Transcript
Wound ManagementDr Saumya Agarwal
Dept of Orthopaedics, JNMC, KLE’S Dr.Prabhakar Kore Hospital, Belagavi
OBJECTIVES• To know Anatomy and Physiology related to
wound Care • To know the wound classifications• To know the wound healing process • Identify Types of wound dressing and drainage• Identify Factors affecting wound healing• To know the Wound assessment• Identify the common complications of wound
INDEX1. Definition of wound2. Types of wounds3. Wound healing 4. Wound assessment5. Kinds of wound drainage6. Complications of wound healing
INDEX
7. Wound dressing Changing a dry sterile dressing Applying wet- to- dry dressing Applying a moist transparent wound barrier Applying a hydrocolloid dressing8. Wound irrigation9. Preventing wound infection
“the primary goal of wound care is not the technical repair of the wound; it is providing optimal conditions for the natural reparative processes of the wound to proceed” – Richard L. Lammers (Roberts and Hedges)
WOUND
A break or “disruption” in the continuity of a body tissue that is followed by restoration of that continuity (wound healing)
Saunders Comprehensive Dictionary, 3 ed. © 2007
HISTORY
• Dates back to Sushruta
Hippocrates (Greek physician and surgeon, 460-377 BCE), known as the father of medicine, used vinegar to irrigate open wounds and wrapped dressings around wounds to prevent further injury. His teachings remained unchallenged for centuries.
Galen (Greek surgeon to Roman gladiators, 130-200 CE) was the first to recognize that pus from wounds inflicted by the gladiators heralded healing
Classification of Wound
Wound may be classified into different ways:
1. Mechanism of injury: Intentional Vs. Unintentional Open Vs. ClosedIncised, contused, lacerated or puncture
2. Degree of contamination 3 . Depth of the wound
Intentional V/s Unintentional wounds
Intentional wound: occur during therapy. e.g., operation or
venipuncture.
Unintentional wound: occur accidentally. e.g., fracture in arm in road
traffic accident.
Open v/s Closed wounds
Open wound: the mucous membrane or skin surface is broken
Closed wound: the tissue are traumatized without a break in the
skin
Types of wounds Incised wounds:
Made by a clean cut with a sharp instrument e.g., those made by the surgeon in every surgical
procedure and usually closed by sutures “ clean surgical wound”
Contused wounds: closed wound made by blunt force Characterized by considerable injury of the soft parts,
hemorrhage and swelling
Types of wounds cont.
Puncture wounds: open wound, penetrating of the skin and often underlying tissues by a sharp instrument
Stab wound: open wound, penetration of the skin and the
underlying tissues, usually unintentional
Types of wounds cont-
Laceration:open wound, edges are often jagged & irregular Often from accidents made by glass
Abrasion:open wound involving only skin, painful, due to surface scrape
Degree of contaminationWounds may be described as “ clean, clean-
contaminated, contaminated or dirty or infected”
Clean wounds: are uninfected wounds in which minimal
inflammation exist, are primarily clean closed wounds; if necessary, a closed drainage system is used
The respiratory, alimentary, genital, or uninfected urinary tracts are not entered
The relative probability of wound infection is ‘1% to 5%’
Degree of contamination
Clean–contaminated wound: are surgical wounds in which the respiratory,
alimentary, genital, or urinary tract has been entered
There is no evidence of infection
The relative probability of wound infection is
‘3% to 11%’
Degree of contamination
Contaminated wounds: include open, fresh, accidental wounds and surgical
procedures with major breaks in a septic technique or gross spillage from the gastrointestinal tract
There is evidence of inflammation
The relative probability of wound infection is “10% to 17%”
Dirty or infected wounds: includes old, accidental wounds containing dead
tissue and evidence of infection such as pus drainage
The relative probability of wound infection is over 27%
Depth of the wound
Partial thickness: the wound involves epidermis and dermis
Full thickness: involving the epidermis, dermis, subcutaneous
tissue, and possibly muscle and bone
Wound Healing
Healing is regeneration (renewal) of tissues.
The time needed for healing depends on location,
and size of wound, and health status of the client.
The response of tissue to injury goes through
several phases.
