Prepared & presented by: Dr :WADIE MADI
General Surgery Department.
Abosleem Trauma Hospital.
Skin: structure and function:
Each skin layer has its own unique function:
Epidermis = protection
Dermis = nourishment of epidermis
Hypodermis = Composed mostly of adipose tissue insulation.
A wound can be defined as:
“A cut or break in the continuity of any tissue, caused by injury
Classification of Wounds:
Skin flaps and
benbow ( 2005)
Fail to pass
Wound Types and Characteristics
• Contusion ( Bruise) – Tissue
injury without breaking of skin.
Purple contusion 5x7 cm on left
•Hematoma – Tissue injury that
disrupts a blood vessels; pooling
of blood under the unbroken skin
hematoma on left face (see
•Sprain –twisting of a joint with
partial rupture of its ligaments;
•Incision (Surgically) made
separation of tissues with clean,
(Approx.3-inch incision on R
lower quadrant of abdomen well
approximated clean and dry with
sutures intact(see figure).
•Laceration – Traumatic
separation of tissues with clean,
smooth edges 2 in jagged (pointy,
uneven) laceration app 4 cm deep
on Lt sole foot.(see figure)
•Abrasion- Traumatic scraping
away of surface layers of skin.
(raw appearing abraded area
diameter on lateral aspect of lower
•Puncture – Wound made by
sharp, pointed object through skin
or mucous membranes and
underlying tissue, (Small circular
entry wound on Rt palm from sharp
pointing nail see figure)
Penetrating- Variable -size open
wound through skin and
underlying tissues made by a
bullet , metal or wood fragment
may extend deeply into body
Jagged Deep wound 10cm in
posterior on L leg(see figure).
•Avulsion – Tearing away of a
structure or a part, such as a
fingertip, accidentally or
surgically.(Avulsion of L leg from
Vent Aspect. Attach only by skin.)
•Ulceration – Excavation of skin and/or underlying tissue from injury
(Ulceration on L sole foot 4 cm x 5 x 2 cm deep. Yellow drainage
present. Wound edges reddened) see figure below:
Wounds according to the depth:
Involves only the epidermis Injury is usually
result from fiction, shearing (cut) or burn.
Involves the epidermis and the dermis, Wounds heal more quickly.
Involves the epidermis, dermis, fat, fascia and exposes bone In
order to heal, all dead tissue must be removed so that
granulation tissue can gradually fill in the defect.
1-serous -clean, watery.
2-Purulent - thick, yellow, green, tan or brown.
3-Sanguineous - bright red, indicative of active bleeding.
4-Serosanguineous -pale, red, watery mixture of serous
Types of wound drainage:
-All wounds heal following a a specific sequence of phases
which may overlap.
-The process of wound healing depends on the type of tissue
which has been damaged and the nature of tissue
-The phases are:
3-Remodeling or maturation phase
Exposure of plasma to
injured site Release of Histamine
Inc bld Flow
Activation of Hageman Factor
Phases of wound Healing:
Starts immediately after injury and lasts 3-6 days or 4-6 days.
(2 major processes occur during this phase:
A-Hemostatic and B-phagocytosis
Tissue and capillaries are destroyed, plasma and blood leaks. Area blood vessels
constrict, platelets aggregates and bleeding stops, scabs ( rough protective
crust) forms, preventing entry of infectious organisms.
B- Inflammation & Phagocytosis
Characterized by oedema, erythema, pain, temperature increase blood flow, to
wound resulting localized redness and edema, attracts WBC and wound
growth factors. ( Wbc arrive-clear debris from wound).
2- PROLIFERATIVE PHASE
-extends from day 3 to about day 21 post injury.
-Macrophages continue to clear the wound debris, Stimulates Fibroblast to
synthesize collagen 9 main ingredient For tissue scaring)
-(New capillary networks are formed).
3- REMODELLING OR MATURATION PHASE
-final healing stage may continue for I year or more.
-Remodelling of scar tissue to provide wound strength.
Cont..Phases of wound Healing:
Types of wound healing:
1-first intention healing: partial thickness wounds.
- a clean incision is made with primary closure, minimal scarring.
-expected when the edges of clean surgical incisions are sutured together,
tissue loss is minimal or absent if the wound is not contaminated with
microorganism. e.g.-abrasion or skin tear.
2-second intention healing:
-accompanies traumatic open wounds with tissues loss or wounds with a
high microorganisms count.
-go through a process involving scar tissue formation a heal slowly because
of the volume of tissue needed to fill the defect.
e.g.-contaminated surgical wound, pressure ulcer.
