WOUNDS-WOUND HEALING & CARE Begashaw M. Layers of Skin.

WOUNDS-WOUND HEALING & CARE

Begashaw M

Layers of Skin

DEFINITION

• Wound - break in normal continuity of a tissue

• cause - transfer of any form of energy

WOUND HEALING

• is a complex biologic process of restoring normal tissue continuity

• integrated sequences of events leading to cellular proliferation and remodeling

• starts immediately following the event of wounding

Wound Healing

Phases of healing

1-Coagulation phase• first phase • is induced immediately following injury• characterized by vaso-constriction, clot

formation and release of platelets

2- Inflammatory phase

• takes place from time of wounding up to 3 days

• Characterized:

inflammatory response

vasodilatation and pouring out of fluid

migration of inflammatory cells and leukocytes

rapid epithelial growth

3- Proliferative Phase

• phase of fibroplasia• starts around the 3rd day of injury• stays for about 3 weeks• is characterized

-fibroblast, epithelial and endothelial proliferation

-Collagen synthesis & ground substance

-blood vessel production

4- Maturation phase

• phase of remodeling• takes the longest period - up to 1 yr• Equilibrium between protein synthesis

and degradation occurs • with cross linking of collagen bundles

leading to slow and continuous increase in tissue strength

Stages of Wound Healing

Stages of wound healing

Cells in Wound Healing

Clinical types of healing

• Healing by first intention

- clean wound closed primarily

- healing by epithelialization

- minimal scar

- <6 hours, longer with facial• Healing by Second intention

- in wide, contaminated wounds

- not primarily closed

- healing by granulation tissue formation

- tissue contraction and epithelialization

- inferior cosmetic result

Healing by third intention:

-left open initially

-closed later-delayed primary closure

-In contaminated -long time lapse since initial injury-severe crush wound

Factors affecting healing

Local factors

-Ischemia

-decreased oxygen tension

-foreign bodies

-tension

-Infection

-Irradiation

Systemic factors

-Systemic diseases-DM, cirrhosis, renal failure, malignancy

-malnutrition

-immunosupression-Drug- steroids,

cytotoxic agents

WOUND ASSESSMENT AND CLASSIFICATION

Assessment History

• Mechanism of injury

• Time

• Place and circumstance

• past and current medical• immunization history

physical examination

• Extent of skin loss

• Degree of circulation

• soft tissue injury• The degree of contamination

• foreign body • tissue necrosis

Classification of wounds

• Closed wound

- an intact epithelial surface

- skin cover not completely breeched

e.g Contusion

Bruise

Hematoma

• Open wounds

- complete break of the epithelial protective surface

E.g Abrasion

Laceration

Puncture

Bites

Open wounds

Tidy• Incised• Clean• Healthy tissue• Seldom tissue

loss

Untidy• crushed• Contaminated• Devitalised

tissue• Often tissue loss

Classification of Wounds

ClassificationCriteriaRisk (%)

Clean Elective, not emergency, non traumatic, primarily closed; no acute inflammation; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered

< 2

Clean-contaminated

Urgent or emergency case that is otherwise clean; elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g., appendectomy) not encountering infected urine or bile; minor technique break

< 10

Contaminated Non purulent inflammation; gross spillage from gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique; penetrating trauma < 4 hours old; chronic open wounds to be grafted or covered

~ 20

Dirty Purulent inflammation (e.g., abscess); preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract; penetrating trauma > 4 hours old

~ 40

Classification of Surgical Wounds

• Clean(no viscus opened)• Clean-contaminated(viscus opened

minimal spillage)• Contaminated(open viscus with

gross spillage or inflammatory ds)• Dirty(pus or perforation or incision

via abscess)

WOUND MANAGEMENT-Priority: ABC

-Stabilize-correct life threatening conditions

• history & P/E -associated injuries

• Assess wound

• treatment

• Follow up

Proper wound care:

• stop bleeding

• irrigation

• debridement

• decision -to close

-leave the wound open

• antibiotics• tetanus prophylaxis

• correcting systemic disease

primary wound closure

• Clean wounds

• Clean-contaminated wounds -if they can be converted into clean wounds

• all missile wounds, animal & human bites should never be primarily closed

• in wounds within 6-8 hours

Delayed primary closure

• for traumatic or contaminated wounds• within 3 days

Secondary closure

• wound left open to heal spontaneously

• contraction (myofibroblasts) and granulation

• requires dressing change• inferior cosmetic result• indication: when 1° closure not

possible or indicated

Specific management

• Bruises -Superficial

-no specific management

-local compress

-analgesics

• Hematoma • collection of

extravasated blood• Management:

- absorbed spontaneously

- Local compress to alleviate pain

- aspiration-very large/ over a cosmetic area

Abrasion

• is rubbing or scraping of skin or mucous membrane -variable depth

• affect only a part or full layer of skin• Management

- Cleanse using scrubbing brushes

- Use antiseptic or clean tap water and soap

- Analgesic

Punctures

• involve deeper structures• opening relatively small as compared with

depth (e.g. needle)• Management:

- Evaluate the depth

- Remove

- Excise damaged tissue

- Cover with antibiotics

- Tetanus prophylaxis

Lacerations- open wounds - knife, or glass- cut or torn tissue• Management:

- cleansing

- Closure

- wound debridement

- antibiotic

- Tetanus Prophylaxis

- Analgesics

Laceration

Crush and avulsion wounds

complicated wounds have more extensive damage caused by compression Management:

- life threatening conditions

- debridement- Early skin cover- late graft

- wound left open if contaminated

- antibiotics

- Tetanus Prophylaxis

- Analgesics

Crush & avulsion

Debridement

Missile injuries

• compound , complicated• excessive tissue damage• high degree of contamination• severe life threatening• Management

- stabilize

- debridement- Antibiotics- Tetanus Prophylaxis - analgesics

- avoid primary closure

Human bites• heavily contaminated • due to polymicrobial-Staph> a-hemolytic

Strep > Eikenella corrodens >Bacteroides• Management

- culture - Scrubbing- irrigation with saline

- debridement

- Leave wound open

- Broad-spectrum antibiotic-augmentin

- Tetanus Prophylaxis

Dog bites• can transmit the rabies virus• animal observation for 10 days Local- irrigation and repeated swabbing - flushing -soap & water/ antiseptics

- anti-rabies serum infiltration

- leave wound open Systemic

- Post exposure anti rabies prophylaxis (1ml, IM) on the 1st, 3rd, 7th, 14th and 28th day

- Tetanus prophylaxis

- Antibiotics

Dog bite

Snake Bites

• First aid :

- irrigation

- pressure bandage proximally

- Immobilize

- Transport to hospital

Hospital Measures- Identify species

- lab- hemoglobin, renal function

- Anti-venom injection

- Supportive care

- Rest

- IV-infusions to combat shock

- Antibiotics

- Blood transfusion

- Tetanus Prophylaxis

- Wound excision

- Fasciotomy for compartment syndrome

WOUND COMPLICATIONS

• Local

- Hematoma

- Seroma

- Infection

- Dehiscence

- Granuloma

- Scar

- Contracture

• systemic

- shock -massive bleeding

- bacteremia & sepsis- death

Hypertrophic Scar

Hypertrophic Scars

Keloid

Keloids

Questions?