Principles of wound management

Question 1

aims of wound management

Answer 1

achieve a healed wound
minimise scar function
preserve function
prevent infection

Question 2

wound management steps

Answer 2

initial management
assessment of patient
assessment of wound
manage open wound
closure of wound

Question 3

initial management

Answer 3

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

Question 4

assessment of the patient

Answer 4

airways, breathing + circulation followed by PE
general health + history should be taken
aetiology of wound + treatment
BCS
appropriate analgesia

Question 5

assessment of the wound

Answer 5

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

Question 6

wound contamination, infection + aseptic technique

Answer 6

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

Question 7

“golden period”

Answer 7

6 hours after injury a contaminated wound may be cleaned + closed primarily without development of infection

Question 8

definitive wound management

Answer 8

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

Question 9

prevention of further wound conamination

Answer 9

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

Question 10

wound protection

Answer 10

wound protected with KY jelly or slain swabs

if animal is v.dirty animal may be bathed

Question 11

tissue handling

Answer 11

shouldn’t be handles atraumatically
shouldn’t probe wound before preperation
shouldn’t replace bone fragments into wound

Question 12

clipping of the hair

Answer 12

should begin at wound margins + move towards periphery

clip generous margin around wound to allow for exploration

Question 13

surgical preperation

Answer 13

KY jelly/swabs replaced to cover wound + skin around wound prepared aseptically
antiseptic kept out of the wound

Question 14

debridement - define

Answer 14

removal of necrotic tissue from a wound

Question 15

debridement

Answer 15

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

Question 16

debridement - skin + subcutis

Answer 16

excise liberally, back to bleeding tissue

preserve vessels

Question 17

debridement - fat + facia

Answer 17

excise liberally

Question 18

debridement - muscle

Answer 18

excise but preserve function

Question 19

debridement - tendon/ligament

Answer 19

staged debridement
preserve function
anastomosis

Question 20

debridement - nerves + vessels

Answer 20

preserve if possible

ligate damaged vessels

Question 21

debridement - bone

Answer 21

preserve if vascularised

remove if unattached + small

Question 22

debridement - joints

Answer 22

lavage + remove small loose fragments

close if possible

Question 23

tissue viability

Answer 23

colour, warmth, sensation, bleeding
complex measurement - doppler ultrasound, transcutaneous pO2, flourescein injection
may change for better or worse over 1st 5 day

Question 24

layered debridement

Answer 24

beginning at wound margins + progressing deeper into the wound
allows each layer to be assessed serperately

Question 25

en bloc debridement

Answer 25

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

Question 26

lavage - aims

Answer 26

remove foreign material + keep tissue hydrated
necrotic tissue, debris + micro-organisms promote infection + delay healing
can be couple with debridement

Question 27

lavage

Answer 27

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

Question 28

establish drainage

Answer 28

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

Question 29

promote development of a viable vascular bed

Answer 29

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

Question 30

reasons for closing a wound

Answer 30

can convert to clean wound
no tension
not crush wound
not infected
granulating wound
won't heal by 2nd intention

Question 31

reasons for not closing a wound

Answer 31

puncture wound
can’t debride + lavage
infected
tension on closure

Question 32

primary closure

Answer 32

direct apposition of skin edges
clean/clean-contaminated wounds
restores normal function quick
needs general anaesthesia + leads to problems if used inappropriately

Question 33

delayed primary closure

Answer 33

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

Question 34

secondary closure

Answer 34

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

Question 35

second intention healing

Answer 35

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

Question 36

disadvantages of second intention healing

Answer 36

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