Basic orders operating in surgical, traumatological departments, intensive care units

1. Order of the Ministry of Health of the USSR No. 408 of 1989 "On measures to reduce the incidence of viral hepatitis in the country."

Epidemiology, clinic, diagnosis, treatment, outcomes, clinical examination of patients with viral hepatitis A, B, delta, etc.

Hepatitis A. Hepatitis A virus( HA) belongs to the family of picornaviruses, is similar to enteroviruses. The HA virus can persist for several months at 4 ° C, several years at -20 ° C, for several weeks at room temperature. The virus is inactivated by boiling.

Only one serological type of HA virus is known. Of the detectable specific markers, the most important is the presence of antibodies to the HA virus of the IgM class( anti-guar antigen IgM), which appear in the blood serum at the onset of the disease and persist for 3-6 months. Detection of anti-HAV IgM indicates hepatitis A and is used to diagnose the disease and identify sources of infection in the outbreaks.

The antigen of the HA virus is found in the stool of patients 7-10 days before clinical symptoms and is used to identify sources of infection.

The anti-HA IgG is detected from the 3rd-4th week of the disease and persists for a long time.

The source of infection are patients with any form of acute infectious process.

Forms of the disease: icteric, jaundice, subclinical, inaparant.

Transmission mechanism - fecal-oral. Its realization occurs through the factors inherent in intestinal infections: water, "dirty hands", food products, household items. People's susceptibility to infection is universal. Immunity after a long-term illness, perhaps, for life.

The incubation period is from 7 to 50 days, an average of 15-30 days.

Pre-zhelto period( prodroma period) - acute onset, fever to 38 ° C and above, chills, headache, weakness, decreased appetite, nausea, vomiting, abdominal pain. There is a feeling of heaviness in the right hypochondrium. The tongue is laid, the abdomen is swollen, the liver reacts when palpation of the abdomen. The duration of this period is 5-7 days. By the end of the pre-jaundiced period, the urine becomes dark, the color of the beer. The feces become discolored. Appears subicteric sclera. The icteric phase of the disease begins.

Jaundice increases rapidly, a number of symptoms weakens, a feeling of heaviness in the right hypochondrium, weakness, a decrease in appetite. Dimensions of the liver increase, it has a smooth surface, compacted. The spleen is enlarged. In the blood - leukopenia, a moderate increase in bilirubin, increased ALAT and ASAT.The icteric period lasts 7-15 days.

The period of convalescence is characterized by the rapid disappearance of clinical and biochemical signs of hepatitis.

There are no chronic forms of GA.

The jaundiced forms of viral hepatitis A have the same clinical( with the exception of jaundice) and biochemical( except for increasing the level of bilirubin) signs.

Erased forms are those in which all clinical signs are minimally expressed.

Inactive forms - asymptomatic carriage, which is detected by the appearance of ALAT activity in the serum and the presence of anti-IgM and IgG.

The diagnosis is made on the basis of clinical data, as well as the detection of anti-HA immunoglobulin M antibodies( anti-HAV IgM) and class G( anti-HAV IgG) in the serum of blood and increasing the activity of AlAT and ACAT and bilirubin in the blood.

Patients are hospitalized in the infectious disease department of the hospital. Recovery usually occurs within 1 to 1.5 months after discharge from the hospital.

HAA convalescent cones are observed in the infectious diseases room, where they undergo a medical examination once a month. They are removed from the register after 3 months in the absence of complaints, normalization of liver size and functional tests.

Treatment, prevention

Mild forms of hepatitis A do not need medical treatment. It is enough to follow a diet, a semi-fast diet, plenty of drinking;with medium-heavy form, the introduction of detoxification means is added: intravenously, 5% glucose solution,

Ringer's solution 500 ml with addition of 10 ml of 5% solution of ascorbic acid are drip.

Severe forms are extremely rare: more intensive infusion therapy may be required.

