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Wound Management

Bertrand Ng VET301 Surgery/Anesthesia English

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Wound Management

Types of Wounds
- Abrasions
  - Partial thickness injuries
    - Blunt trauma: Direct/shearing
      - Very sensitive, minimal bleeding
        Rapidly epithialise/heal
- Puncture Wounds
  - Gunshot Wounds
    - Damage proportional to bullet velocity
      - Shotguns = varying pattern
        Close range = widespread avulsion
        Long range = minimal damage
        Contaminated with microorganisms/hair with missile
        Sucked into wound by negative pressure of cavitation
  - Small/Deep opening
    - Foreign material/bacteria deep
      - Deep tissue injury
        e.g. bites/pharyngeal stick/gunshot
- Lacerations
  - Skin edges torn/irregular
    - Deep (Muscle/tendon) or superficial (skin)
      - Tissue torn away = Avulsion
        Larger areas can devitalise (compromised blood supply)
- Degloving
  - Extensive skin loss from limb
    - Roller/wringer type injury
      - Physiologically flayed
        Intact skin surface but deep fascia disruption
        SubQ undermined
        Can have severe blood supply damage
      - Anatomically torn off
- Contusions/Bruise
  - Direct blow to skin, damages skin/underlying tissue
    - Capillary rupture = hemorrhage/oedema/inflamm
- Sx Wounds
  - Sharply incised wounds, controlled environment
- Thermal Burns
  - Fire/Electric cords/heat lamps/hot liquids
    - Serious injury to skin/tissue
      - Fluid/e-/protein loss and infection
        >50% body surface burnt rarely survive
- Decubital Ulcers
  - Compression of soft tissue between bony prominence and surface
    - Long periods of recumbency
      - Thin animals (Whippets/Greyhounds)
        Can be secondarily infected/affect bone
    - Prevention
      - Adequate movement
        Bedding/Fat
        Good nutrition (Protein/Carbs)
        Dry/clean skin, baths
Types of Management
- First Intention: Primary wound closure
  - Appositional (Suture/Grafting)
  - Indicated in fresh/clean/incised wounds
    - Healing w/ minimal epithelialisation
    - Minimal contamination
- Delayed primary closure
  - First intention: 3-5d after wound, BEFORE granulation
  - Indicated for mild trauma/contamination requiring debridement/cleaning
    - Allows infection control before closure
- Secondary Intension: Healing by contraction/epithelialisation
  - Indicated for dirty/contaminated/trauma wounds
    - Cleansing/debridement needed
    - Little surrounding tension to prevent contraction
  - Not always desirable
    - Fragile epithelium, easily abraded
    - Contraction may impede normal function
- Third Intention: Secondary Closure
  - Closure of wound 3-5d: after granulation
    - Granulation tissue often has to be debrided
  - Indicated for severely contaminated/trauma wounds
    - Epitheliasation/contraction don't work/are undesirable
- To leave Open or Close?
  - Degree of contamination
  - Degree of tissue damage
  - Thoroughness of debridement
  - Blood supply
  - Patient condition
  - Wound location
  - Possibility of closure without tension/dead space
Wound Care
- Immediate
  - Reduce antimicrobial burden
  - Cover wound
  - Rapid/Copious lavage (Water)
  - Topical antimicrobial agent (Reduce surface contamination)
    - Not powders (foreign bodies)
    - Soluble ointment/hypertonic saline
  - Control hemorrhage
  - Clean dry bandage to wound
    - Leave in place until definitive tx
- Controlled Wound Care
  - Prepare wound area
    - Wound lavage
      - Syringe/needle
        Moderate pressure, 35cc syringe, 19G needle
        More effective than pouring
      - High pressure lavage
        Pulsating, high pressure, 5cm from wound, 30sec
        More effective
        More beneficial than harmful really
        Can cause tissue damage/impair defence
        Disseminates bacteria
      - Lavage solutions
        Sterile, balanced electrolyte soln > normal saline
        Tap water effective
        Follow with isotonic saline
        Can cause hypotonic tissue injury
        Less than distilled/sterile water
        Soaps/detergents: Do NOT USE
        Toxic/impair defence
        infection etc.
        Antiseptics, can damage tissue, but use with heavy contamination
      - Antiseptics
        Hydrogen peroxide
        Good cleansing agent (foam removes dirt)
        Damages microvasculature/cells
        Avoid (CONTRAINDICATED)
        Sporicidal, limited bactericidal activity
        Povidone-iodine (Betadine solution), chlorhexidine
        Useful for lavage with intact mm/conjunctiva
        Can be cytotoxic on open wounds
        Use dilute soln
        Less effective with OM/blood/pus etc.
        Diacetate form (Nolvasan) precipitates with saline
        Wound Debridement
        Layered debridement
        Removal of devitalised tissue (systematically deeper)
        Less tissue removal than en bloc
        Most common on extremities with little soft tissue mass
        En bloc debridement
        Complete excision
        Entire wound excised with some normal tissue
        Removes large mass but ensures contaminated tissue removal
        All foreign material
        Hemostasis is important
        Wound lavage repeatedly during debridement
        Enzymatic debridement
        Superficial debridement
        Can be used to superficially debride unhealthy granulation tissue
        Disadvantages
        expensive
        slow
        inadequate debridement
        may dehydrate tissue
