Exam 1 Lec 7-12

Question 1

Lec 7 Principles of Hemostasis

Answer 1

• Hemostasis
• Surgical Hemostasis
• Ligatures
• Topical hemostatic agents
• Energy-based surgical hemostasis

Question 2

What is one of the advantages of Surgical Hemostasis?
How can low-pressure hemorrhage from vessels be controlled?
Why should the sponge be removed gently?
Give examples of hemostatic instruments?
How long should the mosquito hemostats be grasped on the small vessel?

Answer 2

1. It allows proper visualization of tissue during the procedure
   - It prevents life-threatening hemorrhage
2. Applying pressure to the bleeding points with gauze sponges
3. Once the thrombus forms it can be disturbed, so be gentle. Soaking the sponge with saline may help prevent this issue.
4. Mosquito forceps, for small vessels.
   * *The vessel is grasped and clamped with the forceps for several minutes until coagulation occurs**

Question 3

What vessels need to be ligated?
What type of ligatures may be indicated for larger arteries and why? What size suture is best?
What is another type of vascular ligature? Compare the two.
Where does the circumferential need to be placed?
Does the Vascular ligation start or include a surgeon’s knot?
Which knot is more secure, millers or surgeon’s?

Answer 3

• Large vessels DOUBLE LIGATURES
• Transfixation ligatures to prevent the ligature from slipping off the vessel
• The smallest size possible bc of knot security
• Circumferential ligature: it is less likely to bleed but more likely to slip off than transfiguration. It needs to be placed closer to the heart with regard to blood direction flow.
• NO SURGEON’S knot: surgeon’s knot are for tissue under pressure, the circumferential stops the pressure.

Question 4

What are some examples of topical hemostatic agents?
How do they work and on what tissues?
What type of product should not be used in skin incisions and why?
Which ones are non-absorbable, absorbable, how long does it take?
What are two issues with Gel foam?
Which one is a substrate for clot formation?
What issues may be present with Surgicel?

Answer 4

• Bone Wax: sterile mixture of beeswax, paraffin, and isopropyl palmitate. Pressed into bleeding channels of bone. TAMPONADE EFFECT. Non-Absorbable, use caution.
• Gelatin-based Hemostatic Products
  a. Gel foam: Absorbable 4-6 weeks, forms matrix initiates clotting through contact activation. It swells and exerts pressure on the wound. May harbor bacteria, and may exert unnecessary pressure on neighboring vital structures. Liver biopsy 6mm punch holes.
  b. Vetspon
• Cellulose-based Hemostatic Products
  a. Surgicel: Absorbable cellulose sponge more like 4x4 gauze appearance. SUBSTRATE. It can be cut to desired size. Removal is recommended may inhibit callus formation and promote infection. Not activated by tissue fluids other than blood. Use only on site of hemorrhage
• *Gelatin products should not be used in skin incisions as they interfere with healing**

Question 5

Energy-based Hemostasis-Electrosurgery

What is the difference between Electrocautery and Electrosurgery?

Answer 5

-Electrocautery: Electrical current does not enter patient. It coagulates small vessels or cuts tissue by using heat generated by direct current into METAL WIRE or PROBE.
-Electrosurgery: generating heat inside the tissue using an alternating electric current that passes through the tissue creating a circuit.
Electrocautery refers to direct current (electrons flowing in one direction) whereas electrosurgery uses alternating current. In electrosurgery, the patient is included in the circuit and current enters the patient’s body.

Question 6

What size of vessels does electrosurgery work for? How does it affect neuromuscular stimulation?
What is the name of the devices used for electrosurgery?
Why is adequate grounding important?
How or what can you use to prevent potential patient burns?
Is the groundplate necessary during Bipolar electrosurgery? When is bipolar mostly used?

Answer 6

• 1.5-2mm in diameter
• Larger vessels should be addressed by ligation, hemostats, etc.
• Minimal neuromascular stimulation without risk of electrocution.
• Constant waveform, less heat, vaporizes tissue, creates coagulum.