Prophylactic measures - the introduction of immunoglobulin by epidemics to 3.0 ml. Data on immunoglobulin-prophylaxis are entered in registration forms No. 063 / y and 26 / y. Enter the drug is allowed no more than 4 times with intervals of at least 12 months.

Persons who have been in contact with patients with HAV are monitored( once a week for 35 days).

Hepatitis B( HBV) is an independent disease caused by the hepatitis B virus, which belongs to the family of hepadnaviruses. Extremely stable in the external environment.

The source of HS is patients with any form of acute and chronic hepatitis B, as well as chronic "carriers" of the virus. The latter are the main sources of infection. The patient can be contagious already 2-8 weeks before the appearance of signs of the disease.

The incubation period is 6-120 days.

Pre-ironic period. The disease begins gradually. Patients complain of a decrease in appetite, nausea, vomiting, constipation, followed by diarrhea. Often disturbed joint pain, pruritus, increased

Transmission mechanism - parenteral:

• through damaged skin and mucous membranes;

• transplaceptic;

• with blood transfusions;

• Sexually.

the size of the liver, sometimes the spleen. In the blood, leukopenia. The activity of the indicator enzymes AlAT and AsAT in the blood serum is increased. The duration of this period is from 1 day to 3-4 weeks. Jaundice period is long, characterized by the severity and persistence of clinical symptoms of the disease, tends to increase. Jaundice reaches a maximum at the 2-3rd week. There is a long soreness in the right hypochondrium, the liver is smooth, enlarged. In the blood: leukopenia, lymphocytosis, a significant increase in the level of bilirubin, an increase in ALT and ASAT in the serum.

Acute hepatitis B usually occurs in moderate to severe forms, often severe forms.

Fulminant( lightning) forms are rare.

Complications: hepatic coma, encephalopathy.

Chronic forms of hepatitis B are common.

The period of recovalence is longer than with HAV, the clinical and biochemical characteristics persist for a long time.

Specific methods of laboratory diagnosis - the presence of HBs antigen( HBSAg), which appears in the blood long before the appearance of the clinic of the disease.

To distinguish the state of carrier HBsAg from active infection, it is necessary to study in the serum anti-HBsIgM, the absence of such antibodies is characteristic for carrier.

The discharge of reconvalescents in hepatitis B is carried out for the same clinical indications as for hepatitis A. On discharge of convalescent patients, in which the HBs-antigen continues to be detected for a long time, it is necessary to inform the infectious disease doctor and the sanitary-epidemiological station of the district in the polyclinics.

Outcomes of acute viral hepatitis:

• recovery;

• residual events:

• prolonged convalescence;

• post-hepatitis hepatosplenomegaly.

Continuing course of the infectious process:

• protracted hepatitis;

• chronic persistent hepatitis;

• asymptomatic carriage of HBs-antigen;

• chronic active hepatitis;

• cirrhosis of the liver;

• Primary liver cancer.

After discharge from the hospital, the patient is inspected no later than 1 month later. Then he is examined at 3, 6, 9 and 12 months after discharge. Withdrawal is carried out in the absence of chronic hepatitis and a double negative study on HBsAg, conducted at an interval of 10 days.

Treatment:

• detoxification therapy, depending on the severity of the condition;

• reaferon( recombinant alpha-2 interferon);

• symptomatic treatment.

Prevention is aimed at active detection of sources of infection, for this purpose it is necessary to conduct a population survey on the carrier of hepatitis B virus, and first of all to examine people at risk.

Risk groups

1. Donors.

2. Pregnant.

3. Recipients of blood and its components.

4. Staff of blood service establishments, hemodialysis departments, surgery, biochemical laboratories, ambulance stations, resuscitation departments.

5. Patients with a high risk of infection in the staff of hemodialysis centers, kidney transplants, cardiovascular and pulmonary surgery, hematology.

