7-8. Wounds and wound management Flashcards
- CLASSIFICATION OF WOUNDS (lot asked in exam)
- open wound:
-surgical incision & laceration=edges usually clean and free from tissue damage, not get infected (clean, minimal contamination), deep wound, surgical management (low level of injury and contamination), good vascularization
-abrasion=superficial damage not beyond dermis, heavily contaminated (hit by car)
-avulsion =separation of tissue from their deeper attachments >
and degloving = skin and deeper tissues torn from extremity like glove from hand; physiological degloving=car damage not notice first day(wound avulsion) OR mechanical degloving=scratch when car hitter
>avulsion and shearing injuries: loss of deeper tissue; deeper gloving, joints of distal limb frequently exposed, prone to infections!!!, open wound management
-puncture: bite/sting: cat/dog; snake; insect; tick >open wound management; damage assesment ; contamination/infection variable
-burn: thermal; chemical; electrical; radiation
-pressure sores =elbows and hocks of large dogs, open or closed wounds, open sores prone to infection (bone and joints), hygromas
-cast-and bandage-related=iatrogenic wounds most common!>ischemic injury due oversight application of bandaging, not proper padding, excessive exercise, wet or dry bandage, serious wounds may result loss of digits or limbs - closed wound:
-contusion (mustelma)
-hematoma
-crush injury
-hygroma
Most important in wound healing and in tissue wound healing
-blood supply: subdermal plexus
- Blood supply of the (canine and feline) skin and clinical importance
-direct cutaneous arteries: parallel to skin in hypodermic, arise from perforator arteries
-musculocutaneous arteries: perpendicular to skin surface, supply small portions of skin
-subdermal plexus is of major importance
- Wound management options
-surgical management on incisional injuries and lacerations
-surgical vs. open wound management for abrasions
-surgical/open wound management/in combination for avulsions
-damage assessment on puncture wound! open wound management
- Phases of wound healing (also beginning and duration of each phase)
-4 distinctive phases
1. acute inflammatory phase=
>characterized by (5): redness, pain, heat, swell, loss of function
>5 days
>filling with blood and lymph
>immediate vasoconstriction of damaged vessels 5-10min
>vasodilation (dilute toxic substances, provide nutrients and results in blood clot)
>epithelial cells begin to migrate from wound periphery onto exposed tissue
>blood clot dries to form scab
>WBC leaks into wound initiate 2.phase
- debridement phase (breakdown)
>6-12h after injury
>formed inflammatory exudate provide all necessary phagocytic cells and proteolytic enzymes to deal with demarcation
>exudate (of WBC, dead tissue, wound fluid) forms on wound
>necrotic tissue impedes wound healing
>phase ends with rejection of nonvital tissue
>sometimes combined with phase 1 - proliferation phase (reparation)
>3-5days after injury
>signs of inflammation subside
>repair phase
>divided into 3 processes: granulation, wound contraction, epithelization
>neovascularization
-granulation: rate 0.4-1mm/24h
-wound contraction: 5-9 d.after wounding
-epithelialization:proliferation of basal epithelial cells from adjacent skin edges -move over and adhesion to surface of wound - maturation phase (remodeling)
-result as remodeling of tissue
-weeks to year
- Wound healing differences in canines and felines
-intact skin of cats less perfused compared to dogs
-breaking strength of wound 50% less in cats 7 days after primary closure
-formation of granulation tissue takes longer in cats and first appears only at wound edges
-pseudohealing more common in cat
- Protocol for wound management (traumatic wounds)
-many will heal naturally
-need intervention:large, necrotic, infected
-management: 1. stabilization of patient, 1. stopping bleeding (pressure: special dressings for minor wounds - adrenaline.soaed gauzes)
2. reduction of level of contamination, clipping area (ideal up to 4-6h after wounding to prevent bacterial infection) : covering wound, clip and aseptically prepare, culture wound, decried wdead tissue and remove foreign debris from wound, lavage wound throughly, provide wound drainage, promote healing by stabilizing and protecting cleaned wound, perform appropriate wound closure
-dirty or contaminated wound = wound irrigation(lavage), not too high pressure, Ri-Lac or isotonic saline
-debriment: debris or necrotic tissue:
-surgical (most common, remove all necrotic tissue nd debris),
-mechanical (wet-to-dry=changed until granulation, or dry-to-dry dressings=without wetting until granulation; after layered surgical debriment,
-autolytic=moist envi, honey, hydrogels: painless
-enzymatic=proteolytic enzymes applied to wound to break down necrotic tissue
-chemical=nonselective method (cells important healing will also be damaged), with antiseptics, not recommended
-biosurgical =medical maggots (Lucilia sericata) into wound : produce enzymes that dissolve necrotic tissue but spare healthy tissue
Topical wound medications
- honey
- wound-gels
- ABs
- Open wound management
-until wound surgical closure= primary, delayed primary, secondary, drainage, tension lines
-superficial wounds
-dressing, bandage=
-wound-healing enhancers used
-healing process often time-consumin
-might need surgical intervention
- Wound closure options (depending on time of closure)
- primary= clean wounds, surgical wounds and contaminated wound > less 6hours old, direct closure of wound after lavage and debriment, sutures can be removed 1-2 weeks
- delayed primary=wound managed until it is clean and without formation of granulation tissue, then closed, closure 3-5 days after emergence of wound, allows for drainage of wound, decrease contamination and development of clear demarcation line between viable and necrotic tissue prior to surgery
- secondary=closure wound after formation of granulation tissue, contaminated or infected wounds, 2 methods;
>leave granulation tissue intact-separate edges of skin-excision of granulation tissue bed followed by primary closure
>second method preferred: wound edges more mobile, incidence of infection lower, cosmetic reasons - drainage=dead space can left behind; passive (Penrose drain) or active drains
>removal as soon as possible 2-4 days - wound dressings and bandages= dressing-directly surface of wound > bandage-wraps hold plain and medicated dressings in place , pressure to control hemorrhage, obliteration of dead space, protection from external trauma and contamination : primary layer (contact dressing), secondary (absorptive) layer, tertiary (protective) layer
- Functions (goals) of wound dressings/bandages
WOUND DRESSING:
-PROVIDE: moist and warm environemnt, aesthetic appearance
-PROTECT: from trauma, external contamination
-PREVENT: reduce edema
>application of topical medication
>immobilization of wound
>support wound edges
>absorb exudate
BANDAGES:
-appropriate material of adequate width
-smoothly to prevent irritation and skin necrosis
-each turn of bandage should overlap previous turn by 50%
-patients observed for discomfort, swelling, hypothermia, skin discoloration, dryness, odor
- PROTOCOL FOR WOUND MANAGEMENT - 10 POINTS
- clean room and aseptic technique
- obtain complete medical history of patient
- obtain info about cause and age of wound
- make complete assesment of wound
- debride necrotic tissue
- remove contamination
- choose appropriate method of closure
- choose appropriate dressing
- make regular assessments to monitor progression of wound healing
- when dealing with chronic wounds not responding to normal wound management, consider using advanced technique
Wound management best option
-Autolytic debriment : help own organism to heal quicker
>with scalper blade scrape area around wound
DEBRIMENTS
-surgical debriment (best, with scalper blade
-mechanical debriment
-autolytic debriment!!
-enzymatic debriment
-chemical debriment
-biosurgical debriment