Monopolar & Bipolar

MONOPOLAR

• Most common
• Handpiece (active electrode)
• Patient
• Ground piece
• If an adequate low-impedance ground pad is not present, the circuit will inadvertently use alternate paths to ground, and as a result will burn the patient.
• Use a large pad in good contact on a well-vascularized are of tissue (e.g., under chest).
• Keep electrodes clean for adequate performance and lower resistance within circuit.
• *Prevent burns**
  a. Towels damped with water or gel on metal ground plates
  b. Patient return electrodes improve contact over metal plates.
  c. Some models monitor impedance levels
  d. Dry field, clean electrode minimal to no blood on it.
  e. Direct contact with tissue produces lower heat sufficient to coagulate
  f. Indirect contact involves touching the electrode to an instrument. This technique is more precise, your gloves prevent shock.

BIPOLAR

• Forceps-like hand-piece
• Current passes from one tip of the forceps to the opposite tip through the tissue being held between the tips.
• 1 mm apart
• Ground plate not necessary
• Used when precise coagulation is necessary and to prevent damage to adjacent structures, such as during spinal surgery.

Question 7

How does Radiosurgery function and what pieces are involved?
Carbon dioxide Laser
Vessel Sealing

Answer 7

Radiosurgery

• Energy is generated by a low-temperature, high-frequency current (4.0 MHz).
• Radiowaves pass from one active electrode in the hand-piece to a passive electrode beneath or near the patient.
• Precise tissue dissection
• Excellent incissional hemostasis.
• Minimal thermal damage to the surrounding tissues.

Carbon Dioxide Laser

• Most widely used laser in small animal surgery
• Tissue vaporization occurs as this light energy is absorbed by water into the soft tissue
• Little heat dissipates to surrounding tissue.
• Carcinomas, tumors in ears, declawing
• Less inflammation
• Less pain
• Decreased risk of infection
• Soft palate recession

Vessel Sealing

• Electrothermal feedback-controlled, bipolar vessel sealing
• Vessels up to 7mm in diameter
• Uses pressure and pulsed low-voltage energy to fuse COLLAGEN and ELASTIN
• LAPRAROSCOPIC and THORACOSCOPIC
• *SOFT PALATE RESECTION**

Question 8

Lec 8 Surgical Attire and Surgical Suite

Answer 8

• Surgical apparel
• Hand disinfection
• Alternative surgical attire
• The surgical suite

Question 9

What are some of the problems with surgical site infection? What is the goal of aseptic technique, sterility?

Answer 9

• Infection, increased hospitalization time/treatment, increased cost, increased mortality, animal pain, decreased owner satisfaction.
• We want to decrease hospitalization time
• Clean does not mean sterile, dirty is contaminated.

Question 10

What is asepsis and sterile?
What are the barriers of infection?
List items of the surgical attire
How should you wear the surgical scrubs top?

Answer 10

Asepsis: removal of pathogenic organisms
Sterile: Removal of all microorganisms (+/- spores).

Barriers of Infection

1. Environmental
   - surgical suite
   - Equipment and instruments
2. Surgical staff: SKIN people contribute the most to potential contamination. Talking, skin exposure, active movement in or out of the OR.
   - Surgeon
   - Ancillary staff
3. Patient
   - Drapping
   - Skin preparation

Surgical attire

• Gloves: should cover non-water resistant cuffs of gowns. Some times double gloving in LA surgery, orthopedic surgery thicker gloves. Punctures most common in thumb and index finger. Own it!
• Gown (second barrier against skin shedding). Water resistant, but comfortable and breathable. Lint free
• Colic gowns for LA water proof.
• Surgical shoes or foot covers: not useful for LA.
• Face mask: redirects airflow from surgical site. NOT bacterial filters. DON’T TALK. Wear in OR after sterile prep is initiated. Effectiveness <2hrs
• Cap, head cover: reusable should be washed every time. All hair covered.
• Scrubs (first barrier against skin shedding), top tucked in, and covered with lab coat when out of surgery.