6. Patients with any chronic pathology, long-term inpatient treatment.

7. Patients with chronic liver diseases.

8. Contingent of narcological and skin-venereal dispensaries.

Prevention of occupational infections:

• All manipulations during which blood or serum contamination of the hands can occur are carried out in rubber gloves. During operation, all the damage on the hands is sealed with adhesive plaster. To avoid splattering of blood, you should work in masks;

• Hand disinfectants should be avoided frequently when handling hands. Surgeons for hand washing should not use stiff brushes;

• In case of contaminated hands with blood, immediately disinfect them with a disinfectant solution( 1% solution of chloramine) and wash them twice with warm water and soap, wipe dry with a disposable single-use wipe;

• the surface of the workbenches in case of contamination with blood immediately treated with a 3% solution of chloramine;

• Medical workers who have a professional contact with blood should be examined for HBsAg when entering the workplace, and then at least once a year.

1. In order to prevent hepatitis B in all health facilities:

• Use disposable instruments as much as possible;

• strictly follow the rules for disinfection, pre-sterilization cleaning and sterilization of medical equipment;

• medical history of HBsAg carriers should be labeled.

2. OST of the Ministry of Health of the USSR, 1985 42-21-2-85

Sterilization and disinfection of medical devices.

Methods, facilities, modes:

• disinfection( methods, tools);

• pre-sterilization treatment( steps);

• sterilization( methods, modes, means);

• cleaning products from corrosion.

3. Order of the Ministry of Health of the USSR No. 215 of 1979 "On measures to improve the organization and improve the quality of specialized medical care for patients with purulent surgical diseases."

The instruction on the organization and carrying out of sanitary-and-hygienic measures, anti-epidemic regimen in surgical departments, intensive care units is described.

4. Order of the Ministry of Health of the Russian Federation No. 295 of 1995 "On the enactment of the rules for compulsory medical examination for HIV".

List of employees of institutions and organizations that undergo medical examination for HIV infection during compulsory admission to work and periodic medical examinations:

• doctors, middle and junior medical staff on AIDS prevention and control, directly involved in the survey, diagnosis,treatment and care of people infected with the immunodeficiency virus;

• doctors, middle and junior medical staff of laboratories;

• Scientists, workers of enterprises for the manufacture of immunobiological products, whose work is related to the material containing the immunodeficiency virus.

Rules for conducting mandatory medical examination for the detection of HIV infection.

1. Donors of blood, sperm and other biological fluids, tissues, organs are subject to mandatory medical examination.

2. The study of blood serum for the presence of antibodies to the immunodeficiency virus is carried out in 2 ethan.

Stage I - reveals the total spectrum of antibodies against antigens of the HIV virus by enzyme immunoassay.

II stage - an immune blot is conducted to determine antibodies to individual proteins of the immunodeficiency virus.

3. In case of HIV infection in workers of certain enterprises( the list of organizations is approved by the Government of the Russian Federation), they are subject to transfer to another job, excluding the conditions for the spread of HIV infection.

List of indications for the HIV / AIDS survey in order to improve the quality of diagnosis.

1. Patients according to clinical indications:

• febrile for more than one month;

• having an increase in lymph nodes of two or more groups over one month;

• with diarrhea lasting more than one month;

• with unexplained weight loss;

• with persistent and recurrent pneumonia or pneumonia that can not be treated normally;

• with prolonged and relapsing purulent-bacterial parasitic diseases, sepsis;

• with subacute encephalitis;

• with fluffy leukoplakia of the tongue;

• with recurrent pyoderma;

• women with chronic inflammatory diseases of the reproductive system of unclear etiology.

2. Patients with suspected or confirmed diagnosis for the following diseases:

• addiction;

• Sexually transmitted diseases;

• Kaposi's sarcoma;

• Brain lymphomas;

• T-cell leukemia;

• pulmonary and extrapulmonary tuberculosis;

• hepatitis B;

• cytomegalovirus infection;

• generalized or chronic forms of herpes simplex;

• recurrent shingles( faces younger than 60 years);

• mononucleosis;

• Candidiasis of the esophagus, bronchi, trachea;

• deep mycosis;

• anemia of various genesis;

• pregnant - in case of abortion and placental blood sampling for further use as a raw material for the production of immunopreparations.

