1. Wound Management Hameed Ali Al-Timmemi MSc, PhD Surgery
Baghdad University
Surg Depart
Wound Management
Hameed Ali Al-Timmemi
MSc, PhD

2. Surgery
Baghdad University
Surg Depart
Referances
Fossum,T W., Hedlund, C., Johnso,A., Schul, K., Seim, H., Willard, M., Bahr, A., Carroll, G. and Knap, K. (2007). Small Animal Surgery, 3rd Ed., St. Louis, Missouri
Dr H, Al-Timmemmi

3. Epidermis: outermost layer, avascular
Surgery
Baghdad University
Surg Depart
Surgical Anatomy
Skin composed of
Epidermis: outermost layer, avascular
Dermis: lies deep to the epidermis,
Associated adnexa: (hypodermis)
Dr H, Al-Timmemmi

4. Subdermal (deep) plexus Cutaneous (middle) plexus
Surgery
Baghdad University
Surg Depart
Terminal arteries and veins branch from direct cutaneous vessels and Form
Subdermal (deep) plexus
Cutaneous (middle) plexus
Subpapillary (superficial) plexus
Dr H, Al-Timmemmi

5. Surgery
Baghdad University
Surg Depart
Dr H, Al-Timmemmi

6. Surgery
Baghdad University
Surg Depart
Dr H, Al-Timmemmi

7. Surgery
Baghdad University
Surg Depart
Dr H, Al-Timmemmi

8. Wound: Disruption of normal tissue integrity. Wound Healing
Surgery
Baghdad University
Surg Depart
Wound: Disruption of normal tissue integrity.
Wound Healing
Wound healing is a biologic process that restores tissue continuity after injury. It is a combination of
Physical
Chemical, and
Cellular events that restore wounded tissue or replace it with collagen.
Dr H, Al-Timmemmi

9. Wound Classification: A: According to the etiology Abrasion wound
Surgery
Baghdad University
Surg Depart
Wound Classification:
A: According to the etiology
Abrasion wound
Laceration wound
Avulsion (degloving injuries) wound
Puncture wound
Crush wound
Burn wound
Dr H, Al-Timmemmi

10. Surgery
Baghdad University
Surg Depart
Dr H, Al-Timmemmi

11. Closed wound: Skin is contact (not opened) and contusion.
Surgery
Baghdad University
Surg Depart
B: According to the skin involvement
Open wounds: When the whole thickness of skin is opened (Laceration and skinloss)
Closed wound: Skin is contact (not opened) and contusion.
Dr H, Al-Timmemmi

12. Surgery
Baghdad University
Surg Depart
Dr H, Al-Timmemmi

13. Surgery
Baghdad University
Surg Depart
Dr H, Al-Timmemmi

14. Surgery
Baghdad University
Surg Depart
Dr H, Al-Timmemmi

15. Surgery
Baghdad University
Surg Depart
Dr H, Al-Timmemmi

16. C: According to the condition (Clinically) of the wound Clean wound
Surgery
Baghdad University
Surg Depart
C: According to the condition (Clinically) of the wound
Clean wound
Clean-contaminated wounds
Contaminated wounds
Dirty and infected wounds
Dr H, Al-Timmemmi

17. Stages of Wound Healing
Surgery
Baghdad University
Surg Depart
Stages of Wound Healing
Inflammatory phase: characterized by
Increased vascular permeability,
Chemotaxis of circulatory cells,
Release of cytokines and growth factors, and
Cell activation (macrophages, neutrophils, lymphocytes, and fibroblasts).
Hemorrhage cleans and fills wounds immediately after injury.
Blood vessels constrict for 5 to 10 minutes to limit hemorrhage,
But then dilate and leak fibrinogen and clotting elements into wounds.  
Dr H, Al-Timmemmi

