Sadhyo vrana and its management along with modern corelation

sadhyo vrana
its types
management and modern corelation

1. “ SADHYO VRANA” PRESENTED BY- AKSHIT CHAUHAN PG 1 ST YEAR SCHOLAR SHALYA TANTRA DEPARTMENT

2. INTRODUCTION निरुक्ति ( E tymology ) :- वृणोति यस्माद रूढे अपि व्रणवस्तु न नश्यति। आदेह धारणात तस्मात् व्रण इत्युच्यते बुधै।। ( सु.सू. २१/४० ) व्रण गात्र विचूर्णने इति व्रणः | ( सु.चि. १/६ ) परिभाषा (DEFINITION)

3. व्रण के भेद

4. स |ks व्रण निदान :- नानाधारामुखैः   शस्त्रैर्नानास्थाननिपातितैः   | नानारूपा   व्रणा   ये   स्युस्तेषां   वक्ष्यामि   लक्षणम्   ||४|| Different ty pes of wounds are produced by the impact of different types of weapons with different sharp edges on different parts of the body are considered as Sadhyo Vrana.

5. CLASSIFICATION OF SADHYO VRANA छिन्नं   भिन्नं   तथा   विद्धं   क्षतं   पिच्चितमेव   च   | घृष्टमाहुस्तथा   षष्ठं   तेषां   वक्ष्यामि   लक्षणम्   || (सु.चि. 2/8,9)

6. Sushruta Samhita Astang Sangraha Astang Hridayam Madhav Nidan Chinnam Chinnam Ghrishtam Chinnam Bhinnam Viddham Avakritam Bhinnam Viddham Picchitham Vicchinnam Viddham Kshatam   Pravilambitam Kshatam Picchitham   Patitam Picchitham Ghrishtam   Viddham       Bhinnam       Vidhalitam   Types of Sadyo Vrana According to Different Acharyas

7. CHINNA ( छिन्न ) तिरश्चीन   ऋजुर्वाऽपि   यो   व्रणश्चायतो   भवेत्   ||१०|| गात्रस्य   पातनं   चापि   छिन्नमित्युपदिश्यते   |११| Wound which is oblique, straight or broad (wide) including falling off of the part of the body (dismembering) is known as Chinna Vrana. . All the excisional i njuries . . .

8. BHINNA ( fHkUu ) कुन्तशक्त्यृष्टिखड्गाग्राविषाणादिभिराशयः। हतः किञ्चित स्रवेतद्धि भिन्नलक्षणमुच्यते।। सु. चि. २/११ Asayas (viscera of the chest and abdomen) punctured by the tip of Kunta (dagger), Sakti (spear) Risti (lance), Khadga (sword), Visana (horns of animals) and exuding little quantity of fluids- are the features of Bhinna Vrana (puncture of internal organs).

9. KOSTHABHEDA LAKSHANA (FEATURES OF PUNCTURE OF ABDOMEN) When ( Kostha ) is punctured, it becomes filled with blood, fever and burning sensation develop. Blood comes out through urinary tract, anus, mouth and nose. Fainting, dyspnoea, thirst, flatulence, lack of desire for food, non elimination of faeces, urine and flatus, sweating, red colour of the eyes, smell of iron coming out from the mouth, bad smell of the body, pain in the (region of the) heart and flanks are the general symptoms.

10. आमाशयस्थे   रुधिरे   रुधिरं   छर्दयेत्   पुनः| आध्मानमतिमात्रं   च   शूलं   च   भृशदारुणम् |१६| If the blood accumulation is in the Amasaya (stomach) the person vomits blood, has profound flatulence and excruciating pain. पक्वाशयगते   चापि   रुजो   गौरवमेव   च | शीतता   चाप्यधो   नाभेः   खेभ्यो   रक्तस्य   चागमः   |१७| If it is in the Pakvasaya (large intestine) there will be pain, feeling of heavyness, coldness of the area below the umbilicus and bleeding through the orifices ( Guda and Mutra Marga ).

11. VIDDHA ( fon ~/k ) सूक्ष्मास्यशल्याभिहतं   यदङ्गं   त्वाशयाद्विना   ||१९|| उत्तुण्डितं निर्गतं   वा   तद्विद्धमिति   निर्दिशेत्   |२०| Any part of the body except the hollow viscera, injured by weapons or foreign bodies entering through small openings and making the body part bulge up even after the foreign body has come out, such a wound is to be known as Viddha V rana

12. नातिच्छिन्नं   नातिभिन्नमुभयोर्लक्षणान्वितम्   ||२०|| विषमं   व्रणमङ्गे   यत्तत्   क्षतं   त्वभिनिर्दिशेत्   |२१| The wound created by the blunt objects where neither the excessive excisional nor the excessive punctured injury called as Kshata vrana . KSHATA ( क्षत ) May be called as lacerated wound.