Question 11

Hand Disinfection
How long should fingernails be?
What does the ideal hand scrub include?
What is the most important factor in hand disinfection/scrub?

Answer 11

-Scrub reduces normal bacterial flora and other skin protective layers
-Increases change of colonization from pathogenic bacteria. Normal flora returns pre-scrub 8hrs or 2-3 days recolonized.
Goals:
a. remove dirt and soil
b. remove kill transient organisms
c. reduce resident population of bacteria
e. Dirtiness around nails removal
-Nails <2mm, moisturizer, no jewelry

Chlorhexidine gluconate: immediately bactericidal, residual activity potentially inactivated by soap and hand cream
Povidone-iodine: poor residual activity, can cause skin irritation
Alcohol based: Ethanol, isopropanol, n-propanol. Rapid and immediate action. Less irritant

1. Quick
2. Effective
3. Cost-effective
4. Non-irritating
5. Residual action

Hand disinfection technique

1. Preliminary cleaning
2. Under nails
3. First with brush, subsequent brushless from tips of fingernails to elbow.
   * CONTACT TIME*2-5 minutes

Question 12

Alternative Surgical Attire

Answer 12

• Dirty Surgery: sterile gloves only LA field surgery

- Variation, usually no hat or mask, but gown over coveralls.

Question 13

What are some important factors about Surgical Facility?

Staffing the Surgery Area

Answer 13

1. Ergonomic
   - Traffic flow should be minimal
   - Keep doors closed
   - Storage separate from OR
   - Area for instrument preparation separate.
   - Clean and dirty rooms should be 400 sq ft or larger.
2. Easy to clean
   - Floors and walls easy to clean
   - Well-placed drains
3. Well ventilated
   - Temp 68-73
   - Humidity 30-60%
   - Air under mild positive pressure
   - Ideal = Laminar air filtering system through HEPA filter
4. Wall outlets, etc.
   - Above waist height
   - Enough outlets
   - Emergency generator for at least one outlet and light

Staffing

• Ideal 3 people minimum: anesthetists, technician, surgeon
• Operating room supervisor: stock items, surgery log, controlled substances

Question 14

Lec 9 Principles of Tissue Handling
What are the three heuristics (elements of the skill) types in surgery?
What are Dr. William Halsted’s principles?
Are tourniquets ever used?
How does the Aberdeen knot compare to the square knot?

Answer 14

• Surgical technique
• Surgical principles Dr. William Halsted
• Instrument handling
• Tissue dissection and manipulation
• Suturing
• Knot tying
• Aberdeen Knot

Question 15

Why is good surgical technique important?
What are the three heuristic (elements of a skill) elements in surgery?
What are William Halsted’s surgical principles?

Answer 15

• It affects the outcome
  1. Cognitive: planning movements
  2. Perceptual: recognizing tissues
  3. Motor: handling tissues.
• *Good surgeon performs with less repetition and fewer mistakes than the novice**
• Surgical movements are incremental: trade off between speed and accuracy.

William Halsted

1. Meticulous techniques
   - Handle tissue gently
   - Control hemorrhage meticulously
   - Observe strict aseptic technique
   - Eliminate dead space
   - Appose tissues accurately with minimal tension
2. Hemostasis
   - Preserve blood supply to tissues
3. Local anesthetics
4. Patient care

Question 16

What are the surgical techniques involved in Tissue Handling?

Answer 16

• Instrument handling: correct instrument selection prevents tissue crushing, drying out, heat loss, hemorrhage, and loss of vascular supply. Hand tremors unwanted.
• Tissue dissection and manipulation
• Suturing
• Knot tying
• Hemostasis
• Wound closure

Scalpel

• perpendicular to skin
• Full thickness incision with single sweep
• Motions:
  a. Sliding
  b. Pressing
  c. Sawing: experienced
  d. Scraping: experienced

Scissors

• Cut or dissect tissues
• Curved: >maneuverability and visibility
• Straight: mechanical advantage for dense tissue
• Blunt dissection
• Sharp dissection

