wound

1. Dr. Wondwossen M.
WOUNDS

2. Objectives
 Classification
 Wound healing
o Types
o Phases
o Delayed healing
o Abnormal healing
 Wound care

3. Introduction
Disruption of tissue integrity,
leading to division of blood
vessels
It is caused by a transfer of any
form of energy into the body.

4. Classification
1- Closed Vs Open
Closed wounds
Skin Intact / Underlying tissue damaged
e.gs contusion, bruise, hematoma.
Open wounds
-Complete break of the epithelial protective
surface.
e.gs abrasion, laceration, puncture, degloved
wound , bites.

5. 2- Tidy Vs Untidy
Tidy Untidy
- Incised - Crushed
- Clean - Contaminated
- Healthy tissue - Devitalized tissue
- Seldom tissue loss - Often tissue loss

6. 3- Acute Vs Chronic
 Acute wounds
 Wounds that heal in expected period of time
 Eg. Lacerations
 Chronic wounds
- Wound that fails to heal over an extended period of
time
- Caused by inadequate circulation or in which
healing is delayed as a result of vascular compromise
- eg. Ulcers

7. 3- Tetanus Prone Vs Tetanus Non-prone
Tetanus Prone
 wound age >6hrs
 wound depth > 1cm
 presence of devitalized tissue
 contaminated wounds
 Animal bites
Tetanus Non-prone
 wound age <6hrs
 wound depth <1cm
 absence of devitalized tissue
 non contaminated wounds

8. Classification of Surgical Wounds
 Based on the risk of infection & degree of
contamination
- Clean (Class-I)
- Clean-contaminated (Class-II)
- Contaminated (Class-III)
- Dirty (Class-IV)

9. 1- Clean wounds
 No inflammation
 No break in sterile technique
 Wound primarily closed/Not
drained
 Aero- digestive, genitourinary &
Biliary tract not entered
 Potential infection rate 1%-5%
 Examples
 Thyroidectomy
 Mastectomy
 Lipoma excision

10. 2- Clean-contaminated Wound
 No inflammation/Infection present
 Minor break in sterile technique
 Aerodigestive or genitourinary
tract entered without spillage
 Potential infection rate 8% - 10%
 Examples
 Simple appendectomy
 Prostatectomy
 Cholecystectomy

11. 3- Contaminated Wound
 Traumatic wounds
 Acute inflammation present
 Major break in sterile technique
 Gross spillage/contamination
from respiratory,
gastrointestinal, biliary, or
genitourinary tracts
 Potential infection rate 15% -
20%
 Example
 Traumatic wounds

12. 4- Dirty/Infected Wound
 Organisms present at surgical site
prior to procedure/Existing
infection
 Presence of pus
 Perforation (Gastrointestinal,
biliary, respiratory, genitourinary
tract)
 Potential infection rate 27% - 40%
 Example
 Appendiceal abcess
 Peritonitis

13. Wound Healing
 A complex mechanism involving cellular & chemical
activity
 Healing Vs Regeneration
• Wound repair is the effort of injured tissues to
restore their normal function and structural integrity
after injury.
• Regeneration is perfect restoration of the
preexisting tissue architecture in the absence of
scar formation.
• In adult humans the accuracy of regeneration is
sacrified for the speed of repair

14. Types of Clinical Wound Healing
oPrimary Intention
oSecondary Intention
oTertiary Intention (Delayed Primary Closure)

15. Primary Intention
 For clean wounds
 Wound is sutured/closed
 Healing occurs from side-to-
side
 Healing occurs rapidly with little
inflammation and minimal
scarring

16. Secondary Intention
 For contaminated/dirty wounds
 Wound is intentionally left open
 Healing occurs from the bottom–
up
 Granulation tissue containing
myofibroblasts forms wound
contraction
 Scar formation is extensive

17. Tertiary Intention (Delayed Primary Closure)
 For contaminated/dirty
 Wound is left open until
clean for 4-6 days
 Then, wound is closed
 Suturing
 Skin grafting
 Flap

18. Phases of Wound Healing
Hemostasis & Inflammation
phase
Proliferative phase
Maturation & Remodeling phase

19. Hemostasis & Inflammation phase
 Begins within minutes of the injury and lasts 3
days
 Hemostasis
 Vasoconstriction
 Fibrin clot formation
 Inflammation manifested by heat, redness,
swelling, pain, loss of function
 Platelets, Neutrophils & Monocytes
 Goals of this phase are
 Arrest bleeding
 Remove dead tissue & foreign bodies
 Stimulate next phase of wound healing

20. Proliferative phase
 Begins about the 3rd post injury day & continues up to
3wks
 Fibroblasts & Endothelial cells
 Collagen(type-3) & new blood vessels
formation(angiogenesis)

21. Maturation & Remodeling phase
 Lasts until the wound is completely healed, (may take
up to 1-2 yr)
 Tensile strength increased by interweaving of collagen
fibers
 Conversion of type-3 collagen to Type-1 collagen
 Collagen density increases & formation of new blood
vessels decreases
 Mature scar is formed

22. Factors affecting wound healing
Local
 Ischemia
 Infection
 Foreign body
 Edema
Systemic
 Age
 Stress
 Ischemia
 Diabetes
 Steroids
 Smoking
 Immunocompromise
 Malnutrition

23. Abnormal wound healing
 Hypertrophic scar

 Keloid

24. Wound Management
1- Assessment of wounds
- duration since injury
- identification of possible contamination & Fb.
- extent of wound
- associated neurovascular or tendon injury
- need of tetanus prophylaxis
- identification of risk factors that might affect
healing.

25. 2- Wound preparation
- irrigation helps in:
- to visualize areas of the wound.
- to remove Fb
- foreign body removal
- necrotic tissue debridement
- evacuation of hematoma
- haemostasis

26. 3-Wound Closure
Timing
The choices are:
(1) close at the time of initial
presentation
(2) delay closure until after a period of
healing or wound care, and
(3) to allow the wound to heal on its own.
Methods
The closure methods available include:
(1) primary closure by direct
approximation (2) delayed primary closure,
(3) secondary closure-left to heal on its
own.
(4) skin grafting; and

27. 4- Dressing
maintain a moist clean environment
prevent pressure and mechanical trauma
reduce edema
stimulates repair
comfort and aesthetic appearance

28. Other adjuncts
 Antibiotics
o Prophylactic
o Therapeutic
 Tetanus Prophylaxis

29. Special wounds
 Human bites
 Management
o Thorough irrigation with saline or plain water
o Adequate debridement
o Leave wound open
o Broad-spectrum antibiotics
o Tetanus Prophylaxis
o Wound observation
 Dog bites
 Management
o Vigorous irrigation
o Leave wound open
o Tetanus prophylaxis
o Antibiotics
o Post exposure anti rabies prophylaxis (1ml, IM)
on the 1st, 3rd, 7th, 14th and 28th day of bite.

30. Thank You