Note also there is:
(Delayed primary healing If there is high infection risk – patient
is given antibiotics and closure is delayed for a few days
2-Blood glucose levels (impaired white cell function).
3-Hydration (slows metabolism).
5-Lifestyle- enhances bld circulation.
7-Blood albumin levels (‘building blocks’ for repair, colloid
osmotic pressure - oedema).
8-Oxygen and vascular supply.
9-Medication- Corticosteroids (depress immune function).
Factors affecting wound healing:
-heal very easily.
-It passes phases of wound healing.
-Collagen building phase.
Aim of management:
-Healing without complications such as infection and disfiguring.
-(Wound care) includes:
2-Dry or wet to dry dressing to cover the wounds
3-Suturing if acute.
4-Bites -give Prophylaxis.
A- Acute Wounds:
> Uses of ABO in Acute wounds
Only indicated if contaminated or evidence of infection is
>Evidence of infection (local)
Note: (Acute wounds with abscesses if they are large need to be
drained, Smaller once – can manage with antibiotics).
Betadine*, Hydrogen Peroxide*, Saline, Spirit can be used to
cleanse the wound .
Healing of acute wound :
-Wounds with minimal gaping – heals readily with scarring.
-Wounds with gaping or skin loss – heals with Scar tissue formation
Q1- if there is no improvement ???
Q2-When Does a Wound Become Chronic?
(healthy individuals with no underlying factors an acute
wound→ heal within three weeks remodelling → over the
next year or so...)
NOTE: When wound does not follow the normal trajectory it may
become stuck in one of the stages and the wound becomes
Working Definition: wound lasting >3 months
Chronic wound – Fail to heal due to various local and systemic
-Healing process arrests at different levels of healing.
-Wound may appear at different colours.
-Remains at same stage without progressing to wound healing.
-Often an underlying cause remains undetected.
The wound healing cascade impairs and arrests at different stages
Minutes Hours Days Weeks Months Years Time
Local and systemic factors that impede wound
• Local factors
• Inadequate blood supply **
• Increased skin tension
• Poor surgical apposition
• Wound dehiscence
• Poor venous drainage **
• Presence of foreign body and foreign body
• Continued presence of micro-organisms &
• Excess local mobility, such as over a joint
• Systemic factors
• Advancing age and general immobility **
• Obesity ***
• Malnutrition ***
• Deficiency of vitamins and trace elements ***
• Systemic malignancy and terminal illness Shock of
• Chemotherapy and radiotherapy
• Immunosuppressant drugs, corticosteroids,
• Diabetes and CRF***
Chronic Wounds Appearance
approach has been criticised for being too simplistic as wound healing is a
continuum and wounds often contain a mixture of tissue types.
Wound healing continuum
Wound Healing Continuum (Gray et al. 2005) have
been developed. This tool incorporates intermediate colour
between the four key colours
Appears as defined area of persistent
redness in lightly pigmented skin,
whereas in darker skin tones, this ulcer
may appear with persistent red, blue or
If it doesn’t become pale with pressure
aka blanch, this is considered a Stage I
Pressure on anterior tibialis tendon
from compression wrap applied
Stage 2-Partial thickness skin loss involving
epidermis, dermis, or both. The ulcer is
superficial and presents clinically as an
abrasion, blister or shallow crater.
No slough, eschar or undermining
Stage 3- Full thickness skin loss involving
damage to, or necrosis of, subcutaneous tissue
that may extend down to but not through,
The ulcer presents clinically as deep crater with
or without undermining of adjacent tissue.
Stage IV—Full thickness skin loss with extensive
destruction, tissue necrosis, or damage to muscle, bone or
supporting structures (ie. Tendon, joint capsule)
Undermining and sinus tracts may be associated w/
stage IV ulcers
Can differentiate from stage III ulcers because it will
go PAST the Fascia.
past subcutaneous level and goes
to the calcaneous bone
Sacrum, eschar, past sub-
cutaneos tendon exposed
Deep Tissue Injury
Purple or very dark areas that are surrounded
by profound redness, edema, or induration
suggest that deep tissue damage has already
occurred and additional deep tissue loss may
• The deepest level of tissue must be
visible in order to stage a pressure
Management of Pressure Ulcers
Offload Dress Protect
Group 1 Pressure Relief
Group 1 mattress overlays preventative (Qualifications):
1. Completely Immobile Or
2. Limited mobility
3. Any stage pressure ulcer on the trunk or pelvis.
(plus 1 of the below)
4. Impaired nutritional status.
5. Fecal or urinary incontinence.
6. Altered sensory perception.
7. Compromised circulatory status.
Low Air Loss/Alternating Pressure Mattress
(Aggressive pressure ulcer treatment)
(1 large or multiple stage 3 or 4 pressure ulcer(s) on trunk or pelvis)
(Recent flap or skin graft for pressure ulcer).