Needle holders

• Inefficient use of needle holders accounts for more wasted time than poor technique with any other surgical instrument.
• Affects surgical efficiency and tissue trauma

Non-crushing type tissue forceps

• Doyen forceps
• May damage tissue depending upon the length of application
• Digital intestinal occlusion may be less traumatic alternative

Crushing type tissue forceps
-Allis and Bacock, should not be used on tissue to remain in the patient

Hemostatic forceps

• Isolation of bleeders
• Blunt dissection
• Curved tips upward facilitate ligature placement and decreases surgical time
• Minimal ratcheting desirable

Thumb forceps

• As fine tooth as it is required for the task
• Do not use on intestine during anastomosis

Towel clamps

• Clamp just enough to do the job
• careful with what is under the drape
• Do not clamp mammary glands or testicles
• Lorna Edna (non-penetrating)
• Backhaus (penetrating)

Retractors

• Improve exposure and speed surgical time
• Avoid sensitive structures, vessels, nerves.
• Avoid excessive opening
• Avoid pressure injury, ischemia (obstruction of blood flow).

Suction tips

• Poole: body cavities
• Yankauer: oral cavity
• Frazier: neurosurgery
• Proper adjustment, caution around vital tissue
• Choose appropriate tip

Question 17

Tissue Dissection and Manipulation

Answer 17

• Pay attention to lines of tension
• Limit manipulation of tissue
• Cautious and deliberate
• Dissect along the tissue planes (sharp or blunt)
• Know when to use fingers instead of instruments
• Keep tissues moist!!
• Keep patient warm!!

Question 18

Suturing & knots

Answer 18

• The right pattern
• The right needle
• The right suture
• Do not overtighten!
• Avoid ischemia

Knots

• Secure knots
• appropriately buried
• absorbable suture when in contact with body fluids
• Abdominal sutures: leave space between the knots and the skin
• Continous closure is faster

Question 19

Aberdeen Knot
What is the volume compare to the square knot?
What is the knot holding capacity?
What is it used for?

Answer 19

• After a continuous line, similar to quick release knot
• 4 throws make it secure
• It is used as an alternative to the square knot at the end of a continuous line, when the surgeon is left with a loop and a free end.
• Knot volume 32-56% of square
• Holding capacity 24% greater than square

Question 20

Lec 11 General Surgery Etiquette & Procedures

How can we reduce contamination through surgical attire?

Answer 20

-Lab coat bottomed up after leaving the OR

Question 21

Lec 11 General Surgery Etiquette & Procedures

How can we reduce contamination through surgical attire?
How does LA vs. SA patient preparation differ?

Answer 21

• Lab coat bottomed up after leaving the OR
• Induction prep room wear lab coat
• *Patient barrier** Draping and skin preparation

Patient Draping and Skin preparation

• primary difference is anesthesia induction
• LA quick cleaning, SA no cleaning prior to inducing anesthesia unless animal is filthy
• SA: bathing does not reduce bacterial counts, but liberates deeper bacteria through open spores. Dries out skin. Hair must be dry prior to clipping, costs time and money.
• LA: groom and pick feet out prior to induction. Cover feet prior to skin preparation. May bath if necessary. May clip/rough prep while standing.
• Cows standing: TIE the TAIL, clip, block
• Clipping and initial skin preparation should be done in a different room than OR. Start with #40 then #10
• Clip at least 20 cm on either side of surgical site
• Vacuum hair
• Final skin sterile in the OR: use dedicated surgical scrub that stays in OR

Question 22

Technique for Surgical Site Preparation

1. Clip
2. Initial scrub
3. Move to OR
4. Sterile Scrub
5. Drape

What material is best for draping?

