T1 Lecture 2: Fundamentals of Wound Management (classification of wounds) Flashcards
How do we classify wounds?
class 1 is within 0-6 hours of wounding
Class 2 –Within 6-12 hours of wounding
Class 3 - > 12 hours of wounding
How do we classify class 1?
Within 0-6 hours of wounding
– Minimal contamination or tissue damage
– “Golden Period” = Insufficient microbial replication to cause infxn. &
can usually manage w/ 10 closure
How do we classify class 2?
Within 6-12 hours of wounding
– Microbial replication to critical level possible but “Gldn. Period” still in
play
How do we classify class 3?
> 12 hours of wounding
– Microbial replication at critical level allowing for infection
• >105 bacteria/g tissue
What are the types of wound closures?
- Primary Closure (1st Intention)
- Delayed Primary
- Secondary Closure
- Second Intention Healing
State the type of closure:
– Class 1 (& some 2) wounds
Primary Closure 1st intention
most common
State the type of closure:
– Appositional closure before
granulation tissue develops
• W/in 3-5 days of wounding
– Good for Class 2 wounds
Delayed Primary
State the type of closure:
– Appositional closure after
granulation tissue has developed
• > 3-5 days after wounding
Secondary Closure
State the type of closure:
– Healing by
contraction/epithelialization
– Open wound management (OWM)
Second Intention Healing
Name the 8 points of the algorithm for fundamentals of wound management
GPAL Puts dedicated swimming plans
- Global patient assessment
- Prevent nosocomial contamination (cover the wound)
- Aseptically” clip & scrub area
- Lavage, Lavage…Lavage
- Procure culture of wound
- Debridement
- Select appropriate surgical closure method
- Provide drainage if necessary
When you assess the patient what do you address first?
life threatening problems first
Describe the phase?
• Thorough history from owner
– How did injury happen – Polytrauma?
– Likelihood of severe contamination
• Hx of other systemic disease or medications?
– Age Start thinking about how they can heal
• Global prognosis
– Be realistic w/ the owner up front if it’s real bad
• How will analgesia be maintained throughout
the assessment & management period?
Assess the Patient
le patient’s that are wounded but not acting painful are _____ _____
STILL PAINFUL
What kind of anesthesia for evaluation and closure does Dr. C Like?
Local analgesia
Some form of protective bandage w/ or w/out rigid stabilization
indicated for ____ ____ on entry to hospital
– If stable do not place pet in cage unless it has bandage!
all wounds
When aseptically clipping the scrub area, how do you initially protect the wound?
Protect wound w/ sterile lubricant or saline soaked sponges
Hair may be clipped from the wound margin w. scissors dipped in ____ ___ to
prevent hair from falling into the wound
mineral oil
Can you use alcohol in an open wound to initially get rid of material
Alcohol damages open tissue = Never use
Scrub the on the wound or around the wound? Why?
Around the wound,
– Detergents in antiseptic scrubs cause irritation, toxicity
& pain in exposed tissue & may potentiate wound infection
What must you do and make sure of when aseptically clipping and scrubbing?
Make sure patient is stable before transitioning to
this step. Often requires sedation or anesthesia
Describe what is taking place during lavage and why we do it?
Initial wound mgt. begins w/ removal of gross contaminants & copious lavage
– Reduces bacterial numbers mechanically by loosening and flushing away bacteria & associated necrotic
debris
What is the preferred lavage solution?
Sterile isotonic saline or a balanced electrolyte solution (i.e. LRS) (TEST)
Antibiotics or antiseptics (e.g., chlorhexidine or povidone-iodine) in the lavage solution reduce bacterial numbers but what must they do before they are used?
These agents may damage tissue – Must dilute appropriately!!!
Do antiseptics work in an active infection?
No! Little effect
Would you rather lavage or scrub the wound with tissues? Why or why not?
Lavaging = Preferred to scrubbing the wound w/ sponges
– Sponges inflict tissue damage that impairs the wound’s ability to resist infection & allows residual bacteria to elicit an inflammatory response
What is the ideal percentage and ratio for chlorhexidine solution and povidone iodine solution?
• 0.05 % Chlorhexidine solution
(1:40)
• 0.1 % povidone-iodine solution
(1:100)
Describe the use of tap water for gross contamination as an lavage?
Use of running, luke warm tap water for initial cleaning of a heavily contaminated sheering wound
** Tap water is effective & less detrimental than distilled or sterile water, although it causes
some hypotonic tissue damage (cellular & mitochondrial swelling)**
What are the 4 main goals of lavage?
• Remove particulate debris and bacteria via mechanical
contact, inertial forces & fluid dynamic forces
- Remove exudates from infected wounds
- Dilute & remove toxins associated w/ infection
- The forces that must be overcome to remove bacteria from wound beds include capillary, molecular & electrostatic adhesive forces generated by the bacteria
Describe what the new gold standard is for evaluation of fluid pressure of common wound flushing techniques
1L Saline solution bag placed in a pressure cuff, at a cuff pressure of 300 mm Hg =
most consistent technique for generation of 7 to 8 psi 👍
Size of needle does not matter
Why can’t we use the bottle method as a wound flushing technique?
Highest pressure generated w/ the bottle was 3.90 ± 1.30
psi (mean ± SD) w/ a 16-ga needle & full 1-L bottle
Might be sufficient to flush bacteria out of a musculoskeletal
wound but is not sufficient to flush out foreign material
Failed to produce pressures of 7 to 8 psi b/c bottles were too
difficult to squeeze efficiently
Not recommended for highly contaminated wound lavage
How much should you flush
- Available studies indicate amounts between 200-500 mL/wound
- Wound surface area-based protocols = ~50 mL of fluid/cm3 of wound
- Based on this clinical variation 500 mL of fluid for an average wound = Adequate
- Use judgment = Wounds that have high levels of debris contamination, high bioburden debris (i.e. feces) or that occur in immunocompromised patients should be more aggressively irrigated
- Amount of irrigant & type of irrigation used should always be documented in the medical record
What do you do with Minimally/moderately contaminated wounds < 6 to 8 hrs old?
Clean & close w/out culture or use of prophylactic
abx
What do you do with Severely contaminated, crushed/infected wounds, or wounds > than 6 - 8 hours? When do you take these?
Culture
– Samples can be obtained from the wound during the initial wound exploration or during initial debridement
– Clip, clean & lavage wound prior to procuring culture
– If antimicrobial flush solutions are employed = Collect samples before these solutions are used
Culture from _____ ____ is preferred (why?)
Culture from initial debridement = Preferred
– Superficial contaminants removed = Sample more representative of the level of infection & the organisms involved
– Procure block of tissue for sample = Higher diagnostic yield