18. Surgery
Baghdad University
Surg Depart
Vasoconstriction is mediated by catecholamines, serotonin, bradykinin, and histamine.
Platelet aggregation and blood coagulation form a clot that ensures hemostasis and provides a scaffold for cell migration
Platelets also release potent chemoattractants and growth factors (epidermal, platelet-derived, transforming growth factors: a and b) that are necessary in later stages of wound healing
Fibrin and plasma transudates fill wounds and plug lymphatics, localizing inflammation and “gluing” wound edges together.
Dr H, Al-Timmemmi

19. Surgery
Baghdad University
Surg Depart
Inflammatory phase cells such as platelets, mast cells, and macrophages secrete growth factors or cytokines, which initiate and maintain the proliferative phase of healing.
Inflammatory mediators (i.e., histamine, serotonin, proteolytic enzymes, kinins, prostaglandins, complement, lysosomal enzymes, thromboxane, and growth factors) cause inflammation that begins immediately after injury and lasts approximately 5 days. 
Dr H, Al-Timmemmi

20. 2. Débridement phase: Surgery
Baghdad University
Surg Depart
2. Débridement phase:
Chemoattractants encourage neutrophils and monocytes to appear in wounds (approximately 6 hours and 12 hours after injury, respectively)
Degenerating neutrophils release enzymes and toxic oxygen products that facilitate the breakdown of bacteria, extracellular debris, and necrotic material, and they stimulate monocytes
Monocytes are major secretory cells synthesizing growth factors that participate in tissue formation and remodeling
Monocytes become macrophages in wounds at 24 to 48 hours.
Dr H, Al-Timmemmi

21. Macrophages secrete Surgery
Baghdad University
Surg Depart
Macrophages secrete
Collagenases, removing necrotic tissue, bacteria, and foreign material.
Gowth factors andchemotactic d. (i.e., PDGF, TGF-a, b, FGF, and IL-1) can initiate, maintain, and coordinate formation of granulation tissue.
Chemotactic factors (i.e., complement, collagen fragments, bacterial endotoxins, and inflammatory cell products)
Dr H, Al-Timmemmi

22. Platelets release growth factors important for fibroblastic activity.
Surgery
Baghdad University
Surg Depart
Recruit mesenchymal cells, stimulate angiogenesis, and modulate matrix production in wounds.
Platelets release growth factors important for fibroblastic activity.
Lymphocytes appear later in the debridement phase
Dr H, Al-Timmemmi

23. 3. Repair phase: Surgery Usually begins 3 to 5 days after injury
Baghdad University
Surg Depart
3. Repair phase:
Usually begins 3 to 5 days after injury
Macrophages stimulate deoxyribonucleic acid (DNA) and fibroblast proliferation.
Cytokines, in concert with extracellular matrix molecules, stimulate fibroblasts in the surrounding tissue to proliferate.
A tissue oxygen content of approximately 20 mm Hg and slight acidity also stimulate fibroblast proliferation and collagen synthesis.
Dr H, Al-Timmemmi

24. Surgery
Baghdad University
Surg Depart
Fibroblasts originate from undifferentiated mesenchymal cells in surrounding connective tissue and migrate to wounds along fibrin strands in the fibrin clot.
The amount of collagen reaches a maximum within 2 to 3 weeks after injury.
Capillaries invade wounds behind migrating fibroblasts by the process of angiogenesis which relying on interaction of extracellular matrix with cytokines that stimulate migration and proliferation of endothelial cells.
Dr H, Al-Timmemmi

25. GT fills defects and protects wounds.
Surgery
Baghdad University
Surg Depart
The combination of new capillaries, fibroblasts, forms bright red, fleshy GT days after injury.
 GT fills defects and protects wounds.
It provides a barrier to infection, a surface for epithelial migration, and a source of special fibroblasts (i.e., myofibroblasts),
Epithelial repair involves mobilization, migration, proliferation, and differentiation of epithelial cells.
Migrating epithelial cells enlarge, flatten, and mobilize, losing their attachments to the basement membrane and other epithelial cells.
Dr H, Al-Timmemmi

