Musculoskeletal system & Wound Management Flashcards
Clean wounds
Atraumatic and sterile
Clean, contaminated wounds
Minor break in aseptic technique and only minor contamination
Contaminated wound
Recent wound with trauma that has bacterial contamination
Dirty/infected wound
Older wound that is exudative with evidence of bacterial contamination
Open fracture classes
Grade I; small break in skin by bone penetrating
Grade II; soft tissue trauma with the fracture caused by external trauma
Grade III; extensive soft tissue injury with increased communition of the bone
Stages of wound healing
Inflammation
Debridement
Repair/proliferation
Maturation
Inflammation stage of wound healing
Within 5 days of injury
Haemorrhage, vasoconstriction and platelet aggregation initially occur and then within 5-10min there is vasodilation > fibrinogen and clotting as neutrophils, monocytes, fibroblasts endothelial cells and inflammatory mediators are brought to the site
Debridement phase of wound healing
Happens concurrently with inflammation phase and involves WBC entry (neutrophils first) approximately 6 hours after injury which removes ECF debris via phagocytosis. Macrophages are formed within 24-48h of wound occurring and monocytes activate fibroblastic activity stimulating collagen formation and angiogenesis > removal of necrotic tissue, bacteria and foreign material
Repair/proliferation phase of wound healing
Occurs after 5-7 days of initial wound and lasts 2-4 weeks
Angiogenesis, granulation tissue formation and epithelialisation occur. Fibroblasts proliferate and synthesise collagen providing a granulation bed for epithelialisation witch wound contraction evident after 5-9 days
Maturation wound healing phase
Occurs 17-20 days after
Adequate collagen has been deposited, wound contraction and remodelling of epithelium is occurring
Can take years to heal and only achieve 80% of strength
Addressing patients that present with wounds
Stabilise; cover open fractures, stabilise ABC, thoroughly examine patient
Assess and Debridement wounds; decontaminate, create healthy wound bed and promote healing
Broad spectrum antimicrobials (broader spectrum the further it penetrates)
Daily assessment of wounds and further Debridement, bandage changes
Sugar and honey for wounds
Both bactericidal and promote accelerated sloughing of necrotic tissue and formation of the granulation bed
Both osmotic so draw bacteria and debris out of wound
Used in Debridement phase until healthy granulation tissue visible
Change bandage daily or when significant strike through present
Bandage layers
Primary; directly on wounds, determines if adherent or non-adherent bandage
Secondary; padded and aids in absorption of exudates
Tertiary; outermost protective layer
Adherent v. Non-adherent bandages
Adherent: I.e. wet-to-dry
Non-adherent: hydrogels etc
Delayed primary closure
Performed 2-5 days after injury for wounds that have areas of questionable healing, large +- contaminated wounds
Performed once evidence of a healthy granulation bed
Vacuum assisted wound therapy
Set to 75-120mmHg
Improves vascularisation, granulation tissue formation and decreases wound size and volume
Contraindicated; coagulopathy, necrotic wounds, exposed organs/nerves/bones etc, untreated osteomyelitis
Hyperbaric O2 for wound treatment
100% O2 provided under pressure
Increasing O2 to damaged tissues promoting leukocyte oxidative killing of bacteria, reduces oedema and increases nutrient content to the wound
Most common bacteria to wounds
Staphylococcus, streptococcus and e.Coli, enterococcus, proteus, pseudomonas
Bite wounds: clostridium
First degree burns
Superficial and only involve the epidermis
Epidermis will be erythemous and painful to touch
Rapid healing and re-epithelialisation within a week
No wound management required and no systemic effects
Second degree burns
Involve the epidermis and the superficial dermis or may go into deeper dermis
Epidermis will be charred and will slough; plasma leakage will occur and painful or decreased pain sensation if deeper
Hair follicles intact still or not if deeper
May or may not have systemic effects depending on depth
Epithelialisation with minimal scar within 10-21 days unless deeper than scarring and surgical management required
Third degree burns
Full thickness
Skin black and lethargy and eschar
Insensitive to touch
Requires extensive wound management for healing I.e. grafts and flaps
May have life-threatening systemic consequences
Fourth degree burns
Much the same as third degree
Extensive wound management with grafts/flaps required to prevent restrictive joint movement
Burns
Take around 3 days to show full extent and those that have TBSA >20% have severe metabolic consequences and those >50% TBSA should have their owners counselled for euthanasia as very poor prognosis
Estimating total body surface area burned (TBSA)
Head/neck 9%
1 FL 9% each (18% total)
1 HL 18% each (36% total)
Dorsal trunk 18%
Ventral trunk 18%
General approach to burns patients
- Stabilise ABC
- TBSA Score
- Full bloods
- Correct metabolic derangements
- Pain management
- Nutrition!
