Open Wound Management Flashcards
Name problems that might arise owing to open wound management? (4)
- Second intention healing is a slower process than primary wound healing;
- After 2-4 weeks the number of fibroblasts and capillaries in the wound decreases. The wound does not support further epithelialisation or contraction and becomes a chronic granulating wound;
- The surface of open wounds that have healed by epithelialisation may be fragile and easily ulcerated. Hair coverage is often sparse;
- Excessive wound contraction can lead to distortion of body orifices and loss of normal joint movement (contracture).
After 2-4 why does the wound not support further epithelialisation or contraction and becomes a chronic granulating wound?
Number of fibroblasts and capillaries decrease
What is the “golden period” for which traumatic wound may be sutures?
3-6 hours
How to manage a clean laceration?
They are often suitable for primary closure, provided the wound edges are fresh and vascularised with no evidence of crushing, devitalisation or the presence of debris.
How to manage a crushing injury?
They are often associated with extensive damage to the skin and underlying tissues. This may not be apparent for several days, so a period of open wound management is usually indicated.
How to manage a puncture wound?
They are associated with deep tissue crushing and contamination and are best managed, at least initially, as open wounds.
How to manage anatomical degloving injuries?
often heavily contaminated. Damage to deeper tissues may not be apparent at the time of injury so these are best managed as open wounds. In any event, skin loss and tension usually preclude primary closure.
How to manage physiological degloving injury?
necrosis developing several days later. These are managed in the same way as anatomical degloving injuries.
What is anatomical degloving?
The loss of an area of skin with exposure of the underlying tissues. These occur following dragging and scraping of the skin
What is physiological degloving?
The skin is intact but has become separated from its blood supply,
Primary closure or open wound management:
A) Clean skin laceration from barbed wire?
B) Dog Bite?
C) Tarsal shear injury?
A) Primary
B) Open
C) Open
Primary closure or open wound management:
A) Clean laceration of paw, crushed by door?
B) Cut pad
C) Radius/ulna # with small open wound
A) Open
B) Primary
C) Primary
How do we reduce wound contmination?
Irrigation
What are the 2 aims of initial management of open wounds?
Reduce contamination
Prevent further contamination
How do we prevent further wound contamination (2)
Dressings
ABx
What should we use to irrigate wounds?
Saline (although tap water may be just as effective)
Why must care be taken with anti-septic solutions with wounds?
May be toxic to cells if inappropriate dilution
Wound lavage, how can we provide
A) High pressure?
B) Low pressure?
A) 35ml syrnge with 18/19 gauge needle
B) Drip bag and giving set
What is the most important aspect to allow wound decontamination?
VOLUME
What does the thickeness of the secondary dressing layer depend on?
Function
What is the function of the tertiary dressing layer?
Secure
What is the negative of the tertiary dressing layer?
These dressings are porous to allow moisture to evaporate from the secondary layer.
What are the 3 forms of selective debridement?
- Autolytic debridement (the use of gels or dressings)
- Enzymatic debridement
- Biotherapy (maggots).
What are the 2 forms of non-selective debridment?
Surgical debridement
Mechanical debridement e.g. wet to dry dressing
What is a negative of non selective debridement?
It is more aggressive and rapid way to remove necrotic tissue but is less precise resulting in a degree of damage to viable tissues.
What are the 2 forms of surgical debridement?
- en bloc excision
- Layered debridement
What is the most common type of mechanical debridement?
Wet to dry dressing
How do wet to dry dressings work?
Gauze pads moistened with sterile saline are applied to the wound surface.
The moisture dilutes the wound discharge and facilitates its absorption into the gauze and the outer components of the dressing. As the moisture evaporates through the dressing, the gauze dries and adheres to the wound surface and necrotic tissue. To allow adherence to the wound, the gauze should not be over-soaked. When the dressing is removed, the necrotic tissue is stripped away.
How often are wet to dry dressings changed?
8-12 hours
wet to dry dressings are used less - negatives? (3)
- They can be painful to remove, so often sedation or general anaesthesia is required;
- They need to be changed several times a day, particularly in highly exudative wounds;
- They are non-selective, so healthy tissues are damaged at the same time as removal of the necrotic tissue.
When should wet-dry dressing be limited to?
