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Wound

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wound classification management

wound classification management


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  • 1. Wound & Wound Healing
  • 2. Definition of a wound : ANY break in the integrity of the skin or tissues which may be associated with disruption of structure or function  Etiology: - Trauma - Radiation - Infection - Iatrogenic Etc
  • 3. CLASSIFICATION OF WOUNDS
  • 4. RANK & WAKEFIELD CLASSIFICATION  Tidy Wounds  Surgical incisions,  wounds by sharp objects,  keloid,  Untidy Wounds  Avulsion  Crush injury  Devitalised injury
  • 5. BASED ON TYPE OF WOUND  Bruising & contusion  Haematoma  Clean Incised Wound  Lacerated Wound  Abrasion  Crush injury  Penetrating wounds
  • 6. CLASSIFICATION OF SURGICAL WOUNDS  Clean Wound  Clean Contaminated Wound  Contaminated Wound  Dirty Infected Wound
  • 7. CLEAN WOUND  Clean wound is a nontraumatic, uninfected operative wound in which neither the respiratory, alimentary or genitourinary tracts nor the oropharyngeal cavities are entered.  Clean wounds are elective, primarily closed, and undrained wounds.  Infection rate is <2%
  • 8. CLEAN CONTAMINATED WOUND  Gastrointestinal, respiratory or genitor- urinary tracts entered without significant spillage or wounds which are mechanically drained.  Eg: appendicectomy, gallbladder, biliary, pancreatic surgeries  Infection rate <10%
  • 9. CONTAMINATED WOUND  Operative wound contaminated  Fresh traumatic wound from clean source  Gross spillage from the gastrointestinal tract  When infected urine or bile is present  Incision encountering acute non-purulent inflammation.  Eg: penetrating abdominal injury, enterotomy  INFECTION RATE – 15 – 30%
  • 10. DIRTY WOUND  Traumatic wound from dirty source  Fecal contamination  Foreign body, Retained devitalized tissue  Operative wound w/ acute bacterial inflammation or perforated viscus  Presence of pus Eg: abscess drainage, pyocoele INFECTION RATE : 40 – 70 %
  • 11. WOUND HEALING
  • 12. WHAT IS WOUND HEALING???  Wound Healing Is the Physiologic Response to Tissue Trauma  It is related to tissue reconstitution which is the process by which the body replenishes cells that are being lost
  • 13. TYPES OF WOUND HEALING WOUNDHEALING PRIMARY SECONDARY TERTIARY
  • 14. PRIMARY HEALING  Occurs in clean incised wound  More epithelial regeneration than fibrosis.  Wound heals rapidly  Scar will be linear, smooth & supple.
  • 15. SECONDARY HEALING  Occurs in wounds with extensive soft tissue loss  Heals slowly with fibrosis  Wide hypertrophied and contracted scar
  • 16. TERTIARY / DELAYED PRIMARY  Intial wound debridement and control of local infection  Wound closed with sutures or covered with skin graft
  • 17. PHASES OF WOUND HEALING Wound Heals In 3 Phases That Partially Overlap:  Inflammatory Phase  Fibroplasia Phase  Remodelling Phase
  • 18. INFLAMMATORY PHASE
  • 19. INFLAMMATORY PHASE  (aka. lag phase or substrate phase) 0-48 hrs INFLAMMATORY PHASE VASCULAR RESPONSE CELLULAR RESPONSE
  • 20. VASCULAR RESPONSE PRIMARY PHASE – Haemostasis • Vasoconstriction • Platelet Aggregation And Degranulation • Fibrinous Clot • Fibrinolysis
  • 21. VASCULAR RESPONSE SECONDARY PHASE  Venular Vasodilatation - 10 X Increase In Blood Flow  Increased Vascular Permeability - Aids In Flow Of Chemical And Cellular Mediators (PDGF) In Inflammation To Site Of Injury  Lymphatic Obstruction Leads To Tissue Edema
  • 22. CELLULAR RESPONSE Increased Vascular Permeability During Inflammatory Phase Facilitates Margination, Extravasation And Migration Of Cellular Mediators (Pmn’s And Macrophages) PMN’S  Function Short Lived (0-48 Hours)  Attacks Bacteria, Then Leaves  Not Essential For Wound Healing Process
  • 23. Macrophages  Monocyte–derived  Central Cell During Inflammatory Phase Of Wound Repair  Activated By Lymphokines, Immune Complexes  Release Angiogenesis Factor  Phagocytosis Of Wound Debris  Essential For Wound Healing CELLULAR RESPONSE
  • 24. Factors Affecting Inflammatory Phase:  Pus Contains Both Proteolytic And Collagenolytic Enzymes; Prolongs Inflammatory Phase And Retards Epithelialization  Necrotic Tissue, Foreign Body, Haematoma - Prolongation Of Inflammatory Phase  Steroids - Inhibit Macrophage Function
  • 25. PROLIFERATIVE PHASE
  • 26. PROLIFERATIVE PHASE (Aka. Fibroplasia Phase) Day 2 To ~ 6 Weeks CLINICAL SIGNS:  Disappearance Of Inflammatory Signs,  Reduction Of Swelling,  Reduction Of Wound Size (Contraction),  Itching
