Woundcare

1. WOUND CARE
“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)

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

3. INTRODUCTION

4. Wound healing :
PATHOPHYSIOLOGY
•1.) Inflammatory Phase
•Initial response (Day 1-4 post injury)
•rubor, tumor, dolor, calor
•Platelet aggregation and activation
•Leukocyte (PMNs, macrophages) migration, phagocytosis and
mediator release
•Venule dilation
•Exudative
•a biologic debridement
•In wounds closed by primary intention, lasts 4 days

5. •2.) Proliferative Phase
•Day 4-42
•macrophage-released growth factors
Fibroblast proliferation  Increased rate of
collagen synthesis
•Granulation tissue and neovascularization
•Gain in tensile strength

6. •3.) Remodeling Phase
•6wks-1 year
•Intermolecular cross-linking of collagen via
vitamin C-dependent hydroxylation
•Characterized by increase in tensile strength
•Type III collagen replaced with type I
•Scar flattens

7. 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.

8. 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

9. •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.

10. •wound preparation (debridement,cleansing,
etc.)
• dress with saline soaked fine mesh gauze
• follow up in 72-96 hours for debridement
• repeat cleansing and closure if no evidence of
infection

11. Factors that affect wound healing
•Patient factor :Age
•Immunocompromising -DM
-renal failure
-AIDS
-splenectomy
•Medications –systemic steroids/ other
immunocompromising drugs  increased
infection rates
•Wound Characteristics -Time, Location,
Etiology , Mechanism of injury, Laceration
width

12. 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.

13. 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, C,
and zinc.
•T = Tissue necrosis, from local or systemic
ischemia or radiation injury. Blood supply is
important.

14. 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.

15. 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.

16. 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

17. history
•Immunocompromised
•Bleeding disorder.Prolonged bleeding-. Hematoma
can serve as culture medium for wound infection.
•Peripheral vascular disease

18. Mechanism of injury
FORCE OBJECT DAMAGE WOUND
shear Sharp Minimal Linear
compressionBlunt
Right angle
Moderate (+)Stellate
Jagged
tensile Blunt
Oblique angle
Moderate (+)Triangular
Flap

19. TYPES of wound
•Abrasions Superficial layer of tissue is removed
•Avulsions A section of tissue is torn off (partially or totally)
•Lacerations Tissue is cut or torn. Sharply demarcated
borders.

•Puncture Small opening and of indeterminate depth.
•Contusion forceful blow, outer layer of skin intact ; minimal
wound care ; evaluate for possible hematoma
• Combination wound

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

21. •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

22. 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)

23. WOUND PREPARATION

24. 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

25. Topical anesthesia
•Solely / with local infiltration
•Most effective : face and scalp (high vascularity)
•LET (lidocaine, epinephrine, tetracaine)
• TAC (tetracaine, adrenaline/epinephrine, cocaine )
•cotton ball
•soaked with 3–5ml
•applied to the open wound for at least 10 minutes

26. Local anesthetic
Drug Max Dose Onset Duration
Cocaine 6.6 mg/kg Rapid 1 hour
Procaine 10-15 mg/kgRapid 30min-1hr
Tetracaine1.5 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
Bupivacaine2 mg/kg 7-30 min > 6 hours

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

28. Local infiltration
•reduce the pain of anesthetic infiltration
1. Premedicate the wound with a topical anesthetic (described above) or ice.
2. Buffer anesthetic with sodium bicarbonate (1 ml/ 10 ml )  less painful
anesthetic.
3. Needle size : smallest diameter needle. A 30-gauge needle is preferred.
4. Inject slowly (10sec), as pain results when the soft tissue stretches.

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

30. 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

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

32. 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.

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

34. 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

35. “Prophylactic” Antibiotics
If Prescribed
•Duration 3 –7 days
•Wound Recheck in 24 –48 hours

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. WOUND CLOSURE
•Undermine the wound edges
–Release tension

38. 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)

39. Suture supply
needle drivers …
tissue forceps (or skin hook)
Scissors
sterile drapes
sterile gloves
suture materials
sterile gauze

40. Suture Material
•Absorbable
–Chromic catgut ( natural monofilament)
–Vicryl (synthetic braided)
–PDS II (synthetic monofilament)
•Non-Absorbable
–Silk (natural braided)
–Ethilon (synthetic monofilament)
•Monofilament (smooth but stiff) vs. Braided (has
interstices = haven for bacteria)

41. Suture size
Skin
•Face 5/0 or 6/0
•Hands and Limbs 3/0 or 4/0
•Elsewhere 2/0 or 3/0

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

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

44. Suture Techniques
•Simple Interrupted
–Used on majority of wounds
–Each stitch is independent

45. Suture Techniques
•Simple Continuous
–Useful in pediatrics
•Rapid
•Easy removal
–Provides effective hemostasis
–Distributed tension evenly along length
–Can also be locked with each stitch

46. Suture
Techniques
•Horizontal Mattress
–Useful for single-layer
closure of lacerations
under tension

47. Suture
Techniques
•Vertical Mattress
–Useful for everting skin
edges
–“Far-far-near-near”

48. Suture Techniques
•Purse-string
–Useful for stellate lacerations

49. Suture
Techniques
•Instrument tie

50. 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

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

52. 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

53. Wounds appropriate for
consultation/referral
• Primary provider is unable to perform optimal repair
– Skill level does not match complexity of wound
– Practice setting is too busy to allow adequate time for repair
• Underlying injury
– Tendon ,Nerve, Vascular,Joint involvement or underlying
fracture
Eyelid: tarsal plate or lacrimal duct involvement
•Patient requests specialist
• Operative repair necessary
– Skin grafting
– Flap creation or rotation

54. References
•www.cme-ce-summaries.com/emergency-medicine/em2604.html
•www.medstudentlc.com
•www.emedicine.medscape.com
•www.proceduresconsult.com
•Essential Practice of Surgery : Basic Science and Clinical
Evidence;2003;chapter7;pg77-88;H.Peter Lorenzo, Michael T. Longaker.
•Robbins Basic Pathology 8
th
edition;chapter3;pg70-8; Kumar, Abbas,
Faustro, Mitchell.
•Essential Surgery : Problems, Diagnosis & Management ;
chapter11;pg149-58; H.G. Burkitt,C.R.G. Quick, J.B.Reed.
•Wound Management ; powerpoint presentation by UNC emergency
medicine (Medical Student Lecture Series).
•Wound Management Principles ; powerpoint presentation by Donald J
Sefcik and Nicole Y Ottens, FACOEP.
•Wound Management 2001 ; powerpoint presentation by Gavin Greenfield
and Bob Johnston.

55. Practice Time!