Exam 2 - Wound Management & Healing Flashcards
what is the initial management done for a patient that presents with a wound?
patient assessment
bandage/cover wounds
analgesics
wound evaluation when patient is stable
what are the 7Cs/ABCs of acute wound management?
- clip
- clean
- copiously lavage
- cut
- cover
- coaptation
- +/- close & =/- antibiotics
what are the basic acute wound care principles?
- gloves - exam or sterile depending on the wound
- wide clip & copious lavage - don’t want to have to shave every day
- debride
- ensure adequate perfusion - won’t heal anything if they are shocky
why put lube into a wound?
fill with water soluble jelly & then shave the wound - must be water soluble
fur sticks to the jelly & washes away when lavaged
what is the purpose of lavaging a wound?
helps to reduce necrotic debris/contaminants & facilitate wound healing process
repeat every time you look at the wound
what liquids will you use for lavaging in acute wound management? what about further in the healing process?
tap water is okay to start - high volume of lavage
move away from tap water because it is hypotonic & will cause cell death - looking at saline instead
how much pressure is desired when lavaging a wound?
8 PSI
why not use a syringe with a 16G needle for lavaging a wound?
generates too much pressure - about ~16 PSI
too much pressure drives contaminants further into the wound - will become edematous
what is the best set-up for lavaging a tiny wound to get the ideal pressure?
fluid bag with a pressure thing on top set at 300 mmHg with any size needle attached to the line consistently gave 8 PSI
what does dr. thiemann prefer for lavaging a wound?
the thing that looks like a ketchup bottle
T/F: it is okay to use either a chlorhexidine scrub or solution for lavage solution in a wound
false - only can use the solution
what concentration of chlorhexidine solution do you want for lavaging a wound?
0.5% - need to dilute it, usually sold at 2%
take 25mL & put into 1L saline bottle - gives you the concentration
what solution will you chose for lavaging if there is a wound around an eye?
iodine/betadine solution - 1%
or even saline
what are the 4 phases of wound management?
- coagulation
- inflammation/debridement
- repair
- maturation
how long does each phase of wound healing last?
- coagulation/hemostasis - seconds to hours
- inflammation/debridement - hours to days
- repair/proliferative - days to weeks
- maturation/remodeling - weeks to months
what is going on in the coagulation/hemostasis phase of wound healing?
injury occurs & causes:
- vasoconstriction
- platelet aggregation
- leukocyte migration
what is going on in the inflammatory/debridement phase of wound healing?
early - neutrophil chemoattractant release
late - macrophages, phagocytosis & removal of foreign body/bacteria, help signal the repair phase
what is going on in the repair/proliferative phase of wound healing?
fibroblast proliferation
collagen synthesis
extra cellular matrix reorganization
angiogenesis
granulation tissue formation
epithelialization
what is going on in the maturation/remodeling phase of wound healing?
remodeling
epithelialization
ECM remodeling
increase in tensile strength of the wound
what are some examples of mechanisms of debridement?
mechanical - using something to rip off dead tissue
autolytic - help body promote autolysis
enzymatic - least useful
surgical/sharp (layered & en bloc) - usually the go to
layered - cut out the necrotic tissue, look for what is dead/not dead, can be very selective in what you choose to take
en bloc - remove entire wound as if it is a tumor, take entire wound & some fresh healthy tissue, done in places with excessive skin
what is larval therapy? how does it work?
FDA approved/insurance covered option for debridement
sterilized maggots are placed into a wound & the wound is debrided when they secrete digestive enzymes into the necrotic tissue & leaves healthy tissue alone
what wounds are ideal candidates for larval therapy?
bedsores & diabetic ulcers
what are some examples of wounds in which you may choose primary closure?
clean wounds, clean contaminated wounds, & not dog bites/crush wounds
what are some examples of wounds in which you may choose delayed primary closure?
clean contaminated & contaminated wounds
what are some examples of wounds in which you may choose secondary closure?
contaminated & dirty wounds
T/F: any kind of wound may be a candidate for second intention healing
true
T/F: if the tissue of a wound looks questionable, don’t close it
true
what must you assess prior to deciding on type of wound closure?
assess tissue viability, blood flow, & amount of contamination present
what is the purpose of using wound dressings?
