Wound management

Wound Care

1. Wound Management. Dr Imran Javed. Associate Professor Surgery. Fiji National University.

2. It is a circumscribed injury which is caused by an external force and it can involve any tissue or organ. surgical , traumatic It can be mild, severe, or even lethal. Simple wound Compound wound Acute Chronic Definition

3. Wound Shape

4. Incised Wound

5. Abrasions

6. Punctured Wound

7. Lacerated Wounds.

8. Crushed wounds

9. Bite Wounds.

10. Gunshot Wounds.

11. Burn Wounds.

12. Acid Burn Wounds.

13. Frost Bite.

14. Radiation Wounds

15. Clean wound Clean-contaminated wound Contaminated wound Heavily contaminated wound Classification of the wounds

16. Skin Histology

17. Wound Healing

18. Healing By Tertiary Intention

19. Factors affecting wound healing Local Ischemia Infection Foreign body Edema, elevated tissue pressure Systemic Age and gender Sex hormones Stress Ischemia Diseases Obesity Medication Alcoholism and smoking Immuno -compromised conditions Nutrition

20. The wound healing

21. Hemostasis-inflammation Granulation-proliferation Remodeling. Stages of wound healing

22. The main steps of the wound healing 1. Hemostasis-inflammation vasoconstriction fibrin clot formation Pro-inflammatory cytokines and growth factors releasing vasodilatation infiltration PMNs, macrophages cytokines releasing → angiogenesis → fibroblast activation → B- and T-cells activation → keratinocytes activation → wound contraction 2. Granulation-proliferation fibroblast migration collagen deposition angiogenesis granulation tissue formation epithelisation contraction 3. Remodeling regression of many capillaries physical contraction myo -fibroblasts collagen degeneration and synthetisation new epithelium tensile strength – max. 80%

23. Wound Closure.

24. Assessment of Wound. Wound Irrigation. Local Anesthesia. Debridement. Methods of Closure. Dressings and Splints. Anti- septics & antibiotics. Removal of Sutures. Management of Laceration

25. requires information in the following areas:  force of injury,  type of force (e.g. penetrating, hot oil burn)  extent and depth of injury  amount of blood loss  level of contamination of the wound  time from injury to presentation for treatment  involvement of deeper structures damaged (e.g. nerves, tendons)  Direct communication from the outside to a fracture of the bone (a compound fracture). Assessment of the degree of damage

26. All wounds should be cleaned. Irrigation rids the wound of contaminants, debris and bacteria and is considered the most important means of reducing the incidence of wound infection . Cleaning with Anti-septic solutions like betadine is standard method. Local Anesthesia may be topical or infiltrated. Debridement: Once the wound is adequately anaesthetized and irrigated, devitalized wound edges should be debrided using sharp scissors and/or a scalpel blade. Irrigate the wound again after debridement to remove tissue debris. Wound Irrigation & Anesthesia

27. is also known as healing by primary intention. Wounds that heal by primary closure have a small, clean defect that minimizes the risk of infection and requires new blood vessels and keratinocytes to migrate only a small distance. Surgical incisions, paper cuts, and small cutaneous wounds usually heal by primary closure. Primary wound closure

28. also known as healing by secondary intention, describes the healing of a wound in which the wound edges cannot be approximated. Secondary closure requires a granulation tissue matrix to be built to fill the wound defect. This type of closure requires more time and energy than primary wound closure, and creates more scar tissue. Secondary wound closure

29. also known as healing by tertiary intention. Delayed primary closure is a combination of healing by primary and secondary intention, and is usually instigated by the wound care specialist to reduce the risk of infection. In delayed primary closure, the wound is first cleaned and observed for a few days to ensure no infection is apparent before it is surgically closed. Examples of wounds that are closed in this way include traumatic injuries such as dog bites or lacerations involving foreign bodies. Delayed primary closure

30. Types of Sutures. natural and synthetic synthetic materials less reaction less inflammatory reaction absorbable and non-absorbable Non-absorbable sutures offer longer mechanical support monofilament and multifilament monofilaments have less drag Infection is avoided Absorbable suture materials lose tensile strength before complete absorption gut last 4-5 days in terms of tensile strength chromic form, gut can last up to 3 weeks Vicryl and Dexon maintain tensile strength for 7-14 days complete absorption takes several months Maxon and PDS long-term absorbable sutures lasting several weeks requiring several months for complete absorption Non-absorbable sutures silk has the lowest strength nylon has the highest Polypropylene.

31. Running, or continuous stitch made with one continuous length of suture material close tissue layers which require close approximation speed of execution, and accommodation of edema during the wound healing process greater potential for mal-approximation of wound edges with the running stitch than with the interrupted stitch

32. Interrupted Sutures. needle at a 90° angle to the skin within 1-2 mm of the wound edge and in the superficial layer exit through the opposite side equidistant to the wound edge and directly opposite the initial insertion stitch is tied separately used in skin or underlying tissue layers more exact approximation of wound edges can be achieved with this technique than with the running stitch

33. Mattress suture a double stitch that is made parallel (horizontal mattress) or perpendicular (vertical mattress) to the wound edge advantage of this technique is strength of closure each stitch penetrates each side of the wound twice inserted deep into the tissue

34. Purse string Suture. continuous stitch paralleling the edges of a circular wound wound edges are inverted when tied used to close circular wounds, such as hernia or an appendiceal stump

35. Smead -Jones/Far-and-Near a double loop technique alternating far and near stitches greater mechanical strength than continuous or simple interrupted sutures used for approximating fascial edges, especially for patients at risk for fascial disruption or infection

36. Continuous Locking, or Blanket Stitch a self-locking running stitch used primarily for approximating skin edges

37. good approximation edges is paramount to proper wound closure technique deep sutures serve to eliminate the dead space and relieve tension from the wound surface deep sutures also ensure proper alignment of the wound edges and contribute to their final eversion wound closure may require sharp undermining of the tissues to minimize tension on the wound achieve hemostasis eversion of all skin edges avoids unnecessary depression of the resultant scar Features of Good Closure

38. Dressings function to protect the wound, absorb excess exudate and improve comfort. Most lacerations to the facial area and scalp do not need to be dressed. Most commonly, a non-adherent contact layer is placed, followed by a gauze layer and then an adhesive outer layer. Wounds adjacent to joints may require splinting of the joint to prevent excessive tension on the wound. Dressings should be kept clean and dry. Most dressings should be removed in 2 days and the wound reviewed Dressings and Splints

39. Antibiotics are not indicated for simple lacerations. Wounds which are contaminated require careful cleaning and debridement. Antibiotics are often given for human and animal bites. Amoxycillin / clavulanic acid for 5 days is a reasonable choice if antibiotics are to be prescribed . Tetanus prophylaxis. Antibiotics

40. face: 3-4 days scalp: 5 days trunk: 7 days arm or leg: 7-10 days foot: 10-14 days Suture removal

41. Keloid & Hypertrophic Scars.

42. Immediate and delayed complications may occur with wound closure formation of hematoma wound infection. reduced by prophylactic antibiotics L ate complications scar formation excess tension lack of eversion of the edges hypertrophic scarring and keloid formation. stitch marks wound necrosis Wound Complications.