On this page you will study Answers to problems in medicine surgery (Part 3) from the subject of Medicine, in the proposed topic other questions on Medicine are also sanctified. If after studying this material you have questions, then you can ask them in the form below, other like-minded people may help you. If you have new questions, ask in the comments or Contact Us on Email (firstname.lastname@example.org)or Whatsapp.
Patient M., 64 years old, after intravenous drip infusion of drugs, began to complain of pain in the left elbow bend. On the palmar surface of the upper third of the left forearm and the antero-inner surface of the shoulder along the saphenous vein, skin hyperemia is determined, compaction and sharp soreness of the venous wall. What diagnosis will you make? What treatment will you prescribe?
As a result of prolonged intravenous infusion, the patient developed acute phlebitis of the saphenous veins of the left upper extremity. It is necessary to stop infusion into the affected vein, apply a semi-alcohol compress and immobilize the left upper limb, prescribe nitrofuran or sulfa drugs in combination with antibiotics.
Patient M., 58 years old, was admitted to the surgical department for acute thrombophlebitis of the saphenous veins of the left leg. Despite the ongoing conservative treatment for 4 days, the inflammatory process continues to progress: pain in the left thigh, skin hyperemia, tissue compaction and soreness along the great saphenous vein in the lower and middle thirds of the thigh appeared. What is your diagnosis and action?
A patient has acute migratory thrombophlebitis of the superficial veins of the left lower extremity. It must be remembered that spontaneous and migratory thrombophlebitis is often observed in Buerger’s disease, cancer of internal organs, polyarthritis, etc. Therefore, the patient should be additionally examined for these diseases. In addition, urgently in order to stop the progression of the inflammatory process, the patient should undergo an operation in the form of ligation of the great saphenous vein of the left lower extremity at the place where it flows into the femoral vein or phlebectomy.
Patient E., 69 years old, was admitted to a surgical hospital with complaints of severe bursting pains in the right lower leg, swelling of the foot and lower leg, an increase in body temperature to 38.7 ° C. The pain is worse when moving. He fell ill three days ago, when there were convulsive contractions of the gastrocnemius muscle, and later pain in it. The edema appeared on the third day.
The skin on the right leg and foot is slightly hyperemic, tense, and shiny. The circumference of the middle third of the right tibia is 6 cm larger than the circumference of the left tibia at the same level. Movement in the left ankle joint is preserved, but painful. On palpation of the lower leg, there is pain along the vascular bundle, especially in the popliteal fossa. Homans’s symptom is positive (the appearance of pain in the gastrocnemius muscle with maximum flexion in the ankle joint). There is a sharp soreness when squeezing the gastrocnemius muscle.
Complete blood count: leukocytosis, shift of the formula to the left, ESR – 29 mm / h, prothrombin index – 1.
What is your diagnosis and treatment tactics?
A patient has acute deep vein thrombophlebitis of the right leg. He is prescribed bed rest. The right lower limb is given an elevated position, for which you can use the Beler splint. Direct anticoagulants are immediately prescribed with a subsequent transition to indirect ones. Dynamic control of blood coagulation time and prothrombin index is mandatory. A decrease in the prothrombin index below 0.4 is unacceptable. In the case of an overdose of heparin, the antidote is protamine sulfate. At an early stage of the disease, intravenous administration of fibrinolysin and leech therapy (hirudotherapy) are advisable.
In addition, antibiotics, non-steroidal anti-inflammatory drugs (aspirin, butadion), diuretics are prescribed. An oil-balsamic compress is applied to the lower leg. After relief of acute events, it is recommended to wear an elastic bandage.
Patient M, 59 years old, underwent surgery in the gynecological department: supravaginal amputation of the uterus. On the 8th day, a progressively increasing edema of the entire left lower limb appeared. On examination, pale cyanotic spots were revealed on it, the skin was tense. The circumference of the left thigh and lower leg at the level of their middle thirds is larger than the circumference of the right thigh and lower leg by 8 and 6 cm, respectively. The toes of the left foot are warm, active movements in their joints are preserved. The pulse on the dorsal artery of the left foot is determined, weakened. Body temperature 36.7-36.9 ° C. What postoperative complication is possible for the patient? Where and how should the patient be treated further? What is the prevention of such complications?
The postoperative period in the patient was complicated by acute ilio-femoral phlebothrombosis on the left.
The patient needs urgent transfer to a specialized department of vascular surgery, where, under the cover of anticoagulants, she should undergo thrombectomy with the restoration of natural blood flow through the femoral and iliac veins.
Prevention of phlebothrombosis consists in the following: patients with a tendency to hypercoagulability, obesity and over the age of 45 years, immediately before the operation and in the early postoperative period, heparin is prescribed. During the operation, hypervolemic dilution is maintained, pneumatic compression of the legs is performed, if possible, prolonged epidural anesthesia at the level of the lumbar segments, which improves the blood supply to the lower extremities. Immediately after the operation, massage of the lower extremities, breathing exercises and physiotherapy exercises are prescribed. Regular vigorous movement of the ankle joints is highly recommended.
It is equally important in the postoperative period to introduce antiplatelet agents (reopolyglucin, trental, acetylsalicylic acid, etc.), as well as fibrinolysis activators (nicotinic acid, xanthinol nicotinate).
A patient came to the surgeon’s appointment with complaints of pain in the right elbow joint, which appeared 8 days ago after a bruise. In the last 3 days, the pain increased. When viewed in the projection of the olecranon, there is an abrasion under the crust from under which, when pressed, pus is released. Here, swelling, hyperemia, soreness and fluctuation are determined. Movement in the elbow joint is almost completely preserved and painless. Pus was obtained during puncture at the site of fluctuation. On the roentgenogram, no bone-destructive changes were found. What is your diagnosis and treatment tactics?
A patient has an acute purulent bursitis of the bursal sac in the area of the right elbow joint.
Since during the diagnostic puncture pus was obtained from the bag, one should resort to surgical treatment: for this, the bag is opened with a linear incision, washed with antiseptic solutions and drained with a rubber strip.
If there is an abscess limited by the walls of the synovial bursa, and with insignificant phenomena of peribursitis, the choice of surgical intervention may be its total extirpation. To do this, under infiltration anesthesia with a 0.5% solution of novocaine, a horseshoe-shaped incision is made 6-7 cm long, 2 cm proximal to the olecranon along the back of the shoulder. The skin flap from the capsule of the bursa mucosa is separated distally. Particular care must be taken at the next stage when separating the anterior wall of the bag fused with the periosteum of the ulna, so as not to damage the latter and not to open the bag. The wound is sutured, leaving a rubber graduate between the sutures for 1-2 days. A pressure bandage is applied to the elbow joint and immobilization is performed with a plaster splint. The stitches are removed on the 9-10th day.
