig. 8.1. Personal protection equipment.

8.2.5. Bleeding
(for detailed explanation of each method of bleeding control go to the chapter #5)
Heavy bleeding and blood loss can be life-threatening. Apply gloves and follow
standard precautions if you care for a patient with external bleeding. Internal bleeding
is not visible, and is shown when the signs of shock become apparent (described in the
5th section). Take the following steps to prevent additional loss:
 Identify the area that is bleeding.
 Have the patient apply continuous pressure over the bleeding area, if able.
 If the patient is not able, apply continuous, direct pressure over the bleeding
area with a pad and your gloved hand (Fig. 8.2).

Fig. 8.2. Bleeding control by direct pressure and elevation requires self-protection with
gloves.
 Call for help.
 If seepage occurs, increase the padding and pressure. Do not remove the
original pads.
 Elevate the wounded area above the level of the heart, but do not release
pressure.
 Support the elevated area.
 Use binding to hold the padded pressure if there is bleeding from more than one
area.

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 Apply pressure over the appropriate pulse point to control hemorrhage (heavy
bleeding) if direct pressure is ineffective (Fig. 8.3).

Fig. 8.3. Pulse point to control hemorrhage.


 Keep the victim warm and quiet until help arrives. Note: Persons who are
bleeding are often very frightened. Their anxiety contributes to the development
of shock. Continuous reassurance is essential.
 Do not be distracted by copious bleeding in an unconscious person. Always
check the adequacy of the patient’s airway first. If airway, breathing, and
circulation are adequate, quickly apply gloves and take measures to stop the
bleeding.

8.2.6. Shock
Shock is defined as a disturbance of the oxygen supply to the tissues and return of
blood to the heart. It can follow any severe injury, hemorrhage, and many medical
conditions. Early signs and symptoms of shock include:
 Pale, cold skin that is moist or clammy to the touch
 Complaints of weakness
 Weak, rapid pulse
 Rapid and irregular breathing
 Restlessness, anxiety, and thirst
 Perspiration
Care for the patient according to the guidelines listed under fainting (following).
Unless shock is controlled, death can occur. Until help arrives, your care can make the
difference between life and death.
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8.2.7. Fainting
When the blood supply to the brain is reduced for a short time, the person loses
consciousness. It is corrected as soon as blood flow to the brain is restored.
Unfortunately, when consciousness is lost, the patient is likely to fall and injuries can
occur. Ease the patient to the floor to prevent injury (Fig. 8.4.).

Fig. 8.4. Fainting (syncope).


Assist patients who are feeling faint to a safe position. The patient who is sitting and
feels faint should be encouraged to lower her head between the knees. To provide
assistance to a patient who is fainting or in whom shock is suspected, you should:
 Help the patient assume a protected position, sitting or lying down
 Loosen tight clothing
 Position the victim’s head lower than the heart
 Allow the patient to rest for at least 10 minutes
 Maintain normal body temperature
 Call for additional help
 Monitor pulse, respirations, and blood pressure
 Do not give the patient anything to eat or drink

8.2.8. Heart Attack


Heart attacks can occur in any age group, but the high-risk group includes those who
have high blood pressure, smoke, and have a history of heart disease. Signs and
symptoms of heart attack include:
 Crushing pain that can radiate to the jaw and arms, or heaviness in chest
 Perspiration; skin cold and clammy
 Nausea and vomiting
 Pale to grayish color of the face
 Difficulty breathing or absence of breathing
 Loss of consciousness
 Irregular pulse or loss of pulse
 Low blood pressure in later stages
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8.2.9. Stroke
A brain attack (cerebral vascular accident or CVA), also called a stroke, occurs when
there is interference with normal blood circulation to the brain. It usually is caused by
a clot that has lodged in a cerebral vessel or by a blood vessel that has ruptured
(Fig. 8.5).

Fig. 8.5. Types of stroke.


The person with a brain attack usually develops weakness or paralysis on one side of
the body. He or she may become unresponsive or have a seizure. First aid includes:
 Maintaining an airway (Fig. 8.6).

Fig. 8.6. Patient’s tongue position is controlled with head-tilt.


 Providing mask-to-mouth breathing as needed
 Administering CPR, if needed
 Positioning the victim on the side so fluids will drain from the mouth
 Maintaining normal body temperature
 Keeping the victim quiet until help arrives

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8.2.10. Seizures
Seizures or convulsions are sometimes seen when there is a head injury, drug
overdose, and many other medical conditions. Seizures do not always follow the same
pattern. Their range may be:
 A momentary loss of contact with the environment, in which the person seems
to stare blankly.
 A generalized tonic-clonic seizure, in which consciousness is lost, the person
becomes rigid and falls, and the person loses bowel and bladder control.
If you witness a seizure, take the following steps:
 Wear gloves and apply standard precautions.
 Do not restrain the victim’s movements.
 Protect the victim from injury.
 Loosen clothing around the neck.
 Maintain an airway by proper patient positioning (Fig. 8.7). Do not try to put
anything in the victim’s mouth.

Fig. 8.7. Recovery position.

 Protect the victim’s head


 Observe the seizure.
After seizure activity stops:
 Turn the victim to the side so fluid or vomitus can drain.
 Give mask-to-mouth resuscitation if breathing is not resumed immediately.
 Allow the victim to rest undisturbed.
 Stay with the victim but summon medical assistance.
 Report and record seizure activity: time, length of seizure, body parts or activity
involved.

