Wound Healing Flashcards
wound
injury that breaks skin or other bodily tissues
surgical wound
cut or incision made during surgery
purposely made
minimal tissue damage
traumatic wound
sudden or unplanned injury
many wounds seen in ER/GP
bites, burns, lacerations
wound healing
biological process
replace devitalized tissue and missing cellular structures and tissue layers
restores tissue after injury
open (penetrating) wound
broken skin and exposed tissue
abrasion
laceration
puncture
avulsion
thermal wounds
surgical wounds or incisions
abrasion
open wound
skin rubs or scrapes against a rough/hard surface
loss of epidermis and portion of dermis
usually no significant bleeding
scrub and clean wound to avoid infection
laceration
open wound
cut or tear in skin, varies in severity and depth
if deep bleeding can be rapid and extensive
puncture
open wound
small hole/wound by long sharp object
minimal skin damage but underlying damage may be severe
may not bleed much, but can damage internal organs
higher risk of subsequent infection by contamination at time of puncture – dirty wound
avulsion
open wound
partial or complete tearing away of skin and tissue
traumatic injury, pieces of tissue torn and detached
bleed heavily and rapidly
crushing accidents, explosions, gunshots, head on collisions
closed (non penetrating) wounds
damage to tissue under intact skin
usually secondary to blunt trauma
injured tissue not exposed, but can be bleeding and damage to underlying muscle, internal organs, bones
contusion
hematoma
crushing injury
contusion
closed wound
blunt force trauma
does not break skin but causes damage to skin and underlying tissue
blood leaks from vessels
type of hematoma
hematoma
closed wound
collection (pooling) of blood outside a vessel
crushing injury
closed wound
force applied to area over period of time
commonly seen in bite wounds
degloving wound
severe injury
top layers of skin/tissue ripped away in dramatic fashion
other wounds
sinus tract injuries
burns
non healing wounds
open fractures
stings
wound healing
multiple processes continuously interacting
restore tissue after injury
factors that affect how well/quickly wound heals
environment/temperature – moisture favors bacteria
patient’s overall health
drug treatments
phase I of wound healing
inflammatory phase
immediately after injury (within 5-10 mins)
minimizing blood loss by hemostosis
vasoconstriction, platelet aggregation, clot formation, vasodilation, phagocytosis
platelets start wound healing process – cytokines
phase II of wound healing
proliferative phase
begins at 3-5 days, can last for several weeks
granulation contraction
epithelialization of injured tissue
phase III of wound healing
remodeling phase
begins at ~3 weeks, can last weeks to months
formation of new collagen
wound tissue strengthening
scar formation
6 basic steps of wound care
- prevention of further wound contamination (lavage)
- debridement of dead/dying tissue
- removal of foreign debris and contaminants
- provision of adequate wound drainage
- promotion of viable vascular bed
- selection of appropriate method of closure
patient assessment
-hemodynamic stability – make sure patient stable before attending to wound
-hydration
-pain sensation, neuro function – important in limb injuries
-body condition
-organ dysfunction
-anemia – evidence of sepsis
-provide analgesia
wound classification – clean
non contaminated, non traumatic, non inflamed surgical sites
GI, urinary, repsiratory tract not entered
surgical wound
aseptic technique maintained
tissues not predisposed to infection
wound classification – clean-contaminated
GI, urinary, respiratory tracts entered under controlled conditions without unusual contamination
aseptic technique, no spillage of organ contents
some acute traumatic wounds that have been cleaned
minor break in sterility
placement of a drain in a “clean” wound
wound classification – contaminated
surgery where GI contents or infected urine spill into an open cavity
major break in aseptic technique
open fractures
penetrating wounds
new open traumatic wounds/lacerations
antibiotics and lavage +/- debridement
wound classification – dirty and infected
heavily contaminated/infected
purulent discharge, foreign material
abscesses
traumatic wounds > 12 hours after injury
surgery where hollow organ/viscera perforated or fecal contamination occurs
gross spillage of contamianted body contents
antibiotics, lavage, debridement, drainage, +/- bandage
initial approach of wound cleaning
protect with occlusive bandage
provide analgesia
drug therapy – antibiotics
wear gloves
fill wound with water soluble lube – prevent hairs from getting it while clipping
clip and clean with wide margins
do not use scrub in wound bed
lavage
keep tissue hydrated
reduce bacterial contamination
remove necrotic debris
dilution is the solution to pollution
culture after lavage
do not lavage puncture wounds
why culture after lavage?