Patient A., 39 years old, complains of pain in the right knee joint, which bothers for about 2 weeks and gets worse every day. Works as a parquet floor. In the area of the right knee joint, pronounced skin hyperemia, swelling, pain and fluctuation in the projection of the patella are determined. The latter is not running for election. In the lower part of the thigh on the anterior surface there are longitudinal linear stripes of hyperemia; the inguinal lymph nodes are enlarged. Movement in the knee joint is limited and slightly painful. No bone-destructive changes were found on the radiograph of the right knee joint. Pus was obtained in the area of the swelling with a puncture. What happened to the patient? What is your treatment strategy?
A patient has acute purulent prepatellar bursitis of the right knee joint, secondary lymphangitis of the right thigh and inguinal lymphadenitis. In addition, judging by the clinical data, there is a pronounced peribursitis. Therefore, there are all indications for surgical treatment.
In this situation, the optimal intervention would be to open the abscess with two longitudinal parallel incisions along the lateral edges of the bag, rinsing the latter with antiseptic solutions and through drainage through both incisions.
Sometimes after this fistulas remain or later relapses develop. Therefore, for the final cure after stopping the acute process, it is necessary to recommend the patient a planned operation in order to remove the synovial membranes.
Patient K., 28 years old, was admitted to the proctology department of the hospital with a diagnosis of acute thrombosis of hemorrhoids. Complains of pain in the anus, aggravated by movement, an increase in body temperature in the evenings up to 40 C. Due to pain, he cannot sit. Has been ill for 4 days. Ointment compresses and rectal suppositories have no effect. History of chronic hemorrhoids with rare exacerbations. To the right of the anus, skin hyperemia, swelling, and severe soreness are revealed. The underlying tissues are dense, tense, fluctuations are not detected. Digital examination of the rectum revealed swelling and tenderness of its right lateral wall. Blood test: leukocytes 16.3×10 / l, stab neutrophils-7 /, ESR-28mm / h. Do you agree with the preliminary diagnosis? No pain, what is your diagnosis? How much assistance should be provided to a patient in this specialized medical institution?
One cannot agree with the preliminary diagnosis.
The patient has all the clinical signs of acute right-sided ishiorectal purulent paraproctitis. To verify the diagnosis, a puncture with a thick needle can be performed (do not forget about anesthesia!).
The patient needs an emergency operation – opening the abscess. Under intravenous anesthesia, methylene blue, diluted in a 3% solution of hydrogen peroxide in a ratio of 1:10, is injected into the abscess cavity.
After that, with the help of a rectal mirror, the rectal mucosa is examined to identify the fistulous course communicating with the abscess cavity. In the absence of a fistula, radial, arcuate and intersecting incisions are used to open the paraproctitis.
After evacuation of pus (bacterial sowing!), A digital revision of the abscess cavity is performed in order to destroy the internal partitions. The abscess cavity is washed with antiseptic solutions, non-viable tissues are excised. The operation is completed by draining the wound, applying a bandage to the perineum.
The titer of tetanus antibodies should be determined, pain relievers, antibiotics and sulfonamides should be prescribed.
A 20-year-old patient came to the clinic for an appointment with a surgeon complaining of throbbing pain in the coccyx, an increase in body temperature in the evenings to 37.7-38.2 C. She was ill for 4 days before she considered herself completely healthy. In the intergluteal fold in the projection of the coccyx, somewhat to the right, in a limited area, skin hyperemia, swelling are determined, in the center its fluctuation: severe soreness within the inflamed tissues. Digital examination of the rectum revealed no pathology. What is your presumptive diagnosis? How can the surgeon of the polyclinic help this patient?
A patient has acute purulent inflammation of the epithelial-smoky passage (coccygeal dermoid cyst). This is a congenital pathology and, as a rule, it manifests itself in the case of abscess formation.
Under local infiltration anesthesia with a longitudinal linear incision over the abscess, the latter is emptied from pus (bacterial sowing!), Washed with antiseptic solutions, and drained with turunda. After cleansing of pus, the wound heals by secondary intention.
In the future, relapses are quite common. Therefore, the patient should be strongly recommended a radical operation (excision of the epithelial-coccygeal passage) in the “cold period”, when the signs of acute inflammation are stopped.
A 4 year old patient was admitted to the hospital with a diagnosis of acute fissure of the anus. Digital examination of the rectum was not performed either in the clinic or in the emergency room. Complains of pain in the anus, aggravated at the beginning of the act of defecation, an increase in body temperature in the evening to 37.6-38C. Has been ill for 5 days. With digital rectal examination along the left lateral wall of the anal canal with the transition to the ampulla of the intestine, a painful infiltrate with softening in the center is determined. Blood analysis; moderate leukocytosis with a shift of the formula to the left, C0E-19mm / h. What diagnosis will you give to the patient? Is surgical treatment indicated? If so, how will you perform the operation?
The patient has acute submucous purulent paraproctitis. You should not “get carried away” with conservative treatment, waiting for the spontaneous opening of the abscess, which is fraught with a variety of unpredictable consequences. The abscess must be opened. Under intravenous anesthesia, an anal sphincter divulsion is performed in the transverse direction (an anteroposterior divulsion is dangerous by traumatizing the prostate gland, which in the postoperative period may be complicated by persistent acute urinary retention). Under the control of the eye with the help of a rectal mirror, the intestinal mucosa is dissected at the site of the greatest protrusion. The wound is washed with hydrogen peroxide solution and left open.
For the purpose of stool retention, chloramphenicol 0.5 g 4 times a day can be prescribed.
Patient N., 5 years old, after the introduction of a suspension of hydrocortisone into the right shoulder joint two weeks ago, began to complain of pain in it, chills, fever up to 40 C. He did not seek medical help. Self-medicated: compresses, hot water bottles, taking painkillers inside. The deterioration of the condition made me call a local doctor. The patient’s condition is moderate. Pulse-96 beats per minute. The patient holds his right hand in the abduction (abduction) position. The joint is swollen, hot to the touch. The slightest active and passive movements in it are sharply painful. As a local doctor, what disease should you suspect? What are your next steps? What additional research needs to be done and how to treat the patient?
