wounds-wound healing & care begashaw m. layers of skin
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DEFINITION
• Wound - break in normal continuity of a tissue
• cause - transfer of any form of energy
WOUND HEALING
• is a complex biologic process of restoring normal tissue continuity
• integrated sequences of events leading to cellular proliferation and remodeling
• starts immediately following the event of wounding
Phases of healing
1-Coagulation phase• first phase • is induced immediately following injury• characterized by vaso-constriction, clot
formation and release of platelets
2- Inflammatory phase
• takes place from time of wounding up to 3 days
• Characterized:
inflammatory response
vasodilatation and pouring out of fluid
migration of inflammatory cells and leukocytes
rapid epithelial growth
3- Proliferative Phase
• phase of fibroplasia• starts around the 3rd day of injury• stays for about 3 weeks• is characterized
-fibroblast, epithelial and endothelial proliferation
-Collagen synthesis & ground substance
-blood vessel production
4- Maturation phase
• phase of remodeling• takes the longest period - up to 1 yr• Equilibrium between protein synthesis
and degradation occurs • with cross linking of collagen bundles
leading to slow and continuous increase in tissue strength
Clinical types of healing
• Healing by first intention
- clean wound closed primarily
- healing by epithelialization
- minimal scar
- <6 hours, longer with facial• Healing by Second intention
- in wide, contaminated wounds
- not primarily closed
- healing by granulation tissue formation
- tissue contraction and epithelialization
- inferior cosmetic result
Healing by third intention:
-left open initially
-closed later-delayed primary closure
-In contaminated -long time lapse since initial injury-severe crush wound
Factors affecting healing
Local factors
-Ischemia
-decreased oxygen tension
-foreign bodies
-tension
-Infection
-Irradiation
Systemic factors
-Systemic diseases-DM, cirrhosis, renal failure, malignancy
-malnutrition
-immunosupression-Drug- steroids,
cytotoxic agents
WOUND ASSESSMENT AND CLASSIFICATION
Assessment History
• Mechanism of injury
• Time
• Place and circumstance
• past and current medical• immunization history
physical examination
• Extent of skin loss
• Degree of circulation
• soft tissue injury• The degree of contamination
• foreign body • tissue necrosis
Classification of wounds
• Closed wound
- an intact epithelial surface
- skin cover not completely breeched
e.g Contusion
Bruise
Hematoma
• Open wounds
- complete break of the epithelial protective surface
E.g Abrasion
Laceration
Puncture
Bites
Open wounds
Tidy• Incised• Clean• Healthy tissue• Seldom tissue
loss
Untidy• crushed• Contaminated• Devitalised
tissue• Often tissue loss
Classification of Wounds
ClassificationCriteriaRisk (%)
Clean Elective, not emergency, non traumatic, primarily closed; no acute inflammation; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered
< 2
Clean-contaminated
Urgent or emergency case that is otherwise clean; elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g., appendectomy) not encountering infected urine or bile; minor technique break
< 10
Contaminated Non purulent inflammation; gross spillage from gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique; penetrating trauma < 4 hours old; chronic open wounds to be grafted or covered
~ 20
Dirty Purulent inflammation (e.g., abscess); preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract; penetrating trauma > 4 hours old
~ 40
Classification of Surgical Wounds
• Clean(no viscus opened)• Clean-contaminated(viscus opened
minimal spillage)• Contaminated(open viscus with
gross spillage or inflammatory ds)• Dirty(pus or perforation or incision
via abscess)
WOUND MANAGEMENT-Priority: ABC
-Stabilize-correct life threatening conditions
• history & P/E -associated injuries
• Assess wound
• treatment
• Follow up
Proper wound care:
• stop bleeding
• irrigation
• debridement
• decision -to close
-leave the wound open
• antibiotics• tetanus prophylaxis
• correcting systemic disease
primary wound closure
• Clean wounds
• Clean-contaminated wounds -if they can be converted into clean wounds
• all missile wounds, animal & human bites should never be primarily closed
• in wounds within 6-8 hours
Secondary closure
• wound left open to heal spontaneously
• contraction (myofibroblasts) and granulation
• requires dressing change• inferior cosmetic result• indication: when 1° closure not
possible or indicated
Specific management
• Bruises -Superficial
-no specific management
-local compress
-analgesics
• Hematoma • collection of
extravasated blood• Management:
- absorbed spontaneously
- Local compress to alleviate pain
- aspiration-very large/ over a cosmetic area
Abrasion
• is rubbing or scraping of skin or mucous membrane -variable depth
• affect only a part or full layer of skin• Management
- Cleanse using scrubbing brushes
- Use antiseptic or clean tap water and soap
- Analgesic
Punctures
• involve deeper structures• opening relatively small as compared with
depth (e.g. needle)• Management:
- Evaluate the depth
- Remove
- Excise damaged tissue
- Cover with antibiotics
- Tetanus prophylaxis
Lacerations- open wounds - knife, or glass- cut or torn tissue• Management:
- cleansing
- Closure
- wound debridement
- antibiotic
- Tetanus Prophylaxis
- Analgesics
Crush and avulsion wounds
complicated wounds have more extensive damage caused by compression Management:
- life threatening conditions
- debridement- Early skin cover- late graft
- wound left open if contaminated
- antibiotics
- Tetanus Prophylaxis
- Analgesics
Missile injuries
• compound , complicated• excessive tissue damage• high degree of contamination• severe life threatening• Management
- stabilize
- debridement- Antibiotics- Tetanus Prophylaxis - analgesics
- avoid primary closure
Human bites• heavily contaminated • due to polymicrobial-Staph> a-hemolytic
Strep > Eikenella corrodens >Bacteroides• Management
- culture - Scrubbing- irrigation with saline
- debridement
- Leave wound open
- Broad-spectrum antibiotic-augmentin
- Tetanus Prophylaxis
Dog bites• can transmit the rabies virus• animal observation for 10 days Local- irrigation and repeated swabbing - flushing -soap & water/ antiseptics
- anti-rabies serum infiltration
- leave wound open Systemic
- Post exposure anti rabies prophylaxis (1ml, IM) on the 1st, 3rd, 7th, 14th and 28th day
- Tetanus prophylaxis
- Antibiotics
Snake Bites
• First aid :
- irrigation
- pressure bandage proximally
- Immobilize
- Transport to hospital
Hospital Measures- Identify species
- lab- hemoglobin, renal function
- Anti-venom injection
- Supportive care
- Rest
- IV-infusions to combat shock
- Antibiotics
- Blood transfusion
- Tetanus Prophylaxis
- Wound excision
- Fasciotomy for compartment syndrome
WOUND COMPLICATIONS
• Local
- Hematoma
- Seroma
- Infection
- Dehiscence
- Granuloma
- Scar
- Contracture
• systemic
- shock -massive bleeding
- bacteremia & sepsis- death
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