Compulsory HIV testing is prohibited.

Coding patients when referring them to an HIV test:

100 - citizens of the Russian Federation;

102 - drug addicts;

103 - homo and bisexual;

104 - patients with sexually transmitted diseases;

105 - persons with promiscuous sexual intercourse;

106 - persons who are abroad more than one month;

108 - donors;

109 - pregnant( donors of placental and abortion blood);

110 - recipients of blood products;

112 - persons who were in places of deprivation of liberty from at-risk groups;

113 - examined but clinically indicated( adults);

115 - medical personnel working with AIDS patients or infected material;

117 - examined according to clinical indications( children);

118 - other( specify the contingent);

120 - medical contacts with AIDS patients;

121 - heterosexual partners of HIV-infected people;

122 - homosexual partners of HIV-infected people;

123 - partners of HIV-infected people for intravenous drug use;

126 - voluntary survey;

127 - the survey is anonymous;

200 - foreign citizens.

5. Order of the Ministry of Health of the USSR No. 1002 of 04.09.87 "On measures to prevent infection with the AIDS virus."

The following are subject to inspection:

• foreigners who arrived for a period of 3 months or more;

• Russian citizens returning from foreign business trips lasting more than one month;

• people at risk, who received multiple transfusions of blood and its drugs, who suffer from drug addiction, homosexuals, prostitutes;

• citizens who have contacts with patients or virus carriers;

• wishing to undergo an examination.

6. Order No. 286 of the Ministry of Health of the Russian Federation of 7.12.93 and Order No. 94 of 7.02.97 on Improving Control over Sexually Transmitted Diseases.

A notice is given to the patient for the first time in his life with a diagnosis of active tuberculosis, syphilis, gonorrhea, trichomoniasis, chlamydia, ureaplasmosis, gardnerellez, urogenital candidiasis, anurogenital herpes, genital warts, scabies, trachoma, mycosis of the feet( form No. 089 / y-93).

The notice is drawn up in each treatment and prevention institution. The notice is made by the doctor. If the diagnosis is made by the average medical staff, the patients should be referred to the doctor.

To carry out 100% coverage of serological blood tests for syphilis patients entering hospital treatment, who applied to polyclinics for the first time this year - by express method;tuberculosis, neurological, narcological patients, donors - classical serological reactions.

7. Order of the Ministry of Health of the Russian Federation No. 174 of 17.05.99 "On measures to further improve tetanus prevention."

The most effective method of preventing tetanus is active immunization with tetanus toxoid( AC).

Protection against tetanus in children is created by immunization with DTP vaccine or ADS-toxoid, in adults - with ADS-M-anatoxin or AC-toxoid. The completed active immunization course includes primary vaccination and first revaccination. To prevent the occurrence of tetanus in case of trauma, emergency prevention is necessary.

Drugs used for routine active immunization against tetanus:

• DTP - adsorbed pertussis-diphtheria-tetanus vaccine containing 1 ml of 20 billion inactivated pertussis microbial cells, 30 units of diphtheria and 10 units of tetanus toxoid binding;

• ADP - containing 60 ml of diphtheria and 20 units of tetanus toxoid in 1 ml;

• ADS-M - with a reduced content of antigens;

• Ac - tetanus toxoid( in 1 ml of 20 units).

Drugs used in emergency tetanus immunodeficiency:

• AS - adsorbed tetanus toxoid;

• ADS-M;

• IICC - Tetanus serum equine serum, one dose of PSS is 3000 ME;

• PCMI is an anti-tetanus immunoglobulin, one dose is 250 IU.