The patient should be suspected of acute purulent arthritis of the right shoulder joint. It is necessary to organize urgent hospitalization of him in a surgical hospital. From additional studies, it is imperative to make a general analysis of blood, urine, X-rays of both shoulder joints to exclude osteoarthritis (in the first 10 days, bone destruction is not radiologically determined). In addition, a diagnostic and therapeutic puncture of the joint is performed. Upon receipt of pus (bacterial sowing!), The latter is evacuated if possible. The joint is washed with antiseptics, antibiotic solutions. Along with this, general antibiotic therapy is carried out. Mandatory immobilization of the right upper limb with a plaster cast with a window in the joint area.
With the ineffectiveness of conservative treatment, arthrotomy is performed with drainage of the joint and its constant lavage.
If the process progresses and osteoarthritis develops, the joint is resected.
Patient Z., 54 years old, underwent pulmonectomy for cancer of the right lung. After 10 days of the successful course of the postoperative period, the condition began to worsen: general weakness began to increase, nagging pains in the chest appeared, the body temperature rose to 40 C with hectic ranges. Pulse 112-120 beats per minute, acrocyanosis. In the blood, high leukocytosis with a shift of the formula to the left and pathological granularity of neutrophils are revealed. On the radiograph in the chest, the frame determines the level of the fluid of the VII rib. What complication did the patient have after the operation? What is the treatment tactics?
The postoperative period in the patient was complicated by purulent pleurisy (empyema of the pleural cavity) on the right.
In empyema of the pleural cavity without bronchial fistula, puncture is the method of choice. Moreover, punctures are performed daily with aspiration of pus and subsequent introduction of antibiotics and proteolytic enzymes into the pleural cavity. At the same time, detoxification therapy is carried out, the fight against anemia, dysproteinemia, electrolyte imbalance.
In the case of slow stopping of the process by trocar puncture or surgery, a tubular drainage is introduced into the pleural cavity, which allows continuous aspiration of pus with a water-jet pump, electric suction pump or a mechanical vacuum apparatus. The use of double-lumen drains or the introduction of two tubes makes it possible to establish constant aspiration with flow-through irrigation of the pleural cavity with solutions of antibiotics or antiseptics.
Patient M., 59 years old, was transferred to the clinic from the regional hospital, where for 5 weeks he was treated for closed chest trauma, fracture of the VII-IX ribs on the right, post-traumatic pneumonia. On admission she complains of weakness, chills, sweating, chest pain. In recent days, he has been coughing up a yellow-greenish color with a sweetish odor and sputum up to 300 ml. per day. The condition is serious. The skin is pale. Body temperature 37.8-39.9 C. Pulse 100-116 beats per minute. percussion is determined by dullness in the lower parts of the right lung, auscultatory-weakened breathing, intermittent small bubbling rales. Blood test: high leukocytosis, shift of the formula to the left, ESR-58 mm / h.
With a suspicion of what complication the patient was transferred to the clinic? What additional studies should be performed to verify the diagnosis? What is the patient’s treatment tactics?
The patient is suspected of having an abscess in the lower lobe of the right lung. It should be assumed that the abscess is drained out through the bronchus.
If you collect the coughing up phlegm in a vessel and let it settle, then at the bottom of the vessel you can see thick pus, the middle layer is a watery liquid, and on top is a purulent-mucous foamy mass.
To verify the diagnosis, it is necessary to perform fluoroscopy and radiography of the lungs (in an upright position of the patient: standing or sitting), and, if necessary, computed tomography and bronchoscopy.
The patient is recommended to lie on a healthy side (post-round drainage). Antibiotics, sulfonamides are prescribed. Shown is the regular removal of pus from the abscess cavity through a bronchoscope, followed by intratracheal administration of antibiotics, proteolytic enzymes. Along with this, immunity stimulation, detoxification therapy are carried out.
With the ineffectiveness of conservative therapy within 6-8 weeks, surgical treatment is indicated: pneumotomy, forehead or pneumonectomy.
A patient who has had the appendix removed 7 days ago due to acute phlegmonous appendicitis has a fever. The temperature is hectic. Complains of dry mouth, pain at the end of urination, frequent urge to defecate. The wound doesn’t bother. Pulse – 108 beats per minute. Auscultatory: breathing in both lungs is vesicular. The tongue is dryish. The abdomen is of the correct shape, participates in breathing, soft, painful in the lower parts. Symptom Shchetkin – Blumberg negative. Blood test: leukocytes – 17.2×109 / l, stab neutrophils – 8%, ESR – 30 mm / h. the side of the wound is not inflammatory. X-ray examination revealed no pathology of the lungs.
What complication should be suspected? What additional research needs to be done? How to help a patient?
The patient should be suspected of developing an abscess in the postoperative period of the rectal-vesical cavity (excavatio recto-vesicalis).
It is necessary to conduct a digital examination of the rectum and, if possible, a computed tomography of the pelvis. If a rectal examination reveals an overhanging of the anterior wall of the intestine, a sharp pain on palpation, and against the background of infiltration, a focus of softening is noted in the center, then the diagnosis is beyond doubt. An abscess is punctured under the control of a finger or rectal speculum through the anterior rectal wall. Having received pus, the abscess is opened through the needle with a scalpel and drained with a wide-bore rubber tube. The position of the patient in bed with an elevated head end.
Patient K., 47 years old, complains of abdominal pain, nausea. From the anamnesis it is known that in the evening, being drunk, fell on his stomach. He categorically refused to call an ambulance and agreed only 12 hours after being injured.
The patient lies on his right side with legs pulled up to the stomach. The pulse is 100 beats per minute. Blood pressure – 115/80 mm Hg. Art. Tongue dry, coated with a dirty gray bloom. The abdomen does not participate in the act of breathing; the board-like tension of the mouse of the anterior abdominal wall is determined. Pounding your fingertips over your abdomen causes a sharp increase in pain in it. Symptom Shchetkin-Blumberg positive. Peristalsis is not audible (a symptom of “deathly silence”).
You are an emergency doctor. What is your presumptive diagnosis and treatment tactics?
The patient should assume acute peritonitis due to the rupture of the hollow abdominal organ. At the same time, until the issue of the need for an operation is resolved, he should not be injected with drugs, as well as put cold or a heating pad on his stomach, as this can smooth out the clinical picture of the disease and entail delay in performing an emergency operation.
