Wound care seminar ,Kenya wound care society

1. MANAGEMENT OF ACUTE
WOUNDS
PRESENTER:
Dr Evans S Masitara
Plastic Surgery
University Of Nairobi

2. OUTLINE
 Introduction
 Definition
 Classification
 Management
 Complications

3. INTRODUCTION
 Acute wounds contribute to a big proportion of wounds globally.
 In 2006, 11 million traumatic wounds were managed through the emergency
department in the United States of America .
 In Kenya a study by Botchey et al demonstrated RTAs to be a higher contributor
to acute wounds with the lower limb injury being commonest
 Poorly managed acute wounds contribute to a larger proportion of chronic
wounds especially in developing countries
 Cost Millions of usd per year

4. DEFINITION
 Acute wound is defined as a recent wound that has yet to progress through the
sequential stages of wound healing
 Can heal in a timely and orderly manner when properly managed.
 It can however transit into chronic wounds when poorly managed

5. CLASSIFICATION
 Aetiology : Blunt,penetrating,surgical,burn
 Rake and Wakefield : Tidy Vs Untidy
 Relation to Cavity : Penetrating vs Non Penetrating
 Depth : Superficial, Partial thicknes ,Full thickness
 Skin integrity : Open vs closed
 Mechanism : Mechanical, Thermal,Chemical, Radiation,Bite
 Severity ;Simple vs Complex

6. CLASSIFICATION
TRAUMATIC SURGICAL
LACERATIONS CLEAN
BRUISES CLEAN CONTAMINATED
ABRASIONS CONTAMINATED
CONTUSIONS DIRTY
PUNCTURE WOUNDS
BURNS

7. TRAUMATIC WOUNDS
LACERATIONS
 Produced by tearing of soft tissues.
 The wounds are often irregular and
jagged.
 Often contaminated with bacteria and
debris

8. TRAUMATIC WOUNDS
ABRASIONS
 Caused by frictional force to the skin
resulting in an extensive wound that could
be superficial in nature
 Usually do not bleed excessively and can
appear to close up.
 May appear as frictional burns or de-
gloving injuries

9. TRAUMATIC WOUNDS
PUNCTURE WOUNDS/CUTS /INCISIONS
 Caused by a sharp object piercing through
the skin.
 Commonly associated with injuries to the
deeper structures
 Prone to infection

10. TRAUMATIC WOUNDS
BRUISES/HEMATOMAS
 Bruises are wounds associated with injuries to
the blood vessels underneath the skin.
 The skin may remain intact trapping the blood
underneath leading to redness and erythema.
 Excessive accumulation of the blood may result
in clots and later on hematoma

11. TRAUMATIC WOUNDS
COMPLEX TRAUMATIC WOUNDS
 Involve other anatomical structures such as
bone, neuro-vascular structures, thoracic,
abdominal viscera
 Requires MDT

12. COMPLEX TRAUMATIC WOUNDS

13. SURGICAL WOUNDS

14. MANAGEMENT
 Trauma Patient– ATLS
 Primary survey – ABCDE
 FATT
 Secondary Survey – AMPLE History
 Wound assessment

15. HISTORY
 History of events surrounding the wounds
 Potential wound contamination
 Functional loss or inabilities after the injuries
 Pre-hospital wound care
 Tetanus immunization status
 Comorbidities, current medications
 Allergies and substance abuse,
 Social history

16. EXAMINATION
 Wound location
 Status of soft tissue
 Length, width and depth of the wound
 Type of tissue in the wound bed such as bone,
tendons or nerves
 Presence of contaminants
 Neuro-vascular status of the extremity
 Functional status of surrounding structures
 DOCUMENT AND PHOTOGRAPH

17. INVESTIGATIONS
 Blood works –FBC, U N C, X Match,Coagulation
 Radiological – Xray,Trauma series
-FAST
-CT scan
-CT Angiogram

18. TETANUS
 Active immunization against tetanus has been shown to reduce the incidences of tetanus and
morbidity and mortality
 Wound condition
 Immunization history
 Tetanus prone wounds should be left open and should have thorough Surgical debridement
and removal of all dead and devitalized tissues
Two forms:
 Tetanus-toxoid containing vaccine (e.g. Tdap or Td)
 Tetanus-toxoid containing vaccine (e..g. Tdap or Td) + Tetanus immune globulin

