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Wound lecture 1.ppt
- 1. GYÖRGYI SZABÓ A SS I S T A N T P R O F E S S O R DEPARTMENT OF SURGICAL RESEARCH AND TECHNIQUES Classification and management of wound, principle of wound healing, haemorrhage and bleeding control Basic Surgical Techniques, Faculty of Medicine, 3rd year 2021/13 Academic Year, Second Semester 1
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- 3. What is awound? It is a circumscribed injury which is caused by an external force and it can involve any tissue or organ. surgical, traumatic It can be mild, severe, or even lethal. Simple wound Compound wound Acute Chronic 3
- 4. Parts of thewound Wound edge Wound corner Surface of the wound Base of the wound Cross section of a simple wound Skin surface Subcutaneus tissue Superficial fascia Muscle layer Base of the wound Wound edge Surface of the wound Wound cavity 4
- 5. The ABCDE inthe injured assessment The mnemonic ABCDE is used to remember the order of assessment with the purpose to treat first that kills first. A: Airway and C-spine stabilization B: Breathing C: Circulation D: Disability E: Environment and Exposure 5
- 6. Wound management -anamnesis When and where was the wound occured? Alcohol and drug consumption What did caused the wound? The circumstances of the injury Other diseases eg. diabetes mellitus, tumour, atherosclesosis, allergy The state of patient’s vaccination against Tetanus Prevention of rabies The applied first-aid 6
- 7. Classification of theaccidental wounds 1. Based on the origine I. Mechanical: 1. Abraded wound (vulnus abrasum) 2. Puncured wound (v. punctum) 3. Incised wound (v. scissum) 4. Cut wound (v. caesum) 5. Crush wound (v. contusum) 6. Torn wound (v. lacerum) 7. Bite wound (v. morsum) 8. Shot wound (v. sclopetarium) II. Chemical: 1. Acid 2. Base III. Wounds caused by radiation IV. Wounds caused by thermal forces: 1. Burning 2. Freezing V. Special 7
- 8. 1.) Abraded wound (v.abrasum) 2.) Punctured wound (v. punctum) Superficial part of the epidermal layer Good wound healing Sharp-pointed object Seems negligible BUT Anaerobic infection Injury of big vessels and nerves Mechanical wounds 8
- 9. 3.) Incised wound (v.scissum) 4.) Cut wound (v. caesum) Sharp object Best healing Sharp object + blunt additional force Edges - uneven Mechanical wounds 9
- 10. 5.) Crush wound (v.contusum) 6.) Torn wound (v. lacerum) Blunt force Pressure injury Edges – uneven and torn Bleeding Great tearing or pulling Incomplete amputation Mechanical wounds 10 (v. lacerocontusum)
- 11. 7.) Shot wound(v. scolperatium) Close - burn injury Foreign materials Mechanical wound 11 unijured tissue necrobiotic zone necrotic zone foreign bodies aperture slot tunel output
- 12. 8.) Bite wound(v. morsum) Ragged wound Crushed tissue Torn Infection Bone fracture Prevention of rabies Tetanus profilaxis Mechanical wounds 12
- 13. Distal Proximal The woundhealing is good The direction of the flap 13
- 14. 1.) Acid 2.)Base in small concentration – irritate in large concentration – coagulation necrosis colliquative necrosis Chemical wounds 14
- 15. Symptoms and severity dependon: Amount of radiation Length of exposure Body part that was exposed Symptoms may occur immediately, after a few days, or even as long as months. What part of the body is most sensitive during radiation sickness? bone marrow gastrointestinal tract Wounds caused by radiation 15
- 16. 1.) Burning 2.)Freezing a – normal skin 1 - 1st degree – superficial injury (epidermis) 2 – 2nd degree –partial or deep partial thickness (epidermis+superficial or deep dermis) 3 – 3rd degree – full thickness (epidermis + entire dermis) 4 – 4th degree – (skin + subcutaneous tissue + muscle and bone) Treatment: Cooling – cold water and clean covering Wounds caused by thermal forces 16 Metabolic change! - toxemia mild, moderate, severe (redness, bullas, necrosis) rewarm – not only the frozen area but the whole body
- 17. Exotic, poisonous animals Toxins, venom - toxicologist Skin necrosis Special wounds 17
- 18. Classification of thewounds 2. According to the bacterial contamination Clean wound Clean-contaminated wound Contaminated wound Heavily contaminated wound 18
- 19. Superficial Partialthickness Full thickness Deep wound Classification of the wounds 2. Depending on the depth of injury + bone, opened cavities, organs…etc. 19 source: http://www.funscrape.com/Search/1/skin+layers.html