        Examples
        Elase
        Fibrinolysin/deoxyribonuclease, digests exudate, slow debridement
        Granulex
        Trypsin debrides necrotic tissue, Balsum of Peru stimulates capillary bed/bactericide, Castor Oil promotes epitheliasation/analgesia
        Debrisol
        Trypsin/Chymotrypsin
        liquefies exudate/slow debridement/mild burning
        Removal of contaminated/devitalised/necrotic tissue/foreign material
        Speed healing/prevent infection
        Thorough wound exploration
        Aseptic technique
        Antibiotic Therapy
        NOT a substitute for proper wound debridement/lavage
        Topical Antibiotics
        Indicated to treat contamination
        Reduce bacteria on surface, but not invasive
        Contraindication
        Some act as foreign bodies
        Use for short period, avoid resistance
        Form
        Use aqueous/soluble form
        ointments slowly liberate, but are occlusive
        Can cause anaerobe growth
        NO powders: Foreign Body
        Impregnated dressings
        Other topical substances
        Silver nanoparticle dressing
        Hypertonic saline dressing
        Bactericidal
        Systemic Antibiotic Therapy
        Unnecessary in minor wounds/healthy granulation
        Will not prevent infection
        not for contamination
        Indicated for wound infection
        Base choice on C&S
        4-5 days course
        Disadvantages
        Poor blood supply: Won't reach site
        Toxic/allergic complications
        Disturbs normal flora
      - Removes debris/loose tissue/bacteria
        Large volume = > removed
        ONLY LAVAGE if you can remove the fluid
        i.e. not into penetrating injuries
    - Protect with KY jelly/gauze/sterile lubricant
      - Remove bandage
        Clip fur
        Prepare skin with skin antiseptic
        Flush KY from wound/remove sponges
Bandaging
- Indications
  - Promotes healing/protects wound
  - Prevents wound dessication
  - Promotes acid environment/preventing CO2 loss/absorbing NH3
    - Increased O2 dissociation
  - Keep wound warm (healing + O2 dissociation)
  - Compression: minimise dead space
  - Absorbed exudate (debridement)
  - Immobilise wound: prevents capillary/cell disruption
  - Prevents excessive contraction/movement stimulates contraction
- Components
  - Primary layer
    - In contact with wound surface
      - Hydrophilic or non-hydrophilic
  - Moist wound care
    - Moisture: facilitates repair
      - Trapped wound exudate = good factors
        Natural debridement
        Drawing nature of fluid = cellular/debris removal
      - accelerates epitheliasation
    - Nonadherent bandages
      - Indicated to prevent damage to underlying surface
        Contact layer nonadherent, can have surrounding adhesive
    - Hydrophilic non-adherent
      - Hydrocolloid
        Matrix material: Very hydrophilic
        Absorbs exudate, creates "coagulum" on surface
        Debrides wound, keeps moist
        "Dry dressings", pastes, foam, flakes
        Occlusive/semiocclusive
        Use for moderately/copiously exudative wounds
      - Hydrogel
        Water based/hydrophilic
        Mixes with wound exudate
        rovides exogenous moisture for wound
        Impregnated bandage or paste
        Occlusive/semi-occlusive depending on back of dressing
        Indicated for minimally exudative wounds
    - Non-hydrophyllic non-adherent primary layers
      - Can be used with hydrophilics
        Hydrogelpaste/hydrocolloid flakes etc.
      - Examples
        Adaptic: Fine mesh gauze impregnated with petrolatum
        Nonadherent, no moisture, permeable (not hydrophilic)
        Enhance contration/delay epithelialization
        Release, Telfa: rayon/polyethylene dressing
        Nonadherent (not hydrophilic)
        Trap wound exudate
    - Other Wound Dressings
      - Honey
        Antibacterial (H2O2 from glucose, hypertonic, low pH etc.)
        Enhances debridement, reduces edema/inflammation, enhances granulation tissue/epitheliasation
      - Sugar
        Hypertonic?!? Wound fluid??
      - Porcine SI submucosa (SIS)
        Semi-occlusive
        Exogenous source of collagens etc.
        Scaffold for incorporation into tissue
        No benefit for open wound healing
      - Silver
        Impregnated dressing, silver nanoparticles
        Slow release
        Chronic infected wounds
        Expensive, not for initial decontamination
      - Hypertonic saline (Curasalt)
        20% saline
        Bactericidal
        Heavily contaminated/infected wounds
        Early stage wound management
    - Secondary Bandage Layer
      - Absorbent layer over primary layer
      - Used to pad bandage
    - Tertiary bandage layer
      - Protective/conforming layer over secondary
        Occlusive or non-occlusive
        Occlusive (waterproof tape/plastic)
        Not indicated: trap excess fluid at surface
        Macerate tissue
        Impermeable to air
        Only use for short periods
        Nonocclusive
        Preferred: allows air through
        Vulnerable to environment contamination
        Need to change
  - NO Adherent bandages indicated. Drying procedures (wet-dry bandage/leaving open) are NOT acceptable

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Description: VET301 Surgery/Anesthesia Mind Map on Wound Management, created by Bertrand Ng on 15/11/2017.
Created by: Bertrand Ng
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Wound Management

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