The patient should be urgently transported on a stretcher to a hospital.
A 50-year-old man was admitted to the emergency room with complaints of abdominal pain, which appeared suddenly, like a blow with a dagger, 10 hours ago. For 18 years he has been suffering from gastric ulcer.
Tongue dry, coated. Pulse – 104 beats per minute. Blood pressure is 120/80 mm Hg. Art. The abdomen does not participate in the act of breathing, it is tense boardlike, painful mainly in the epigastrium and along the right lateral canal. Percussion hepatic dullness is not defined. Symptom Shchetkin-Blumberg positive. Peristalsis is not audible.
What is your diagnosis? What diagnostic tests should be performed in the emergency room before the patient is hospitalized?
The patient has a perforated stomach ulcer, complicated by acute peritonitis. Even before hospitalization, he needs to perform general blood and urine tests, perform a digital examination of the rectum and make a general X-ray of the abdomen to detect free gas in the abdominal cavity (the “sickle” of gas under the dome of the diaphragm). X-rays are taken while the patient is standing or sitting.
During an operation for acute peritonitis 18 hours ago, it was established that it was caused by perforation of a cancer of the rectosigmoid colon. A significant amount of turbid effusion with fecal odor was found in the abdominal cavity. The tumor is mobile, metastases in the liver, at the root of the mesentery were not detected. The peritoneum is hyperemic, with punctate hemorrhages. The loops of the small intestine are edematous, in places covered with fibrin, somewhat swollen, peristalsis is absent. The abdominal cavity is drained with the help of an electric suction device.
What is the further tactics of the surgeon with such a picture of peritonitis?
After removal of purulent contents from the abdominal cavity, the rectosigmoid segment should be resected together with the tumor and an unnatural anus (anus praethernaturalis) should be formed. When resecting the intestine, the anastomosis, as a rule, is not superimposed, but an artificial intestinal fistula (enterostomy, colostomy) is formed, since in conditions of purulent peritonitis, the formation of interintestinal anastomoses is extremely dangerous by the frequent development of failure of their seams. After the source of peritonitis is eliminated, the abdominal cavity is washed (lavage) with 5-6 liters of antiseptic (heated solution of furacilin, chlorhexidine bigluconate, dioxidine, etc.)
Decompression of the small intestine (signs of paralytic intestinal obstruction) can be performed by inserting a nasogastrointestinal tube.
The operation should be completed by draining the abdominal cavity with the introduction of microirrigators into it for local antibacterial therapy.
Patient Sh., 54 years old, for a perforated gastric ulcer, 5 hours after the disease, underwent gastric resection according to Billroth-II in the modification of Hofmeister-Finsterer. On the 4th day after the operation, the patient’s condition worsened sharply, there were hiccups of epigastric pain, which soon began to spread throughout the abdomen. Pulse – 116 beats per minute, weak filling. Breathing – 23 per minute, shallow, audible over both lungs. Tongue coated with white, dry. The abdomen is moderately distended, does not participate in the act of breathing, tense, painful mainly in the epigastric region. Symptom Shchetkin-Blumberg positive. Intestinal peristalsis is not audible. Dullness is noted in the sloping places of the abdomen.
What postoperative complication should you think about? What is the most likely reason for it? What is your tactics for further treatment?
The patient has postoperative diffuse peritonitis, which, apparently, developed due to the failure of the sutures of the gastrointestinal anastomosis or the duodenal stump. The patient is shown an emergency relaparotomy. If an anastomotic defect or stump suture failure is detected, it is necessary to try to suture the defect. If this is not possible, a tampon and a drainage tube should be brought to the anastomosis or to the incompetent duodenal stump. Decompression of the gastrointestinal tract is carried out by two probes: nasogastric and nasogastrointestinal. The abdominal cavity must be drained and through the counterpertures in both hypochondria and both iliac regions, drained with tubes, through which psritoneal dialysis will subsequently be carried out. In addition, the patient is prescribed adequate infusion therapy, antibiotics,
Patient P., 84 years old, was admitted to the surgical department with complaints of persistent diffuse abdominal pain, which appeared 3 days ago in the epigastric region. A day ago there was a single vomiting. The day before he had an independent chair. The tongue is coated, dry. The abdomen is swollen, tense, painful in all parts, but somewhat more along the right lateral canal. Tympanitis is determined percussion in all parts of the abdomen. Hepatic dullness is preserved. Shchetkin-Blumberg’s symptom is positive. Peristalsis is not audible. Blood test: leukocytes-18.1×10 / l, stab-10 /, segmented-70 /, lymphocytes-18 /, monocytes-2 /, SOE-1bmm / h. On the general X-ray of the abdomen, there is no free gas, and there are no Kloyber cups, the loops of the small intestine are pneumatized.
What is your presumptive diagnosis and treatment tactics?
The patient has a clinical picture of acute peritonitis, possibly of appendicular etiology. After a short preoperative preparation (infusion therapy, aspiration of gastric contents, shaving of the skin of the anterior abdominal wall), he is shown an emergency operation under intubation anesthesia. The goals of the operation are to eliminate the source of peritonitis, sanitize and drain the abdominal cavity, and decompress the intestines.
A patient was admitted to the surgical department on the 5th day from the moment of illness with a clearly delimited appendicular infiltrate. Against the background of the treatment, the patient’s condition began to improve: body temperature returned to normal, leukocytosis decreased. On the 5th day of stay, severe abdominal pains suddenly appeared in the hospital, the body temperature increased, the pulse became more frequent, the tongue became dry, there was a single vomiting. The abdomen is swollen, painful in all parts, the abdominal wall is limitedly involved in the act of breathing, the Shchetkin-Blumberg symptom is positive. Leukocytosis increased from 9.3×10 / l to 1b.7×10 / l.
What complication did the patient develop? Your tactics? What are the indications for the use of gauze tampons.
The patient had a breakthrough of the abscessed appendicular infiltrate into the free abdominal cavity with the development of diffuse peritonitis. The patient needs emergency surgical care. A wide “appendicular” incision can be selected as an operative access when the process is limited mainly to the right abdomen, or a mid-midline laparotomy with a diffuse process. The abdominal cavity must be thoroughly drained. In the cavity of the abscess (and if the appendix is easily removed, then a tampon and a microirrigator should be brought to its stump for the introduction of antibiotics.
In the presence of significant changes in the peritoneum, drainages should be introduced through counterpertures in the hypochondria and iliac regions for peritoneal lavage with simultaneous active general treatment of peritonitis.