help protect the wound, prevent/control infection, & enhance healing
T/F: moist wound healing has been the standard of care in human medicine since the 1960s
true - don’t need to ‘air it out’
what are some contraindications to using sugar in a wound dressing?
if there is healthy granulation tissue or epithelial tissue
what are some indications for using sugar in a wound dressing?
use in open, contaminated, & infected wounds
why is sugar used as a dressing in wound healing?
antibacterial due to the high osmolality
decreases edema, increases macrophages which helps to signal the repair phase, & great to use in the inflammatory stage of wound healing
how is sugar used in a wound dressing?
place 1cm thick in the wound with frequent bandage changes!!!
why is honey used as a dressing in wound healing?
same advantages as sugar - decreases wound pH, H2O2, antibacterial, effective antimicrobial, & best used in the inflammatory/early repair stages
USE UNPASTEURIZED
pasteurized - doesn’t have all the benefits for promote wound healing, only the hyper osmolality
why is silver used as a dressing in wound healing?
antibacterial for MRSA & pseudomonas, & fungicidal
best in inflammatory/repair phases
DOES NOT DEBRIDE
what wounds are ideal for using silver as a wound dressing?
burns, contaminated, & infected wounds
how is silver acticoat used as a wound dressing?
moistened with sterile water & covered with semi-occlusive bandage (loban) & isn’t changed for a week
where does alginate come from?
derived from kelp
what is alginate used for in wound dressings?
good for debridement & decreasing edema - promotes autolytic debridement
great for inflammatory/repair phases - often combined with silver to get both antibacterial & debridement
why is it a benefit that alginate is high in calcium?
can active prothrombin in clotting cascade so it is a good option when mild hemostasis is needed
what wound type is contraindicated for using hydrogel as a wound dressing?
if the wound is infected
what is a side effect associated with hydrogel?
can lead to the development of exuberant granulation tissue
what are the benefits of using hydrogel as a wound dressing?
soothing, hydrating option & promotes autolytic debridement
good for using in the inflammatory/repair phase
when may you reach for hydrogel for a wound dressing? where would you put it & why?
if a dog that was missing comes in & has an older dry wound to help hydrate it - supports healing by second intention
only on the wound because it can macerate healthy skin!!!!
what wound dressing option supports healing by second intention?
hydrogel
what wound dressing option is antibacterial but doesn’t provide debridement?
silver
what is a wet-to-dry bandage? when is it used?
moisten a 4x4 with sterile saline & bandage with something semi-permeable to the air
wait for it to dry & rip it off - mechanical debridement
early inflammatory phase
why are wet-to-dry bandages not used as often anymore?
they are not moist wound healing & are painful for the patient
what is vacuum assisted wound closure?
use of sub-atmospheric pressure to promote or assist wound healing or remove fluid from a wound site
what does vacuum assisted wound closure do?
increases blood flow, removes extravascular fluid, increases granulation tissue, speeds wound closure (increases contraction), decreases bacteria in the wound
when is vacuum assisted wound closure best used?
inflammatory/early repair phase
what does vacuum assisted wound closure NOT do?
debride the wound
what is the definition of failure to heal/chronic wound?
wounds that fail to heal after 1 month
what are some underlying conditions that result in failure of healing in wounds?
metabolic abnormalities/medications
failure in contraction
failure in epithelialization
‘pocket’ wounds - indolent
ongoing infection
what is the most important part in approaching a chronic wound? what are some examples of this?
need to diagnose the cause of why it isn’t healing
look for excessive tension, motion, endocrine abnormalities, neoplasia, & infection
what are some examples of strange bugs often associated with chronic non-healing wounds?
nocardia, actinomyces, fungus, oomycetes, & mycoplasma
why do we biopsy chronic wounds?
submit for histopath to look for neoplasia & send to culture to look for weird bugs or foreign material
what are some metabolic abnormalities/medications that may cause chronic wounds?
inadequate nutritional support, endocrine disorders, animals on steroids, radiation, & chemo
what are some reasons we see failure of wound contraction?
excessive tension & restrictive fibrosis (chronic wound with a lot of scar tissue, so there is no pull that happens during wound contracture)
how is tension free closure done?
pay attention to the lines of tension (tiger stripes)
close parallel with the lines of tension
may use tension relief - releasing incision
why do we commonly see failure of epithelialization in chronic wounds?