13. PICHCHITA ( पिच्चितं ) प्रहारपीडनाभ्यां   तु   यदङ्गं   पृथुतां   गतम्   ||२१|| सास्थि   तत्   पिच्चितं   विद्यान्मज्जरक्तपरिप्लुतम्   |२२| Injury by heavy objects leading to crush that part with bone and muscles and wound appeared mixed with blood called as pichchita vrana. May be correlated as crush injury .

14. GHRISTA ( घृष्ट ) विगतत्वग्यदङ्गं   हि   सङ्घर्षादन्यथाऽपि   वा   ||२२|| उषास्रावान्वितं   तत्तु   घृष्टमित्युपदिश्यते   |२३| The injury created by strong rubbi ng force leading to expose the underlying tissue and serous discharge called as Ghrista vrana. May correlated to Abrasion.

15. SADHYO VRANA SAMANYA CHIKITSA छिन्ने भिन्ने तथा विद्धे क्षते वाऽसृगतिस्रवेत् | रक्तक्षयाद्रुजस्तत्र करोति पवनो भृशम् ||२३|| स्नेहपानं हितं तत्र तत्सेको विहितस्तथा | वेशवारैः सकृशरैः सुस्निग्धैश्चोपनाहनम् ||२४ || धान्यस्वेदांश्च कुर्वीत स्निग्धान्यालेपनानि च | वातघ्नौषधसिद्धैश्च स्नेहैर्बस्तिर्विधीयते |२६| When, in any kind of wound, either Chinna, Bhinna , Viddha or Kshata , bleeding is more, then Vata getting aggravated by loss of blood, produces severe pain. For this, Snehpana ( oleation ) along with Seka (fomentation) is beneificial . Upanaha (warm poultice) either from Vesavara or Krasara , added with Sneha should be applied; hot fomentation be done using Dhanya sweda . Application of Snigdha Lepa (unctuous pastes) on the part, administration of Sneha Basti (oil-enema), using oil preapred from  Vata shamak drugs.

16. PICCHITA AND GHRASTA VRANA पिच्चिते च विघृष्टे च नातिस्रवति शोणितम् ||२६|| अगच्छति भृशं तस्मिन् दाहः पाकश्च जायते | तत्रोष्मणो निग्रहार्थं तथा दाहप्रपाकयोः ||२७|| शीतमालेपनं कार्यं परिषेकश्च शीतलः  | In Picchita and Ghrista Vrana blood does not flow out greatly. There will be feeling of severe burning sensation and formation of pus. Then, in order to mitigate the heat, burning sensation and pus formation, Sheeta Alepa and Parisheka should be applied on that part.

17. कर्ण स्थानादपतं स्थापयित्वा यथास्थितम् || सीव्येद्यथोक्तं तैलेन स्रोताभिप्रतर्पयेत् ।। ३१ ।। VISHESHA CHIKITSA CHINNA VRANA CHIKITSA •The ear which has become displaced should be replaced in its usual site. •Sutured and dressed with medicated oil. •The orifice of the ear should also be filled with medicated oil ( vataghn Aushadhi ).

18. कृकाटिकान्ते छिद्रे तु गच्छत्यपि समीरणे ।। सम्यङ्गिवेश्य बन्धीयात् सीव्येच्चापि निरन्तरम् ।। ३२ ।। आजेन सर्पिषा चैवं परिषेकं तु कारयेत् ।। उत्तानोऽन्नं समश्रीयाच्छयीत च सुयन्त्रितः ।।३३।। •When the cut wound is at the end/ border of the Kṛakatika and air is coming out, then it ( Krakatika ) should be placed in its place properly, •Continuous suture done and bandaged. •The area should be bathed with Aja Ghrita . •The patient should be asked to eat lying with his face up and sleep well restrained .

19. शाखासु पतितांस्तिर्यक् प्रहारान् विवृतान् भृशम् ।। सीव्येत् सम्यङ्गिवेश्याशु सन्ध्यस्थीन्यनुपूर्वशः ।।३४।। बद्ध्वा वेल्लितकेनाशु ततस्तैलेन सेचयेत् ।। चर्मणा गोफणाबन्धः कार्यो यो वा हितो भवेत् ।। ३५ ।। WOUNDS OF THE EXTREMITIES •Wound of the extremities which are cut obliquely and found gaping wide, then it should be sutured after pushing the bone and joints inside, placing them in their proper places Then bandaged adopting either Vellitaka type or Gophana type, whichever is comfortable.