Answer 22

• One 4x4 per scrub
• Site of incision outwardly. Circle starts in center
• Scrub constant vs. alternating with alcohol are options
• !!Most important is contact time!!
• Never chlorhixidine nor alcohol for ophthalmic. Dilute povidine-iodine

Draping

Washable
-Pima cotton: can be treated to make water resistant for 75 washes. Higher thread count the better
Disposable
-cellulose, wood pulp, polyester, or synthetic.
-Lint free: lower particle count in air
-Must be reinforced with polyethylene or plastic film to be water resistant.
-Cover all visible surfaces of patient, except face
-Use double gloving when contamination is likely
-Place drape adjacent to incision first then move peripherally. DO NOT GO BACK to INCISION
-Quadrant with largest sheet on top
-Towel clamps should not penetrate below subsequent layers. Once clamp penetrates = contaminated
-Draping limbs = Loban and Vetrap

Question 23

How do you need to position the instrument table?
Who can go between the table and surgery site?
What do you need to do with the packs?
What about the table and light before setting up for surgical field?

Answer 23

SA

• Table close to the surgeon’s dominant hand if no assistant. EXCEPT NEUTERS.
• Only sterile people
• Non-scrubbed person NEVER extends their arm over sterile field
• Technician usually not sterile
• Get anesthesia as far as possible from surgery area
• Maximize location on table for surgical procedure
• NO instruments on patient.

LA

• Padding important to prevent nerve damage
• Instrument table by assistant, not at the end.
• Sterile backed gowns important!!

Packs

• minimize the time they are open, just right before surgery
• Check table height: arms bent and even with surgical field
• Double check patient’s position
• Turn on the light

Question 24

What is the general orders for opening the pack and table drape with and without assistance?
Who do you check with before you start cutting?

Answer 24

With assistance

1. open table drape or use outer pack drape as table drape
2. Open outer layer of pack and drop inner layer wrapped pack onto table “protect” your dirty arm
3. Open selected suture and scalpel blade onto pack, from distance.

Without assistance

1. Open gown
2. Open gloves onto gowns
3. Go scrub
4. Open pack to get drapes
5. Drape
6. Organize instruments
7. Cut

Check with anesthetist first!!

Question 25

What jobs are there for the assistant surgeon?

How do you pass an instrument?

Answer 25

• Organize table
• Count gauze sponges: radiopaque show on x-ray when left inside the patient.
• Count instruments
• Hand instruments
• Retract things
• Hold things
• Cut suture (the most important job): check length with surgeon before cutting
• Run suture

**Pass instrument like you mean it **

Question 26

Writing a surgery report
What is the goal?
What things are important and how do you go about it?
What about using templates?
Medical terminology?
What do you start the report with?

Answer 26

• Accurately report what occurred during the procedure
• Details are important and go in a step by step manner about it
• Include lengths, instruments, suture most everything used.
• Templates need to be tailored
• Use proper medical terminology
• Generic names, avoid brand names
• Not a lot of filler words, “then this” “that”

Parts
1. Start with animal being anesthetized/restrained (bried) and position.
“The dog was anesthetized and place in a dorsal recumbency in a V through” (table)
“The horse was anesthetized and placed in dorsal recumbency with both limbs suspended from dorsal leg brackets with carpal flexion 45 degrees.
2. Describe area prepared and how it was prepared
“The right flank from the second to last rib to tuber coxae was clipped and prepared for surgery using 1% povidone-iodine scrub and alcohol.”
3. Describe the approach: location, length (cm), and instruments used
“A 3 cm prescrotal incision was created with a #10 scalpel blade. The subcutaneous tissues were bluntly dissected with Metzenbaum scissors”

THE BODY REPORT

• Describe major findings (think pathology report) in order
• What was explored
• Describe major procedures in order

-Ligation, size of suture
-General (skin vessel ligated)
-Transection instrument used
-Blunt dissection
-Sharp dissection
-Implants placed: exact number, sizes, etc.
4. End with how the animal recovered from anesthesia
-“Animal recovered uneventufully from anesthesia.” “The horse remained recumbent for a prolonged period and required assistance to stand during recovery from anesthesia”
5. Incision closure
-Layers, patterns, suture, +/- needle type.
“The linea alba was closed with USP 3 polyglactin 910 in a simple continuous pattern. The subcutaneous layer was closed with 2-0 polydionanone in a simple continous pattern. The skin was stapled.”

