Principles of wound management Flashcards
aims of wound management
achieve a healed wound
minimise scar function
preserve function
prevent infection
wound management steps
initial management assessment of patient assessment of wound manage open wound closure of wound
initial management
wound should be covered to prevent contamination + trauma + help haemostasis - dry gauze, linen or sterile dressing
tourniquet rarely needed + can cause trauma
support fractures to reduce pain, prevent soft tissue injury + reduce contamination of deeper tissue from movement of fracture fragments in open fractures
assessment of the patient
airways, breathing + circulation followed by PE general health + history should be taken aetiology of wound + treatment BCS appropriate analgesia
assessment of the wound
aetiology, location, nature, extent + degree of contamination
rest of affected region exam
thorax wound - integrity of pleural + peritoneal space established
limb wound - bone, joint + neuro damage
wound contamination, infection + aseptic technique
all traumatic wounds dirty/contaminated
most contaminants in wounds are from hospital - strict aseptic technique needed
sample after debridement + lavage
antibiotics can be prophylactic or therapuetic but not neeeded once granulation tissue is formed - resistant to infection
“golden period”
6 hours after injury a contaminated wound may be cleaned + closed primarily without development of infection
definitive wound management
protect wound from desiccation + contamination
preparation + clipping
debridement of necrotic tissue
removal of foreign material + contaminants - lavage
provision of adequate wound drainage
promotion of viable vascular bed
selection of appropriate method closure
prevention of further wound conamination
on admission wound protected from further contamination, trauma or drying by dressing
saline-soaked swabs good for debridement
antibiotics/antiseptics can be added to the dressing but these are questionable
animals should be sedated/anaesthetised for adequate wound preperation
in concious animal, local or regional anaesthetic techniques can be used
wound protection
wound protected with KY jelly or slain swabs
if animal is v.dirty animal may be bathed
tissue handling
shouldn’t be handles atraumatically
shouldn’t probe wound before preperation
shouldn’t replace bone fragments into wound
clipping of the hair
should begin at wound margins + move towards periphery
clip generous margin around wound to allow for exploration
surgical preperation
KY jelly/swabs replaced to cover wound + skin around wound prepared aseptically
antiseptic kept out of the wound
debridement - define
removal of necrotic tissue from a wound
debridement
all necrotic tissue should be removed
*inadequate debridement is most common cause of delayed wound healing
done with scalpel, adherent dressings, hydrogel dressings + enzymes
scalpel used most commonly - initial phases
dressing used for 1st few days
enzymes not used often - good for pocket wounds
avoid use of diathermy, ligating large pedicles + excessive retraction or dissection
debridement - skin + subcutis
excise liberally, back to bleeding tissue
preserve vessels
debridement - fat + facia
excise liberally
debridement - muscle
excise but preserve function
debridement - tendon/ligament
staged debridement
preserve function
anastomosis
debridement - nerves + vessels
preserve if possible
ligate damaged vessels
debridement - bone
preserve if vascularised
remove if unattached + small
debridement - joints
lavage + remove small loose fragments
close if possible
tissue viability
colour, warmth, sensation, bleeding
complex measurement - doppler ultrasound, transcutaneous pO2, flourescein injection
may change for better or worse over 1st 5 day
layered debridement
beginning at wound margins + progressing deeper into the wound
allows each layer to be assessed serperately
en bloc debridement
complete excision of wound with no entry to the wound
wound may be closed/packed with swabs
simple technique with gives clean wound which can be closed primarily
removes more tissue + results in larger wound + may be damage to surrounding vital tissue
lavage - aims
remove foreign material + keep tissue hydrated
necrotic tissue, debris + micro-organisms promote infection + delay healing
can be couple with debridement
lavage
simple + cheap apparatus for lavage in 18 gauge needle attached to 20ml syringe + bag of fluid via giving set + 3-way tap
wound edges elevated to examine deeper fascial planes
asses wound infection
generally performed daily after changing wound dressings
antibiotics/antiseptics can be given
establish drainage
fluid in wound impairs immune response, incr bacterial growth + decr blood supply
open wounds drain best
when closing a wound allow drainage - leave part of wound open, fenestration of part of skin surface, use phsiologic/synthetic implant
promote development of a viable vascular bed
debridement, drainage + protect from trauma + contamination
ideally circulation can support granulation tissue formation
exposed area of bone denuded of periosteum may not - drill small holes into cancellous bone to promote coverage of cortical bone by using muscle flap to cover bone
reasons for closing a wound
can convert to clean wound no tension not crush wound not infected granulating wound won't heal by 2nd intention
reasons for not closing a wound
puncture wound
can’t debride + lavage
infected
tension on closure
primary closure
direct apposition of skin edges
clean/clean-contaminated wounds
restores normal function quick
needs general anaesthesia + leads to problems if used inappropriately
delayed primary closure
apposition of skin edges 2-5 days after injury
wound covered with sterile dressing
contaminated wounds
decr infection
used when contamination can’t be removed, judgement of tissue viability, definitive debridement cant’t be done initially
secondary closure
closure in presence of granulation tissue
can be combined with reconstructive techniques to avoid tension
for superficial contamination, invasive infection + wounds closed by primary that get infected
5-10 days after injury
direct apposition of granulating surfaces or excision of granulation tissue + primary close
excision of granulation tissue may decr infection + better cosmetics but takes longer + is more traumatic
healing is rapid after closure as wound is already in prolifererative phase of healing
delay in closure + decr tissue pliability may make closure difficult
second intention healing
healing by contraction + epithelialisation
contraction normally successful in small animals due to abundant, elastic skin
generally reserved for dirty wounds which can’t be closed by other techniques
large defects - not enough skin to closure so left to heal
laxity in adjacent skin + tension assessed
disadvantages of second intention healing
expensive in many bandage changes, hospital visits + medications
healing is prolonged
healing be not complete - chronic non-healing
cosmetic result is relatively poor
recurrent wound breakdown may occur if fragile epithelium present over large area
recurrent wound breakdown may occur if fragile epithelium present over large area
stenosis/impairment of function or orifices may occur with adjacent wounds
decr range of motion of limb may occur with wounds near joints
