Management of Traumatic Wounds Flashcards
How does the healing of superficial wounds differ in dogs and cats?
If SQ tissue is removed in cats, granulation and healing take much longer. In dogs, removal of SQ tissue doesn’t make much difference.
What are 3 things to consider with bite wounds?
- Size and number of animals involved (eg. cat + cat vs. big dog + small dog/cat; one-on-one vs. pack-on-one)
- Location of wound (eg, limbs vs. neck/trunk)
- Clinical assessment of severity of trauma
What suture material would be best for a deep wound?
Absorbable monofilament, with antimicrobial would be best.
What is a degloving injury?
Shearing force which severs cutaneous vessels supplying the skin
What is the difference between a physiologic and anatomic degloving injury?
Physiologic = Skin devitalized, but still in palce Anatomic = Skin avulsed from underlying tissue
What do you commonly see combined with degloving in dogs and cats?
Crush injury
With impalement, what should you tell the owner if they call in?
DO NOT REMOVE
With a gunshot wound, do you need to get all the fragments?
Not really unless it’s close to or in a joint.
What 4 things do we assess in a burn patient?
Cause
Concurrent injury (smoke inhalation in a house fire)
Extent (% TBSA)
Depth
What is a major issue with burn patients?
Hypovolemia
What is really important with burn wound management?
Nutritional support
Whata 4 things make up your initial burn management?
Cool injured tissue
Topical treatment
Analgesics
Fluid resuscitation
What are the 3 general burn wound outcomes?
<15% TBSA - Usually easily managed
15-50% TBSA - May require extensive treatment
>50% - Significant complications and prolonged treatment
What are 2 classifications of traumatic wounds?
Penetrating - Open
Non-penetrating - Closed (eg. sterile abscess)
NOTE: Open traumatic wounds should be considered contaminated at best
What are 2 common topical treatments for burns?
Aloe (anti-inflammatory)
Silver sulfadiazine
NOTE: These two work synergistically
When do you need to really worry about fluid resuscitation in a burn patient?
When burns >15% TBSA
When can you use hydrotherapy for burn patients?
With partial thickness burns
How can you easily tell if a burn is partial or full thickness?
If the fur doesn’t epilate easily, tissue is probably still healthy
What are 6 possible causes for a nonhealing wound?
FB Immunodeficiency Pathogens (hard to culture organisms) Concurrent dx Nutritional status Drugs
What types of FBs, if any, can usually be well tolerated?
Non-porous FBs
What is the most common FB?
Plant-based
What is common to see with a sinus tract?
Will “pseudo” heal, but reappears when Abx are fnished
Define sinus tract.
Communication between mesothelial surface and skin.
Define fistula.
Communication between two epithelial surfaces, lined by epithelium.
What diagnostics can you do to find a FB in a wound?
RADs (most plant materials are NOT radio opaque)
U/S
What can you use to help visualize the wound tract?
Dilute methylene blue
What do you need to be careful of when removing FBs from wound tracts?
The longer the FB has in the body, the more friable it becomes.
What do you do with a wound tract if you don’t have U/S or CT?
Remove all abnormal tissue and look for FB
What is the most common source of contamination for a traumatic wound?
Endogenous flora
What are 3 sources of contamination for a traumatic wound?
Endogenous flora Accident site (usually pretty wimpy bacteria) Hospital (nosocomial, tougher bugs)
What 3 factors influence bacterial development?
Number and type Host defense Exogenous factors (FBs, soil)
What is the “Golden period”?
Time from contamination until bacteria reach 10^6/g of tissue
What is the trouble with infection potentiating factors?
Can reduce the number of bacteria needed for infection to as low as 100 (from 10^6)
What must you do with all wound patients?
Assess the entire patient!
If not ready to deal with wound, what should you do?
Protect it to prevent further contamination.
If comes in bandaged, DO NOT take a peek until you’re ready to deal with it.
What are the 3 steps to initial management of traumatic wounds?
Thorough exam of wound (look for fx, explore penetrating wounds and consider what might be underneath)
Debridement
Wound Lavage
Wat 4 minimum precautions should you take in evaluating the wound?
Temporarily close or pack the wound
Clip and prep surrounding skin (don’t be afraid to go wide)
Cap, mask and gloves
Ideally aseptic technique
How much bacteria can be removed with wound lavage?
Up to 90%
What do you normally use as wound lavage solution?
Saline or balanced electrolyte solution
Can have antiseptics, but difficult to dose
What is the easiest way to lavage a wound?
Large syringe with 18G or 20G needle on the end is best.
What is the most tissue friendly wound lavage solution?
BES
Good for wounds that are not overly contaminated
What is the best antiseptic to use?
Povidone-Iodine
Why should you dilute Iodine?
Increases free Iodine
What is the residual activity of Iodine?
4-6 hours
NOTE: If colour changes to a light yellow, all iodine has been used up
What are 2 disadvantages of Iodine?
Forms inactive complexes with organic matter Systemic absorption (toxicity and metabolic acidosis)
What are 3 advantages to using Chlorhexidine?
Activity less affected by organic matter
Long residual action
Side-effects uncommon (usually hypersensitivity)
T/F: Residual activity of Chlorhex increases with repeated applications.
True
What happens to Chlorhex if mixed with a poly ionic solution?
It forms a precipitate
NOTE: Antibacterial activity is maintained for 2 weeks, and precipitate doesn’t seem ti interfere with wound healing.
What is debridement?
Removal of devitalized tissue and foreign bodies
What are 5 methods of debridement?