- Comfort
- AM’s
- Wound management
Metabolic consequences in burns patients
Hypovolaemic shock due to thrombosis, capillary leakage, and massive fluid shifts to burn sites > electrolyte and fluid deficits
Expect these patients to be anaemic, hyproteinaemic, electrolyte derangement, Oliguria, have pre-renal azotaemia and haemolysis
Expectations day 2-6 post burns
Watch for DIC, UA oedema, immune dysfunction, infection, SIRS and anaemia and address as needed
Expectations day 7 onwards for burns
Watch closely for hyperthermia, hypoxaemia, sepsis, pneumonia and wound demarcation
FFP amount for burns patients
0.5ml/kg X TBSA
- plasma volume equilibriums around day 2 so watch very closely for fluid overload
Nutritional requirements for burns patients
Full RER
High calorie and protein
Give GI protectants as Gi ulceration common due to Gi hypoperfusion
Thermal damage in burns patients
May be ongoing so need to address quickly I.e. cooling and aloe Vera
Closure of burn wounds
Usually delayed until at least days 3-5 due to wanting to know the extent of injury
However initial clipping and lavage and debridement should be done ASAP to limit depth of injury
Aloe Vera and silver sulfadiazine in burn wounds
Aloe Vera; antithromboxane and prevents progression of thermal injury
Silver sulfadiazine; placed when wound >24h, bactericidal and can be applied 2-3X a day
PROM’s
Passive rang of motion exercises
Prevent joint contracture, increased lu,Patric flow and prevent soft tissue shortening
There is no active muscle contraction and will not prevent muscle atrophy but very useful if I,Poe enter early
AROM exercises +- assisted
Good transition from PROM’s
Increases muscle strength and bone strength
Re-educates normal movement patterns
Assisted standing benefits
Improves muscle strength
Improves circulation
Improves respiratory function
Stimulates proprioceptive inputs
Neuromuscular re-education
Walking patients
Helps articulate cartilage and connective tissue healing
Improves cardiovascular, lymphatic and respiratory function
Enhances emotional well being
Massage
Increases blood and lymphatic flow
Improves GI motility
Reduces muscle spasm
Relieves stress and anxiety
Petrissage
Kneading
Effleurage
Stroking
Tapotement
Tapping/percussion
Vacuum-assisted closure should not be used on wounds that:
a. are obviously infected
b. are neoplastic in nature
c. cover large areas on the body
d. are older than 24 hours
B
Patients with burns over large portions of the body can experience retained fluid in the wounds, leading to:
a. fluid overload
b. electrolyte loss
c. better wound healing
d. hyperglycemia
B
A large wound first treated with honey bandages until granulation tissue forms and then surgically closed undergoes which type of wound closure?
a. Primary closure
b. Delayed primary closure
c. Secondary closure
d. Second intention
C
According to the rule of 9s, what is the TBSA of a burn involving the head, neck, and one front limb?
a. 9%
b. 18%
c. 27%
d. 36%
B
Burns affecting the epidermis, dermis, and subcutaneous layer are defined as:
a. first degree
b. second degree
c. third degree
d. fourth degree
C
Avulsion fractures are broken bones:
a. that involve tendons or ligaments
b. with multiple fragments
c. with a splintered fragment but an incomplete fracture
d. associated with penetration of the skin
A
Which phase of wound healing begins between 6 and 12 hours post injury?
a. Inflammatory phase
b. Maturation phase
c. Proliferation phase
d. Debridement phase
D
An enterotomy would be an example of which type of wound?
a. Clean
b. Clean-contaminated
c. Contaminated
d. Dirty
B
The sebaceous glands are located in which layer of the skin?
a. Epidermis
b. Dermis
c. Subcutaneous layer
d. Muscle layer
B
A wound that causes damage to underlying tissues and capillaries but does not break the skin is which type of wound?
a. Avulsion
b. Laceration
c. Abrasion
d. Contusion
D
