25. Protocol for wound management (traumatic wounds)

Question 1

25. Protocol for wound management (traumatic wounds)

Answer 1

Wound management
-many will heal naturally
-some need intervention(large,necrotic,infected)
-management
1)stabilization of the patient!
1)stopping the bleeding(pressure;special dressings for minor wounds[adrenaline-soaked gauzes etc.])
2)reduction of the level of contamination,clipping the area(ideally up to 4-6
hours after wounding to prevent bacterial infection)

Wound etiology
-identification of the causative agent necessary before initiating treatment
-trauma vs. dermatologic disease(including
parasitosis)vs. neoplasia vs. ?
-important to treat the underlying cause in case
of non-traumatic wounds
-some wounds are impossible to treat successfully

-temporarily cover the wound to prevent further trauma and contamination.
-assess the traumatized animal and stabilize its condition.
-culture wound.
-débride dead tissue and remove foreign debris from the wound.
-lavage the wound throughly.
-provide wound drainage.
-promote healing by stabilizing and protecting the cleaned wound.
-perform appropriate wound closure.

Wound irrigation (lavage)
-dirty or contaminated wounds can be cleaned by irrigation
-obvious debris,necrotic tissue,dirt and bacteria will be washed away by fluid under pressure
-irrigation pressure should not be too high because it may damage tissue and push contamination further into the wound
-minimal to moderately contaminated wounds–cleaning performed
using isotonic saline or Ri-Lac
-in selected patients,dilute antiseptic solutions such as 0.05% chlorhexidine or 1% povidone–iodine solution can be used

Debridement
-in case of debris or necrotic tissue
-anaesthesia often required
-objective to convert the open contaminated wound into a surgically clean wound
-different methods(choice depends on the patient):surgical,mechanical,autolytic,enzymatic,chemical,biosurgical
-more than one procedure may be necessary

Surgical debridement
-used most commonly
-goal is to remove all obvious necrotic tissue and debris
-difficult to distinguish necrotic nonviable tissue from healthy viable tissue during the inflammatory phase
-layered approach often used(superficial tissues removed first)
-removal to the level where active bleeding is present
-questionably viable tissue should be left in place and re-evaluated
-en-bloc debridement sometimes used(complete excision of the wound and all affected tissue)

Mechanical debridement
-performed using wet-to-dry or dry-to-dry dressings after layered surgical debridement or as the sole means of debridement
-wet-to-dry dressing(typically changed daily until granulation)
>primary dressing of gauzes wetted with isotonic saline
>several layers of wet gauze followed by several layers of dry gauze added
>as the bandage dries,it adheres to the wound surface
>adhering tissue is removed as the dressing is changed
-dry-to-dry– same procedure without wetting
-several disadvantages
-some authors believe that these dressings no longer meet the expected standard of care in veterinary medicine

Autolytic debridement
-creation of a moist wound environment to allow endogenous enzymes to dissolve nonviable tissue
-often preferred in wounds with questionable tissue viability
-highly selective for devitalized tissue
-can be performed with interactive dressings such as hydrogels,hydrocolloids,hydrofibres and foam dressings
-use of honey or sugar topically(attraction of fluid)
-painless
-slow process

Enzymatic debridement
-proteolytic enzymes are applied to the wound to break down the necrotic tissue
-wounds with small amounts of necrotic tissue or debris
-(trypsin,fibrinolysin,chymotrypsin,desoxyribonuclease,papain-urea
and collagenase)
-sometimes used as an adjunct to mechanical and chemical wound debridement
-effectiveness questionable
-slow process

Chemical debridement
-nonselective method(cells important for healing are also damaged)
-can be performed with antiseptics
-(Dakin’s solution,chlorhexidine, povidone-iodine,hydrogen peroxide)
-not generally recommended

Biosurgical debridement
-placement of medical maggots(Lucilia sericata)into the wound
-the maggots produce enzymes that dissolve the necrotic tissue,but
spare healthy tissue
-maggots specially bred,expensive
-may be indicated for management of deep wounds

Topical(paikallinen)antibiotics and antiseptics
-systemic(mouth,vein)AB preferred(only for infected wounds)
-the use of topical antibiotics and antiseptics is controversial–no
beneficial effect once infection is established
-do not replace proper debridement

Topical wound medications
-antimicrobials(tuhota/estää microorganismien kasvua) and antibiotics(tappaa bakteereja)
>triple antibiotic ointment
>silver sulfadiazine
>nitrofurazone
>gentamicin sulfate
>cefazolin
>mafenide
-wound-healing enhancers
>aloe vera
>tripeptide-copper complex
>D-glucose polysaccharide
>honey
>sugar
>growth factors
>hydrolyzed bovine collagen
>chitosan