1. Wound management Wound management.ppt

Wound management.ppt

1. Wound management

2. Wounds heal by 2 methods 
1.It can heal fast and directly
2. It can heal slowly with granulation
and perhaps with lots of pus and at
the end with scarring.

7. Primary Intention:

Where the skin edges are brought together, a wound
heals by primary intention. Epithelialisation is rapid,
there is less connective tissue deposition (scar tissue)
but the wound will contract from end to end by 20%

8. Secondary intention

This patient has had
tangential excision of a
rhinophyema. The wound
is left open to heal by
secondary intention, a
process which involves
contraction,
epithelialisation and scar
tissue deposition. In this
case, healing occurred in
10 days.

9. 
The time after the accident is the first
important factor
1.Within 6 hours, bacteria grows
minimally
2. From 6 to 12 hours, it start growing.
3.After 24 hours it grows fast.

10. 
The presence of foreign bodies and dead tissues
especially dead muscles, That’s the second factor.

Location of the wound is the third important factor.
One can close most of the wound on the
face, head and hands but for those wounds at the
lower limbs, buttocks or axilla, It’s better not to
close immediately because one would take the risk
of infection especially for contaminated wounds.

11. 
One can close most clean wounds especially they
arrive within 6 hours of accident and there’s no foreign
body nor dead tissue (espercially on face and hands).

One can close wounds that’s more than 3 days and
there’s no sign of infection.

For all others, It’s best to do the dressing and
debridement of the wound, then look at it again 2-7
days later. Then one can decide if the wound should be
closed. In case of doubt, don’t close it.

For all other wounds from 6-48 hours after the
accident, It’s important to do the dressing and
debridement only and see the wound 2-3 days later if
the wound is clean then close the wound at that
juncture.

12. War wound
It is often multiple.
It is often contaminated
For all soft tissue injury, most of the time it’s
complicated by damage in other structures
The wounds at buttock, thigh or perineum can
enter the abdomen;
Wounds at thorax can enter abdomen.

13. 
Detail examination on the whole patient,
especially with attention at the buttock and
the back.

The patient need to be undressed all if
possible.

Respect the local culture and religious
factor

Stabilisation and surveillance

14. Treatment of the wound is a
procedure in 2 stages:

Debridement of the wound

Delay Primary Closure.

16. Technique of debridement (1)

Debridement is a procedure where all the dead
and damaged tissue which are contamined with
bacterias and dirt should be cut and removed
completely.

Leave the tissue with good health which can
combat infection at the surface if the wound is not
closed.

17. Technique of debridement (2)
Clothings, dressings and slabs should remove
carefully.
Sterrile compresses can stay on the wound.
Big area of the skin around the wound like the
whole circumfence of the limbs need to be
washed with soap, shaved, dried then wash
again with antiseptic.
In case of multiple wounds, the posterior
wound need to be handled first before the
anterior wounds .

18. Debridement:
1.Wash with chlorhexine, povidone iodine can
cause dammage
2.Treat the tissues gently
3.Remove all foreign bodies with scalpal or forceps
4.Wash with a lot of liquids like ringer lactate,
normal salines and sterile water if possible with
syringe of 50ml
5.If it’s necessary to extend the wound, follow the
length of the limbs and do lazy S over the joint

19. Injuried tissues
1.Skin : cut 1-3mm around the wound except on the face
2.Fat Tissue : cut generously until healthy tissue
3.Muscles and fascias: cut all torn fascias, remove all
dead muscles; dead muscles won’t bleed when it was
cut and it does not move when pinch with forceps;
they look dark and bluish. In any doubt, cut it away
because dead or injuried muscles are very good
culture medium for bacterias
4.Bones: Remove all bones that are separated but let
those attached by periosteum remain

20. 
5. If the bone is exposed, try to cover with surrounding
muscles, if not possible then cover with wet compresse
and decide how to cover it in the second intervention.

6. Tendons: It’s possible to do skin graft if the
paratendon is intact but for those without it, one need
flaps to cover them; cut and remove injuried tendons;
Don’t repair them if the wound is much contaminated

7. Nerves and vessels: Try to cover them with
surrounding tissues; of course try to repair major
arteries, but don’t repair cut nerve immediately

8. Stop all bleeding if possible, remove the tourniquet if
one is using, then check for the remaining bleeding

21. Hematoma

The presence of a large haematoma generally
implies that a major vessel has been damaged.

Dislodging the haematoma can result in
sudden heavy blood loss.

