Wound management

wound treatment / wound management

1. Wound Management Dr Sumer Yadav

2. “the primary goal of wound care is not the technical repair of the wound; it is providing optimal conditions for the natural reparative processes of the wound to proceed” – Richard L. Lammers (Roberts and Hedges)

3. plastic surgeon consultation (a) the acute wound where the final appearance may be the principal concern, (b) the wound in a patient whose medical status and/or mode of injury predisposes her to wound healing difficulties and the threat of a problem wound, or (c) the established chronic wound refractory to past interventions.

4. GOALS of wound care Facilitate hemostasis Decrease tissue loss Promote wound healing Minimize scar formation

5. TYPES of Wound Healing 1.) Healing by first intention (aka. primary wound healing or primary closure) wound closed by approximation of wound margins or by placement of a graft or flap , or wounds created and closed in the operating room. Best choice for wounds in well-vascularized areas Indications -recent (<24h old) -clean -viable tissue -tension-free treated within 24 h, prior to development of granulation tissue. epithelialize within 24 to 48 h. Water barrier function restored  can shower or wash.

6. 2.) Healing by second intention (aka. secondary wound healing or spontaneous healing) wound left open and allowed to close by epithelialization and contraction. Commonly : management of contaminated or infected wounds. without surgical intervention. Unlike primary wounds , approximation of wound margins occurs via reepithelialization and wound contraction by myofibroblasts. Presence of granulation tissue. Complications -late wound contracture -hypertrophic scarring

7. 3.) Healing by third intention (aka. tertiary wound healing or delayed primary closure) wounds that are too heavily contaminated for primary closure but appear clean and well vascularized after 4-5 days of open observation . Inflammation  reduced bacterial concentration (“debribe”)  allow safe closure. Indications :- infected or unhealthy wounds with high bacterial content, -wounds with a long time lapse since injury, or -wounds with a severe crush component with significant tissue devitalization. Wound edges are approximated within 3-4 days tensile strength develops as with primary closure.

8. Factors that affect wound healing In general, remember “DIDN'T HEAL” D = Diabetes : -diminishing sensation and arterial inflow ++ acute loss of diabetic control  diminished cardiac output, poor peripheral perfusion, and impaired polymorphonuclear leukocyte phagocytosis. I = Infection : -potentiates collagen lysis. Bacterial contamination + susceptible host + wound environment = wound infection. Foreign bodies (including sutures) potentiate wound infection.

9. DIDN’T HEAL D = Drugs : Steroids and antimetabolites impede proliferation of fibroblasts and collagen synthesis. N = Nutritional problems: Protein-calorie malnutrition and deficiencies of vitamins A (collagen synthesis, antioxidant), C (collagen synthesis), and zinc (fibroblast proliferation ). Malnutrition- Impaired organ f unction , Impaired collagen s ynthesis , Impaired immune function, Reduced antioxidant activity T = Tissue necrosis , from local or systemic ischemia or radiation injury. Blood supply is important.

10. DIDN’T HEAL H = Hypoxia : -esp the distal extent of the extremities. Blood volume deficit, unrelieved pain, or hypothermia  sympathetic overactivity  local vasoconstriction  Inadequate tissue oxygenation. E = Excessive tension on wound edges  local tissue ischemia and necrosis.

11. DIDN’T HEAL A = Another wound : Competition for the substrates required for wound healing. L = Low temperature : (relatively) distal aspects of the upper and lower extremities (a reduction of 1-1.5°C [2-3°F] from normal core body temperature) is responsible for slower healing of wounds at these sites.

12. Basics Wound evaluation and history Wound preparation and closure Optimize systemic parameters Debride nonviable tissue Reduce wound bioburden Optimize blood flow Reduce edema Use dressings appropriately Use pharmacologic therapy Close wounds with suturing/grafts/flaps as indicated

13. Wound Evaluation -HISTORY identify all extrinsic and intrinsic factors that jeopardize healing and promote infection – mechanism of injury – time of injury (accelerated growth phase of bacteria starts at 3 hours post wound) – environment in which wound occurred potential contaminants, foreign bodies – species of animal if bite wound – pt’s medical problems (allergies to medication) / immune status tetanus immunization status

14. Wound assessment Examine for: – amount of tissue destruction – degree of contamination – damage to underlying structures

15. • Body Location – Proximity to Other Structures – Joints –Nerves –Tendons –Vasculature – Test integrity of each structure • Assess laxity/muscle and tendon function • Assess 2-point discrimination • Assess vascular supply

16. Physical examination Wound Location – importance in the risk of infection – high endogenous bacterial counts in hairy scalp, forehead, axilla, groin, foreskin of penis, vagina, mouth, nails – wounds in areas of high vascularity more easily resist infection (scalp, face)

17. Wound Preparation - Anesthesia Topical Solution or paste LET TAC EMLA Local Direct infiltration 1% lidocaine with or without epinephrine Bupivicaine or sensorcaine for longer acting anesthesia Regional Block Local infiltration proximally in order to avoid tissue disruption Smaller amount of anesthesia required