Group 2 Pressure Relief
Diabetic foot ulcer:
7th leading cause of
death in the USA
16 million (6% of
population) people in
the USA have diabetes
Each year: 798,000
new cases of DM
15% of all diabetics will
develop diabetic foot
14-20% patients with DFU
Grade 3 Grade 4 Grade 5
Corns and Calluses
Nails: Thickened or Atrophic, Ingrown ,Color of nail bed,
Discharge, Fungal infections
Edema: poor fitting shoes, impedes healing
Color & temperature of feet
Goal for HgbA1c of <7
Intermittent claudication to sharp, unrelenting pain.
Diminished or absent pulses.
Pallor and coolness.
Loss of hair.
Tight shiny skin.
Characteristics of Arterial
Characteristics of Arterial
Located in areas of pressure, tips of toes
Deep, may involve joint.
Usually circular in appearance.
Wound base pale to black.
Little, if any, edema
Achy, cramping pain
Hyperpigmentation of skin
Lots of edema
Inverted Champagne Leg
tissues become ´woody´
in texture and the leg
narrows near the ankle
Venous Insufficiency Characteristic
Irregular Wound Edges.
Moderate to heavy exudate.
Partial to full thickness.
Venous Ulcer Characteristics
Elimination of Edema
Moist Wound Care.
Management of Venous Disease
Treating the Whole patient versus treating the Hole in
DRESSINGS - material applied to wound with or without
medication, to give protection and assist in healing.
(-what are the purposes?)
Protect from contamination.
Provides medication, moist healing environment, etc.
When picking out your dressings, remember the Cardinal
(Keep Moist tissue Moist and Dry tissue
1-DRY TO DRY DRESSINGS
-used primarily for wounds closing by primary intention.
-offers good protection, absorption & provide pressure
-they adhere to the wound surface when drainage dries.
- when remove can cause pain and disruption of
-What are the types of dressings?
2-WET TO DRY DRESSINGS
-used for untidy or infected wounds that must be
debrided and closed by secondary intention.
how can it be done?
- gauze saturated with sterile saline or antimicrobial sol's.
is packed into the wound, the wet dressing are then
covered by dry dressings
(Q-when to changed?) (As-when it becomes dry.)
3-WET TO WET DRESSINGS
-used on clean open wounds or on granulating surfaces.
-provide a more physiologic environment (warmth
moisture) which can enhance the local healing
processes and assure greater patient comfort.
-surrounding tissues can become ulcerated.
(high risk for infection).
Examples of methods used in
Hydrogels are indicated for
management of pressure ulcers,
skin tears, surgical wounds, and
burns, including radiation
therapy burns. Because they
contain up to 95% water,
hydrogels cannot absorb much
exudate and should be reserved
for dry wounds or wounds with
minimal to moderate drainage.
-Because they are occlusive, hydrocolloid dressings do not allow
water, oxygen, or bacteria into the wound. This may help facilitate
angiogenesis and granulation. Hydrocolloids also cause the pH
of the wound surface to drop; the acidic environment can inhibit
Like hydrogels, hydrocolloids can help a clean wound to
granulate or epithelialize and encourage autolytic ( distruction of
cells by own enzymes) debridement in wounds with necrotic
tissue. However, because of their occlusive nature, hydrocolloids
cannot be used if the wound or surrounding skin is infected.
3-Alginate Dressings :
Used in wounds with moderate to heavy drainage, the
alginate forms a gel when it comes in contact with wound
fluid. Capable of absorbing up to 20 times its weight in
fluid, an alginate can be used in infected and noninfected
wounds. Because an alginate is highly absorbent, it
should not be used with dry wounds or wounds with
minimal drainage; it could dehydrate the wound, delaying
Indications: Highly exudative wound requiring a
non-stick surface (e.g. venous stasis)
Highly absorbent (20 times weight)
Non-adherent wound contact layer, hydrocellular
foam, waterproof outer layer.
Allows for autolytic debridement and gaseous
Can be left in place for 72 to 96 hours.
Explain the procedure to the patient.
Hand washing before and after the procedure.
Clean from least contaminated to the most
Use separate cotton for each stroke.
Start from the center going outward.
Observe aseptic technique.
C-Procedures: include(14 steps)
1-Check physician's order for specific wound care and
Helps to plan for proper type and amount of supplies
2-Secure equipment and wash hands thoroughly.
To save time and effort. Reduces transmission of
3- Assess the existing dressing
Indicates types of dressing or applications to use.