Surgical Autolytic (moisture retentive bandage) Chemical (enzymes) Mechanical (adherent primary bandage) Biosurgical
What is the most commonly used method of surgical debridement?
Layered, but will still have some contamination at the end
What is “en bloc” debridement?
Surgical debridement where the wound is packed, sutured closed and then you dissect around the mass from the packing.
What is another term for chemical debridement?
Enzymatic debridement
What are the indications for chemical debridement (4 ways)?
Poor anesthetic risk
Minimal debridement necessary
Surgical debridement may damage important structures
Adjunct to other methods
What is a cheap and readily available enzymatic debridement agent?
Granulex
What are the 3 components of Granulex?
Trypsin (debriding agent)
Castor oil (minimize dessication)
Balsam of Peru (stimulates capillary formation)
What are the 2 primary parts of granulation tissue?
Fibroblasts
Blood vessels
Define mechanical debridement.
Devitalized tissue and FB are trapped in primary bandage layer
What are indications for mechanical debridement?
Wound in lag phase with heavy contamination or thick viscous exudate.
What sort of dressings are used in mechanical debridement?
Wet-to-dry or dry-to-dry dressings with wide mesh gauze
DON’T FORGET TO COUNT YOUR GAUZE!!!
NOTE: Antiseptics often used to wet dressings in contaminated/infected wounds.
If you have a wound that is inappropriate for closure after the initial lavage and debridement, what do you do next?
Stabilize patient
When using an adherent dressing on a wound not yet ready for closure, when should you discontinue?
When the wound bed is healthy, then switch to non-adherent dressings until wound closure.
What is negative pressure therapy?
Vacuum assisted closure with constant or intermittent suction applied to wound (constant is best)
When does negative pressure/vacuum therapy work best?
Wound in late lag or early proliferative phase.
How does vaccum/negative pressure therapy help?
Promotes more rapid granulation tissue formation in acute wounds.
Improves the local environment to enhance second intention healing of chronic wounds.
What is important to remember with negative pressure/vacuum therapy?
Accelerated granulation tissue formation (within 48hrs) may incorporate sponges so need to be careful.
What is calcium alginate?
A non-woven felt from seaweed
What 3 functions does calcium alginate have?
Fluid absorption (Extremely hydrophillic) Promotes autolytic wound debridement Aids in hemostasis
What are 2 indications for calcium alginate?
Moderate to heavily exudative wounds
Wound adequately debrided, but not good for closure
What is a benefit to calcium alginate over gauze?
Less painful to change than gauze.
What are 4 benefits of using honey?
Cleanses wound
Hygroscopic (attracts and holds water from surroundings)
Promotes granulation tissue
Antibacterial/antifungal
How does honey work as an antibacterial/antifungal (3 ways)?
Osmotic effect
Low pH
Produces inhibine which produces H2O2 and phenolic acids
What is sugar’s primary effect?
Antibacterial due to osmolality, also helps lower pH.
What other beneficial effect does sugar have within a wound?
Promotes granulation tissue by attracting macrophages
What 4 actions does Maltodextrin (Intracell) have?
Chemotactic (PMNs, Lymphos and Macros)
Energy for cells
Stimulates rapid granulation and epithelialization
Antibacterial properties
Does all the shot have to come out of a gun shot wound?
No, some can stay UNLESS it’s in or near a joint.
What are the two types of adherent dressing?
Wet-to-dry
Dry-to-dry
In what 2 situation is a wet-to-dry bandage indicated?
Necrotic tissue +/- FBs
High viscosity exudate
What is the benefit to a wet-to-dry bandage?
It liquefies viscous exudate enhancing entrapment in dressing
When are dry-to-dry bandages indicated?
In highly exudative wounds to aid in wound debridement
What makes Kerlix AMD (dry-to-dry dressing) so great?
Broad spectrum antibacterial activity
What are 4 indicatinos for a dry-to-dry bandage?
Degloving injury
Bite wounds
Lacerations
Deep “cavity” wounds
What are 3 disadvantages of adherent dressings?
Bacteria can flourish
Wet dressings can cause maceration
Bacterial strike-through
What are 2 common uses of non-adherent dressings?
Protect a sutured wound
Cover wounds in a reparative stage
What are 3 advantages of non-adherent dressings?
Keeps wound moist
Allows excess fluid to drain
Doesn’t damage newly formed reparative tissue
What are the 2 classifications of Moisture retentive dressing?
Semi-occlusive
Occlusive
When is it better to use moisture retentive dressings?
Wounds in late debridment because optimize body’s inherent healing ability
What do you need to be careful of with moisture retentive dressings?
If the wound has too much exudate, it will separate the bandage from the wound.
What are 3 types of biological dressing?
Equine amnion
Xenografts and allografts
Extracellular matrix-derived
Why do we not often use xenografts and allografts in veterinary medicine?
Because they’re often rejected
What are 3 types of extraccellular matrix-derived biological dressings?
Collagen
Porcine small intestinal submucosa (PSIS)
Porcine urinary bladder submucosa (PUBS)
What is so nice about porcine small intestine submucosa (PSIS)?
It is a “smart tissue” that takes on the characteristics of the tissue it is placed in.
What are 3 indications for use of PSIS?
Deglovng injuries and other large skin defects
Biological dressing until definitive reconstruction
Dermal substitute to “guide” wound repair
How do you apply PSIS?
Put rough side in contact with the wound surface, suture into wound bed, under the wound edge