The use of gauze tampons is shown:
with unreliable elimination of the source of peritonitis in order to delimit it from the free abdominal cavity;
with local limited purulent peritonitis in combination with tubular drainage;
in case of capillary bleeding in combination with a hemostatic sponge.
A patient came to your appointment with complaints of severe twitching pains in the second finger of the right hand. 4 days ago I pricked my finger while cutting fish. The last 2 nights I did not sleep because of pain. The nail phalanx of the finger is swollen, there is swelling and sharp soreness along its palmar surface. Movement in the interphalangeal joints is moderately limited. Axillary lymph nodes are not palpable.
What is your diagnosis? What kind of help will you provide to a patient in a polyclinic?
A patient has a subcutaneous panaritium of the second finger of the right hand in the phase of purulent inflammation. The abscess must be opened. As anesthesia, you can successfully use conductive anesthesia of the digital nerves at the base of the finger according to Oberst-Lukashevich. Its technique is as follows. Depending on the thickness of the finger, take a 2- or 5-gram syringe, a short, thin, sharp needle, 2-6 ml of warm 0.5 or 1% solution of novocaine or trimecaine. After iodine treatment of the skin of the fingers and hand, the needle is inserted on the sides from the back surface at the base of the finger or at the level of its middle phalanx. The solution is injected distally, first on one side of the phalanx, then on the other, slowly, gradually advancing the needle to the palmar surface of the finger.
Patient K., 36 years old, deeply pricked 1 finger of the right hand with a cable. A day later, pulsating pains in the finger, its swelling appeared. He did not seek medical help, and only the last two sleepless nights made him come to the clinic’s surgeon. The nail phalanx of the finger is clavate thickened, there is pain during probe palpation of almost the entire crumb of the distal phalanx of the finger. Flexion in the interphalangeal joint is limited.
Your diagnosis and prompt access?
A patient has a subcutaneous panaritium of the nail phalanx of the 1st finger of the right hand. Since the infection in the subcutaneous tissue of the finger covers almost all of the soft tissue, two lateral incisions are needed to open the abscess. A horseshoe-shaped incision of the “fish mouth” type is currently recognized as unjustified, since it often passes through uninfected tissues and, in addition, after its healing, a painful scar deforming the phalanx is often formed. In all cases, incisions in the direction of the skin lines are preferable, ensuring a free outflow of pus. After applying a bandage, immobilization of the finger is indicated.
A patient came to the appointment with purulent subcutaneous panaritium 2 fingers of the right hand. Indications for surgery are unconditional. The patient’s consent was obtained, but before the incision, effective exsanguination is required to thoroughly remove all affected nonviable tissue.
How will you implement it?
A dry surgical field during finger surgery can be created by placing a small rubber flagellum on the base of the finger. To reduce the painful sensations of squeezing, the flagellum is applied to the previously anesthetized area.
The mother brought a 9-year-old boy to see the surgeon, who is worried about pain in 1 finger of the right hand. Has been ill for 3 days. When viewed on the palmar surface of the nail phalanx of the finger, an area of swelling of a dull white color with a diameter of up to 0.b cm is determined, surrounded by a thin belt of hyperemia.
What help should be given to a child?
The process with skin felon tends to spread, so the abscess must be opened immediately using sharp Cooper or nail scissors.
Carefully lifting the edges of the incision with tweezers, the peeled epidermis underneath should be carefully excised, leaving no pockets from which further spread of infection is possible. The exposed surface is dried, examined to reveal the fistulous tract inward (subcutaneous panaritium in the form of a “cufflink”). The wound surface is closed with a bandage with an antiseptic.
Patient D., 40 years old, came to an appointment about a boy ??? 4 fingers of the right hand with total damage to the periungual ridge and underlying fiber. The patient considers himself 2 weeks from the moment when he tore off the hangnail. The surgeon examined the patient and opened the abscess with a lateral incision near the nail. 2-3 drops of pus were discharged from the wound. The wound was washed with an antiseptic solution, a bandage was applied to it. After the operation, baths, compresses with Vishnevsky ointment, penicillin injections were used, but there was no noticeable improvement. The question arose about repeated surgery.
What mistake was made by the surgeon? Which operation was more rational to perform in this case?
The surgeon’s mistake was that he inadequately opened the periungual roller and did not provide a free outflow of pus. With a total defeat of the periungual roller with underlying fiber, Kenswell’s operation is indicated. Its essence is as follows. After treatment of the skin and anesthesia with unilateral paroichia on the side of the purulent-inflammatory focus, an incision is made, starting from the back along the edge of the nail in the proximal-palmar direction, 1-1.5 cm long. It is very important that such access exposes the corner of the nail bed, where most often purulent discharge is delayed. After cutting the skin, the supraungual plate is retracted and turned away. The sharp branch of the scissors is brought under the peeled edge of the nail, which is excised. Pus and necrotic tissue are carefully removed. Beware so as not to damage the nail bed and nail roller, otherwise the newly growing nail will be deformed and split. After sanitation, the shifted flap is placed in place and fixed with a bandage.
Patient O., 44 years old, a housewife, complained of pain in 1 finger of the left hand. Sick for about a week from the moment when she removed the splinter (fish bone) from under the nail. At first, the pain was minor. I used trays with a hypertonic solution of sodium chloride, potassium permanganate, compresses with Vishnevsky’s ointment, applied baked onions. There was no improvement. A sleepless night spent the night before “made” come to the reception. On examination, the opacity facing the base towards the free edge of a gray-yellowish color is determined, the tip of which is located in the center of the nail plate in the form of a triangle. Pressure on the nail plate is painful. The movements in the interphalangeal joint are carried out in full.
What is your diagnosis and treatment tactics?
A patient has a subungual felon of the first finger of the left hand. Surgical intervention is shown. Its essence lies in performing a wedge-shaped resection of the nail plate over the affected area, removing pus, a foreign body (if any), necrotic tissues, “ensuring a free outflow of pus.
A surgeon to the department. infection, a 34-year-old man was hospitalized with complaints of pain in the index finger of the right hand on the 22nd day from the onset of the disease. It is known that in the polyclinic on the 8th day from the moment of illness, he was operated on for subcutaneous panaritium. After the operation, I used baths with 10% sodium chloride solution, bandages with streptocidal ointment. Vishnevsky ointment. UHF therapy was carried out. For 2 weeks of such treatment, there was no noticeable improvement. The nail phalanx of the finger is clavate thickened, painful. On its palmar-radial surface, there is a linear wound with excessive granulations and scanty serous-purulent discharge.