Wound healing
Inflammatory
phaseProliferative
phaseMaturation
phase
Timetable of Wound Healing
• Hemostasis immediate
• Inflammation 1-4 days
• Granulation Tissue 5-20 days
• Tissue remodeling 21 days-2 years or maturation
Inflammatory Phase
Also called exudative phase
1-4 days
Blood clots forms
Wound becomes edematous
Debris of damaged tissue and blood clot are
phagocytized
Proliferative PhaseAlso called fibroblastic or connective tissue phase5-20 daysCollagen producedGranulation tissue formsWound tensile strength increases.After 2 weeks, the wound has only 3% to 5% of the
original skin strengths. by the end of a month, only 35% to 59% of wound
strength.Never more than 80% of strength is regained.
Maturation Phase
Also called resorptive or remodeling phase
21 days to months or even years
Fibroblasts leave wound
Maximum tensile strength increases
Collagen fibers reorganize and tighten to
reduce scar size
Forms of Wound Healing
• The amount of tissue loss, the existence of contamination or infection and damage to tissue are all factors that determine the type of wound healing that will occur.
• Process of healing takes place in one of three waysHealing by primary (first) intentionHealing by secondary intention(granulation)Healing by delayed primary closure (tertiary
intention)
Healing by primary (first) intention
Wound is clean, in a straight line, with little
loss of tissue.
All wound edges are well approximated with
sutures.
Usually rapid healing with minimal scarring.
Drainage is minimal
Wound Healing
Healing by secondary intention (granulation)
When surgical wounds are characterized by tissue loss
with inability to approximate wound edges, the process of
repair is less simple and takes longer.
This type of wound is left open and allowed to heal from
the inside toward the outer surface
In infected wound this process allows the proper
cleansing and dressing of the wound as healthy tissue
builds up from the inside
Healing by secondary intention (granulation) cont-
The area of tissue loss gradually fills with
granulation tissue (fibroblasts and capillaries)
Scar tissue is extensive because of the size of
the tissue gap that must be closed. Contraction
of surrounding tissue also takes place
Consequently this healing process takes longer
than primary intention healing
Healing by delayed primary closure (tertiary intention)
This healing process takes place when approximation of
wound edges is delyed by 3-5 days or more after injury or
surgery.
There is greater granulation, greater risk of infection,
greater inflamatory reaction and more scars. The condition contribute to a decision for a delayed closure
are: Traumatic Wound Heavy contamination of wound Surgical Debridement of a wound
Healing By Tertiary Intention
Plastic Surgeon Consultation
(a) acute wound where final appearance may be principal concern,
(b) wound in a patient whose medical status
and/or mode of injury predisposes her to wound healing difficulties and threat of a
problem wound, or
(c) the established chronic wound refractory to past interventions
Reconstructive Ladder
Cont,
Determine results of laboratory data pertinent to healing: Leukocyte count Blood coagulation studies
Factors affecting wound healingLocal• Ischemia, hypoxia• Infection• Foreign body• Edema, elevated tissue
pressure
Systemic• Age and gender• Sex hormones• Stress • Diabetes• Obesity• Medication• Alcoholism and smoking• Immuno-compromised
conditions• Nutrition• Systemic disorders• Procedural considerations
Kinds of wound drainage Sanguinous exudate ( Dark or bright red) Serosanguinous exudate (mix between two types) Serous exudate (watery, clear) Purulent exudate (viscous fluid varies in color e.g, yellow-white, green)
Complications of wound healing
1. Hemorrhage2. Haematoma3. Infection4. Abnormal scar formation as
Adhesion, Granuloma Keloid, Neuroma Hypertrophic scar, Contractures
5. Disruptions of wounds as Hernia Dehiscence, Evisceration, Fistula, Sinus tract
Basics• Wound evaluation and history• Wound preparation and closure• Optimize systemic parameters• Debride nonviable tissue• Reduce wound bioburden• Optimize blood flow• Reduce edema• Use dressings appropriately• Use pharmacologic therapy• Close wounds with suturing/grafts/flaps as indicated
Wound Preparation - Anesthesia• Topical
– Solution or paste– LET 4%, 0.1%, 0.5%– TAC 0.5%, 0.05% and 11.8% – EMLA 5%
• Local– Direct infiltration– 1% lidocaine with or without epinephrine– Bupivicaine or sensorcaine for longer acting anesthesia
• Regional Block– Local infiltration proximally in order to avoid tissue disruption– Smaller amount of anesthesia required
Local anestheticDrug Max Dose Onset Duration
Cocaine 6.6 mg/kg Rapid 1 hour
Procaine 10-15 mg/kg Rapid 30min-1hr
Tetracaine 1.5 mg/kg Moderate 2 hours
Lidocaine 5 mg/kg 5-30 min 2 hours
(with Epi) 7 mg/kg 5-30 min 2-3 hours
Bupivacaine 2 mg/kg 7-30 min > 6 hours
Epinephrine
Vasoconstrictive –Increases Duration of Action–Promotes Hemostasis–Avoid end-arterial blood supply areas–May increase pain (low pH)
Wound Preparation - Hemostasis
• Direct Pressure–Usually best choice • Ligatures
– Use a tourniquet• Chemicals
–Epinephrine–Gelfoam–Oxycel–Actiform
• Cautery
Debridement & Reduction of Bioburden
• Surface irrigation with saline• Debridement: surgical, enzymatic (papain with
urea, collagenase), mechanical (pressurized water jet), autolytic, maggots
• Antibiotics: cellulitis, decreased rate of healing, increased pain, straw colored oozing from skin, contaminated wounds, mechanical implants
• Removal of Foreign Body
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
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
Hair removal
Shaving – Increases risk of infection X 10 !
