Surgical topic for both injuries and natural trauma

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WOUND CARE
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GOALS OF WOUND CARE
 Facilitate hemostasis
 Decrease tissue loss
 Promote wound healing
 Minimize scaring

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Stages in wound healing
 Inflammation( 0.1-3 days)
 Granulation tissue formation (0.3- 10days)
 Wound Contraction( 3-30days)
 Wound remodeling / Collagen accumulation( 30-100 days)

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Wound Healing Pathophysiology
• 1.) Inflammatory Phase
• Initial response (Day 1-4 post injury)
• rubor, tumor, dolor, calor
• Platelet aggregation and activation
• Leukocyte (PMNs, macrophages) migration, phagocytosis and
mediator release
• Venule dilation • Exudative • a biologic debridement • In wounds
closed by primary intention, lasts 4 days

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 • 2.) Proliferative Phase
 • Day 4-42
 • macrophage-released growth factors
 Fibroblast proliferation
 Increased rate of collagen synthesis
 • Granulation tissue and neovascularization
 • Gain in tensile strength

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 • 3.) Remodeling Phase
 • 6wks-1 year
 • Intermolecular cross-linking of collagen via vitamin C-
dependent hydroxylation
 • Characterized by increase in tensile strength • Type III collagen
replaced with type I
 • Scar flattens

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TYPES OF WOUND HEALING
 1.) Healing by first intention (aka. Primary wound healing or primary
closure)
 • wound closed by approximation of wound margins or by placement of a
graft or flap, or wounds created and closed in the operating room.
 • Best choice for wounds in well-vascularized areas
 • Indications –recent (<24h old)-clean-viable tissue-tension-free
 • treated within 24 h, prior to development of granulation tissue.
 • epithelialize within 24 to 48 h. Water barrier function restored
 can shower or wash.

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 2.) Healing by second intention (aka. Secondary wound healing or
spontaneous healing)
 • wound left open and allowed to close by epithelialization and
contraction.
 • Commonly : management of contaminated or infected wounds. •
without surgical intervention.
 • Unlike primary wounds, approximation of wound margins occurs
via reepithelialization and wound contraction by myofibroblasts.
 • Presence of granulation tissue. • Complications –late wound
contracture-hypertrophic scarring

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 • 3.) Healing by third intention (aka. Tertiary wound healing or delayed
primary closure)
 • wounds that are too heavily contaminated for primary closure but appear
clean and well vascularized after 4-5 days of open observation.
 • Inflammation reduced bacterial concentration (“debribe”) allow safe
closure.
 • Indications :- infected or unhealthy wounds with high bacterial content,-
wounds with a long time lapse since injury, or –wounds with a severe crush
component with significant tissue devitalization.
 • Wound edges are approximated within 3-4 days • tensile strength
develops as with primary closure.

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 • wound preparation (debridement,cleansing, etc.)
 • dress with saline soaked fine mesh gauze
 • follow up in 72-96 hours for debridement
 • repeat cleansing and closure if no evidence of infection

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FACTORS AFFECTING WOUND
HEALING
• Patient factor :Age
• Immunocompromising –DM-renal failure-AIDS-splenectomy
• Medications –systemic steroids/ other immunocompromising
drugs
increased infection rates
• Wound Characteristics –Time, Location, Etiology , Mechanism of
injury, Laceration width

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 Factors that affect wound healing • In general, remember
“DIDN’T HEAL”
 • D = Diabetes: -diminishing sensation and arterial inflow ++
acute loss of diabetic control diminished cardiac output, poor
peripheral perfusion, and impaired polymorphonuclear leukocyte
phagocytosis.
 • I = Infection: -potentiates collagen lysis. Bacterial
contamination + susceptible host + wound environment = wound
infection. Foreign bodies (including sutures) potentiate wound
infection.

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 • D = Drugs: Steroids and antimetabolites impede proliferation of
fibroblasts and collagen synthesis.
 • N = Nutritional problems: Protein-calorie malnutrition and
deficiencies of vitamins A, C, and zinc.
 • T = Tissue necrosis, from local or systemic ischemia or
radiation injury. Blood supply is important.

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 • h = hypoxia: -esp the distal extent of the extremities. Blood
volume deficit, unrelieved pain, or hypothermia sympathetic
overactivity
 local vasoconstriction inadequate tissue oxygenation.
 • e = excessive tension on wound edges
 local tissue ischemia and necrosis.

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 A = Another wound: Competition for the substrates required for
wound healing.
 • L = Low temperature: (relatively) distal aspects of the upper
and lower extremities (a reduction of 1-1.5°C [2-3°F] from
normal core body temperature) is responsible for slower healing
of wounds at these sites.

