Wound Management & treament of genagrene.pptx

Wound mx

1. Wound Management & Gangrene Dr. SOUMYAJIT JANA Dept. of General Surgery MTMC

2. DEFINITION Wound management is an ongoing treatment of a wound, by providing appropriate environment for healing, by both direct and indirect methods, together with the prevention of skin breakdown. Proper Management is determined by the wound’s size, depth, severity and location. This management is changing rapidly due to the advancement in technologies which is shedding more light onto the etiology of the wound and its healing process.

3. GOALS of Wound Care Facilitate hemostasis Decrease tissue loss Promote wound healing Minimize scar formation  Key components 1. Cause(s) of the wound: treatable? 2. Patient centered concerns: pain; factors that can influence healing? adherence to the treatment? 3. Local wound factors: Think ‘DIME’ - need for Debridement? - an undiagnosed infection? - how is the margin/edge doing?

4. Principles Resuscitation Management of immediate life-threatening injuries History and Wound evaluation Wound bed preparation Optimize blood flow/Reduce edema Use appropriate dressings Use pharmacologic therapy Close wounds Optimize systemic parameters

5. History Age Occupation/functional requirement Symptoms Event/Mechanism of injury Contamination/Potential for foreign body Care given Tetanus status Allergies Medications Comorbidities Previous scar formation Social history

6. GENERAL EXAMINATION Site Size and depth Shape Edge, Tunneling, Undermining Wound bed – Base, floor, colour, discharge Neurovascular function Tendon function Underlying structures Wound contamination / Foreign bodies DONOR SITE AVAILABILITY

7. INVESTIGATIONS General Patient Fitness – CBC, PT-INR, LFT, Total protein and Albumin Investigate Local Wound Condition – wound biopsy, wound biopsy for histology Establish A Diagnosis – doppler USS, angiography Assess Involvement Of Underlying Structures – Xray , Ultrasound Investigate Comorbid Conditions - genotype, FBS / HbA1c.

8. Wound Bed Preparation A. Anesthesia – Topical, Local, Regional Block B. Cleaning/Irrigation - Use normal saline - High pressure / Large syringe (60mL) attached to a 14-gauge

9. Wound Bed Prep (Contd..) C. Debridement  Removes foreign matter & devitalized tissue  Creates sharp wound edge  Excision with elliptical shape  Respect skin lines

10. Wound Bed Preparation (Contd…) D. Infection  All chronic wounds contain bacteria and the presence of bacteria obtained from a surface swab does not define Infection.  Critical to wound healing is whether bacterial balance is achieved (contamination or colonization) or bacterial damage (infection).

11. Wound Bed Preparation (Contd…) E. Moisture balance  Appropriate moisture is required to facilitate the action of growth factors, cytokines, and migration of cells including fibroblasts and keratinocytes.  Excessive moisture - cause damage to the surrounding skin – maceration & skin breakdown.  Inadequate moisture - impede cellular activities and promote eschar formation resulting in poor wound healing.

12. Wound Bed Preparation (Contd…) F. Edge  A 20 to 40% reduction in two and four weeks respectively, is likely to be a reliable predictor of healing.  A wound edge that is not migrating after appropriate wound bed. preparation and healing is stalled, then advanced therapies should be considered.  rule out other causes and co-factors.  Consider other wound related outcomes such as: reduced pain reduced bacterial load, reduced dressing changes or an improved quality of life.

13. Wound Dressings Ensures moist wound condition - absorb exudates - protects wound - protects knots

14. Negative Pressure Wound Therapy(NPWT)/ Vacuum Assisted Closure (VAC) expeditiously prepare a wound bed for surgical closure by tertiary intent. most wounds will heal optimally with a negative pressure of 75 - 125 mm Hg. Mechanisms of action - visible contraction which occurs when negative pressure is applied - Provides direct and complete wound bed contact - Removes exudate - Reduces edema - Promotes granulation tissue formation by facilitating cell migration and proliferation

15. Negative Pressure Wound Therapy(NPWT)/ Vacuum Assisted Closure (VAC) Indications: – Large wounds – Cavities – Large amount of exudate Contraindications: - malignancy - ischemia - inadequately debrided wounds

16. Wound Cover CHOICE OF WOUND COVER – graft, flap, skin substitutes PRIORITISATION Preserve Life Preserve Function Cosmesis Availability Grafts & Flaps • Radiation wounds require flaps. • Chronic non healing ulcers. • Extensive areas of ulceration. • Major soft tissue loss.

17. Adjuvant Treatments: • Antibiotics • Analgesics • Tetanus prophylaxis • Nutrition – vit A, Vit C, Zinc • Reduce edema – elevation (avoid in arterial disease) • Rest/Positioning • Physiotherapy • Rehabilitation

18. Special wounds Wound Care In Patients Pressure Sore (Trophic Ulcers) • Debridement • Dressings • air-fluidized beds, air mattresses, air flotation and water flotation devices, and low air-loss beds • Should be aggressively nourished and receive vitamin supplementation. • administration of growth hormone or anabolic steroids.

19. Wound Care in Patients with Diabetes • components of pressure necrosis, functional microangiopathy, and neuropathy. • Selective debridement, control of glucose levels, pressure offloading. • Revascularization • use of growth factors Wound Care in Patients with Venous Ulcers • Compression therapy is essential for venous stasis ulcers (use of stockings, elastic wraps, and multilayer wraps) • ideally the pressures exerted should be between 30- and 40-mm Hg • continued for several weeks following successful closure of the wound • contraindicated in patients with an ABI <0.7

20. GANGRENE Macroscopic death of tissue with putrefaction. • Pre gangrene : rest pain, colour changes, oedema, hyperaesthesia , ischaemic ulceration. • Types : (A) Dry (B) Wet

21. DRY GANGRENE Blood supply : arterial – gradually deprived venous flow – unimpeded • Arterial occlusion- chronic or acute • Colour change: Greenish- black – dry mummified. • Line of separation is present. • Stump is conical. Line of demarcation: • dead tissue and living tissue. • Band of Hyperemia • layer of granulation • Hyperesthesia • seen in: Senile, diabetic, buerger ’s , raynaud’s , frost bite, vascular occlusion, embolism, ligation

22. WET GANGRENE • Arterial & venous block • Infection and putrefaction. • Cold , pulseless, swollen, edematous, blebs • Horrible odour • No line of demarcation • Constitutional symptoms present. • Spreads faster • Seen in acute inflammation, venous thrombosis, Gas gangrene, bed sores

23. TREATMENT LIMB SAVING METHODS: • DRUGS:  Antibiotics  Vasodilators  Pentoxiphylline , dipyridamole, aspirin, toclpidine . Care of foot: • Dry • Footwear- MCR • Nutrition • Avoid injury, pressure, warming • Pus drainage • Control diabetes • Treat cause

24. Surgeries : • Lumbar sympathectomy. • Profundaplasty . • Endarterioectomy . • Femoropopliteal thrombectomy. • Arterial bypass graft. AMPUTATION : • Ray amputation • Below knee amputation • Above knee amputation • Trans condylar – Gritti stokes amputation • Modified syme’s

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