With a suspicion of what complication the patient was referred to the hospital? What additional research should be performed in order to verify the diagnosis?
Most likely, the patient’s subcutaneous panaritium was complicated by bone, which is most often due to a small incision, insufficient revision of the wound, non-radical removal of necrotic tissues, and poor drainage. X-rays of the finger are taken to clarify the diagnosis. Destructive changes in the bone on radiographs are found 10-15 days after the onset of the disease. In the X-ray picture of bone marrow; panaritium distinguish three stages. In stage 1, spotted osteoporosis is detected, in stage II – a periosteal reaction, in stage III – a destructive process in the bone, sometimes with sequestration.
Patient R., 23 years old, was admitted to the department of a surgeon. infections with complaints of pain in the 2nd finger of the left hand. 2 weeks ago I pricked my finger with metal shavings. Within a week, he was treated at the polyclinic by puncture, antibiotic therapy, and immobilization of a finger. Improvement did not come, therefore, was sent to inpatient treatment. The finger in the proximal interphalangeal joint is bent, spindle-shaped, thickened, edematous, the skin is hyperemic, palpation in the joint area is sharply painful, there are practically no movements in the joint.
What is your diagnosis? What additional research needs to be done? What is your treatment strategy?
A patient has an articular panaritium of the proximal interphalangeal joint of the second finger of the left hand. To clarify the condition of the articulating bones, an X-ray examination of the finger is necessary. In the absence of sequestration of the articulating phalanges, fistulas and previous incisions by the L-shaped approach along the rear myj-lateral surface of the affected joint, its capsule is exposed. The latter is opened along the lateral surface of the finger or in the place of its greatest protrusion.
It is desirable to keep the side Ligaments intact. The joint cavity is washed with antiseptics, pathological granulations, affected areas of the capsule and ligaments are excised. The wound is washed again. A bandage and an immobilizing splint are applied in a functionally advantageous position of the finger. With destructive changes in the articulating surfaces of the phalanges, resection of the phalanx head, base or joint as a whole is indicated.
You are an emergency pediatrician. You were called in the evening to see a 7-year-old boy because his condition worsened. Approximately 1.5 days. A child with complaints of headache was released back home from school. At home, he was examined by a district pediatrician and prescribed anti-inflammatory and antibacterial drugs for an acute respiratory viral infection. On examination, the child’s condition is severe, inhibited. Temperature 40 C. According to the mother, there were hallucinations before the ambulance arrived. The face is pale, acrocyanosis. Pulse-128 beats per minute. Breathing is 28 per minute, superficial. In the lower parts of the lungs, scattered dry and moist rales are heard. The abdomen is soft and painless. The liver and spleen are not enlarged. There is pain on palpation in the lower third of the right thigh, its swelling.
What disease should you think about? Your tactics?
A child should be suspected of acute hematogenous osteomyelitis of the right hip. In this case, overdiagnosis of osteomyelitis has less dangerous consequences than delayed recognition of the disease.
The patient needs to enter a lytic mixture, immobilize the right lower limb and urgently transport it to the hospital.
A 9-year-old boy was admitted to the emergency room of the hospital with complaints of pain in his right leg. Has been ill for 2 weeks. He was treated at home. The condition worsened, therefore he was sent for inpatient treatment. Body temperature in the evenings up to 40 C. Single scattered dry and moist rales are heard in the lungs. The liver and spleen are not enlarged. There are edema and hyperemia of the skin in the lower third of the right thigh, sharp soreness. The knee joint is enlarged in volume, the leg is bent in it, the movements are painful. Additionally, it was found that 3 weeks ago he hit his right hip on the desk.
What is your diagnosis? What research needs to be done in the emergency room? What is your treatment strategy?
Judging by the clinical data, the child should be suspected of acute hematogenous osteomyelitis of the right thigh, complicated by subperiosteal abscess or intermuscular phlegmon.
In the hospital emergency room, complete blood counts, urine tests, chest fluoroscopy and radiographs of the right thigh should be performed.
The patient is hospitalized in the surgical department, where he is shown an emergency operation: opening of the intermuscular phlegmon, subperiosteal abscess, or trepanation of the bone in order to empty the abscess. General treatment is carried out according to the principles of treatment of acute purulent-septic diseases.
The mother brought a 13-year-old boy to see the surgeon, who over the past year has been periodically troubled by aching pains in the upper third of the left leg? As a rule, pain occurs when the weather changes and at night. Outwardly, the lower leg was normal. There is a limited hypersensitivity when pressing on the tibia 5 of the upper third of it. Movement in the knee joint is carried out in full. On radiographs in the spongy part of the tibial metaphysis, a round cavity with a diameter of about 1 cm is determined. surrounded by a clearly visible zone of sclerosis like a narrow border and gentle periosteal overlays on the surface of the bone.
What is your diagnosis and tactics?
The child has a primary chronic form of hematogenous osteomyelitis: Brody’s intraosseous abscess. The patient should be referred to the surgical department for surgical treatment. In this case, as a rule, bone trepanation is performed, curettage of the inner wall of the abscess with suturing the wound tightly without or with muscular plastics of the bone cavity.
A surgeon to the department. Infection, a patient was admitted with complaints of pain in the right leg, a periodic increase in body temperature to 38-39 C. Moves with crutches, 12 months ago suffered an open fracture. She was treated with skeletal traction and a plaster cast. However, due to pain, he cannot move independently. On the anterior surface of the right lower leg there is a fistula with scanty purulent discharge. The shin is edematous, moderate tissue hyperemia is observed around the fistula. On radiographs of the lower leg, a pseudarthrosis, terminal osteolysis of tibial fragments, endosteal sclerosis, thickening and fimbling of the periosteum are noted.
What was the diagnosis of the patient? What additional research methods are needed? What is your treatment strategy?
The patient suffers from chronic post-traumatic osteomyelitis of the right tibia (fistulous form). From additional studies, it is necessary to perform fistulograms to determine purulent pockets. The patient is shown surgical treatment. The fistula and necrotic tissues are excised. In end osteomyelitis with the formation of a pseudarthrosis, the ends of the bones are resected and bone fragments are fixed with the Ilizarov apparatus.
