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Wound Management

Ronald Merrell, MD FACSVirginia Commonwealth University

Types of wounds

• Abrasion• Thermal• Puncture or stab• Gunshot high velocity or low velocity• Gunshot high velocity or low velocity• Laceration• Avulsion• Amputation• Open Fracture

Types of Incisions

• Clean• Clean contaminated• Contaminated

Types of Healing

• First Intention. Primary closure• Second Intention. Secondary closure• Third Intention. Granulation and

t ti ft lcontraction or graft closure• Chronic Wound. Biologically very different• Regeneration. Not by scarring

Biology of wound healing

• Day 1-3 inflammation• Day 3-28 proliferation• 1-3 months remodeling

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Principles of wound management

• Primum non nocere• “I’m not dead yet”• Get it clean• Do not entomb contamination• Do not entomb contamination• Drain pus. The pressure problem• Allow body to normalize the environment• Remember normal tissue perfusion

pressure (25mmHg)

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Venous Stasis ulcer

Adjuncts to healing

• Magic potions, factors, chemicals, creams, antibiotics

• Hyperbaric oxygenP iti• Positive pressure

• Negative pressure• Strong positive thoughts and meditation

This will not hurt much and other lies

• Hypotonic solutions hurt. So do hypertonic • Salt in wound hurts, Saline does not• Ischemia• Stretch• Pressure• Low pH• Excessive heat

What is basic to healing

• Advantage to host rather than microbe• Clean• No Hematoma• Gentle apposition• Gentle apposition• Proper position• Perfusion• Oxygenation• Clean dressing

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Final Thoughts• Anticipate the outcome• Does it really look the way you want?• A neat bandage implies careful work• A comfortable bandage is kind. Tape hurtsg p• When you look at a wound the patient is

studying your reaction• When you take down a dressing, ditto• Removing sutures is a big deal• I made the incision, the patient made the scar