W O U N D S

Question 1

Describe first stage of wound healing and 3 things that could impair it.

Answer 1

COAGULATION. Begins instantaneously following wound formation. Coagulation and complement cascades are activated and platelets create a hemostatic plug. The release of various inflammatory mediators from activated platelets set the stage for steps that follow.
Coagulation is impaired by anti-coagulants, anti-platelet agents, and coagulation factor deficiencies.

Question 2

Describe second stage of wound healing and 3 things that could impair it.

Answer 2

INFLAMMATION. This occurs as wound is inundated with macrophages and polymorphonuclear leukocytes in response to various inflammatory mediators. Bacteria, cellular debris, dirt, and other foreign material also are cleared from the wound site during this stage.
Inflammation is impaired by steroids, other immunosuppressive agents, or congenital/acquired immunodeficient states.

Question 3

Describe third stage of wound healing and 2 things that could impair it.

Answer 3

COLLAGEN SYNTHESIS. This occurs by fibroblasts in vicinity of the wound in response to various growth factor peptides.
Collagen synthesis is impaired by vitamin deficiencies, particularly Vitamin C, and protein-calorie malnutrition.

Question 4

Describe fourth stage of wound healing.

Answer 4

ANGIOGENESIS (granulation). This occurs in response to peptide growth factors such as vascular endothelial growth factor. The presence of new vascular networks is what gives granulation tissue that beefy red appearance and is very reassuring that HEALING is under way!

Question 5

Describe fifth stage of wound healing.

Answer 5

EPITHELIALIZATION occurs with migration of epithelial cells over the wound defect. The integrity of basement membrane is restored as Type IV collagen and other matrix components deposit. Foreign bodies, such as suture, and necrotic tissue remain separated form the wound by these migrating epithelial cells.
Once this step has occurred, the wound is ESSENTIALLY WATERPROOFED.
This stage is usually complete by 24-48 hours.

Question 6

Describe sixth and final stage of wound healing.

Answer 6

CONTRACTION. The surrounding uninjured skin is pulled over wound defect and size of scar decreases, which is made possible by action of myofibroblasts which possess contract mechanism similar to muscle cells This is a long process – it takes many months to complete. DO NOT CONFUSE WITH SCAR CONTRACTURE ** as scar contracture occurs AFTER wound repair has CEASED. Scar contracture can lead to undesirable effects since architecture of surrounding tissue may become distorted.

Question 7

What 3 things must be true in order for a surgical wound to be classified as “clean”?

Answer 7

Wound created in sterile, non-traumatic fashion in area that is free of pre-existing infection.
Respiratory, alimentary, genital, urinary tract not entered.
All persons involved maintained strict, aseptic technique.

Question 8

What 2 things are true in order for a surgical wound to be classified as “clean-contaminated”?

Answer 8

Respiratory, alimentary, genital or urinary tract entered but no significant spillage of contents (e.g., feces) and no established local infection.
Only minor break in aseptic technique.

Question 9

Define 4 examples of contaminated surgical wounds.

Answer 9

Gross spillage from GI tract
GU and biliary tracts entered in presence of infection (e.g., cholangitis)
Wound was result of recent trauma
Break in aseptic technique

Question 10

2 examples of dirty/infected surgical wounds.

Answer 10

Wound was result of remote trauma and contains devitalized tissue
There is established infection or perforated viscera prior to procedure.

Question 11

Early SSI (surgical site infection) that develop in first 24 hours post op are most likely d/t which 2 organisms?

Answer 11

Clostridium or Strep –these grow fast because they excrete enzymes that digest local tissue and impair host defenses. Any infections due to other bacteria become apparent later (4-5 days post op) because they lack such virulence factors.

Question 12

7 normal flora of skin

Answer 12

S. epidermidis, S. aureus, diphtherioids, strep, P. aerugionsa, anaerobes, candida

Question 13

6 normal flora of URT

Answer 13

S. viridans, S. pyogenes, S. pneumoniae, Neisseria, S. epidermidis, H. influenzae

Question 14

Normal flora of Esophagus + stomach

Answer 14

Lactobacillus

Question 15

4 normal flora of Sm. bowel

Answer 15

Streptococci, enterobacteria, bacteriodes, very low density lactobacilli

Question 16

4 normal flora of Lg. bowel

Answer 16

Bacteriodes, Enterobacteria (es. E. coli, Klebsiella, Salmonella), S. aureus, Clostridium

Question 17

4 normal flora of lower urinary tract

Answer 17

S. epidermidis, streptococci, diphtherioids, gram + rods

Question 18

Normal flora of Vagina

Answer 18

Lactobacilli

Question 19

Staph aureus and coag neg staph commonly isolated following wounds that follow which types of procedures?

Answer 19

Thoracic (cardiac and non-cardiac), neurologic, breast, ophtho., vascular and orthopedic surgeries

Question 20

Gram negative bacilli and anaerobes from wound infections develop following which types of procedures?

Answer 20

Appendectomy, colorectal, biliary tract, OB-gyn, urological cases

Question 21

It’s unusual for wound infection to cause fever before POD#3. What is the most common cause of post-op fever in first 24 hrs?

Answer 21

Atelectasis

Question 22

5 W’s of Post Op Fever

Answer 22

Wound infection
Wind (atelectasis)
Water (UTI)
Walking (DVT)
Wonder drugs

Question 23

Proper eval of febrile pt post-op

Answer 23

CBC, blood and urine cultures, UA, CXR. If intraabdominal abscess suspected, CT may be useful. LP for pt with fever and AMS especially if pt s/p craniotomy for neurosurg procedure.

Question 24

Anti-microbial ppx for gram + cocci

Answer 24

1st and 2nd gen cephs

Question 25

Anti-microbial ppx for gram - rods

Answer 25

3rd gen cephs, aminoglycosides

Question 26

What causes a hematoma to form?

Answer 26

Incomplete hemostasis. This can be due to inadequate intraoperative hemostasis, the administration of anticoagulants or anti platelet agents, or the presence of coagulation disorder.

Question 27

Complications of hematoma.

Answer 27

Pain and increased risk of wound infection because pooled blood is an excellent growth medium for microorganisms!

Question 28

What intra-operative things can lead to wound failure?

Answer 28

POOR OPERATIVE TECHNIQUE including:
Suture material with inadequate tensile strength. Since absorbable sutures lose tensile strength quick, NON ABSORBABLE should be used to close fascia.

Inadequate # of sutures -sutures no greater than 1 cm apart; if >1 cm, herniation of viscera may occur.

Too small bite size. Sutures placed no less than 1 cm from wound edge. If closer –> fascia could tear.

Question 29

What patient factors can lead to wound failure?

Answer 29

Systemic illness that impair wound healing such as malnutrition, corticosteroid tx, sepsis, uremia, liver failure or poorly controlled DM.
Physical factors that place stress on incisional site such as coughing/retching, obesity, and presence of ascites.

Question 30

2 Cardiac complications of scar formation

Answer 30

Pericadial tamponade secondary to rupture of ventricular aneurysm.
CHF secondary to ruptured chordae tendinae and resulting incompetent valve