18. Local anesthetic Drug Max Dose Onset Duration Cocaine 6.6 mg/kg Rapid 1 hour Procaine 10-15 mg/kg Rapid 30min-1hr Tetracaine 1.5 mg/kg Moderate 2 hours Lidocaine 5 mg/kg 5-30 min 2 hours (with Epi) 7 mg/kg 5-30 min 2-3 hours Bupivacaine 2 mg/kg 7-30 min > 6 hours

19. Epinephrine Vasoconstrictive – Increases Duration of Action – Promotes Hemostasis – Avoid end-arterial blood supply areas – May increase pain (low pH)

20. Wound Preparation - Hemostasis Direct Pressure–Usually best choice Ligatures Use a tourniquet Chemicals – Epinephrine – Gelfoam – Oxycel – Actifoam Cautery

21. Debridement & Reduction of Bioburden Surface irrigation with saline. Debridement: surgical, enzymatic (papain with urea, collagenase), mechanical (pressurized water jet), autolytic, maggots. Antibiotics: cellulitis, decreased rate of healing, increased pain, straw colored oozing from skin, contaminated wounds, mechanical implants. Removal of FB.

22. Wound Preparation – Foreign Body Removal Suspect with point tenderness Visual inspection (to the apex) Imaging Glass, metal, gravel fragments >1mm should be visible on plain radiographs Organic substances and plastics are usually radiolucent Always discuss and document possibility of retained foreign body

23. Wound preparation : CLEANING high pressure irrigation (Normal Saline) min 100-300 ml with continued irrigation at least 8 psi force to the wound  the irrigation fluid dislodges foreign bodies, contaminants, and bacteria. A simple device setup 30-60 ml syringe and an 14-gauge angiocatheter.

24. Hair removal Shaving – Increases risk of infection X 10 ! Clip Hair with Scissors Matt Hair with Ointment Never shave eyebrows ( may not regrow )

25. Wound Preparation – Debridement Removes devitalized tissue Creates sharp wound edge Excision with elliptical shape Respect skin lines

26. Wound closure in relation to time Primary closure Suture, staple, adhesive, or tape Performed on recently sustained lacerations: <12 hours generally and <24 hours on face Secondary closure Secondary intent Allowed to granulate Tertiary closure Delayed primary (observed for 3-4days)

27. SUTURE TECHNIQUES Deep layer approximation Absorbable sutures Buried knot Serves two purposes Closes potential spaces Minimizes tension on the wound margins

28. Skin Closure Key – wound edge eversion “Approximate, don’t strangulate” Anticipate wound edema Choose appropriate size of suture for location of laceration

29. Other devices in wound closure Staples Quick, poor aesthetic result where scar is less of an issue (hairy scalp) Adhesives Dermabond clean, sharp edges, clean nonmobile areas, laceration less than 5 cm in length Tape Steri-strips superficial, straight laceration under little tension

30. After care • Wound Dressings • Maintain moist –24 –48 hours – Augments reepithelialization •“Water-Tight” after 48 hours •Bandages – Soft-splint – Absorb exudates – Protects Wound – Protects knots

31. Optimize systemic parameters Age: cannot be reversed, usage of growth factors, aggressive optimization of systemic parameters & supplementation. Avoidance of ischemia & malnutrition. Correction of diabetes, removal of FB. Avoidance of steroids, alcohol, smoking. Avoidance of reperfusion injury: total contact casting, compression therapy.

32. Optimize systemic parameters-nutrition Glucose  - give energy for angiogenesis and the deposition of new tissue.  Fatty acids- essential for cell structure and have an important role in the inflammatory process. Protein deficiency- contribute to poor healing rates with reduced collagen formation and wound dehiscence.   Vitamins- vitamins A (collagen synthesis, antioxidant), C (collagen synthesis), and zinc (fibroblast proliferation )..

33. Optimize blood flow & oxygen supply Warmth Hydration Surgical revascularization Hyperbaric O2 therapy: limb salvage.

34. Reduce edema Elevation Compression Negative pressure wound therapy: removes pericellular transudate & wound exudate as well as deleterious enzymes. Cannot be used in ischemic, badly infected or inadequately debrided wounds or in malignancy.

35. Indications for systemic antibiotic for traumatic wounds • Injury 6 hours old on the extremities Injury 24 hours old on the face and scalp Tendon, joint, or bony involvement • Cartilage involvement • Mammalian bite • Co-morbidity (diabetes mellitus, extremes of age, steroid use, morbid obesity) Puncture wound Complex intraoral wound

36. Wound preparation -Tetanus prophylaxis Clean wounds Incompleted immunization  toxoid >10 years, then give toxoid Tetanus prone wound Incompleted immunization  Toxoid & immunoglobulin > 5 years, give toxoid

37. Dressings Absorption characteristics: none – films, low – hydrogels, moderate - hydrocolloids, high – foams, alginates, collagen. Hydrogels (eg. starch) rehydrate wounds (benefit in small amounts of eschar, infected wounds). Hydrocolloids promote wound debridement by autolysis. Antimicrobial dressings: silver, cadexomer iodine, mupirocin, neomycin.