4-Explain the procedure to the patient and instruct Pt not
to touch wound area or sterile supplies.
Decreases anxiety and to gain cooperation.
Sudden unexpected movement on Pt‘s part could
result in contamination of wound and supplies.
5-Loosen and remove the dressing with the use of the
dressing forcep.( If the dressing adheres to the wound,
loosen it by moistening with sterile NSS).
Microorganism can be transferred by direct contact
from dressing to hands. An intact scab is a body
defense and can be damage if not handled gently.
6-Observe the dressing for the amount type, color and
odor of the drainage.
Provides estimate of drainage amount and assessment
of wound's condition.
7. Discard the soiled dressing in the waste receptacle.
Reduces the transmission of microorganism.
8-Clean the wound aseptically using the dressing forcep
from the center going outward in
circular motion with:
A. Betadine cleanser
B. Dry gauze
C. Betadine antiseptic solution
(use each gauze for only one stroke)
9-Apply a new dressing by gently placing the gauze
sponges at the wound center and moving progressively
outward to the edges of the wound site.
Promotes proper absorption of drainage and protects
wound from entrance of microorganism.
10. Secure the edges of the dressing to the patient’s skin
with strips of adhesive tapes.
Ensures that dressing remains intact and covers
11-Make the patient feel comfortable and tidy the unint.
Promotes Pt's sense of well-being. Enhances comfort.
12-Do the aftercare of the equipment.
Soak the dressing forceps in 5% lysol solution for 30
minutes, then wash them with soap and water, Rinse
them then dry ,Send them for sterilization..
13. Wash hands(Prevent
spread of microorganism).
14-Chart: site of wound, character of wound/ discharges,
treatment given if any(e.g. ointment used) and reaction
For proper documentation and legal purposes.
Indication: Diabetic foot ulcer
Activates endothelial cells and fibroblasts
Stimulates vascular proliferation, migration, new
blood vessel formation
People who use 3 or more tubes of
REGRANEX® Gel may have an increased risk from
Can be very effective
Have a new “360” program to help patients obtain
medication and monitor progress.
Indicated in Stalled Wounds
ORC inactivates MMPs and Elastace
more than half in
wound surface area
Continue same care
Cellular Tissue Products
So many, so little time
And so many more….
2 Days post
4 weeks post
2 wks s/p 2nd Oasis
Cellular Tissue Products
Hyperbaric Oxygen Therapy (HBOT) is breathing 100%
oxygen while the entire body is pressurized to a point greater
than sea level
What Is It?
This is usually
2to 2.4 absolute
(the equivalent of
exerted by a33-45
foot dive into
UHMS Indications for HBOT
1-Air or Gas Embolism.
2-Carbon Monoxide Poisoning(Co Poisoning Complicated
By Cyanide Poisoning).
3-Clostridial Myositis and Myonecrosis (Gas Gangrene).
4-Crush Injury, Compartment Syndrome and Other Acute Traumatic
Central Retinal Artery Occlusion.
Enhancement of Healing In Selected Problem Wounds.
9-Necrotizing Soft Tissue Infections.
10 -Osteomyelitis (Refractory).
11 -Delayed Radiation Injury (Soft Tissue and Bony Necrosis).
12 -Compromised Grafts and Flaps.
13 -Acute Thermal Burn Injury .
Adjunctive HBOT and Problem Wounds
HBOT is only one component of a comprehensive
wound healing program.
Non-healing wounds are evaluated to determine
underlying conditions which might interfere with
More conservative measures should be tried first.
What We Will Cover Today?
Diabetic Foot Ulcer.
Vascular Changes from Radiation:
Medial thickening (progressively depletes the blood supply to
the irradiated tissue).
Collagen deposition may also cause severe scarring and
further blood vessel obliteration, resulting in tissue hypoxia
Effects of Ionizing Radiation on the Cell:
Rapid cell death with heavy doses.
DNA Synthesis impaired, mitosis delayed.
Soft Tissue Radionecrosis
treatment for Cancer of
Same neck, 07/09/02
after 40 hyperbaric
Long-term survival of skin grafts and flaps depend
When the wound bed does not have enough oxygen
supplied the graft may partially fail.
HBO2 can help by assisting in the preparation and
salvage of skin grafts and compromised flaps.
Gas gangrene infection
High amounts of oxygen can inhibit the replication,
migration, and production of endotoxin.
Advantages of using HBOT as adjunct to for gas
life-saving because exotoxin production is rapidly halted.
limb and tissue-saving.
preventing limb amputation that might otherwise be
Diabetic Foot Ulcer:
Wagner Grade 3.
Used in conjunction with standard wound care,
Improved results compared to routine wound care.