Information on Wound
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- 1. Classification and management of wound, principle of wound healing, haemorrhage and bleeding control 1
- 2. WOUND 2
- 3. What is a wound? ⚫ It is a circumscribed injury which is caused by an external force and it can involve any tissue or organ. surgical, traumatic It can be mild, severe, or even lethal. Simple wound Compound wound Acute Chronic 3
- 4. Parts of the wound Wound edge Wound corner Surface of the wound Base of the wound Cross section of a simple wound Skin surface Subcutaneus tissue Superficial fascia Muscle layer Base of the wound Wound edge Surface of the wound Wound cavity 4
- 5. The ABCDE in the injured assessment The mnemonic ABCDE is used to remember the order of assessment with the purpose to treat first that kills first. ⚫ A: Airway and C-spine stabilization ⚫ B: Breathing ⚫ C: Circulation ⚫ D: Disability ⚫ E: Environment and Exposure 5
- 6. Wound management ⚫When and where was the wound occured? ⚫Alcohol and drug consumption ⚫What did caused the wound? ⚫The circumstances of the injury ⚫Other diseases eg. diabetes mellitus, tumour, atherosclesosis, allergy ⚫The state of patient’s vaccination against Tetanus ⚫Prevention of rabies ⚫The applied first-aid 6
- 7. Classification of the accidental wounds 1. Based on the origin ⚫ I. Mechanical: ⚪ 1. Abraded wound (vulnus abrasum) ⚪ 2. Puncured wound (v. punctum) ⚪ 3. Incised wound (v. scissum) ⚪ 4. Cut wound (v. caesum) ⚪ 5. Crush wound (v. contusum) ⚪ 6. Torn wound (v. lacerum) ⚪ 7. Bite wound (v. morsum) ⚪ 8. Shot wound (v. sclopetarium) ⚫ II. Chemical: ⚪ 1. Acid ⚪ 2. Base ⚫ III. Wounds caused by radiation ⚫ IV. Wounds caused by thermal forces: ⚪ 1. Burning ⚪ 2. Freezing ⚫ V. Special 7
- 8. 1.) Abraded wound (v. abrasum) 2.) Punctured wound (v. punctum) ⚫ Superficial part of the epidermal layer ⚫ Good wound healing ⚫ Sharp-pointed object ⚫ Seems negligible BUT ⚫ Anaerobic infection ⚫ Injury of big vessels and nerves Mechanical wounds 8
- 9. 3.) Incised wound (v. scissum) 4.) Cut wound (v. caesum) ⚫ Sharp object ⚫ Best healing ⚫ Sharp object + blunt additional force ⚫ Edges - uneven Mechanical wounds 9
- 10. 5.) Crush wound (v. contusum) 6.) Torn wound (v. lacerum) ⚫ Blunt force ⚫ Pressure injury ⚫ Edges – uneven and torn ⚫ Bleeding ⚫ Great tearing or pulling ⚫ Incomplete amputation Mechanical wounds 10 (v. lacerocontusum)
- 11. 7.) Shot wound (v. scolperatium) ⚫ Close - burn injury ⚫ Foreign materials Mechanical wound 11 unijured tissue necrobiotic zone necrotic zone foreign bodies aperture slot tunel output
- 12. 8.) Bite wound (v. morsum) ⚫ Ragged wound ⚫ Crushed tissue ⚫ Torn ⚫ Infection ⚫ Bone fracture ⚫ Prevention of rabies ⚫ Tetanus profilaxis Mechanical wounds 12
- 13. Distal Proximal The wound healing is good The direction of the flap 13
- 14. 1.) Acid 2.) Base ⚫ in small concentration – irritate ⚫ in large concentration – coagulation necrosis ⚫ colliquative necrosis Chemical wounds 14
- 15. Symptoms and severity depend on: ⚫ Amount of radiation ⚫ Length of exposure ⚫ Body part that was exposed Symptoms may occur immediately, after a few days, or even as long as months. What part of the body is most sensitive during radiation sickness? bone marrow gastrointestinal tract Wounds caused by radiation 15