It is wise to prepare vascular control before a
haematoma is evacuated.

22. Fasciotomy

The deep fascia must be incised along the length of the skin
incision.

This may allows wide and deep retraction, and exposes the
depths of the wound.

Gloved finger is the best for exploration and assessing the
extent of damage.

Fascial compartments may need decompression by
fasciotomy to allow post-operative tissue oedema and avoid
muscle ischaemia.

23. Foreign Bodies
The wound should be extended by incision and the
edges be retracted.
Blood clots, debris, dirt and missile fragments should be
removed.
Gentle and copious irrigation with saline must be used
to wash out the residual debris and blood clots.
Explore the wound with gloved finger.

24. 
Do not open fresh planes in healthy tissue,

Do not explore unnecessarily for metallic
fragments,

It is absolutely vital to remove fragments of
old clothing, in driven dirt and vegetation.

25. Perforating Limb Wounds

These should be dealt with by excising the wounds
on each side of the limb separately.

Simple through and through wounds with minimal
soft tissue damage can be left alone without
exploration except wound dressing.

Where there is significant tissue damage or damage
to major vessels, the wounds require exploration.

26. Limitation of closure

Wounds should be left wide open, without any closure of skin
or deep structures. Except:

face,neck,scalp and genitals – closed primarily,

soft tissues of chest wall – tissue closed to keep airtight, but skin
open,

head – dura closed directly,

hand – all viable tissues should be preserved and covered with
healthy tissue,

joints – synovial membranes should be closed as far as possible, if
not, covered it up with joint capsule or muscle,

blood vessels – repaired vessel should be covered with viable tissue.

27. The Medications

Antibiotic :Penzylpenicillin, 5 Mega-
units 6 hourly IV,/IM ou Ampicillin 2g
IV/IM 3 times/D

Vaccine: ATT

Pain Control

28. Dressings (1)

Adequately excised wound should be covered with a
bulky absorbent dressing made of dry fluffed-up
gauze and held in place with a loose crepe bandage.

The AIM is to draw inflammatory fluid out of the
wound and into the dressing.

The wound should not be “packed” with tight
dressing or vaseline gauze since this may form a
plug and prevent the free outflow of fluid.

29. Dressings (2)
Wound awaiting delayed primary closure ( DPC )
should not have dressings changed until formal
closure.
Except there are signs of persisting contamination
and infection develop:
- development of toxicity in the patients,
- moist wound with offensive smell,
This indicates the need for immediate attention
and further excision.

30. 
Good Bad Smell vs Bad Bad Smell

Wound that’s infected, their dressing
slide off easily; If the wound is dry
and very adherent to the wound and
need lots of saline to remove it, very
likely it’s not infected

31. Immobilization

In all cases where there is extensive soft tissue
wound, even in the absence of a fracture, the
entire limb should be imobilized.

This can be achieved by a plaster back slab.

32. Indication for immediate
primary suture

1. For most part of the body when it was cut by clean
knife or broken glasses; it is within 6 hours after the
accident; with all tissues viable and without tension
in closure

2. For most of the wounds at face, head and the
neck; most small wounds in the hand, arm and on
the scalp, One can close the wound due to good
circulation up to 24 hours after the accident

3. All the wounds with the dura, pleura, peritoneum
or synovial membrane of joints opened, one should
close immediately

33. Delay Primary Suture
closing the wound from 3 to 7 days after the accident

1. For all wounds more than 6 hours after
the accident, or those with dirty or damaged
tissues

2. All serious wounds like gunshot wounds,
snake, animals or human bites or crush
wounds

3. All wounds that need skin graft to close it

4. All patients in shock because of the poor
peripheral circulations

34. 
5. With open fractures

6. when one does not have antibiotics

7. All war wounded

35. Delay Primary Suture (1)
Adequate primary surgical excision is vital for uncomplicated
wound closure by DPC.
DPC is the wound closure performed within seven days of injury.
The aim is to close the wound during the fibroblastic phase of
wound healing. This occurs between 3 to 6 days following injury.
Some wounds may be closed safely earlier:
- face, neck, scrotum (3 day ),
- Body trunk, upper limbs (4-5 day ),
- Lower limbs (5-7 day ).

36. Delay Primary Suture (2)
As with all wounds, the obliteration of dead space
is an accepted principle of DPC management.
Absorbable sutures are used to approximate deep
structures but undue tension should be avoided.
Avoid drains whenever possible in DPC. If used,
remove within 24 hours.
After DPC, wound should be covered with some
layers of dry gauze.