Management of Traumatic Wounds Flashcards
What are 2 general classifications of traumatic wounds?
- Penetrating (open)
- Non-penetrating (closed)
What are 4 classifications of operative wounds?
- Clean
- Clean-contaminated
- Contaminated
- Dirty
Open traumatic wounds should initially be considered what?
Contaminated
What are 7 common wound etiologies?
- Lacerations
- Bite wounds
- Degloving injuries
- Sinus tracts
- Burns
- Toxins
- Non-healing wounds
How does the healing of superficial wounds differ in dogs and cats?
Granulation tissue takes longer to form in cats.
Which suture material would be most appropriate for an open wound?
Why?
- Absorbable monofilament
- Less risk of bacteria
What type of a wound can result from shearing forces which sever cutaneous vessels supplying the skin?
Degloving injury
With what type of degloving injury is the skin devitalized but still in place?
Physiologic degloving injuries
With what type of degloving injury is the skin avulsed from underlying tissue?
Anatomic degloving injuries
What type of degloving injuries are more common in dogs and cats?
Combined degloving and crush injuries
What color does skin turn if it is dead?
Black
Once skin that has been left on starts to do what, it is time to remove it?
Skin starting to slough
What are 2 types of missile wounds?
- Arrow wounds
- Gunshot wounds
What should the owner be told to do with an arrow wound?
Leave it in and cut the shaft off if possible.
Is removal of all lead fragments necessary?
No
When is removal of all lead fragments important?
When the injury involves a joint.
What are 3 main categories of burns?
- Thermal
- Chemical
- Electrical
What are 3 types of hot liquid burns?
- Water (steam)
- Grease
- Wax
What are 3 main types of thermal burns?
- House fires
- Hot liquids
- Direct contact
What are 3 possible sources of direct contact burns?
- Heating pads
- Heat lamps
- Exhaust pipes
What are 4 aspects of assessing a burn patient?
- Cause
- Concurrent injury
- Extent of burn
- Depth of burn
What are 2 categories based on depth of burn?
- Partial thickness
- Full thickness
What are 2 ways to evaluate the percent total body surface area with determining the extent of a burn?
- Rule of 9s
- Calculate
What are 4 aspects of burn wound management?
- Fluid resuscitation
- Smoke inhalation
- Wound management
- Nutritional support
What are 3 problems seen with smoke inhalation?
- Direct heat injury
- Carbon monoxide
- Inhaled toxins
What can be a problem with large burns?
Hypovolemia
What are 4 components of initial burn management?
- Cool injured tissue
- Topical treatment
- Analgesics
- Fluid resuscitation
Which 2 topical treatments for burns work together in a synergistic manner?
- Aloe vera
- Silver sulfadiazine
Topical treatments for burns delay development of infection under what?
Under eschar (hard crust/scab)
Fluid resuscitation should be considered with what percentage of total body surface area?
Greater than 15% TBSA
When should wound debridement be done with burns?
Early
What is NPWT stand for?
How is it closed?
- Negative pressure wound therapy
- Vacuum-assisted closure (VAC)
If there is hair remaining in a wound and it sticks pretty tight, what type of indicator is this for tissue survival?
Tissue will probably survive.
What percentage TBSA burns are usually easily managed?
Less than 15%
What percentage TBSA burns may require extensive treatment?
Greater than 15% to less than 50%
What percentage TBSA burns are often associated with significant complications and prolonged treatment?
Greater than 50%
What are 6 possible causes of non-healing wounds?
- Foreign bodies
- Immunodeficiency
- Pathogens
- Concurrent disease
- Nutritional status
- Drugs
What are 2 types of foreign bodies that should be removed?
- Porous materials
- Organic materials
What are 4 types of foreign body materials that are relatively inert unless contaminated?
- Glass
- Gravel
- Pellets (steel, lead)
- Carbon material
Sinus tracts are most commonly caused by what?
Plant material foreign bodies
Plant material foreign bodies can migrate a significant distance causing a draining tract that is lined by what?
Granulation tissue
Antibiotic administration with sinus tracts will cause what?