Question 27

Lec 12 Open Wound Management

What are the most important initial steps in wound management?

Answer 27

• Wound need to be covered immediately clean towel or bandage to prevent further trauma and contamination.
• Assess the traumatized animal and stabilize its condition.
• Clip and aseptically prepare the area around the wound.
• Remove debris from the wound
• Culture the wound.
• Life-threatening injuries need to be stabilized first*
• Lavage the wound thoroughly
• Provide drainage
• Close if appropriate

Question 28

What is the “GOLDEN PERIOD” how long?

What is the difference between an infected and contaminated wound?

Answer 28

• First 6-8 hours between wound contamination at injury and bacterial multiplication to greater than 10^5 CFU per gram of tissue.
• Infected >10^5 CFU per gram of tissue. They are usually grossly dirty and covered with a thick, viscous exudate.

Question 29

What is Contamination, Colonization, Infection?

What are the classification of wounds?

Answer 29

• Contamination: presence of microbes on surface
• Colonization: surface microorganisms are replicating
• Infection: invasion and replication of microbes within the tissue.

Classification

• Class 1: 0-6 hours, no infection.
• Class 2: 6-12 hours, no infection.
• Class 3: older than 12 hours, infection likely.

Types of wounds

-Abrasion: superficail. Sensitive to pressure. Heal rapidly
-Puncture Wound: small skin opening with deep tissue contamination and damage. Damage proportional to missle velocity.
-Laceration: may be superficial or deep and have irregular edges. Created by tearing that damages skin underlying tissue and muscles, etc.
-Avulsion or Degloving injury: tearing tissues form their attachments and creating of skin flaps.
a. Anatomic degloving: skin and various levels of underlying tissue are torn off the limb.
b. Physiological degloving: skin surface is intact but separated or avulsed from underlying subcutaneous tissue and blood supply.
-Thermal burn: caused by heat or chemicals. Risk of infection and sepsis is high.
Possible:
a. Severe fluid loss
b. Electrolyte loss
c. Protein loss
-Crush injuries: combination of other types of wound with extensive damage and contusions to skin and deeper tissue.
-Decubital Ulcers: result of compression of the skin and soft tissues between a bony prominence and a hard surface. Results in skin loss over the bony prominence. May extend into deeper soft tissue and bone. Often seen in recumbent animals

Question 30

Which type of wound heals by first intention and is associated with surgical procedures?

Answer 30

1. Primary wound closure: First intention healing
   - minimal trauma, heal by first intention, wedges are apposed.
   - within hours of injury
2. Delayed primary closure
   - Appositional closure Within 3-5 days
   - Before granulation
   - Mildly contaminated
   - Require some cleansing, debridement and open wound management
3. Healing by Contraction and Epithelialization (Second Intention Healing)
   - Wound left open to heal
   - May be inefficient and fail to produce a functional outcome
   - Dirty wounds, contaminated wounds, traumatized wounds.
   - Some cleaning and debridement, but no primary closure.
   - May be secondary closure an option
4. Secondary Closure (Third intention healing)
   - Appositional closure >5days after wounding over the granulation tissue, some debridement may be necessary
   - Granulation tissue formed in bed: microbial resistance and vascular substrate.
   - Severely contaminated
   - Severely traumatized
   - Infected

Question 31

What does the Solution to Pollution is Dilution mean?
Immediate wound care
Should chlorhixidine or povidone-iodine be used?
What does wound irrigation accomplish?
Do antiseptics have an effect on established bacteria?
How can you irrigate with 7-8 psi?
Is it better to use higher pressures and why?

Answer 31

-Copious irrigation (even with tap water)
-Cover wound with antimicrobial agent
-Bandage to protect
-Clipping and prepping the are around the wound
-Water soluble lubricant
-Close temporarily with staples or Michael clips.
-Alcohol is very damaging to exposed tissue and should be used only on intact skin
!!!NO Detergents or antiseptic scrubs!!
-Sterile isotonic saline or balanced electrolyte solution (lactated Ringer’s solution) is the preferred lavage solution.
-No distilled or sterile water

Wound irrigation: removes bacteria mechanically and loosens necrotic debris.

