Caso clínico II: Manejo y tratamiento de las heridas
Variando un poco la temática de los casos, y aprovechando los monográficos sobre suturas os dejo el siguiente supuesto clínico:
Mujer de 57 años que acude al servicio de Urgencias porque mientras limpiaba el campo con una hoz se corta en la mano con el siguiente resultado:
La paciente tiene como antecedente médico de interés que es hipertensa. No alergias medicamentosas conocidas ni intervenciones quirúrgicas relevantes.
En la exploración física aparentemente flexiona adecuadamente los 5 dedos, si bien es conveniente profundizar en esto. Las constantes vitales son normales, con una buena tensión arterial a pesar de que ha perdido bastante sangre.
¿Cuál sería tu manejo y tratamiento médico y quirúrgico de esta paciente?
Si queréis más datos de la exploración física podéis preguntar e iré contestando.
¡Ánimo y muchas gracias por participar!
Etiquetas: Casos clíncos
posted by Juan @ 1:02 p. m.
336 comments
336 Comments:
Hace cuánto se pegó el tajo?
Muy buena pregunta...
Hace 6 horas
Entonces voy a pensar que el "apaño" de dedo que se ha dejado la buena señora está contaminado... y que no es muy buena idea una sutura primaria (joe... el tto de las heridas lo di en 3º, qué lejos). Habría que limpiar la herida, antibióticos (de eso no piloto nada)... (ahora sigo)
(sigo), lavar bien la herida, explorar sensibilidad y movilidad, anestesiar la herida para explorarla bien, si hay zonas claramente necróticas, desbridarlas (el pulpejo ese negrillo no me gusta un pelo) y suturar pero con puntos separaditos (que corra el aire) porque tiene muchas papeletas de infectarse. Y bueno, preguntar a la señora cuándo fue la última vez que se vacunó con la antitetánica y seguir el protocolo (Ig +/- toxoide).
En fin... ya iré aprendiendo a hacerlo mejor, jejejej
Muy buen punto de partida... ¿más opiniones?
Este comentario ha sido eliminado por un administrador del blog.
Bueno, pues la herida en si no tiene muy mas aspecto, apenas se ve sangrar, aunque hay una zona de dudosa vitalidad, otra cosa es el paso de 6 h...
Mi propuesta se inicia con cosas que ya ha puesto sofi...
Lo primero y principal es asegurar que el dedo está recibiendo bien la sangre oxigenada, una buena forma es el relleno capilar y si teneis a mano un pulsi a veces puede darnos informacion... esto lo haremos siempre antes de anestesiar por que algunas anestesias locales llevan adrenalina (que puede vaso constreñir)
Habría que empezar por realizar una anestesia troncular del dedo, es una tecnica muy sencilla que se puede realizar en la sala de curas, no tiene sntido anestesiar solo la herida por que para ver bien y explorar correctamente los tendones flexores del dedo tendremos q disecar un poquito, ademas la herida es grande y esto nos permite anestesiar todo el dedo con unos 4cc o incluso menos...
Limpiar la herida, abundante suero salino a chorro por si hubiera restos de tierra directamente sobre la herida, colocar una gasa esteril sobre la misma y hacer q flexione la interfalangica proximal y medial de forma activa, lo comprobaremos sobre el lecho pero es importante que en el primer examen veamos q tal.
Una vez limpiemos los exteriores de la herida y el resto del dedo y de la mano con alguna solucion antiseptica colocamos un paño y envolvemos el resto de la mano salvo el dedo con paño steril sobre una mesa de mayo y nos colocamos sentados para poder trabajar con comodidad... Lo primero es demostrar de visu la integridad flexora para ello disecaremos sin exceso (por q al despegar se puede edematizar) y observaremos el superficial y el profundo, mientras exploramos traccionaremos de los tendones observando q las falanges se flexionan... Si conseguimos demostrar la integridad podemos seguir con la herida, en caso de que no (llamar al trauma), o si nos atrevemos y encontramos los cabos se puede hacer sutura primaria del tendon con diversas tecnicas, por ejemplo la de Bunnel
En cuanto a la Herida, Lo tengo que pensar un poquillo mas, el pulpejo está mal, pero hay q tener en cuenta que es una zona sensible que si la quitamos ya no vamos a poder recuperar esa sensibilidad, aunqu desde luego si hay zonas de muy dudosa vitalidad habra q friedrichzar, otra opcion es hacer plastias tipo cruzado de dedos.. eso para el pulpejo, el resto de la herida parece no tener problema para hacer una sutura primaria, teniendo en cuenta el edema y el hecho de q haya tension puede dar problemas, una buena opcion es hacer una incision de descarga en el dorso del dedo, y cerrar en cremallera, en este caso la herida al ser oblicua resta un poco de tension... aunq ya digo q esto lo tengo q meditar un poquito mas...