The inflammatory phase of wound healing, i.e. no longer than 3-5 days, is unlikely to cause significant trauma to the cells involved in the proliferative phase of wound healing.
When in enzymatic debridement a good idea?
When surgical debridement is not a good idea.
Name some enzymatic debridement options
- Papain-urea (Accuzyme® Ointment, Healthpoint Ltd.)
- Papain-urea, chlorophyllin copper complex (Panafil®, Healthpoint Ltd.)
- Trypsin (Granulex® V, Pfizer)
- Collagenase (Santyl à, Healthpoint Ltd.)
- Deoxyribonuclease with fibrinolysin (Elase, Astellas Pharma).
How do autolytic debridement products work?
These products work by retaining moisture at the wound and softening necrotic tissues, thereby enhancing phagocytosis.
Why is some cases is surgical debridement with or without a short period of wet-to-dry dressings is a better option than autolytic debridment?
There is a risk of promoting infection in the presence of large amounts of necrotic tissue.
Hydrogels:
- What do they contain?
- Where are they applied?
- What function? (3)
- Water
- Wound surface (would macerate skin at edges)
- HYDRATE, facilitate autolytic debridement, absorb exudate
Hydrophillic pastes and powders:
- What wounds are they used in?
- What is the function? (2)
- Exudative
- Absorb exudate and facilitate autolytic debridement
What are the wound functions of honey?
- reduce local oedema
- retain wound fluid
- promote autolytic debridement
Selective vs non selective debridement:
A) Manuka honey
B) Accuzyme ointment
C) Maggots
D) Layered debride
A) Selective
B) Selective
C) Selective
D) Non Selective
Selective vs non selective debridement:
A) Hydrogel
B) Hydrocolloid paste
C) Wet to dry dressing
D) En bloc
A) Selective
B) Selective
C) Non Selective
D) Non Selective
How are wound dressing classified? (3)
- Their adherence to the wound
- Their absorptive capacity
- Their ability to retain moisture at the wound.
Name a non - adhesive dressing
Adaptic® from Johnson and Johnson, is a knitted acetate fabric impregnated with petrolatum.
What does the porous nature of Adaptic® from Johnson and Johnson, allow?
Exudate to pass into the absorptive (secondary) layer of the bandage
How can moisture retention be provided with Adaptic® from Johnson and Johnson?
Topical woind gel/ointment
When are low adherent dressings suitable?
No further mechanical debridement needed
How do non adherent dressing aid autolytic debridement?
Retain some of the absorbed fluid at wound surface
What is the main aim of non adherent dressings?
Absorb fluid in exudative wounds
Polyurethane foams e.g. allevyn or cutimed:
A) Absorption?
B) Autolytic debride?
C) Moisture?
A) High
B) Less effective (cf alginate/hydrocolloid)
C) Retain some; semi occlusion and moisture retentive
Alginate dressings:
A) Made of?
B) Absorption?
C) Hemostatic effects as a result of?
D) Wound type?
E) Anti microbial?
A) Alginic acid (from algae)
B) High
C) Activates prothrombin
D) Exudate (cover with absorptive dressing)
E) impregnate with silver/manuka honey
What does a moist wound environment promote?
Autolytic debridement
Hydrogel dressing:
A) Made of?
B) Transparency allows?
C) Absorptive?
D) Promote?
E) Change dressing?
A) Water retained in hydrophilic polymer
B) Semi transparent - visualization
C) limited
D) Autolytic debridement
E) 3-4 days
What wounds are hydrogel dressings best for?
Open wounds free from necrotic tissue/infect
Hydrocolloid dressings:
A) Promote?
B) Absorption?
C) Wound type?
A) Autolytic debridement and 2ry intention healing
B) Some
C) Free from necrotic tissue/infect
Vapour-permeable film:
A) Occlusive?
B) Not indicated for.. (3)
C) Common use
A) Semi
B) necrotic, infect, exudate
C) Protect sutured wounds
Primary function of knitted acetate fabric?
Low adherence
Primary function of polyurethane foam?
Absorption
Primary function of hydrogel dressing?
Moisture retention
Primary function of gauze swab?
Adherence
Benefits of sub atmospheric pressure across wound? (5)
- increased wound perfusion
- decreased oedema
- increased granulation tissue formation
- decreased bacterial colonisation
- removal of wound exudate.