Emergency tetanus prophylaxis is performed with:

• injuries with a violation of the integrity of the skin and mucous membranes;

• burns and frostbite of II-IV degrees;

• Community-acquired abortions;

• deliveries outside medical facilities;

• gangrene of any type, carbuncles and long-term abscesses;

• Animal bites.

Emergency tetanus prophylaxis consists of primary surgical treatment of the wound and simultaneous specific immunoprophylaxis. It must be carried out as early as possible and up to 20 days from the time of injury.

Drugs are not administered:

• for children who have documentary evidence of planned preventive vaccinations according to age, regardless of the period after the next vaccination;

• for adults who have a document confirming the complete course of immunization no more than 5 years ago.

Enter only 0.5 ml of AS-toxoid:

• for children who have documented routine preventive vaccinations, without the last age-specific revaccination;

• adults who have a document on the immunization course conducted more than 5 years ago;

• for people of all ages who received two shots no more than 5 years ago, or one inoculation no more than two years ago;

• for children from 5 months of age, military personnel whose vaccination history is unknown.

Active-passive tetanus prophylaxis:

• When active-passive tetanus prophylaxis is administered, 1 ml of AS, then another syringe to another part of the PCMI body( 250 ME) or after an IICC( 3000 ME) intradermal test;

• Active-passive vaccination is given to people of all ages who received two shots more than 5 years ago, or one vaccination two years ago;

• to unvaccinated people, as well as to persons who do not have a documented vaccination warning.

To complete the course of immunization against tetanus for 6 months to 2 years, 0.5 ml of AS or 0.5 ml of ADS-M should be revaccinated.

Emergency prophylaxis of tetanus with repeated traumas

Persons who, in the event of a trauma in accordance with their vaccination history, received only AS( ADS-M), in case of repeated injuries, they perform emergency prophylaxis as previously vaccinated, but not more often than once in 5 years.

Emergency prophylaxis of tetanus in radiation-thermal lesions - 1 ml of AS and 250 PSKI are administered.

Conditions and technique for emergency tetanus prophylaxis

Given that after the introduction of MSS and preparations containing tetanus toxoid, especially sensitive people may develop a shock, for each vaccinated it is necessary to organize medical supervision within an hour after vaccination. Before the injection of the AS, the ampoule is shaken until a homogeneous suspension is obtained. The opened ampule with AC or PSS can be stored, covered with a sterile tissue, for no more than 30 minutes.

The drug is drawn into a syringe from the ampoule with a long needle with a wide opening. For injection, use a different needle. The AS is administered in an amount of 1 ml. At the same time, another 250 IU of PCMI is intramuscularly injected into another part of the body, in the absence of PCPI, 3000 MEPSS is administered.

Before the introduction of MSS, an intradermal test with horse serum diluted 1: 100 is mandatory, to determine sensitivity to whey proteins( ampoule is marked in red).An intradermal test is not performed if a sample with a diluted 1: 100 rabies gamma globulin was sampled for 1-3 days before the administration of the MSS.

A separate ampoule, sterile syringes and a thin needle are used to place the sample. The diluted 1: 100 serum is injected intradermally into the flexor surface of the forearm in an amount of 0.1 ml. The reaction is taken into account after 20 minutes. The sample is negative if the diameter of the edema or redness at the injection site is less than 1 cm. With a negative cutaneous MPS sample( from the ampoule marked in blue), subcutaneously in an amount of 0.1 ml. If no reaction occurs after 30 minutes, the remaining dose of serum is injected with a sterile syringe. During this time, the opened ampoule with PSS should be closed with a sterile tissue.

Emergency prophylaxis by revaccination AS AS62 AUD AS injected in the amount of 0.5 ml according to the instructions to the drug.

All the cases of post-vaccination complications that develop after the administration of preparations containing tetanus toxoid, and also after the administration of MPS or POCCHI( shock, serum sickness, nervous system diseases), medical personnel immediately report to Sanitary and Epidemiological Station.