What will happen once antibiotics are discontinued?
- “Pseudo” healing with antibiotic administration
- Draining tracts will reappear when antibiotics are discontinued.
How quickly does sinus tract healing take place once the foreign body is removed?
Heals rapidly
What is not necessary if foreign body can be identified and removed?
Complete excision of draining tract is not necessary.
A communication between the mesothelial surface and the skin is known as what?
Sinus
A communication between 2 epithelial surfaces is known as what?
Fistula
Fistulas are lined by what?
Epithelium
What are 2 types of draining tracts?
- Sinus
- Fistula
Which type of draining tract is often associated with foreign body migration?
Sinus draining tract
What are 4 forms of diagnostics used to look for foreign bodies?
- Radiographs
- Contrast studies
- Ultrasound
- CT/MRI
You are most likely to detect a foreign body with which type of diagnostic tool?
Ultrasound
What can be done to a foreign body sinus tract prior to surgery?
Why is this done?
- Instill dilute methylene blue.
- Makes following the tract easier.
What are 3 possible sources of contamination in a traumatic wound?
- Endogenous flora
- Accident site
- Hospital
What are 3 factors influencing the development of wound infection?
- Number and type of bacteria
- Host defense mechanisms
- Exogenous factors
How long does the time from contamination until bacteria invade and replicate to >10^5/gm of tissue?
What is this known as?
- Generally 6-8 hours
- “Golden period”
What are 2 possible exogenous factors that can influence the development of a wound infection?
- Foreign bodies
- Soil infection potentiating factors
Negatively charged particles with large surface area involved in wounds are known as what?
Infection potentiating factors
What are 2 things infection potentiating factors do?
- Inhibits phagocytosis and bacterial killing
- Binds to positively charged antibiotics
Infection potentiating factors can be found in what?
Clays and organic soil components
What are 3 examples of infection potentiating factors?
- Montmorillinite
- Kaolinite
- Illite
Infection potentiating factors can reduce the number of bacteria required to cause infection to what?
As few as 100
Initial management of traumatic wounds includes what 3 aspects?
- Physical examination
- Protect wound with bandage to prevent further contamination
- Avoid temptation to “take a peek”
What should be done prior to administering pain medications when evaluating patients with traumatic wounds?
Check neurologic status of limb injuries.
What should limb wounds be assessed for?
Orthopedic injuries
What type of wounds should be explored when the patient is stable?
Abdominal wounds
What should be considered with penetrating thoracic wounds?
Consider etiology and exam findings.
What are 2 things that are done after thoroughly examining the wound?
- Debridement
- Wound lavage
What are 4 examples of minimum precautions to take when evaluating a wound?
- Temporarily close or pack wound
- Clip and prep surrounding skin
- Caps, masks, gloves
- Ideally, complete aseptic technique
Up to what percent of bacteria can be removed with wound lavage?
Up to 90%
You should use what quantity of fluid with what amount of pressure for wound lavage?
- Large quantities
- Moderate pressure
What are 2 types of fluid used for wound lavage?
- Saline
- Balanced electrolyte solution +/- antiseptics
What is typically used to perform wound lavage?
18-20 G needle and syringe that fits comfortably in hand
Povidone-Iodine needs to be diluted to what ratio?
Why do you need to dilute the iodine?
- 1:10 or less
- In order to free the iodine from the molecules they are bound to.
Povidone-Iodine has residual activity for how long?
4-6 hours
What are 2 disadvantages to Povidone-Iodine use?
- Forms inactive complexes with organic matter
- Systemic absorption leading to toxicity
What type of activity does Chlorhexidine have?
Broad-spectrum activity
What is the dilution level needed for chlorhexidine?
What is the percentage of the solution?
- 1:40 Dilution
- 0.05% solution
What is used to dilute chlorhexidine?
What should NOT be used?
- Sterile irrigating water
- Distilled water
What are 3 advantages to chlorhexidine use?
- Activity less affected by organic matter
- Long residual action
- Side-effects uncommon
How long does the first dose of chlorhexidine typically last?
Does repeated use make the DOA longer or shorter?