  • 27. KEY-ELEMENTS:  Net Collagen Synthesis,  Increase In Wound Tensile Strength,  Scar Formation PROLIFERATIVE PHASE
  • 28. PROLIFERATIVE PHASE EPITHELIALISATION WOUND CONTRACTION C COLLAGEN DEPOSITION
  • 29. EPITHELIALIZATION  Is A Requirement For Orderly Progression Into The Proliferative Phase. It Starts In The Inflammatory Phase.  It Requires De-differentiation, Mitosis, Migration And Then Re-differentiation By Basal Cells Of Epidermis PROLIFERATIVE PHASE
  • 30. WOUND CONTRACTION  “wounds heal from side to side but contract from end to end”  Thought to be mediated by myofibroblast - can produce collagen but also contains smooth muscle filaments.  Highest rate of contraction from days 10-21 PROLIFERATIVE PHASE
  • 31. Wound Contraction  Begins approximately 4-5 days after wounding.  Represents centripetal movement of the wound edge towards the center of the wound.  Maximal contraction occurs for 12-15 days, although it will continue longer if wound remains open.
  • 32. Wound Contraction  The wound edges move toward each other at an average rate of 0.6 to .75 mm/day  Wound contraction depends on laxity of tissues, so a buttocks wound will contract faster than a wound on the scalp or pretibial area.  Wound shape also a factor, square is faster than circular.
  • 33. Wound Contraction  Contraction of a wound across a joint can cause contracture.  Can be limited by skin grafts, full better than split thickness.  The earlier the graft the less contraction.  Splints temporarily slow contraction.
  • 34. COLLAGEN DEPOSITION  Prior to collagen deposition fibroblasts deposit “ground substance” composed mainly of glycosaminoglycans.  Function of ground substance is to create scaffold onto which collagen can be deposited, aggregated, and oriented in appropriate fashion PROLIFERATIVE PHASE
  • 35.  Starting at day 3 or 4 collagen is deposited, net collagen deposition is positive until day 21.  It reaches a maximum at 60 days post- injury (80% of tensile strength of normal skin) PROLIFERATIVE PHASE
  • 36. MATURATION & REMODELLING
  • 37. MATURATION AND RE- MODELLING PHASE  3 Weeks To 1-2 Years  Type III Collagen Is Replaced By Type I Collagen, Creation Of More Stable Bonds Between Fibers - Decreases The Amount Of Collagen Required To Maintain Wound Integrity  Duration Of Phase Dependent Upon Patient Age (Decreased Age - Increased Duration), Racial Differences, Type Of Wound, Body Location And Duration Of Inflammatory Phase
  • 38. Incised wound  Caused by sharp cutting instruments.  Minimum loss to tissue tends to gap (the extent of gaping depends upon elasticity and tension).  Edges are regular.  Bleeds freely and painful.  Heals by primary intension healing.
  • 39. Lacerated wound  Caused by tearing of tissues,  Wounds have irregular jagged borders  Loss of tissue is limited to skin and s/c tissue.
  • 40. DEGLOVING/AVULSION INJURY  Occurs when skin & subcutaneous tissue are stripped from underlying fascia leaving neurovascular structures, tendons, bone exposed.
  • 41. What is the type of wound according to Rank & Wakefield classification?
  • 42. FACTORS AFFECTING WOUND HEALING
  • 43. FACTORS WOUND HEALING LOCAL SYSTEMIC
  • 44. LOCAL FACTORS  Infection & haematoma  Presence of necrotic tissues and foreign body  Poor blood supply  Venous or lymph stasis  Tissue tension  Large defect or poor apposition
  • 45. LOCAL FACTORS  H/O IRRADIATION  Underlying diseases lie malignancy / osteomyelitis  Tissue hypoxia
  • 46. GENERAL/SYSTEMIC FACTORS  Age  Obesity, smoking  Malnutrition  Vitamin deficiency  Anaemia, uremia, jaundice  Diabetes  Steroids & cytotoxic drugs
  • 47. MANAGING ACUTE WOUND  HAEMOSTASIS  CLEANSING  EXPLORATION AND DIAGNOSIS  DEBRIDEMENT  REPAIR OF STRUCTURES  REPLACEMENT OF LOST TISSUES
  • 48.  SKIN COVER IF REQUIRED  SKIN CLOSURE WITHOUT TENSION  ALL THE ABOVE WITH CAREFUL TISSUE HANDLING
  • 49. WHEN DOES A WOUND BECOME CHRONIC?  In healthy individuals with no underlying factors an acute wound should heal within three weeks with remodeling occurring over the next year or so.  If a wound does not follow the normal trajectory it may become stuck in one of the stages and the wound becomes chronic. 
  • 50.  Chronic wounds are thus defined as wounds, which have “failed to proceed through an orderly and timely process to produce anatomic and functional integrity, without establishing a sustained anatomic and functional result.