A medical conference discusses the medical history of a 23-year-old men suffering hron. hematogenous osteomyelitis of the right thigh. On radiographs in the diastal metaphysis of the femur is determined a cavity with a free-lying sequestration up to 1.5 cm in diameter. To the patient surgical treatment is indicated.
What would you suggest for filling the sequestral cavity after sequestrectomy and sanitation, “sequestral coffin”?
The most effective for plastic replacement of a bone defect is filling it with a blood clot, autogenous bone or cartilaginous pieces with the addition of antibiotics in solid forms, as well as a muscle flap on the proximal or distal pedicle. Also used are fillings from the periosteum, skin, preserved bone, round stem-like flaps, devoid of skin.
After being discharged home from the hospital for 3 weeks, the condition the newborn is progressively worsening. He is lethargic, crying, refuses breasts, does not gain in mass. The skin is pale gray, acrocyanosis. Frequent regurgitation, unstable stools are noted. Body temperature is constant 37.6-37.9 C. The abdomen is soft, does not respond to palpation. In place of the fallen off umbilical cord there is a weeping wound with flaccid, pale granulations covered with purulent bloom.
As a local pediatrician, what disease do you suspect in a child and what will you do?
The newborn should be suspected of umbilical sepsis and urgently admitted to the intensive care unit.
In the course of treatment, it is extremely important to ensure dynamic observation of the surgeon, since umbilical sepsis is often accompanied by peritonitis.
Patient C, 22 years old, complains of weakness, chills, constant high temperature (38-40), aching pains in the lower abdomen, scant spotting bleeding from the vagina. With a thorough history taking, it was established that 8 days ago she had a criminal abortion. The condition began to deteriorate from day 2. For honey. did not ask for help. The condition is serious. The skin is pale, the face is earthy, the sclera is icterus. Pulse-124 beats per minute. rhythmic, weak filling. Tongue dry, moderately coated. The abdomen is soft, painful above the bosom and in the iliac regions. Symptoms of peritoneal irritation are questionable.
As an ambulance doctor, what diagnosis will you make of the patient and what will you do?
The patient should be suspected of endometritis, postabsorption sepsis. She must be urgently transported to the gynecological department on a stretcher.
A 72-year-old patient has been amputated at the level of the middle third of the right thigh due to wet diabetic gangrene of the right foot to the lower leg. On the 4th day, due to suppuration, the stitches were removed from the stump, the wound was divorced, drained with tampons. Over the next 10 days, the purulent discharge from the wound stopped, but the granulation was flaccid, pale. The stump is edematous. The general condition of the patient is serious. Inhibited. There is a gray-earthy color of the skin, icterus of the sclera. Body temperature is constantly kept in the range of 39-40 C. Pulse-124-136 beats per minute, weak filling. Tachypnea. In the right hypochondrium, the liver edge protruding by 3-4 cm is palpable. Daily diuresis is 300-400 ml. The patient is suspected of acute postoperative sepsis.
What research should be done to verify the diagnosis?
In the diagnosis of sepsis, the most important is the presence of a primary focus (entrance gate), the corresponding clinical picture and positive results of blood cultures. Blood for crops is taken multiple times, at different times of the day, if possible before and at the time of the chill attack (at the height of the fever). In parallel, it is necessary to periodically monitor the bacteriological findings from the primary focus.
A negative blood culture result does not rule out the diagnosis of sepsis. A positive blood culture not only allows verification of the diagnosis, but also contributes to the correct selection of an antibacterial drug.
OCTRA SPECIFIC SURGICAL INFECTION
A man, 44 years old, inadvertently fell into an open sewer well. Received an open fracture of both bones of the right shin in the lower third of it. A surgeon. the department processed the wound with the imposition of a blind suture on it and the use of skeletal traction. By the end of 2 days from the moment of injury, the patient developed euphoria, he started complaining of pain in the wound, a feeling of bursting in it and the pressure of a bandage. The body temperature was subfebrile for two days.
What complication do you suspect in the patient? What local changes are characteristic of the complication you suspect?
The patient may develop Clostridial wound infection (gas gangrene). The injured limb should be examined immediately. Clostridial wound infection is characterized by the presence of edema in the wound area. An objective criterion for controlling the speed of its spread and depth is the method of applying circular ligatures above and below the site of the primary lesion (“ligature symptom”).
A frequent, although not permanent sign of a Clostridial wound is the accumulation of gas, which is palpably defined as a symptom of crepitus in its area.
And finally, when removing the sutures from the wound, the bottom and walls are covered with a dirty gray coating, the muscles are dull, they disintegrate when captured with tweezers, the discharge is scanty, brownish in color. When pressed on the brine edges, gas bubbles are released.
Three patients with fractures of the lower leg bones and extensive contaminated soil and scraps of clothing with lacerated wounds of the lower extremities were delivered to the district hospital from the scene of a traffic accident. Your actions?
After partial sanitization, the victims are shown to carry out emergency measures for the non-specific and specific prevention of tetanus and gas gangrene.
Nonspecific prophylaxis of anaerobic infection (you should start with it!) Includes the fight against shock, immobilization of the affected limb, as early as possible thorough surgical debridement of the wound, the use of antibiotics.
With the specific prevention of gas gangrene, polyvalent anti-gangrenous serum is injected subcutaneously or intramuscularly in the amount of 30 000 IU, having previously performed an intradermal test with serum diluted in a ratio of 1: 100 in order to detect sensitivity to horse protein.
For emergency specific prophylaxis of tetanus, tetanus toxoid, anti-tetanus serum or anti-tetanus human immunoglobulin are used, guided by the “Instructions for the use of purified adsorbed liquid tetanus toxoid (AC-toxoid)”.
A patient undergoing treatment in the trauma department, on the 3rd day after reposition of an open fracture of the tibia of the left leg in the middle third of it with immobilization of the limb with a posterior plaster splint, developed pain in the area of injury. When examining a patient by a doctor, general and local signs of gas gangrene were established. In the complex of therapeutic measures, the administration of anti-gangrenous serum is prescribed.
At what dose, how and by whom should antigangrenous serum be administered?
The therapeutic dose of anti-gangrenous serum is 150,000 ME (50,000 ME each against CI. Perfringens, oedematiens, septicum). It is recommended to use polyvalent serum or a mixture of monovalent sera prior to bacteriological identification of pathogens, and after establishing a bacteriological diagnosis, a serum homologous to the isolated pathogen is prescribed.