Dependera de lo que hagamos (si hacems plastias y eso) lo q pondremos luego, en ese caso conviene inmovilizarlo con una férula metalica por ejemplo, por q estas se retiran con facilidad y pueden reponerse para curar la herida...
Poner la antitetanica y coBertura antibiotica al menos 7 dias... y por ahora no se me ocurre nada
por cierto si hemos realizado sutura tendinosa del flexor, siempre hay q colocar una férula con los flexores en relajacion...y la exploracion de la sensiblidad siempre la haremos antes de anestesiar.
Uff! poco más que decir, no...?. Muchas gracias toni por una opinión tan cualificada. Me gustaría seguir contando contigo en los post de suturas.
Un saludo
Gracias Juan, el tema de los dedos me gusta por q es tan especifico como interesante, de todos modos seguro q me he dejado alguna cosilla por ahí y esa herida habría q vigilarla de cerca, hay varias escalas q dudan mucho sobre suturas primarias a partir de 6h (esta está en el Límite...) en cuanto a participar en el blogg de suturas... Si algo que aportar (o que yo pueda opinar, me encantaria participar... Iré entrando por aqui. Me parece Muy interesante Tu post.
Hola!!!
Creo en la enseñanza de una forma ilustrativa... cómo aprenderíamos los médicos si no fuera con fotos!!!
Yo misma he hecho cientos de fotos a escáneres, a pacientes en la mesa de quirófano...
Ejemplo, te encuentras ante una anomalía anatómica, dígase cientos de divertículos en el intestino delgado, se manda al estudiante, se llama al fotógrafo del hospital, se usa el superzapatófono del cirujano jefe,
pero el objetivo es ese, fotografiarlo, para luego poderlo enseñar.
Pues bien, el otro día salió esta conversación a flote en un entorno en el que no había sólo médicos (y para más inri había una periodista y un juez en prácticas)... Les parecía una práctica aberrante fotografiarles sin antes haber pedido permiso por escrito (ostras, hay que despertar al paciente si no lo has hecho antes!!!). Es un derecho constitucional el de la propia imagen... pero a mí me parece llevado al extremo.
Qué te parece? Tú cómo lo haces? Les informas de este blog a tus pacientes?
Leo con frecuencia tu blog, un saludo de una cirujanita.
Pues normalmente la gente no pone problemas al pedir permiso para realizar fotografías. Ahora bien, como todo en esta vida, hay que tener un poco de tacto... p. ej. el otro día una niña de 16 años había sufrido una amputación de la falange distal de su 2 dedo izquierdo, y estaba muy afectada. Evidentemente, no tiene sentido fotografiar esa herida.
Las fotos las saco de una base de datos que tengo, y antes de publicarlas compruebo que el paciente no sea reconocible (hay unas normas de tratamiento de imágenes con fines docentes). A ellos no les digo donde podrían aparecer sus lesiones, simplemente les pido permiso para sacar una fotografía con fines educativos, y casi nunca ponen problemas. El colgarlas aquí, sinceramente, no creo que ninguno de los lectores entre aquí con ánimo de cotillear ni con fines morbosos, ya que, por suerte o por desgracia, la red tiene contenidos mucho más interesantes para esto.
Un saludo, y gracias por leerme!!
Creo que no sera necesaria la plastia, ya que la herida tiene forma de Z.
Limpiar, desinfectar, aproximar con puntos, y ea, creo que la mujer se apaña.
Saludos, y ¡gracias por el blog!
Hola! me parece muy interesante tu blog y los casos clínicos.
Me podriais recomendar algún libro que esté bien sobre suturas, colgajos...? gracias
Cati, la verdad, me has dado idea para un post. Tengo que informarme para contestar a eso, lo que sí pondré es una relación de enlaces chulos. Trabajaré en ello.
Un abrazo y gracias por venir
Amelie, tu opinión coincide con la mía. Un abrazo
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De intrusa me meti a este blog... pero no sería una posibilidad en vez de suturar intentar cierre con curaciones? Si esta infectado se puede colocar un hidrogel con plata para bajar la carga bacteriana y ayudar a mantener el ambiente humedo, en general en la mano el manejo con curaciones tiene super buen resultado estetico, siempre teniendo el cuidado de que no haga retracciones de la cicatriz para mantener la funcionalidad.
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