8.2.11. Vomiting and aspiration


Food and air are both taken into the body through the mouth. The passageway by
which food and air enter is shared. Occasionally a patient aspirates, which is
potentially serious. This occurs when food, water, vomitus, or other objects

203
accidentally go down the trachea and into the lungs. Signs and symptoms of aspiration
include choking on food or an object, coughing, cyanosis, and vomiting.
If a patient has aspirated anything:
 Stay with the patient and call for help.
 Use standard precautions and select personal protective equipment appropriate
to the procedure.
 Do not give the patient any liquids.
 Keep the patient’s head elevated.
 Turn the patient’s body to the side if she is vomiting while lying down. If
turning the patient’s body is not possible, turn the head to the side.
 Provide an emesis basin if the patient is vomiting.
 If the patient begins choking and an airway obstruction occurs, follow the
procedure for clearing an obstructed airway.
 After the episode, assist the patient with mouth care.
 Make observations:
o Observe any vomitus for color, odor, presence of undigested food, blood,
or coffee-ground appearance. Save the emesis for the nurse to inspect.
o Measure or estimate the amount of vomitus or blood, and record on the
intake and output record.

8.2.12. Electric shock


Severe burns and cardiac and respiratory arrest can result from electric shock. You
must protect yourself as you try to rescue the victim. Rescue steps include:
 Turn off the electricity at the source, such as at a fuse box, before touching the
victim, if possible.
 If the source of electricity cannot be controlled, try to move the victim away
with some nonconductive material, such as a wooden broom handle.
 Once free of the electrical source, check the victim for breathing and pulse.
 Summon medical help.
 Administer CPR, if necessary (chapter 7).
 Once breathing and heart function are restored, check for burns and other
injuries. Keep the victim lying down and comfortable.
 Give first aid for burns or other injuries.

8.2.13. Burns
Burns may be caused by heat, chemicals, or radiation. There is a high risk of infection
with any burn. Burns are classified as partial thickness or full thickness, depending on
the degree of injury.
 Follow these steps for emergency treatment of burns:
 Call for help immediately.
 If the patient’s clothing is on fire, use a coat or blanket to smother the flames.
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 Cool water may be applied to lower skin temperature and to stop further tissue
damage.
 Cool a burn with cold water. Avoid using ice, which will damage sensitive
tissue. Never break blisters on a burn. Cover them loosely with material that
will not stick to the tissue.

8.2.14. Orthopedic injuries


Orthopedic injuries include injuries to bones, joints, muscles, and ligaments.
A fracture is a break in a bone. A sprain is an injury to a ligament caused by sudden
overstretching. A strain is excessive stretching of a muscle that results in pain and
swelling of the muscle. A dislocation occurs in a joint when one bone is displaced
from another bone.
If you suspect that a patient has suffered a sprain, strain, dislocation, or fracture:
 Stay with the patient.
 Immobilize the injured extremity.
 Do not attempt to move the patient.
 Call the nurse immediately.
 If the patient is on the floor and a fracture is suspected, avoid moving her until
after the nurse assesses her and informs you what action to take.
 Monitor the patient’s vital signs as instructed.

8.2.15. Head injury


A patient with a known or suspected head injury always requires close observation and
monitoring. Bleeding inside the skull commonly occurs when the head strikes a broad,
hard object, such as the floor. Some serious complications of head injuries may not be
apparent until 72 hours (or more) after a head injury. This is particularly true in elderly
persons.
Signs and symptoms of a possible head injury include:
 Change in the patient’s level of alertness or consciousness
 Change in orientation (ability to recognize time, place, person)
 Memory loss
 Unequal pupils
 Visual disturbances
 Blood or clear fluid leaking from ears or nose
 No response to verbal stimulation
 Headache
 Nausea and/or vomiting
If you think a patient has suffered a head injury:
 Stay with the patient and call for help.

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 Keep the environment quiet and calm.
 Do not give the patient anything to drink.
 Reassure and orient the person.
 Elevate the head on a pillow.
 Do not move the patient if he is on the floor.
 Monitor vital signs regularly after the injury.

8.2.16. Accidental poisoning


If you suspect that a poisoning has happened:
 Call for help immediately.
 Try to determine what the patient has taken and save the container.
 The doctor may administer a substance that will cause vomiting. (Not all
substances can be safely removed by vomiting.)

8.3. Action in an Emergency

8.3.1. In the health care facility


 Stay with the patient and signal for help.
 Have the patient stop any activity and assume a comfortable position.
 Help keep the patient calm.
 Elevate the head of the bed to assist breathing.
If the patient is unconscious:
 Check for breathing and heartbeat.
 If necessary, institute CPR.

8.3.2. In the community


In the community, and if the victim is conscious, proceed as follows.
 Evaluate the situation.
 Activate the EMS.
 Have the victim sit and assume a comfortable position. Loosen tight clothing.
 Provide fresh air but keep the victim comfortably warm.
 Monitor pulse and respirations and be prepared to initiate CPR.
In the community, if the victim is unconscious, follow steps 1 and 2. Then:
 Check for breathing and heartbeat.
 If heartbeat is present but breathing has ceased, open the airway and institute
mask-to-mouth resuscitation.
 If breathing and heartbeat have ceased (cardiac and respiratory arrest), perform
CPR until a professional takes charge.

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Издательство Курского государственного медицинского университета.
305041, г. Курск, ул. К. Маркса, 3.

Лицензия ЛР № 020862 от 30.04.99 г.


Формат 60х84 1/16. Усл. печ. л. 13,0.
Тираж экз.

Отпечатано в типографии КГМУ.


305041, г. Курск, ул. К. Маркса, 3.

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