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1. Wound healing and wound care Dr. GOVIND KUSHWAH M.S. (GENERAL SURGERY) ASSISTANT PROFESSOR DEPT. OF GEN. SURGERY ABVGMC VIDISHA(M.P.)

2. Wound healing and wound care 1.INTRODUCTION 2.PHASES OF WOUND HEALING 3. Factors influencing healing of a wound. 4. Classification of wound closure and healing. 5. Management of wound.

3. INTRODUCTION 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 healing is a mechanism whereby the body attempts to restore the integrity of the injured part.

4. Classification of wound •Simple wounds– only skin is involved. •Complex wounds– vessels,nerves , tendons or bones are involved. •Tidy wounds •Untidy wounds Closed wounds – •Contusion •Abrasion • Haematoma Open wounds – •Incised wounds •Lacerated wounds •Crush injuries •Penetrating wounds Clean wound Clean contaminated wound Contaminated wound Dirty wound

5. PHASES OF WOUND HEALING 1.The inflammatory phase :- it begins immediately after wound healing. It lasts for 2-3days. • Features of inflammation are rubor , calor , tumour , dolor and loss of function. • Macrophages secrete fibroblastic growth factor which enhances angiogenesis. • Polymorphonuclear leukocytes (PMN leukocytes) appear after 48 hours which secrete inflammatory mediators and bactericidal oxygen derived free radicals. • These cells also remove clots, foreign bodies and bacteria. • Chemical factors involved in wound healing are: • Growth factor—platelet derived, epidermal, Transforming, Interleukin, Tumour necrosis factor, Prostaglandins, Collagenase Elastase .

6. 2.The proliferative phase: The proliferative phase lasts from the third day to the third week, -Collagen and glycosamines are produced by fibroblasts. • Hydroxyproline and hydroxylysine are synthesised by specific enzymes using iron, alpha ketoglutarate and vitamin C. • Tropocollagen is produced which aggregates to form collagen fibrils. • 80-90% of their final strength (in postoperative wounds) is achieved in 30 days 3. The remodelling phase (maturing phase) : -It begins at 6 weeks and lasts for 2 years. -There is maturation of collagen by cross-linking which is responsible for tensile strength of the scar. -Collagen production is not present after 42 days of wound healing.

7. Factors influencing healing of a wound. ■ Site of the wound ■ Structures involved ■ Mechanism of wounding -Incision -Crush -Crush avulsion ■ Contamination (foreign bodies/bacteria)a ■ Loss of tissue ■ Other local factors -Vascular insufficiency (arterial or venous) -Previous radiation -Pressure ■ Systemic factors -Malnutrition or vitamin and mineral deficiencies -Disease (e.g. diabetes mellitus) -Medications (e.g. steroids) -Immune deficiencies (e.g. chemotherapy, acquired -immunodeficiency syndrome (AIDS)) -Smoking.

8. Classification of wound closure and healing. ■ Primary intention Wound edges opposed Normal healing Minimal scar ■ Secondary intention Wound left open Heals by granulation, contraction and epithelialisation Increased inflammation and proliferation Poor scar ■ Tertiary intention (also called delayed primary intention) Wound initially left open Edges later opposed when healing conditions favourable

9. Management of wound. Managing the acute wound ■ Cleansing ■ Exploration and diagnosis ■ Debridement ■ Repair of structures ■ Replacement of lost tissues where indicated ■ Skin cover if required ■ Skin closure without tension ■ All of the above with careful tissue handling and meticulous Managing the acute wound technique

10. COMPARTMENT SYNDROME:- It is common in calf and forearm. Closed injuries cause haematoma leading to increased pressure. It is often associated with fracture of the underlying bone which in turn compresses the major vessel further aggravating the ischaemia causing pallor, pulselessness , pain, paraesthesia , diffuse swelling and cold limb. If allowed to progress it may eventually lead to gangrene or chronic ischaemic contracturewith deformed,disabled limb. Muscle necrosis releases myoglobulin which is excreted in the urine, damages the kidneys leading into renal failure. Note: Affected muscle when passively stretched worsens the pain – the most reliable clinical sign. Treatment:- • Compartment pressure will be persistently more than 30 mm Hg. It can be measured by placing a fine catheter in the compartment and using a pressure monitor. This is an indication for fasciotomy . Adequate lengthy incision involving skin, fat and deep fascia should be done until underneath muscle bulges out properly. Multiple incisions should be made if needed. Separate incision in each compartment should be done.

11. CRUSH INJURY Crush injury is one where a part of the body is being squeezed/compressed between two high force or pressure systems. It causes extensive lacerations, bruising, compartment syndrome, crush syndrome, fractures, haemorrhage etc. with extensive tissue destruction and devitalisation . Renal failure, hypovolaemic shock and sepsis are the most dreaded problems in crush injuries. CRUSH SYNDROME It is due to crushing of muscles causing extravasation of blood and release of myohaemoglobin into the circulation leading to acute tubular necrosis and acute renal failure. Causes • Earthquakes. • Mining and industrial accidents. • Air crash. • Tourniquet. Initially tension increases in the muscle compartment commonly in the limb, which itself impedes the circulation and increases the ischaemic damage. In 3 days, urine becomes discoloured and scanty, patient becomes restless, apathy and delirious with onset of uraemia . Crush syndrome is often life threatening. Injuryis much worser than initial look.

12. Effects of crush syndrome • Renal failure • Toxaemia • Septicaemia • Disability with extensive tissue loss • Gas gangrene Treatment • Tension in the muscle compartment is relieved by placing multiple parallel deep incisionsin the limb so as to prevent further damage. • Mannitol is given to improve the urine output by improving the renal function. • Alkalisation of urine is done by giving sodium citrate or sodium bicarbonate. It increases the solubility of acid haematin in the urine and so promotes its excretion. Urinary pH should be above 6.5 until urine does not show any myoglobin . Mannitol – alkaline diuresis should be 8 liter/day.

13. Initial aggressive volume load using saline about 1–1.5 liters/hour is ideal in these patients. • Haemodialysis is done sometimes as a life-saving procedure. • Other measures: • Catheterization. • Oxygen therapy. • Antibiotics. • Blood transfusion. • Correction of severe hyperkalaemia .

14. DEGLOVING INJURIES :- • It occurs due to shearing force between tissue planes as traction – avulsion injury . It usually occurs between subcutaneous tissue and deep fascia or between muscle and bone. It can be localised or circumferential . • It can be in one plane or multiple planes. • It is commonly observed in machinery injuries or major road traffic accidents. It is much more extensive than of on initial presentation . • Under anaesthesia fluoroscein is injected intravenously and viable skin is visible as fluorescent yellowish – green colour under ultraviolet light. As injection of fluoroscein is not fully safer, serial excision is better to look for dermal punctate bleeding. • It needs examination under general anaesthesia , wound excision/radical excision, flap coverage, micro flap surgeries, skin grafting, with proper asepsis, and blood transfusion as there is significant blood loss in these injuries.

15. THANK YOU Dr. GOVIND KUSHWAH M.S. (GENERAL SURGERY) ASSISTANT PROFESSOR DEPT. OF GEN. SURGERY ABVGMC VIDISHA(M.P.)