- 20. Wound management -history Ancient Egypt – lint (fibrous base-wound site closure), animal grease (barrier) and honey (antibiotic) „closing the wound preserved the soul” Greeks – acute wound= „fresh” wound; chronic wound = „non-healing” wound maintaining wound-site moisture Ambroise Paré – hot oil oil of roses and turpentine, ligature of arteries instead of cauterization Lister pretreated surgical gauze – Robert Wood Johnson 1870s; gauze and wound dressings treated with iodide 20
- 21. Applied wound management- colour continuum black black-yellow yellow yellow-red red red-pink pink 21 source: Applied wound management supplement – www.wounds-uk.com
- 22. Applied wound management infectioncontinuum contamination colonisation infection sterility critical colonisation 22 the quantity and diversity of microbes source: Applied wound management supplement – www.wounds-uk.com
- 23. Applied wound management exudatecontinuum volume high - 5 medium - 3 low - 1 high - 5 medium -3 low - 1 Viscosity 23 source: Applied wound management supplement – www.wounds-uk.com
- 24. The wound managemanet Temporary wound management (first aid) clean, hemostasis, covering Final primary wound management clean, anaesthesis, excision, sutures ALWAYS: thoracic cavity, abdominal wall or dura mater injury NEVER: war injury, inflammation, contamination, foreign body, special jobs, bite, shot, deep punctured wound Primary delayed suture (3-8 days) clean, wash – saline, cover excision of wound edges, sutures 24
- 25. The wound managemanet 25 Early secondary wound closure (2 weeks) after inflammation, necrosis – proliferation anesthesia, refresh wound edges, suturing and draining Late secondary wound closure (4-6 weeks) anesthesis, scar excision, suturing, draining greater defect – plastic surgery
- 26. The surgical wound Surgical incision Stretch and fix Handling the scalpel Langer lines Skin edges Vessels and nerves Hemostasis Langer lines The wound edges Handling the scalpel 26 source: http://www.med- ars.it/galleries/langer.htm
- 27. Tissue unifying anddressing the wound Skin: Stiches Clips Steri-Strips Tissue glues Fascia and subcutaneous layers: Interrupted stiches Fat – fat necrosis! Dressing: sterile, moist, antibiotic-containing, non-allergic, non-adhesive 27
- 28. The wound healing Hemostasis-inflammation Granulation-proliferation Remodelling capillaries fibroblasts lymphocytes macrophages neutrophyl gr. thrombocytes 0 1 2 3 4 5 6 7 8 9 10 11 10 13 14 15 28 http://www.worldwidewounds.com/2004/august/Enoch/images/enochfig1.jpg
- 29. The main stepsof the wound healing 1. Hemostasis-inflammation vasoconstriction fibrin clot formation proinflammatory citokines and growth factors releasing vasodilatation infiltration PMNs, macrophages cytokines releasing → angiogensis → fibroblast activation → B- and T-cells activation → keratinocytes activation → wound contraction 29 2. Granulation-proliferation fibroblast migration collagen deposition angiogensis granulation tissue formation epithelisation contraction 3. Remodelling regression of many capillaries physical contraction – myofibroblasts collagen degeneration and synthetisation new epithelium tensile strength – max. 80%
- 30. Types of woundhealing Healing by primary intention Healing by secondary intention Healing by tertiary intention 30 source: http://quizlet.com/13665246/chapter-3-tissue-renewal-regeneration- and-repair-flash-cards/
- 31. Factors affecting woundhealing Local Ischemia Infection Foreign body Edema, elevated tissue pressure Systemic Age and gender Sex hormones Stress Ischemia Diseases Obesity Medication Alcoholism and smoking Immunocompromised conditions Nutrition Hyperbaric oxygen treatment 31 infection ischemia foreign bodies edema/ elevated tissue pressure IMPAIRED HEALING
- 32. Complications of woundhealing I. Early complications Seroma Hematoma Wound disruptin Superficial wound infection Deep wound infection Mixed wound infection 32
- 33. 1.) Seroma 2.)Hematoma Filled with serous fluid, lymph or blood Fluctuation, swelling, redness, tenderness, subfebrility TREATMENT: Sterile punture and compression Suction drain Early complications of wound healing 33 Bleeding, short drainage time, anticoagulant Risk of infection Swelling, fluctuation, pain, redness TREATMENT Sterile puncture Surgical exploration
- 34. 3.) Wound disruption A.partial – dehiscenece B. complete - disruption Surgical error Increased intraabdominal pressure Wound infection Hypoproteinaemia TREATMENT: U-shaped sutures Early complications of wound healing 34