19. TETANUS PRONE WOUNDS
 Age of wound >6hours
 Avulsion configuration
 - depth >1cm
 Mechanism of Injury, Missiles, crush or burns
 May have signs of infections
 May have devitalized tissues
 May have contaminants such as soil, feacal matter and grass
 May have denervation and ischemic tissues

20. TETANUS VACCINATION

22. MEDICATION
 Antibiotics – Prophylaxis when indicated
 Adequate analgesia – NSAIDS
- Opiates
- Local Anaesthesia
- Regional Blocks
- General anesthesia

23. LOCAL ANAESTHESIA
Drug Maximum dose
 Bupivacaine 0.25% (2.5 mg/ml) 2 mg/kg
 Bupivacaine 0.25% with epinephrine 3 mg/kg
 Lidocaine 1% (10 mg/ml) 4.5 mg/kg
 Lidocaine 1% with epinephrine 7 mg/kg
 Procaine 1% (10 mg/ml) 7 mg/kg
 Procaine 1% with epinephrine 9 mg/kg

24. SURGICAL DEBRIDEMENT
 Surgical toilet refers to the removal of contaminants in the wound and all necrotic tissues.
 Surgical toilet is the mainstay in the management of acute wounds.
 Acute wounds that have a good surgical toilet done are likely to heal faster than those without.
 Poorly done surgical toilet leads to wound sepsis that results in the wound being arrested in the
inflammatory phase of wound healing.
 Where applicable tourniquet should be utilized to assist in arresting bleeding.
 Patients with extensive wounds may need blood for grouping and cross matching done during
or before surgical toilet.

26. DEBRIDEMENT

27. DEBRIDEMENT
Surgical toilet encompasses the following steps
 Wound cleaning and irrigation
 Identification of important anatomical structures
 Removal of devitalize tissues and foreign materials
 Wound closure/ dressing with appropriate dressing materials for delayed closure

28. CLEANING AND IRRIGATION
 Allows for dilutions and washing away of wound contaminants.
 Pro Proliferative
 Irrigation volumes of 50 to 100 ml per cm of laceration is recommended.
 Adjusted to the wound characteristics and degree of contamination.
 Wound cleaning solution- Isotonic, non hemolytic, nontoxic, colourless ,easy to
sterilize,cheap
 Povidine iodine, chlorohexidine or hydrogen peroxide may be toxic to the cells
 Normal saline,Setrilized water,commercial wound cleansers

29. IRRIGATION PRESSURE
 No Consensus
 Generally pressure irrigation beneficial
 Very High pressures detrimental >8psi
 Equipment used for irrigation has included
 Bulb syringes, syringes with an attached needle or catheter,
 Intra-venous or irrigation fluid in plastic containers with a pour cap or nozzle, and
pressure canisters
 Newer Calibrated devices in market
 SOAKING NOT ADVISED

30. IRRIGATION

31. IDENTIFICATION OF STRUCTURES
 Neurovascular/Tendons
 Identify
 Spare
 Protect
 Tag
 Repair /reconstruction
 Early vs Delayed

32. DEVITALISED TISSUE
 Remove all contaminants and dead tissue meticulously while protecting viable
tissues.
 Keep reconstruction in mind
 Tissues of uncertain viability may be left till the next session of surgical toilet so as
to give them a chance for survival.
 Dead muscle is identified by color and unresponsiveness to diathermy or cautery.

33. DEVITALISED TISSUE

34. WOUND CLOSURE
 General Principles
 Minor non contaminated ,early presentation -1 Closure
 6-10hours –Extremety
 10- 12hours –Scalp and face
 Contaminated wounds- Debride, Dressing ,Relook 48-72hours

35. WOUND CLOSURE
 Wound closure methods could be by;
Primary wound closure with sutures, staples, glue or tape
 Delayed primary wound closure in wounds that are not clean and require either repeat debridement or
cleaning before closure
 Secondary intention, preserved for small wounds or in patients who cannot undergo surgery. Takes time and
is generally discouraged,associated with scars and contracture formation.
 Skin graft, for extensive wounds with good vascularity bed.
 Flaps are recommended for wounds with poor vascularity base or with exposed bone and neuro-vascular
structures are best covered by flaps

36. WOUND CLOSURE

37. SKIN GRAFTS

38. SOLEUS FLAP

39. PARAUMBILICAL FLAP

40. FREE FLAP

41. Complications
 Chronicity
 Severe Infection
 Wound dehiscence
 Limb Loss
 Osteomyelitis
 Malignant Transformation

42. REFFERENCES

43. THANK YOU