26. Surgery
Baghdad University
Surg Depart
Epithelial cells in the layers behind these altered cells migrate over them until they contact the wound surface.
The migrating cells move under scabs and produce collagenase, which dissolves the base of the scab so it can be shed.
Wound contraction reduces the size of wounds subsequent to fibroblasts, reorganizing collagen in granulation tissue and myofibroblast contraction at the wound edge
Wound contraction involves a complex interaction of cells, extracellular matrix, and cytokines.
Wound contraction stops when wound edges meet, when tension is excessive
Dr H, Al-Timmemmi

27. 4. Maturation phase Surgery
Baghdad University
Surg Depart
4. Maturation phase
Wound maturation begins once collagen has been adequately deposited in wounds (17 to 20 days after injury) and may continue for years.
The cellularity of granulation tissue is reduced as cells die.
There is also a reduction in collagen content of the extracellular matrix
Dr H, Al-Timmemmi

28. Collagen synthesis and lysis occur at the same rate in maturing scars.
Surgery
Baghdad University
Surg Depart
Nonfunctionally oriented collagen fibers are degraded by proteolytic enzymes (matrix metalloproteinases) secreted by macrophages, epithelial cells, endothelial cells, and fibroblasts within the extracellular matrix.
As the number of capillaries in fibrous tissue declines, the scar becomes paler.
Scars also become less cellular, flatten, and soften during maturation.
Collagen synthesis and lysis occur at the same rate in maturing scars.
Dr H, Al-Timmemmi

29. Type of wound healing Healing by first intention
Surgery
Baghdad University
Surg Depart
Type of wound healing
Healing by first intention
Healing by 2nd intention
Healing by 3rd intention
Healing by mixed intention
Healing under scab:
Dr H, Al-Timmemmi

30. Treatment of infected wound
Surgery
Baghdad University
Surg Depart
Treatment of Wounds
Clean wounds
Contaminated wound
Treatment of infected wound
Dr H, Al-Timmemmi

31. Surgery
Baghdad University
Surg Depart
Wound Closure
1. Primary wound closure: Wounds may be closed immediately (within 1 to 3 days after injury).
2. Delayed primary wound closure: when they are free of infection but before granulation tissue has appeared
3. Secondary closure: after the formation of granulation tissue
4. Secondary intention: allowed to contract and epithelialize
Dr H, Al-Timmemmi

32. Surgery
Baghdad University
Surg Depart
Factors that affect the decision to close wounds include the following:
Howlong time that has elapsed since injury. wounds older than 6 to 8 hours are initially treated with bandages
Degree of contamination
Amount of tissue damage
Completeness of debridement
Status of the wound's blood supply
Dr H, Al-Timmemmi

33. 7. Extent of tension or dead space 8. Location of the wound
Surgery
Baghdad University
Surg Depart
6. The animal's health
7. Extent of tension or dead space
8. Location of the wound
Dr H, Al-Timmemmi

34. Factor effect wound healing: A. Local factors that Influence healing
Surgery
Baghdad University
Surg Depart
Factor effect wound healing:
A. Local factors that Influence healing
1. Oxygenation
2. Infections:
3. Foreign body
4. Venous sufficiency
B. Systemic factors that influence healing
Age
Sex Hormones
Diabetes
Dr H, Al-Timmemmi

35. 5. Medications 6. Obesity 7. Nutrition Surgery 4. Stress
Baghdad University
Surg Depart
4. Stress
5. Medications
6. Obesity
7. Nutrition
Dr H, Al-Timmemmi

36. Complication of wound:
Surgery
Baghdad University
Surg Depart
Complication of wound:
Bleeding
Syncope
Shock
Traumatic neuralgia
Damage to nerve
Traumatic emphysema
Traumatic fever.
Dr H, Al-Timmemmi

37. 11. Venous thrombosis and embolism 12. Gas gangrene
Surgery
Baghdad University
Surg Depart
8. Cellulitis.
9. Erysipelas
10. Septicemia & pyemia.
11. Venous thrombosis and embolism
12. Gas gangrene
Dr H, Al-Timmemmi