- 35. 1.) Diffuse 2.)Localized Located below the skin TREATMENT Resting position Antibiotic Dermatological consultation Anywhere TREATMENT Surgical exploration Drainage X-ray examination Early complications of wound healing Superficial wound infection 35 e.g. erysipelas e.g. abscess
- 36. 1.) Diffuse 2.)Localized TREATMENT Surgical exploration Open therapy H2O2 and antibiotics e.g. anaerobic necrosis Inside the tissues or body cavities TREATMENT surgical exploration drainage Early complications of wound healing Deep wound infection 36
- 37. Mixed wound infection e.g.gangrene necrotic tissues putrid and anaerobic infection a severe clinical picture TREATMENT aggresive surgical debridement effective and specified (antibiotic) therapy 37 Complications of wound healing I. Early complications
- 38. Complications of woundhealing II. Late complications Hyperthrophic scar Keloid formation Necrosis Inflammatory infiltration Abscesses Foreign body containing abscesses 38
- 39. Hypertrophic scar Keloid Develop in areas of thick chorium Non-hyalinic collagen fibres and fibroblasts Confine to the incision line TREATMENT Regress spontaneously (1-2 yrs) Late complications 39 Mostly African and Asian population Well-defined edge Emerging, tough structure Overproliferation of collagen fibers in the subcutaneous tissue Subjective complains TREATMENT Postoperative radiation Corticosteroid + local anaesthetic injection
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- 41. Anatomical Diffuse Arterial– bright red, pulsate Venous – dark red, continuous Capillary – can become serious Parenchymal Bleeding 41
- 42. Bleeding Severity of bleeding– the volume of the lost blood and time 42 source: http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/
- 43. The direction ofhemorrage External Internal In a luminar organ (hematuria, hemoptoe, melena) In body cavities (intracranial, hemothorax, hemascos, hemopericardium, hemarthros) Among the tissues (hematoma, suffusion) 43
- 44. Bleeding Preoperative hemorrhage Prehospitalcare! – maintenance of the airways, ventillation and circulation bandages, direct pressure, turniquets Intraoperative hemorrhage anatomical and/or diffuse depending on the surgeon, the surgery, position, the size of the vessel, pressure in the vessel ANESTHESIA! Postoperative bleeding ineffective local hemostasis, undetected hemostatic defect, consumptive coagulopathy or fibrinolysis 44
- 45. Local General Hematoma,suffusion, ecchymosis Compression in the pleural cavity, in pericardium, in the skull Functional disturbancies – e.g. hyperperistalsis Pale skin, cyanosis, decreased BP. and tachycardia, difficulty in breeding, sweeting, decreased body temperature, unconsciousness, cardiac and laboratory standstill, laboratory disorders, signs of shock Signs of the bleeding 45
- 46. Surgical hemostasis Aim –to prevent the flow of blood from the incised or transected vessels Mechanical methods Thermal methods Chemical and biological methods 46
- 47. Surgical hemostasis Mechanical methods Digital pressure – direct pressure, e.g. Pringle maneuver Tourniquet Ligation Suturing Preventive hemostasis Clips Bone wax other 47
- 48. Thermal methods Lowtemperature Hypothermia – eg. stomach bleeding Cryosurgery dehidratation and denaturation of fatty tissue decreases the cell metabolism vasoconstriction 48
- 49. Thermal methods Hightemperature Electrosurgery – electrocauterization Monopolar diathermy Bipolar diathermy Laser surgery coagulation and vaporization for fine tissues 49
- 50. Thermal methods Hightemperature Electrocoagulation Electrofulguration (A) Electrodessication Electrosection 50
- 51. Hemostasis with chemicaland biological methods vasoconstriction coagulation hygroscopic effect Absorbable collagen Absorbable gelatin Microfibrillar collagen Oxidized celluloze Oxytocin Epinephrine Thrombin Hemcon QuikClot 51
- 52. Hemostasis with chemicaland biological methods HemCon 52
Editor's Notes
- #12 A kialakult lőcsatorna első rétegében elhalt szövetek és idegen anyagok helyezkednek el (pl.: ruhadarabok). Körülötte kialakul az elsődleges necroticus zóna, amelyben a lökéshullám és a hőhatás miatt elhalt szöveteket észlelünk. E körül a necrobioticus zóna helyezkedik el, amelyben vérzést, érkárosodást, trombusokat észlelünk, majd körkőrösen a molekuláris rázkódtatás zónája, amely éles határ nélkül megy át az ép szövetekbe. A lőcsatornát mindig fel kell tárni!