lack of a vascular bed/lack of granulation tissue - wounds with exposed bone or tendons (epithelium won’t advance over exposed bones/tendon)
too much motion!!!!
what are pocket/indolent wounds?
failure of epithelialization seen in cats
looks like round wound edges where epithelium doesn’t advance across
must move in new tissue to actual heal the wound
what is an infected chronic wound?
prolonged presence of neutrophils in a wound may be a factor in the conversion of acute wounds into non-healing chronic wounds
instead of a wound environment that promotes healing, it becomes very inhospitable to the wound
what is a biofilm?
community of bacteria within self-produced extracellular polymeric substance including:
polymeric sugars, bacterial proteins, bacterial DNA, & co-opted host substances
what attachment sites do we see biofilms on?
abiotic surface (metallic implant) - electrostatic interactions between bacteria & material surface
biotic surface (wound surface) - specific receptor-ligand interactions & initial repulsive electrostatic forces
what is the pathogenesis of a biofilm?
biofilm attaches & is able to share its DNA with other bacteria & then forms the mature slime/matrix that protects itself from antibiotics & raises the MIC needed to treat the problem
what therapy is recommended when treating a chronic wound with a biofilm?
sharp debridement
electrical field
MIC is altered - keep this in mind for topical & systemic therapy
VAC/negative pressure bandage
how are biofilms prevented?
much better hygiene (good hand washing), extreme PPE, protect the wound
what is MMP in regards to chronic wounds?
matrix metalloproteinase
why does it matter that there are increased MMP levels in chronic wounds?
it degrades the ECM & growth factors
reduces cell responsiveness in the wound
increases the inflammatory response
& delays wound healing
T/F: every bite wound injury requires an exploration
true - whether it is done when the animal is awake, under sedation, or under general anesthesia
what are some indications for placing a drain into a wound?
neck dissection, dog bite wounds, groin dissection, +/- skin flaps & neoplasia
what are some disadvantages of placing a drain into a wound?
increased risk of infection, erosion of adjacent structures, adhesion to adjacent structures, increased dehiscence, premature loss, drain obstruction, & pain
what drain type is never appropriate to place inside the thorax & abdomen?
penrose drain
how much fluid is produced in a drain per day?
1-2ml/kg/day - presence of the drain induces fluid production
T/F: the presence of a drain induces fluid production
true
when do you remove a drain from a wound?
fluid production plateaus!!!
dogs may be at risk for seroma formation if drainage is >0.2ml/kg/hr when the drain is removed
may also use cytologic evaluation
T/F: when placing a drain, always bandage the exit & prevent the animal from removing the drain themselves
true
why is the loss of paw pads, especially MC/MT, a serious injury in dogs? what about cats?
normal skin in a dog can’t withstand daily physical abuse
may work in sedentary indoor cats
T/F: paw pads tend not to heal as well as other tissues & don’t heal well by second intention, so take large bites of tissue when suturing
true
how can you approach a paw pad injury in the golden period of the wound?
lavage, debride, primary closure of SQ & skin - get large bites of tissue & apply a bandage or splint
how to do you treat a paw pad injury that is presenting to you some time after the trauma occurred?
lavage, debride, & bandage - can do a delayed primary or secondary closure
complete loss of all paw pads may require what treatment?
limb amputation
what are some surgical options for treating an injury of the MC or MT paw pad?
digital pad transfer - accessory carpal pad
pad grafting
what can you do if there is only single digital pad loss?
digit amputation
why do we see aural hematomas in companion animals?
usually occur secondary to pinna trauma or history of head shaking/scratching from otitis externa
what are the goals for treating aural hematomas?
treat the pinna immediately - this is how you can save the ear to make it look normal
remove the blood clot, prevent recurrence, & retain the natural appearance of the ear
what is the key in treating biofilms?
early intervention with multiple therapies
what imaging should you use for dog bite wounds?
radiographs depending on the severity of the attack
don’t forget the spine & look to see if air is present in the abdomen
T/F: protecting the wound is a big part of therapy for chronic wounds
true - #1 is the e-collar
what wound closure is usually used for dog bite wounds?
delayed primary - manage open for a few days & then close
what is the general surgical therapy used for treating aural hematomas?
s-incision & then skin is tacked down to underlying cartilage