- 16. 1.) Burning 2.) Freezing ⚫ a – normal skin ⚫ 1 - 1st degree – superficial injury (epidermis) ⚫ 2 – 2nd degree –partial or deep partial thickness (epidermis+superficial or deep dermis) ⚫ 3 – 3rd degree – full thickness (epidermis + entire dermis) ⚫ 4 – 4th degree – (skin + subcutaneous tissue + muscle and bone) ⚫ Treatment: ⚫ Cooling – cold water and clean covering Wounds caused by thermal forces 16 Metabolic change! - toxemia ⚫ mild, moderate, severe (redness, bullas, necrosis) ⚫ rewarm – not only the frozen area but the whole body
- 17. Exotic, poisonous animals ⚫ Toxins, venom - toxicologist ⚫ Skin necrosis Special wounds 17
- 18. Classification of the wounds 2. According to the bacterial contamination ⚫Clean wound ⚫Clean-contaminated wound ⚫Contaminated wound ⚫Heavily contaminated wound 18
- 19. ⚫Superficial ⚫Partial thickness ⚫Full thickness ⚫Deep wound Classification of the wounds 2. Depending on the depth of injury + bone, opened cavities, organs…etc. 19 source: http://www.funscrape.com/Search/1/skin+layers.html
- 20. Wound management - history ⚫ Ancient Egypt – lint (fibrous base-wound site closure), animal grease (barrier) and honey (antibiotic) „closing the wound preserved the soul” ⚫ Greeks – acute wound= „fresh” wound; chronic wound = „non-healing” wound maintaining wound-site moisture ⚫ Ambroise Paré – hot oil ↔ oil of roses and turpentine, ligature of arteries instead of cauterization ⚫ Lister pretreated surgical gauze – Robert Wood Johnson →1870s; gauze and wound dressings treated with iodide 20
- 21. Applied wound management - colour continuum black black-yellow yellow yellow-red red red-pink pink 21 source: Applied wound management supplement – www.wounds-uk.com
- 22. Applied wound management infection continuum contamination colonisation infection sterility critical colonisation 22 the quantity and diversity of microbes source: Applied wound management supplement – www.wounds-uk.com
- 23. Applied wound management exudate continuum volume high - 5 medium - 3 low - 1 high - 5 medium -3 low - 1 Viscosity 23 source: Applied wound management supplement – www.wounds-uk.com
- 24. The wound managemanet ⚫Temporary wound management (first aid) ⚪ clean, hemostasis, covering ⚫Final primary wound management ⚪ clean, anaesthesis, excision, sutures ⚪ ALWAYS: thoracic cavity, abdominal wall or dura mater injury ⚪ NEVER: war injury, inflammation, contamination, foreign body, special jobs, bite, shot, deep punctured wound ⚫Primary delayed suture (3-8 days) ⚪ clean, wash – saline, cover ⚪ excision of wound edges, sutures 24
- 25. The wound managemanet 25 ⚫Early secondary wound closure (2 weeks) ⚪ after inflammation, necrosis – proliferation ⚪ anesthesia, refresh wound edges, suturing and draining ⚫Late secondary wound closure (4-6 weeks) ⚪ anesthesis, scar excision, suturing, draining ⚪ greater defect – plastic surgery
- 26. The surgical wound ⚫ Surgical incision ⚫ Stretch and fix ⚫ Handling the scalpel ⚫ Langer lines ⚫ Skin edges ⚫ Vessels and nerves ⚫ Hemostasis Langer lines The wound edges Handling the scalpel 26 source: http://www.med- ars.it/galleries/langer.htm