- #16 ulcers on people’s backs, chests, mouth, etc. are common when one is exposed to a vast amount of radiation
- #24 Wound exudate » View large image. If a wound produces a large amount of fluid (exudate)1, the healing process can be slowed down. Increased exudate levels can be a symptom of infection and increased oedema. And the more a wound exudes, the higher the risk of maceration of the surrounding skin2 – and exudate leakage. Exudate leakage is not only clinically challenging to treat – it also prevents some patients from participating in social activities, or from going out altogether. Problems often associated with exuding wounds are [1-2] : a negative impact on the patient’s quality of life very time consuming treatment complications such as infection, wound pain and maceration that slows the healing process The composition and amount of wound exudate1 varies depending on the stage of the healing process. In the inflammatory phase of wound healing, exudate levels are usually high, which may be a sign of wound infection. Unlike acute wound exudate, chronic wound exudate contains enzymes (proteases) that break down proteins and newly formed cells. To break the vicious cycle in a non-healing wound, the exudate must be led away from the wound with an absorbent dressing. Controlling wound exudate Control of exudate, removal of unhealthy tissue by debridement and management of bacterial load are all part of good wound bed preparation. A good wound dressing keeps the wound moist and absorbs exudate, locking it inside the dressing to prevent maceration. Offering excellent absorption and retention, Biatain foam dressings are proven to deliver superior exudate management.[3-4] With longer wear time (up to seven days), minimal risk of leakage and maceration, your patients’ wounds will heal faster.[1,5-7]
- #31 Tertiary Intention When a wound is intentionally kept open to allow edema or infection to resolve or to permit removal of exudate, the wound heals by tertiary intention, or delayed primary intention. These wounds result in more scarring than wounds that heal by primary intention but less than wounds that heal by secondary intention. (Johnstone, Farley,& Hendry, 2005)
- #35 Breast reduction – dehiscence – 2weeks
- #36 Diffuse – erysipelas – caused by hemolytic streptococci Localized – joint abscess This patient developed an abscess over the metacarpophalangeal joint of the thumb after an accidental cut with a kitchen knife. See Also Scar location related to patient and parent satisfaction with ... A 15-year-old Hispanic girl with bump 12-year-old boy admitted for febrile illness What is your diagnosis? Source: Jeray KJ Answer The answer is methicillin-resistant Staphylococcus aureus. Surgeons at one hospital system found that MRSA may become a more common bacteriologic flora of hand infections, and if so, surgeons must adjust their choices for empiric antibiotics. After noticing a marked increase in the number of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) cases, surgeons at the Greenville Hospital System in South Carolina conducted a retrospective chart review of all orthopedic consultations done for hand infections from November 2003 to October 2005.