20. छिन्नां नि:शेषतः शाखां दग्ध्वा तैलेन बुद्धिमान् ।। बध्नीयात् कोशबन्धेन प्राप्तं कार्यं च रोपणम् ।। ३७।। When the extremity has been completely seperated from the body then the wise physician should do Sneha Dagdh (using oil) . Kosha type of bandage and take measures for healing the wound. पृष्ठे व्रणो यस्य भवेदुत्तानं शाययेत्तु तम् ।। अतोऽन्यथा चोरसिजे शाययेत् पुरुषं व्रणे ।। ३६। When the wound is in the back, then the person should be placed in supine position (with face upward). When it is in the chest, he should be placed in prone position (face downward).

21. BHINNA AND VIDDHA VRANA CHIKITSA If Medvarti ( Omentum ) comes out, the doctor should sprinkle Kashaya Bhasma and krishna mritika powder on it and tie it with a thread and cut it with a honey coated weapon ( Agnitapta shastra ) and tie a bandage. After the patient has digested the food properly, he should be given Ghartapana . Apart from Snehpana , milk should also be given. Milk prepared with Sharkara, Mulethi, lakh, Gokhru and Eranda relieves pain and burning sensation. Failure to pierce the Medvarati may result in flatulence (gurgling sound in the stomach due to gas), pain in abdomen or even death.

22. तत्रान्तर्लोहितं पाण्डुं शीतपादकराननम् ।। शीतोच्छ्वासं रक्तनेत्रमानद्धं च विवर्जयेत् ।।५१।। If the person develops internal bleeding, paleness, coldness of hands, feet, and face, cold breath, redness of the eyes and flatulence, then such a person should be rejected.

23. RAKTA PURNA KOSTHA CHIKITSA- INTERNAL HAEMORRHAGE AND ITS TREATMENT आमाशयस्थे रुधिरे वमनं पथ्यमुच्यते । पक्वाशयस्थे देयं च विरेचनमसंशयम् ।।५२।। आस्थापनं च निःस्नेहं कार्यमुष्णैर्विशोधनैः। यवकोलकुलत्थानां निःस्नेहेन रसेन च ।। ५३ ।। भुञ्जीतान्नं यवागूं वा पिबेत् सैन्धवसंयुताम् । अतिनिःस्रुतरक्तो वा भिन्नकोष्ठः पिबेदसृक् ।।५४।। If haemorrhage is in the- • Amasaya - Vamana • Pakvasaya – Virechana and Sneha Rahita Asthapana Basti. • Yusa / Yavagu prepared from Yava , Kola, Kulattha and Saindhava should be given . If bleeding has been severe or the organs are punctured, then Raktapana is advised.

24. स्वमार्गप्रतिपन्नास्तु यस्य विण्मूत्रमारुताः।। व्युपद्रवः स भिन्नेऽपि कोष्ठे जीवति मानवः ।।५५।। When faeces, urine and flatus are seen moving in their own channels, when there are no complications, then the person survives even if the abdominal organs are punctured .

25. अभिन्नमन्त्रं निष्क्रान्तं प्रवेश्यं नान्यथा भवेत् | पिपीलिकाशिरोग्रस्तं तदप्येके वदन्ति तु ||५६|| प्रक्षाल्य पयसा दिग्धं तृणशोणितपांशुभिः | प्रवेशयेत् कृत्तनखो घृतेनाक्तं शनैः शनैः ||५७|| MANAGEMENT OF INTESTINAL PROTRUSION If the intestine has come out without being torn, then it should be inserted inside in its previous state. Some acharyas are of the opinion that the intestine should be inserted inside by holding the two torn ends of the intestine with the head (mouth) of an ant. The intestine (which has come out) covered with grass ( Trina ), blood( rakta ) and dust ( Dhooli ) should be washed with milk, applied with ghee and then inserted slowly by a (physician) with a hand having cut nails.

26. If the protruding intestine does not go back inside, then three ways are described to put it back in its place. 1 Touch the throat with a finger (inside the throat), 2 Sprinkle water on the patient to scare him, 3 A strong person should hold the patient's hands and legs from both sides and lift them up and shake them in such a way that the intestine goes back inside. Intestine which has been improperly placed or entangled with each other is fatal. In such condition the abdomen should be wrapped with a cloth and ghee is poured over it. The person should be made to drink ghee added with oil of eranda comfortably warm for stool softening and vatanulomana .