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Wound Evaluation
–HISTORY
• identify all extrinsic and intrinsic factors that jeopardize healing
and promote infection– mechanism of injury– time of injury
(accelerated growth phase of bacteria starts at 3 hours post
wound)– environment in which wound occurred
potential contaminants, foreign bodies– species of animal if bite
wound– pt’s medical problems (allergies to medication) / immune
status
• tetanus immunization status

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 History
 • Immunocompromised
 • Bleeding disorder.Prolonged bleeding-. Hematoma can serve
as culture medium for wound infection.
 • Peripheral vascular disease

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TYPES OF WOUNDS
 • Abrasions Superficial layer of tissue is removed
 • Avulsions A section of tissue is torn off (partially or totally)
 • Lacerations borders. Tissue is cut or torn. Sharply demarcated
• Puncture Small opening and of indeterminate depth
 . • Contusion forceful blow, outer layer of skin intact ; minimal
wound care ; evaluate for possible hematoma
 • Combination wound

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Wound Assessment
• Examine for:
– amount of tissue destruction
– degree of contamination
– damage to underlying structures

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 •Body Location
 –Proximity to Other Structures
 –Joints
 –Nerves
 –Tendons
 –Vasculature
 –Test integrity of each structure
 •Assess laxity/muscle and tendon function
 •Assess 2-point discrimination
 •Assess vascular supply

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Physical Examination
• Wound Location
– importance in the risk of infection
– high endogenous bacterial counts in hairy scalp, forehead, axilla,
groin, foreskin of penis, vagina, mouth, nails
– wounds in areas of high vascularity more easily resist infection
(scalp, face)

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Wound Preparation
Anesthesia • Topical
– Solution or paste– LET– TAC– EMLA
• Local
– Direct infiltration
– 1% lidocaine with or without epinephrine
– Bupivicaine for longer acting anesthesia
• Regional Block
– Local infiltration proximally in order to avoid tissue disruption
– Smaller amount of anesthesia required

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 Wound Preparation – Hemostasis
 • Direct Pressure–Usually best choice
 • Ligatures– Use a tourniquet
 • Chemicals–Epinephrine–Gelfoam–Oxycel–Actifoam
 • Cautery

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 Wound Preparation – Foreign Body Removal
 • Suspect with point tenderness
 • Visual inspection (to the apex)
 • Imaging– Glass, metal, gravel fragments >1mm should be
visible on plain radiographs– Organic substances and plastics
are usually radiolucent
 • Always discuss and document possibility of retained foreign
body

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 Wound preparation : CLEANING
 • high pressure irrigation (Normal Saline)
 • min 100-300 ml with continued irrigation
 • at least 8 psi force to the wound
 the irrigation fluid dislodges foreign bodies, contaminants, and
bacteria.
 • A simple device setup 30-60 ml syringe and an 14-gauge
angiocatheter.

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 Wound Preparation – Debridement
 • Removes devitalized tissue
 • Creates sharp wound edge
 • Excision with elliptical shape
 • Respect skin lines

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 Indications for systemic antibiotic for traumatic wounds
 • Injury 6 hours old on the extremities
 • Injury 24 hours old on the face and scalp
 • Tendon, joint, or bony involvement
 • Cartilage involvement
 • Mammalian bite
 • Co-morbidity (diabetes mellitus, extremes of age, steroid use, morbid obesity)
 • Puncture wound
 • Complex intraoral wound

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 Wound preparation –Tetanus prophylaxis
 • Clean wounds
 – Incompleted immunization toxoid
 – >10 years, then give toxoid
 • Tetanus prone wound
 – Incompleted immunization Toxoid & immunoglobulin
 – > 5 years, give toxoid

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WOUND CLOSURE
 Wound closure in relation to time
 • Primary closure– Suture, staple, adhesive, or tape
 – Performed on recently sustained lacerations: <12 hours
generally and <24 hours on face
 • Secondary closure– Secondary intent– Allowed to granulate
 • Tertiary closure– Delayed primary (observed for 3-4days)

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 Suture supply
 needle drivers …
 tissue forceps (or skin hook)
 Scissors
 sterile drapes
 sterile gloves
 suture materials
 sterile gauze

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 Suture Material
 • Absorbable
 – Chromic catgut ( natural monofilament)
 – Vicryl (synthetic braided)
 – PDS II (synthetic monofilament)
 • Non-Absorbable
 – Silk (natural braided)
 – Ethilon (synthetic monofilament) •
 Monofilament (smooth but stiff) vs. Braided (has

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 After care
 •Wound Dressings
 • Maintain dry –24 –48 hours–Augments reepithelialization
•“Water-Tight” after 48 hours
 •Bandages–Soft-splint–Absorb exudates–Protects Wound–
Protects knots

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Suture removal guide
 Face 3-5
 Arm 7 days
 Anterior Trunk 7 days
 Back 10-14 days
 Scalp. 10-14
 Feet and hand ….10-14 days
 Joints. 10-14

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 Wounds appropriate for consultation/referral
 • Primary provider is unable to perform optimal repair
 – Skill level does not match complexity of wound
 – Practice setting is too busy to allow adequate time for repair
 • Underlying injury– Tendon ,Nerve, Vascular,Joint involvement or
underlying fracture
 Eyelid: tarsal plate or lacrimal duct involvement
 • Patient requests specialist •
 Operative repair necessary– Skin grafting– Flap creation or rotation