38. Suture removal guidelines Anatomic location Days (average) face 3-5 arm 7 anterior trunk 7 back 10-14 feet and hand 10-14 joint 10-14 scalp 10-14

39. Skin Substitutes Autologous keratinocyte sheets. Biobrane Oasis Alloderm Integra (sites prone to contracture, coverage of tendons, bone, surgical hardware) TransCyte Dermagraft Orcel

40. Collagen & chondroitin sulphate : Integra Apligraftrade: skin substitute containing collagen and seeded cells Alloderm : immunologically inert, nonliving, allogenic, acellular dermal matrix with intact basement membrane prepares wound bed for grafting

41. Tegaderm Used for simple shallow wound dressing Protects from water loss mechanical injury and drying

42. TransCyte (ECM matrix generated by allogenic human dermal fibroblasts serves as a matrix for neodermis generation ORCEL : Composite cultured skin. Fibroblasts, keratinocytes seeded on opposite sides of bilayered matrix of bovine collagen

43. Dermagraft living allogenic dermal fibroblasts grown on a degradable scaffold. Good resistance to tearing

44. Pharmacologic therapy Antimicrobials PDGF- becaplermin - US-FDA approved – dibetic foot ulcers EGF- under trial VEGF- under trial Vit A: steroid use Absolutely of no use in normally healing wounds

45. Flaps & Grafts Radiation wounds require flaps. Chronic nonhealing ulcers. Extensive areas of ulceration. Major soft tissue loss. Other therapies: electrical stimulation for recalcitrant ulcers.

46. beta-Glucan stimulates the macrophage activity and promotes rapid wound healing. Beta-Glucan Collagen mesh or Glucan II (Beta-Glucan) mesh. . Rapid healing without dressing changes painless treatment.                            

47. BIOLOGIC DRESSINGS

48. HONEYSOFT Natural dressing Honey-impregnated dressing Chronic unhealing wounds.  Impregnated into a compress of EVA (ethylenevinylacetate) mesh Honey cleans the wound without disturbing it  Removing the dressing causes no damage no known side effects                            

49. NPWT/VAC expeditiously prepare a wound bed for surgical closure by tertiary intent. works through- relief of edema, improving interstitial diffusion of oxygen to cells, removes deleterious enzymes most wounds will heal optimally with a pressure of 125 mm Hg, other wounds may only tolerate a setting of 75 mm Hg before capillary flow is occluded.

50. NPWT/VAC Indications- lymphatic leaks, venous stasis ulcers, diabetic wounds, and wounds with fistulae , sternal wounds, orthopedic wounds, and abdominal wounds Some instances, it has enabled avoidance of free flaps can also be used to assist the neovascularization of skin grafts and tissue engineered skin substitutes Contraindications- malignancy, ischemia, inadequately debrided or badly infected wounds

51. Hyperbaric Medicine (HBO) (typically, 100% O2saturation at 2 to 3 ATA) raises the dissolved oxygen saturation in plasma from 0.3% to nearly 7%. Stimulates angiogenesis and fibroblast migration, enhances neutrophil and antibiotic killing action, and suppresses alpha toxin production in gas gangrene. if the periwound area/extremity demonstrates a rise in tcPO2when the patient inspires supplemental oxygen, the patient is likely to benefit from HBO. not benefit from HBO: those with a normal environmental perfusion, and those with ischemic limbs who need a bypass to restore blood flow to a limb

52. Patients with irradiated skin or steroid users Patients who are on steroids should receive vitamin A (25,000 IU daily by mouth or 200,000 IU topically t.i.d .). The progressive endarteritis obliterans and microvascular damage, along with fibrotic interstitial changes, results in a wound marked by ischemia, hampered by cellular senescence, and prone to infection. gingerly debrided , antimicrobial dressings, growth factors and even hyperbaric oxygen therapy, microvascular free flap.

53. Pressure sore care Should be aggressively nourished and receive vitamin supplementation. administration of growth hormone or anabolic steroids. Debridements Dressings air-fluidized beds, air mattresses, air flotation and water flotation devices, and low air-loss beds.

54. Wound Care in Patients with Diabetes components of pressure necrosis, functional microangiopathy , and true neuropathic derangements. Selective debridement, control of glucose levels, pressure offloading. Revascularization use of growth factors

55. Wound Care in Patients with Venous Stasis Ulcers Compression therapy is essential for venous stasis ulcers. stockings, elastic wraps, and multilayer wraps, Unna boot-paste dressings and low-stretch bandages. contraindicated in patients with an ABI <0.7 ideally the pressures exerted should be between 30 and 40 mm Hg continued for several weeks following successful closure of the wound.

56. “ God heals, and the doctor takes the fees ” Benjamin Franklin(American Statesman, scientist, Philosopher)

57. THANK YOU