- 8-12 hours
- Longer after repeated use
Chlorhexidine diluted in what type of solution will begin to form what within hours?
- Polyionic solution
- Form a precipitate, a chlorhexidine chloride salt
At typical dilutions of chlorhexidine, adequate antibacterial activity is maintained for approximately how long?
2 weeks
Does the chlorhexidine chloride salt precipitate seen with chlorhexidine solution interfere with wound healing?
Does not appear to interfere with wound healing.
Removal of devitalized tissue and foreign bodies is known as what?
Debridement
What are 5 potential methods of debridement?
- Surgical
- Autolytic
- Chemical
- Mechanical
- Biosurgical
What is the most commonly used method of surgical debridement?
Layered surgical debridement
Complete excision of a wound as with tumor excision is called what?
“En bloc”
What are 4 indications for the use of chemical debridement?
- Poor anesthetic risks
- Minimal debridement of open wounds is necessary
- When surgical debridement may damage important structures
- Adjunct to other methods
What are 4 examples of chemical debridement solutions?
- Granulex
- Trypsin
- Castor Oil
- Balsam of Peru
When the devitalized tissue and foreign bodies get trapped in the primary bandage layer, this is known as what type of debridement?
Mechanical debridement
Mechanical debridement is primarily indicated for what type of wounds?
Wounds in the lag phase with heavy contamination or thick viscous exudate.
What is a disadvantage of mechanical debridement?
Not as tissue friendly as moisture retentive dressings or the use of enzymatic agents.
What are 4 forms of mechanical debridement?
- Wet-to-dry
- Dry-to-dry
- Wide mesh gauze
- Adjunct to surgical/enzymatic debridement
Doing what to dressing at removal with warm solutions helps the dressing release from the wound improving patient comfort?
Rehydrating
When should adherent dressings (wet-to-dry or dry-to-dry) be discontinued?
What are indicated at this point until wound closure is performed?
- Once the wound bed is healthy.
- Non-adherent, moisture retentive dressings.
What can be used after surgical debridement to promote more rapid granulation tissue formation with acute wounds?
Negative wound pressure therapy
What can be used to improve local environment to enhance second intention healing with chronic wounds?
Negative wound pressure therapy
Is constant or intermittent suction better when using vacuum assisted closure?
Constant
When does negative pressure wound therapy with vacuum assisted closure work best?
When used on wounds in late lag (debridement) phase or early proliferative phase of wound healing.
What are 6 benefits of vacuum-assisted closure?
- Increased tissue blood flow
- Decreased interstitial edema
- Decreases bacterial burden in wound
- May help remove inflammatory cytokines from wound
- accelerated granulation tissue formation
- Less frequent bandage changes
What is a non-woven felt-like material derived from seaweed that is extremely hydrophilic?
Fluid absorption converts the felt to what?
- Calcium alginate
- A gel
Calcium alginate aids in what?
Hemostasis
What are 3 indications for the use of topical wound medications and dressings?
- Moderate to heavily exudative wounds in early stages of healing
- Wound adequately debrided but not amenable for closure
- Less painful to change than gauze dressings
What are 4 actions of honey on a wound?
- Cleanses wound
- Hygroscopic
- Promotes granulation tissue formation
- Antibacterial/antifungal
The antibacterial effect of sugar is primarily due to what?
Osmolality
What are 3 other actions of sugar in a wound?
- Cleanses wound
- Reduces edema
- Promotes granulation tissue formation
How does sugar promote granulation tissue formation?
Attracts macrophages
What is a D-glucose polysaccharide that comes in a hydrophilic soluble powder?
Maltodextrin
Hydrocolloid or polyurethane occlusive dressings are examples of what type of dressing?
Moisture retentive dressings
What type of dressings are better than adherent dressings for wounds in late debridement/proliferative phase?
Why?
- Moisture retentive dressings
- They optimize the body’s inherent wound healing abilities.
Moisture retentive dressings help to maintain the normal physiologic ratios of what 4 factors?
- Proteases
- Protease inhibitors
- Growth factors
- Cytokines