27. शिरसोऽपहृते शल्ये बालवर्तिं निवेशयेत् । बालवर्त्यामदत्तायां मस्तुलुङ्गं व्रणात् स्त्रवेत् । । ६९।। हन्यादेनं ततो वायुस्तस्मादेवमुपाचरेत् । व्रणे रोहति चैकैकं शनैर्बालमपक्षिपेत् ।। ७० ।। SIRA SHALYA- FOREIGN BODIES IN THE SKULL After removing the foreign bodies from the head then Bal Varti should be inserted into the wound. If Bal Varti is not used then Mastulunga may flow out through the wound leading to Vata Prakopa which can be fatal. After the wound has healed Bal Varti should be removed one by one

28. क्षते क्षतविधिः कार्यः पिच्चिते भग्नवद्विधिः । घृष्टे रुजो विगृह्याशु चूर्णैरुपचरेद् व्रणम् ।।७६।। • For Kshata Vrana – Kshata Chikitsa ( su chi 23-24) • For Picchita Vrana – Bhagna Chikitsa • For Ghrasta Vrana pain should be mitigated quickly and the wound treated with dusting powder (of drugs). KSHATA , PICCHITA AND GHRASTA VRANA CHIKITSA

29. विश्लिष्टदेहं   पतितं   मथितं   हतमेव   च   ||७७|| वासयेत्तैलपूर्णायां   द्रोण्यां   मांसरसाशनम्   | अयमेव   विधिः   कार्यः   क्षीणे   मर्महते   तथा   ||७८|| A person whose body parts have been displaced, who has fallen from a high place, who has been crushed, and who has been injured, should be placed in a tub filled with oil ( tail droni ) and given food along with Mansrasa . The same method should be used for a patient who is weak( ksheena ) and has injuries in Marma sthana .

30. WOUND A wound is a break in the integrity of the skin or tissues often, which may be associated with disruption of the structure and function. Wound is simply a disruption of any tissues- soft tissue or bone or internal organs.

31. Classification Of Wounds

32. TYPES OF WOUND

33. CONTUSION OR BRUISE It is due to blow or blunt force to the skin and tissues underneath wherein blood vessels or capillaries are damaged underneath. Minor soft tissue injury crushes small vessels causes skin discolouration without breaking the skin. Broken vessels cause seepage of blood underneath. More common on the skin over the bones, lax areas like face, scrotum, eyes.

34. ABRASION In this wound, epidermis of the skin is scraped away exposing the dermis. They are painful as dermal nerve endings are exposed. Abrasion heals by epithelialization. Any dirt or foreign body on the abrasion should be removed to avoid formation of poor tattoo like scar.

35. HAEMATOMA It is a localized collection of blood after blunt trauma or after surgery. Collected fluid blood gets clotted in few minutes to hours. Later eventually it liquefies to form a discolored fluid. It may be located in subcutaneous/intramuscular/subfascial/intra-articular regions. Large haematoma may get infected to form an abscess; Needs drainage under general or local anaesthesia. Small haematoma usually gets absorbed (like scalp haematoma). Often haematoma contains reddish plasmatic fluid which should be aspirated using wide bore needle.

36. INCISED WOUND They are caused by sharp objects such as knife, blade, glass, etc. This type of wound has a sharp edge and is less contaminated. Primary suturing is ideal for such wounds, as it gives a neat and clean scar .

37. LACERATED WOUND They are caused by blunt injury such as fall on a stone or due to road traffic accidents (RTA). Edges are jagged. The injury may involve only skin and subcutaneous tissue or sometimes deeper structures also. Due to the blunt nature of the object, there is crushing of the tissue which may result in haematoma, bruising or even necrosis of the tissue. These wounds are treated by wound excision and primary suturing provided they are treated within six hours of injury.

38. PUNCTURED WOUND It is usually a stab wound with a pointed object; here depth of the wound is more than the width. Deeper vital structures or organs may be injured, so should be assessed; foreign body or object may be present in the depth of the wound. Wound should be explored under general or regional anaesthesia to assess the depth and severity of the injury and sutured layer by layer after a thorough saline wash.