• May use nontoxic wound cleansers: soften necrotic tissue and act as surfactant allowing easy rinse off.
• Antiseptics have little to no effect on established bacteria.
• To generate 7-8 psi, 1 liter bag of fluid within a cuff pressurized to 300 mmHg needle 18 gauge. Saline 0.9%
• Not better to use higher pressures. Damage to underlying tissue. Reduce resistance to infection.

Question 32

What does debridement involve?
How can devitalized tissue be removed? such as muscle, contaminated fat?
What to do after surgical debridement?

Answer 32

• Removal of necrotic or damaged tissue, foreign bodies, microorganisms, etc.
• The goal is to obtain fresh clean wound margins and bed for primary or delayed closure to be possible

Devitalized tissue removal:

• Wet-dry bandages: adhere to surface and pull the debris off wound. Maintain moist wound environment and absorb exudates. Effective in early stages, but debridement is painful and non-selective
• Biosurgical methods: maggots (Lucilia sericata). Best suited for necrotic, infected, or chronin nonhealing wounds. They promote granulation tissue formation.
• Enzymes: used in adjunct to lavage and surgical debridement. Beneficial in poor anesthetic risks. Do not damage living tissue. Break down necrotic tissue and liquefy coagulum and bacterial biofilm. Must remain in contact with wound.
• Surgical excision: sharp dissection, electrosurgery, laser. Begin at surface. Muscle until it bleeds and contracts. Subcutaneous should be avoided. Fat can be deliverately excised. Cutaneous vessels should be spared. Danger or removal of excessive amount viable tissue.
• *With penetrating wounds it may be necessary to enlarged the wound for proper assessment**
• Autolytic mechanisms: enzymes dissolve nonviable tissue. Highly effective and preferred over surgical method. Less painful. Accomplished with hydrophilic, occlusive, semiocclusive bandages.

After surgical debridement

• Hydrophilic dressing
• Wound drainage
• Wound closure

Question 33

When is it appropriate to use antibiotics? topical antimicrobials and antibiotics?
Are oitments good at treating infection?
Which is the drug of choice for Burn wounds?
Which one penetrates necrotic tissue?
Which broad-spectrum antibacterial and hydrophilic medicine is useful to treat wounds?
Which ointment is effective against Gram-negative including pseudomonas?
Which is particularly useful in severely contaminated wounds and effective agaist pseudomonas/Clostridium?

Answer 33

• Severely contaminated, crushed, or infected wounds, or older than 6-8 hours, typically bnefit from antibiotic therapy.
• Based on culture and susceptibility testing

Topical

• Bacitracin, Neomycin, Polymyxin.
• Efficacy against pseudomonas is poor
• More effective in preventing that treating
• preferred in open wounds
• Apply 1-3 hours of contamination
• Powders act as foreign bodies DO NOT USE

Burn wounds

• Silver Sulfadiazine
• Effective against most gram positive/negative and most fungi.
• Serves as antimicrobial layer
• Penetrates necrotic tissue

Nitrofurazone

• Hydrophilic properties: draw body fluid from wound tissue
• Little effect against pseudonomas
• Delays wound epitheliaziation
• Loses some antibacterial effect organic debris presence

Gentamicin Sulfate
-Used before and after grafting wounds

Cefazolin

• Gram positive and some Gram negative
• Topical antibiotic in wound fluid.
• Wound irrigation produces higher concentrations for longer periods.

Mafenide

• Topical Sulfa
• Pseudomonas and Clostridium spp.

Honey Sugar

• Early in wound healing
• Discontinue once granulation starts
• Attracts macrophages
• Provide cellular energy

Question 34

What are some of the benefits of vacuum assisted closure?

Answer 34

• Increased rate of granulation
• Accelerated healing times
• Wound cleaning
• Improved blood flow
• Reduced edema