- #37 Localised – massive empyema (see the article)
- #42 Figure 1: Diffuse terminal ileal ulceration and angiomal formtion with oozing hemorrhage from these ulcers. Mentions: In the absence of a primary ulcer, Dieulafoy's lesion was seen in the terminal ileum with oozing hemorrhage from this lesion 10 cm away from the ileocecal valve (Figure 1). The bleeding could not be controlled by endoscopic hemostasis using thermal coagulation or any other endoscopic intervention. A decision was made accordingly for urgent explorative laparotomy to save her life. An ileocolectomy (emergency limited segmental resection for a known bleeding source) was also done on our patient (Figure 2). Histology revealed this to be of the Dieulafoy type of lesion in the distal ileum (Figure 3).
- #44 Conjunctival suffusion with subconjunctival hemorrhage (ou), which was suggestive of leptospirosis, developed on the second hospitalization day.
- #48 The Pringle maneuver. The portal triad is occluded by guiding the posterior blade of the clamp through the foramen of Winslow with the aid of the left index finger. -6. kép: amennyiben vérnyomásmérő áll rendelkezésre, úgy pneumatikus vértelenség felhelyezése. 280 Hgmm-re felfújjuk a vérnyomásmérő mandzsettát, így a sebalapot megtekinthetjük. Betadines vagy Octeniseptes fedőkötés, steril pólya, korrekt nyomókötés 7-8.kép: a nyomókötés felhelyezése után a vértelenség felengedése. Amennyiben erős vérzést észlelünk, ismételten felfújjuk a mandzsettát és revideáljuk a kötést. (az erős vérzés forrása csak technikai hiba lehet az elsősegélynyújtó részéről).
- #49 Timed spot freeze technique used to treat a malignancy (possibly a small basal cell cancer), demonstrating freeze ball formation and the 5-mm treatment margins necessary to achieve a temperature of −50ºC (−58 ºF) and, thus, the required depth of 4 to 5 mm. Cryosurgery is a method of superfreezing tissue in order to destroy it. The technique is used to treat tumors, control pain, and control bleeding. Information The cold is introduced through a probe which has liquid nitrogen circulating through it. To destroy diseased tissue, the tissue is cooled to below -20 degrees Celsius. Other procedures that control pain or bleeding are cooled to a lesser degree to prevent tissue damage.
- #50 Electrocoagulation: A fine wire probe or other delivery mechanism is used to transmit radio waves to tissues near the probe. Molecules within the tissue are caused to vibrate which lead to a rapid increase of the temperature, causing coagulation of the proteins within the tissue, effectively killing the tissue. At higher powered applications, full desiccation of tissue is possible. Two forms of electrosurgery: (A) Electrodesiccation with an active electrode tip touching the skin and showing penetration of planned tissue damage. (B) Fulguration with sparking from electrode to tissue. Treatment area is more superficial than in desiccation.Added by BiomedGuy AboutEdit Fulguration, also called electrofulguration, is the destruction of tissue by means of a high-frequency electric current applied with a needlelike electrode. In fulguration, the electrode is held away from the skin to produce a sparking at the skin surface and more shallow tissue destruction Fulguration is especially useful in treating superficial epidermal lesions, such as a superficial basal cell carcinoma of the trunk.[1] LinksEdit ReferenceEdit ↑ http://www.aafp.org/afp/2002/1001/p1259.html | Electrosurgery for the Skin | BARRY L. HAINER, M.D.,RICHARD B. USATINE, M.D., | Am Fam
- #52 HemCon Medical Technologies, Inc. began with funding from the United States Army and access to research by Dr. Kenton Gregory, Dr. Bill Wiesmann, the Oregon Medical Laser Center, and Providence Health Systems. The result was the HemCon® Bandage, which was designed to control life threatening bleeding. Related Links: History & Mission Management Team Board of Directors Products Educational Resources Distribution and Sales Product Training Success Stories Media Room Customer Feedback Careers The bandage was ushered through the FDA clearance process in a near-record 48 hours, and was soon deployed on the battlefield. Since then, the bandage has been used extensively and is credited with helping save over 100 lives with no adverse events reported. In 2005, the Army Surgeon General mandated that any soldier serving in Iraq or Afghanistan will carry at least one HemCon Bandage. This commitment by the U.S. Army is a testament to the efficacy and value of the HemCon Bandage. HemCon is rapidly changing from a military provider to a broad-based supplier of medical technology. With new products, strong partnerships in distribution, and a world class development team, we will continue to be unwavering in our commitment to innovate in all that we strive to achieve.