WOUNDS-WOUND HEALING & CARE Begashaw M

Layers of Skin

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

Wound Healing

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

Stages of Wound Healing

Stages of wound healing

Cells in Wound Healing

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 ClassificationCriteria Risk (%) 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 DirtyPurulent 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

Delayed primary closure for traumatic or contaminated wounds within 3 days

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

Laceration

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

Crush & avulsion

Debridement

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 28 th day - Tetanus prophylaxis - Antibiotics

Dog bite

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

Hypertrophic Scar

Hypertrophic Scars

Keloid

Keloids

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