- 27. Tissue unifying and dressing the wound Skin: ⚫ Stiches ⚫ Clips ⚫ Steri-Strips ⚫ Tissue glues Fascia and subcutaneous layers: ⚫ Interrupted stiches Fat – fat necrosis! Dressing: sterile, moist, antibiotic-containing, non-allergic, non-adhesive 27
- 28. The wound healing ⚫Hemostasis-inflammation ⚫Granulation-proliferation ⚫Remodelling capillaries fibroblasts lymphocytes macrophages neutrophyl gr. thrombocytes 0 1 2 3 4 5 6 7 8 9 10 11 10 13 14 15 28 http://www.worldwidewounds.com/2004/august/Enoch/images/enochfig1.jpg
- 29. The main steps of the wound healing 1. Hemostasis-inflammation vasoconstriction fibrin clot formation proinflammatory citokines and growth factors releasing vasodilatation infiltration PMNs, macrophages cytokines releasing → angiogensis → fibroblast activation → B- and T-cells activation → keratinocytes activation → wound contraction 29 2. Granulation-proliferation fibroblast migration collagen deposition angiogensis granulation tissue formation epithelisation contraction 3. Remodelling regression of many capillaries physical contraction – myofibroblasts collagen degeneration and synthetisation new epithelium tensile strength – max. 80%
- 30. Types of wound healing ⚫ Healing by primary intention ⚫ Healing by secondary intention ⚫ Healing by tertiary intention 30 source: http://quizlet.com/13665246/chapter-3-tissue-renewal-regeneration- and-repair-flash-cards/
- 31. Factors affecting wound healing ⚫ Local ⚪ Ischemia ⚪ Infection ⚪ Foreign body ⚪ Edema, elevated tissue pressure ⚫ Systemic ⚪ Age and gender ⚪ Sex hormones ⚪ Stress ⚪ Ischemia ⚪ Diseases ⚪ Obesity ⚪ Medication ⚪ Alcoholism and smoking ⚪ Immunocompromised conditions ⚪ Nutrition Hyperbaric oxygen treatment 31 infection ischemia foreign bodies edema/ elevated tissue pressure IMPAIRED HEALING
- 32. Complications of wound healing I. Early complications ⚫Seroma ⚫Hematoma ⚫Wound disruptin ⚫Superficial wound infection ⚫Deep wound infection ⚫Mixed wound infection 32
- 33. 1.) Seroma 2.) Hematoma ⚫ Filled with serous fluid, lymph or blood ⚫ Fluctuation, swelling, redness, tenderness, subfebrility TREATMENT: ⚫ Sterile punture and compression ⚫ Suction drain Early complications of wound healing 33 ⚫ Bleeding, short drainage time, anticoagulant ⚫ Risk of infection ⚫ Swelling, fluctuation, pain, redness TREATMENT ⚫ Sterile puncture ⚫ Surgical exploration
- 34. 3.) Wound disruption A. partial – dehiscenece B. complete - disruption ⚫ Surgical error ⚫ Increased intraabdominal pressure ⚫ Wound infection ⚫ Hypoproteinaemia TREATMENT: ⚫ U-shaped sutures Early complications of wound healing 34
- 35. 1.) Diffuse 2.) Localized ⚫ Located below the skin TREATMENT ⚫ Resting position ⚫ Antibiotic ⚫ Dermatological consultation ⚫ Anywhere TREATMENT ⚫ Surgical exploration ⚫ Drainage ⚫ X-ray examination Early complications of wound healing Superficial wound infection 35 e.g. erysipelas e.g. abscess
- 36. 1.) Diffuse 2.) Localized TREATMENT ⚫Surgical exploration ⚫Open therapy ⚫H2O2 and antibiotics e.g. anaerobic necrosis ⚫ Inside the tissues or body cavities TREATMENT ⚫ surgical exploration ⚫ drainage Early complications of wound healing Deep wound infection 36
- 37. Mixed wound infection e.g. gangrene ⚫ necrotic tissues ⚫ putrid and anaerobic infection ⚫ a severe clinical picture TREATMENT ⚫ aggresive surgical debridement ⚫ effective and specified (antibiotic) therapy 37 Complications of wound healing I. Early complications