Wound Preparation – Debridement
• Remove devitalized tissue• Create sharp wound edge• Excision with elliptical shape• Respect skin lines
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 3-4 days)
SUTURE TECHNIQUES
• Deep layer approximation– Absorbable sutures– Buried knot– Serves two purposes
• Closes potential spaces• Minimizes tension on wound
margins
Skin Closure
• Key – wound edge eversion
• “Approximate, don’t strangulate”
• Anticipate wound edema
• Choose appropriate size of suture for location of laceration
Other devices in wound closure• Staples
– Quick, poor aesthetic result– where scar is less of an issue
• Adhesives– Dermabond– clean, sharp edges, clean nonmobile areas, laceration < 5 cm in length
• Tape– Steri-strips– superficial, straight laceration under little tension
After care
•Wound Dressings • Maintain moist 24-48 hours
–Augments re-epithelialization •“Water-Tight” after 48 hours•Bandages–Soft-splint–Absorb exudates–Protects Wound–Protects knots
Optimize systemic parameters• Age: cannot be reversed, aggressive optimization of
systemic parameters & supplementation
• Avoidance of ischemia & malnutrition
• Correction of diabetes, removal of FB
• Avoidance of steroids, alcohol, smoking
• Avoidance of reperfusion injury: total contact casting, compression therapy
Optimize systemic parameters-nutrition
• Glucose - give energy for angiogenesis and deposition of new tissue
• Fatty acids - essential for cell structure and have an important role in the inflammatory process
• Protein deficiency - contribute to poor healing rates with reduced collagen formation & wound dehiscence
• Vitamins - vitamin A (collagen synthesis, antioxidant), C (collagen synthesis), and zinc (fibroblast proliferation )
Optimize blood flow & oxygen supply
• Warmth
• Hydration
• Surgical revascularization
• Hyperbaric O2 therapy: limb salvage
Reduce edema• Elevation
• Compression
• Negative pressure wound therapy: removes pericellular transudate & wound exudate as well as deleterious enzymes. Cannot be used in ischemic, badly infected or inadequately debrided wounds or in malignancy.