39. PENETRATING WOUND When a weapon enters a body cavity such as thorax or abdomen, the injury is termed as penetrating injury. Only wound of entry is seen. Abdomen and chest are common sites. Liver, bowel, spleen, major vessels and other visceral organs may be involved. Ultrasound and CT scan should be done to evaluate deeper organ injuries. Under general anesthesia wound should be explored properly.

40. PERFORATING WOUND When the weapon after perforating the body tissues, comes out from the other side making an exit wound, the injury is termed as perforating injury. It has wound of entrance and exit. Generally it is seen with gunshot wounds.

41. CRUSHED WOUNDS These are caused by blunt trauma due to RTAs, wall collapses, earthquakes or industrial accidents. These wounds are dangerous as they may cause severe haemorrhage, death of the tissues, and/or crushing of blood vessels. These patients are more prone for infections like gas gangrene and tetanus. They are often accompanied by Degloving injury and compartment syndrome.

42. It is a serious condition characterized by increased pressure in one of the compartments of the body resulting in ischaemia of the tissues. . Typically occurs in closed lower limb injuries .

43. WOUND TYPES ILLUSTRATION

44. CLASSIFICATION BASED ON THICKNESS OF WOUND Superficial wound involving only epidermis and dermal papillae. Partial thickness wound with skin loss up to deep dermis with only deepest part of the dermis, hair follicle shafts and sweat glands are left behind. Full thickness wound with loss of entire skin and subcutaneous tissue causing spacing out of the skin edges. Deep wounds are the one extending deeper, across deep fascia into muscles or deeper structures. Complicated wounds are one associated with injury to vessels or nerves. Penetrating wound is one which penetrates into either natural cavities or organs.

45. CLASSIFICATION BASED ON SEVERITY Simple wounds the integrity of the skin is traumatized without loss or destruction of tissue and without the presence of foreign body in the wound. Combined/complex wounds tissue is lost or destructed by means of a crush, burn or foreign body in the wound .

46. CLASSIFICATION BASED ON TIME ELAPSED Acute wounds are those that progress through the normal phases of healing and typically show signs of healing in less than 4 weeks. Examples are—surgical or traumatic or burn wounds. Chronic wounds are those that do not follow the normal healing process and show no signs of healing in 4 weeks.

47. GENERAL PRINCIPLES OF MANAGEMENT OF OPEN WOUND

48. WOUND CLOSURE OR WOUND SUTURING 1. Primary suturing Suturing the wound within a few hours following an injury (six hours is ideal) is called primary suturing. Primary suturing can be done provided: It is an incised or cut wound with a sharp object such as knife or razor blade. Minimal injury to structures on either side. There should not be any infection.

49. Precautions to be taken while doing primary suturing : Foreign body, if present in the deeper aspect of the wound, should be removed. Associated injury to blood vessels, nerves or tendons should be recognized and repaired. Wound on the abdomen may have associated visceral injuries. Prevention of tetanus by administering tetanus toxoid 0.5 ml intramuscularly.

50. 2. Wound excision and primary suturing of skin This is indicated when: Wound edges are jagged. Wound is contaminated with organisms or foreign body. Tissues are crushed and devitalized. In such situations, wound is explored and devitalized tissues and foreign body, if present, are removed. The wound is irrigated with antiseptic agents. Thus, lacerated wound is converted into an incised wound and then sutured .

51. Precautions to be taken are: It should be done within 6 hours. Tetanus and gas gangrene prophylaxis. Repair of tendons and nerves can be done at a later date, if contamination is excessive.

52. Wound with skin loss Complications of skin loss Secondary infection of the wound. The underlying structures such as tendons and nerves are in danger. Diabetic patients can develop septicemia. Deformity and disability can occur at a later date. Hence, skin grafting should be done as soon as possible. It may occur after surgical procedures or accidents etc

53. Principles of debridement Ideally done under general anaesthesia. Assess the extent of injury/loss of tissues. Control bleeding. Excision of devitalized tissue better done with scissors. Good saline wash/irrigation is better than betadine/hydrogen peroxide wash. “Aim is to convert an untidy wound into a tidy wound.”

54. 4. SECONDARY SUTURING After operations, sutures may give way because of severe infection with persistent discharge of pus. In such cases 7-14 days later, after controlling infection, the skin is freed from the edge of the wound and the granulation tissue and skin are approximated.

55. CHARACTERISTICS OF AN IDEAL WOUND DRESSING Creates a moist environment Removes excess exudates Prevent desiccation Allow gaseous exchange Impermeable to microorganism Thermally insulating Prevent particulate contamination Provides mechanical protection Non-toxic Easy to use and cost effective