- 38. Complications of wound healing II. Late complications ⚫Hyperthrophic scar ⚫Keloid formation ⚫Necrosis ⚫Inflammatory infiltration ⚫Abscesses ⚫Foreign body containing abscesses 38
- 39. Hypertrophic scar Keloid ⚫ Develop in areas of thick chorium ⚫ Non-hyalinic collagen fibres and fibroblasts ⚫ Confine to the incision line TREATMENT ⚫ Regress spontaneously (1-2 yrs) Late complications 39 ⚫ Mostly African and Asian population ⚫ Well-defined edge ⚫ Emerging, tough structure ⚫ Overproliferation of collagen fibers in the subcutaneous tissue ⚫ Subjective complains TREATMENT ⚫ Postoperative radiation ⚫ Corticosteroid + local anaesthetic injection
- 40. BLEEDING AND HEMOSTASIS 40
- 41. Anatomical Diffuse ⚪ Arterial – bright red, pulsate ⚪ Venous – dark red, continuous ⚪ Capillary – can become serious ⚪ Parenchymal Bleeding 41
- 42. Bleeding Severity of bleeding – the volume of the lost blood and time 42 source: http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/
- 43. The direction of hemorrage ⚫External ⚫Internal ⚪ In a luminar organ (hematuria, hemoptoe, melena) ⚪ In body cavities (intracranial, hemothorax, hemascos, hemopericardium, hemarthros) ⚪ Among the tissues (hematoma, suffusion) 43
- 44. Bleeding ⚫ Preoperative hemorrhage Prehospital care! – maintenance of the airways, ventillation and circulation bandages, direct pressure, turniquets ⚫ Intraoperative hemorrhage anatomical and/or diffuse depending on the surgeon, the surgery, position, the size of the vessel, pressure in the vessel ANESTHESIA! ⚫ Postoperative bleeding ineffective local hemostasis, undetected hemostatic defect, consumptive coagulopathy or fibrinolysis 44
- 45. Local General ⚫ Hematoma, suffusion, ecchymosis ⚫ Compression in the pleural cavity, in pericardium, in the skull ⚫ Functional disturbancies – e.g. hyperperistalsis ⚫ Pale skin, cyanosis, decreased BP. and tachycardia, difficulty in breeding, sweeting, decreased body temperature, unconsciousness, cardiac and laboratory standstill, laboratory disorders, signs of shock Signs of the bleeding 45
- 46. Surgical hemostasis Aim – to prevent the flow of blood from the incised or transected vessels ⚫Mechanical methods ⚫Thermal methods ⚫Chemical and biological methods 46
- 47. Surgical hemostasis Mechanical methods ⚫Digital pressure – direct pressure, e.g. Pringle maneuver ⚫Tourniquet ⚫Ligation ⚫Suturing ⚫Preventive hemostasis ⚫Clips ⚫Bone wax ⚫other 47
- 48. Thermal methods ⚫Low temperature ⚪ Hypothermia – eg. stomach bleeding ⚪ Cryosurgery ⯍ dehidratation and denaturation of fatty tissue ⯍ decreases the cell metabolism ⯍ vasoconstriction 48
- 49. Thermal methods ⚫High temperature ⚪ Electrosurgery – electrocauterization ⚪ Monopolar diathermy ⚪ Bipolar diathermy ⚪ Laser surgery coagulation and vaporization for fine tissues 49
- 50. Thermal methods ⚫High temperature ⚪ Electrocoagulation ⚪ Electrofulguration (A) ⚪ Electrodessication ⚪ Electrosection 50
- 51. Hemostasis with chemical and biological methods vasoconstriction coagulation hygroscopic effect Absorbable collagen Absorbable gelatin Microfibrillar collagen Oxidized celluloze Oxytocin Epinephrine Thrombin Hemcon QuikClot 51
- 52. Hemostasis with chemical and biological methods HemCon 52