Indications for systemic antibioticfor 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• Co-morbidity (diabetes mellitus, extremes of
age, steroid use, morbid obesity)• Puncture wound• Complex intraoral wound
Wound preparation -Tetanus prophylaxis
• Clean wounds– Incompleted immunization toxoid– >10 years, then give toxoid
• Tetanus prone wound– Incompleted immunization Toxoid &
immunoglobulin (500 IU)– > 5 years, give toxoid
Dressings• Absorption characteristics: none – films, low –
hydrogels, moderate - hydrocolloids, high – foams, alginates, collagen
• Hydrogels (eg. starch) rehydrate wounds (benefit in small amounts of eschar, infected wounds)
• Hydrocolloids promote wound debridement by autolysis
• Antimicrobial dressings: silver, mupirocin, neomycin
Suture removal guidelines
• Anatomic location Days (average)face 3-5arm 7
anterior trunk 7back 10-14limbs 10-14joint 10-14scalp 10-14
Skin Substitutes• Autologous keratinocyte sheets• Biobrane• Oasis• Alloderm• Integra (sites prone to contracture, coverage of
tendons, bone, surgical hardware)• TransCyte• Dermagraft• Orcel
Integra : Collagen & chondroitin sulphate
Apligraftrade: skin substitute containing collagen and seeded cells
Alloderm: immunologically inert, nonliving, allogenic, acellular dermal matrix with intact basement membrane prepares wound bed for grafting
Tegaderm
Used for simple shallow wound dressing Protects from water loss mechanical injury and drying
TransCyte (ECM matrix generated by allogenic human dermal fibroblasts serves as a matrix for neodermis generation
ORCEL: Composite cultured skin. Fibroblasts, keratinocytes seeded on opposite sides of bilayered matrix of bovine collagen
living allogenic dermal fibroblasts grown on a degradable scaffold. Good resistance to tearing
Pharmacologic therapy• Antimicrobials
• PDGF- becaplermin- (Regranex) US-FDA approved – dibetic foot ulcers
• EGF- under trial
• VEGF- under trial
• Vit A
Beta-Glucan stimulates macrophage activity and promotes rapid wound healing.
Beta-Glucan Collagen mesh or Glucan II (Beta-Glucan) mesh. Rapid healing without dressing
BIOLOGIC DRESSINGS
CCS
HONEYSOFT
Natural dressingHoney-impregnated dressing Chronic unhealing wounds. Impregnated into a compress of EVA (ethylenevinylacetate) mesh
Honey cleans the wound without disturbing it
Removing the dressing causes no damage no known side effects
Effects of honey and sugar dressings on wound healing.Mphande AN1, et al
NPWT/VAC
• expeditiously prepare a wound bed for surgical closure by tertiary intent
• works through - relief of edema, improving interstitial diffusion of oxygen to cells, removes deleterious enzymes
• most wounds will heal optimally with a pressure of 125 mm Hg, other wounds may only tolerate a setting of 75 mm Hg before capillary flow is occluded
NPWT/VAC• Indications- lymphatic leaks, venous stasis ulcers,
diabetic wounds, wounds with fistulae, sternal wounds, orthopedic wounds and abdominal wounds
• Some instances, it has enabled avoidance of free flaps can also be used to assist the neovascularization of skin grafts and tissue engineered skin substitutes
• Contraindications- malignancy, ischemia, inadequately debrided or badly infected wounds
Wound Vac Demonstration - YouTube (480p).mp4
Hyperbaric Medicine• (HBO) (typically, 100% O2 saturation at 2 to 3 ATA) raises the
dissolved oxygen saturation in plasma from 0.3% to nearly 7%.
• Stimulates angiogenesis and fibroblast migration, enhances neutrophil and antibiotic killing action, and suppresses alpha toxin production in gas gangrene.
• If the periwound area/extremity demonstrates a rise in tcPO2 when the patient inspires
supplemental oxygen, the patient is
likely to benefit from HBO.
Patients with irradiated skin or steroid users
• Patients who are on steroids should receive vitamin A (25,000 IU daily by mouth or 200,000 IU topically t.i.d.)
• The progressive endarteritis obliterans and microvascular damage, along with fibrotic interstitial changes, results in a wound marked by ischemia, hampered by cellular senescence, and prone to infection
Pressure sore care• Should be aggressively nourished and receive vitamin
supplementation
• Administration of growth hormone or anabolic steroids
• Debridements
• Dressings
• Air-fluidized beds, air mattresses, air floatation and water floatation devices, and low air-loss beds.
Wound Care in Patients with Diabetes
• components of pressure necrosis, functional microangiopathy, and true neuropathic derangements
• Selective debridement, control of glucose levels, pressure offloading
• Revascularization
• use of growth factors
Stem cells in wound therapy
• Stem cell-based therapies have the potential to enhance cutaneous regeneration, largely through trophic activity.
Stem Cells in Wound Healing: The Future of Regenerative Medicine? A Mini-ReviewDuscher D et al
Despite the multiple barriers to clinical implementation, stem cells have shown sufficient promise to garner a place in the field of regenerative medicine.
References
• Campbell book of Orthopaedics• Rockwood and Green book of
Orthopaedics• Bailey and Love short practice of Surgery• Internet
Questions in exam
• Wound coverage in Orthopaedics?• VAC therapy?• Skin graft?• Flaps?• Wound healing?
top related