For therapeutic purposes, serum is injected intravenously slowly by drop (1 ml per minute), after dissolving 100 ml of serum in 400 ml of isotonic sodium chloride solution and heating to 36-37 ° C. Serum can be re-administered if indicated. The amount of serum injected depends on the clinical condition of the patient. Serum is injected necessarily by a doctor or under his supervision.
After the prophylactic administration of antigangrenous serum to the patient, he developed chills, tightness in the chest, sharp abdominal pains, vomiting, a drop in blood pressure, cold sweat, cyanosis, twilight consciousness.
What complication arose as a result of the administration of anti-gangrenous serum? What will be your actions?
The patient developed a clinical picture of anaphylactic shock in response to the administration of antigangrenous serum.
It is necessary to immediately establish an intravenous transfusion of polyglucin, intravenously inject diphenhydramine (suprastin, diprazine), prednisolone (dexamethasone, hydrocortisone), adrenaline. Subsequently, after an increase in blood pressure, to increase the BCC in special cases, you can use any infusion media, giving preference to colloidal plasma substitutes.
A patient undergoing treatment in the surgical department for lacerated wounds of the right thigh, contaminated with soil, with multiple crushing of muscles, on the second day developed local and general signs of gas gangrene. The complex of therapeutic measures includes the introduction of anti-gangrenous serum.
How do you put an intradermal test for equine protein sensitivity and how will you interpret the result?
To perform an intradermal test in order to detect sensitivity to horse protein, a syringe with 0.1 ml divisions and a thin needle are needed. A separate syringe and needle is required for each sample. The injection is made into the flexor surface of the forearm. 0.1 ml of diluted serum is injected intradermally and the reaction is monitored for 20 minutes.
The test is considered negative if the diameter of the papule does not exceed 0.9 cm and the redness around is limited. The test is regarded as positive if the papule reaches a diameter of 1 cm or more and is surrounded by a significant area of redness.
In case of a negative intradermal test, 1 ml of undiluted anti-gangrenous serum is injected subcutaneously. If there is no reaction to the serum administration, then after 30 minutes all the required serum dose is administered.
A serviceman with multiple extensive shrapnel wounds to the soft tissues of both lower extremities, buttocks and back during treatment developed clear symptoms of anaerobic Clostridial infection.
The administration of a therapeutic dose of antigangrenous serum was prescribed. When an intradermal test for sensitivity to equine protein was performed, the papule on the forearm reached 1.4 cm in diameter after 20 minutes.
As the surgeon on duty, what would you do in this situation?
The victim has clear signs of gas gangrene. This is an absolute indication for the administration of anti-gangrenous serum, despite the fact that the intradermal test for sensitivity to horse protein is positive.
In this case, under the supervision of a physician, horse serum diluted in a ratio of 1: 100 is injected under the skin, used for an intradermal test, with an interval of 20 minutes at doses of 0.5 ml, 2 ml, 5 ml. In the absence of a response to the injections of these doses, 0.1 ml of undiluted anti-gangrenous serum is injected subcutaneously after 20 minutes. After 30 minutes, if there is no reaction, all the required amount of serum is injected intravenously.
In case of a positive reaction to one of the above doses, the serum is not injected or injected under anesthesia, having everything necessary to provide assistance in case of anaphylactic shock.
A 69-year-old patient was admitted to the surgical department with gas gangrene of the right lower leg extending to the lower third of the thigh. The patient’s condition is serious, signs of intoxication are growing. For health reasons, the patient underwent amputation of the right lower limb at the level of the upper third of the thigh under a tourniquet. A thorough hemostasis was performed. A stump is formed from the cut out flaps. Along the edges of the suture line, the stump was drained with rubber graduates. A returning bandage was applied to the stump.
What mistakes were made by surgeons during the operation?
During the operation, surgeons made mistakes, since the technique of amputation of limbs affected by gas gangrene has its own characteristics.
Firstly, a hemostatic tourniquet is not used in such situations.
Secondly, with a correctly selected level of amputation (much higher than the visually determined border of non-viable tissues), stitches are not applied to the stump in the next 1-2 days. In the presence of edema or gas accumulation above the amputation site, it is advisable to perform economical longitudinal incisions with the obligatory dissection of the fascial cases, and the amputation itself should be carried out using the guillotine method.
The place and method of ligation of the great vessels is selected depending on the level of amputation. For proximal femoral or shoulder amputation, it is advisable to ligate the vessels from a separate access (common femoral or subclavian artery). With distal amputation, the vessels are isolated in the amputation wound, ligated and transected.
A patient with gas gangrene of the right leg was admitted to the department. The tactics of emergency treatment have been determined.
Considering the high contagiousness of anaerobic Clostridial infection, you, as the head of the department, must organize and control the observance of the sanitary and epidemiological regime in the department. What is the essence of it?
In the emergency room, a patient with anaerobic Clostridial wound infection should undergo full or partial sanitation.
The patient is placed in a separate ward, which should exclude the possibility of contact ** ™ er0 (and means of caring for him) with other patients.
Before admission (and after discharge), the patient’s bed, the bedside table and the bedside vessel are wiped with a rag abundantly moistened with 6% hydrogen peroxide solution and 0.5% detergent solution. Bedding (mattress, pillow – blanket, pajamas) auto-key according to the mode: 2 atm, 1 ^ 2 C and 20 min.
For washing and toilet pain * 1 * use soap in small packages. Pain dishes are freed from food debris, soaked in 2% sodium bicarbonate solution and boiled for 1.5 hours.
The room is cleaned at least 2 times a day with a wet method, using a 6% solution of hydrogen peroxide with a 0.5% solution of detergent – Cleaning equipment (buckets, basins, rags) is labeled and after use autoclavable, like bed accessories …
The medical staff in the ward puts on special gowns and shoe covers * ‘- When examining and dressing the patient, they use oilcloth aprons, which are treated with a 6% solution in ° D ° ROD of peroxide. The dressing is used only once. During dressing or surgery, it is collected in a specially dedicated bix, autoclave and destroyed.
The patient’s underwear and bed linen are collected in polyethylene or thick cotton bags, soaked in a 1-2% solution of sodium bicarbonate or detergent, and then boiled for 1.5 hours.
Used instruments are immersed in 6% hydrogen peroxide solution with 0.5% detergent solution for 1 hour or boiled for 1 hour.
After disinfection, they are disassembled and washed in running water. Sterilization of instruments, gloves, dressing material is carried out with steam P ° D Pressure, dry heat, chemical solutions, gases.