8. Order No. 297 of 7/10/97 "On improving measures for the prevention of human diseases by rabies".

The Russian Federation annually registers from 5 to 20 cases of human infection with rabies. In order to improve the quality of anti-rabies care and improve measures for the prevention of rabies, I order:

• to set up anti-rabies care centers on the basis of medical and preventive institutions that have a trauma department;

• conduct annual seminars for health professionals on rabies and rabies prevention;

• organize mandatory preventive immunization against rabies for persons whose professional activities are associated with a risk of infection with the rabies virus;

• exercise strict control over the availability of anti-rabies drugs and their storage conditions in the health facility;

• to increase awareness-raising among the population, using mass media and visual agitation.

1. It is created on the basis of the medical institution, which has in its structure a trauma unit or traumatology department.

2. The head of the Center appoints a trauma doctor or a surgeon who has been trained in organizing and providing anti-rabies assistance.

3. The Center's activities are carried out in contact with health facilities, centers of the State Sanitary Epidemiological Service, veterinary service.

Main tasks and functions of the center:

1. The Center carries out coordination, organizational, methodological, advisory and practical assistance to medical and preventive institutions in the provision of medical care to persons at risk of infection with the rabies virus.

2. Carries out reception and rendering of medical aid to victims of bites, scratches, muffling by animals, persons exposed to the risk of infection with the rabies virus.

3. Organizes permanent seminars on training and retraining of specialists, anti-rabid assistance to the population.

4. Communicates and inter-informs with veterinary authorities throughout the service area on the epizootic state of the area.

5. Organizes and conducts sanitary-educational work on the prevention of rabies among the population.

Rights of the Center:

• receive the necessary information from health facilities, centers of Gossanepidnadzor, veterinary service;

• to submit proposals to the public health authorities on the issues of improving and improving anti-rabies activity, to attract consultants of various profiles, if necessary.

Instruction on the order of operation of the medical and preventive institution and the Gossanepidnadzor centers for the prevention of diseases of rabies.

. The first medical help for persons who have bitten, bitten, scorched by any animal, as well as persons who have received skin lesions and foreign material on the mucous membranes when cutting andautopsy of animals, autopsies of people who died from hydrophobia, are provided by all health facilities.

1. The course of therapeutic and prophylactic immunization is prescribed immediately and is performed in the trauma centers, and in the absence of them in surgical rooms or departments:

• abundantly rinse wounds, scratches, scratches with a jet of water with soap( or any detergent), treat the edges of the wound70% alcohol or tincture of iodine, apply a sterile bandage. The edges of the wound inflicted on the animals during the first three days are not to be excised or stitched, excluding damages that require special surgical interventions but vital signs;

• In case of extensive wounds, after a preliminary local treatment of the wound, several leading sutures are applied;

• In order to stop external bleeding, the bleeding vessels are flushed.

2. Emergency tetanus prophylaxis is carried out.

3. The victim is sent to the emergency department or surgical department of the hospital for the purpose and conduct of an anti-rabies vaccination course.

4. For each person who receives the call, a telephone message is sent and a written "emergency" notice is sent( registration form No. 058y) within 12 hours to the center of Gossanepidnadzor, trauma centers.

5. In the absence of trauma centers, surgical offices and departments are obliged:

• in case of initial treatment the victim should provide him with first medical aid, promptly transmit the telephone message, send a written notice( registration form No. 058 / y) to the center of Gossanepidnadzor( station);

• fill in for each victim "Card for applying for anti-rabies help"( registration form No. 045 / y) in duplicate;

• designate and ensure the implementation of a course of anti-rabies vaccinations in accordance with current regulations, including on weekends and holidays;

• provide hospitalization for the following categories of victims:

a) persons who have received severe and multiple bites and bites of dangerous localization;B) persons living in rural areas;

c) grafting repeatedly.