if do it before will just get significant contamination, will not get an accurate reading
surgical debridement
freshening edges – scalpel blade, may be some active bleeding
sometimes only indicated in preparation for wound closure
chemical (enzymatic) debridement
very expensive, not painful (no analgesia)
poor anesthetic patients, minimal debridement
very slow, not good for large wounds
mechanical (bandaging) debridement
traps devitalized tissue in primary layer of bandage
wet to dry vs dry to dry
materials inexpensive
painful – materials stick to bandage
have to change at least once per day
biosurgical debridement
maggot therapy – maggots eat dead tissue
what to debride
contaminated SQ fat
shredded fascia
macerated muscle
devitalized skin
skin edges (3-5 mm)
what not to debride
direct cutaneous vessels
hypodermis
cutaneous muscles
bones with attachments
ligament attached to bone
nerves
other vital structures
what determines wound management plan
wound classification
time since injury
location of wound
degree of contamination
degree of tissue trauma
extent of tension or dead space
blood supply of wound
clinical condition of patient
results after debridement and lavage
wound closure – first intention
-primary closure
-within a few hours after injury (6-8 hours)
-best choice for healthy wounds in well vascularized areas
-closed within 24 hours of injury with sutures or staples
-minimal edema
-no local infection or serous discharge
-minimal scar formation
-healing rapid
-clean surgical or fresh traumatic wound after cleaning (clean-contaminated)
should you close a contaminated wound
aggressively debride
good blood supply
no evidence of established infection
less than 6 hours old
wound closure – third intention
-delayed primary closure (18-24 hours)
-start wound management at 6-8 hours post injury
-prior to granulation formation
-wounds sutured closed before granulation tissue forms
-moderate to marked tissue edema
-older wounds
-questionable viability
-debride
-significant swelling and/or skin tension
-best for infected or unhealthy wounds that are too contaminated for primary closure
-appear clean and well vascularized in 3-5 days
-don’t use for dirty or significantly contaminated wounds
-contaminated or infected wounds, extremity wounds, wounds from blunt trauma
wound closure – secondary closure
-after granulation tissue present
-wound closure > 5 days after injury
-medical management of wound initially, then surgical closure
-ensure wound in clear of infection before closing
-excision of epithelialized edges and some granulation tissue may be required
-recommended for infected wounds or large wounds
-if primary closure fails can then use secondary closure
wound closure – second intention
-non closure
-contraction and epithelialization
-secondary wound healing or spontaneous healing
-wound is left open
-some may be surgically closed later (secondary closure)
-recommended when patient is poor anesthetic candidate, infected wounds, large wounds
-risk of contracture formation – proud flesh in horses
-moderate to small trunk wounds or burns
-abscesses – can’t clear with initial lavage (don’t want to suture bacteria into body)
-distal extremity wounds – not enough skin
-fistulae
-takes a long time, expensive
wound closure – epithelialization
healing of partial thickness wounds (includes first degree burns and abrasions)
golden period
wound treated within 6-8 hours after injury
bacterial levels not multiplied to critical numbers yet
tissues not infected
should wounds treated after the golden period be closed
no
infection is likely
tissue viability
don’t want to suture dead/necrotic tissue into patient
attachment
color
texture
temperature
bandaging
covers drains and wounds
reduces dead space and edema
debrides wounds (mechanically)
vehicle for antiseptic
immobilization
cleanliness
holds dressing in place
primary layer of bandage – dressing
directly on wound
gauze or mesh material that promotes early healing
allows fluid to pass through secondary layer and prevents tissue from drying out
secondary layer of bandage
absorbs fluid
pads the wound
decreases dead space
supports or immobilizes limbs
frequently cast padding or roll gauze
tertiary (outer) layer of bandage
provides some pressure on wound
holds inner layers in place
protects inner layers from environment
usually adhesive tape or elastic wraps (vet wrap)
hydrophilic foam
hydrophilic dressing
maintains moist wound environment
not too moist – bacteria
not too dry – kills tissues
low adherence to wound surface
high fluid handling capacity
decreased bandage changes
decreased tissue maceration
topical agents – granulated sugar
inflammatory to early repair phase
hyperosmotic
requires frequent bandage changes
exudative wounds
decreased bacterial proliferation
promotes debridement and granulation/epithelialization
1 cm thick layer
SID to TID bandage changes
topical agents – honey
inflammatory to early repair phase
hyperosmotic effect may damage healthy tissues
requires frequent bandage changes
manuka honey – properties that promote wound healing
promotes debridement, granulation, epithelialization
reduces edema and inflammation
easy to acquire and store, inexpensive
messy
topical agents – silver
inflammatory and repair phases
no clinical evidence of resistance
topical agents – antibiotics
inflammatory and repair phases
broad spectrum
may also supply zinc to the wound environment
topical agents – enzymatic agents
inflammatory phase
slow, expensive
topical agents – biologic (maggots)
inflammatory phase
selective debridement
requires specialized dressing to contain the maggots
when to place a drain
in place 3-7 days
when dead space cannot be eliminated
when fluid accumulation likely
when infection present
passive drains
relies on gravity, pressure differentials, overflow to move fluid/gas
fluid exits around tube at incision site
active drains
apply artificial pressure gradient to pull fluid/gas from wound
involves suction
management of cuts, tears, lacerations
usually complete closure
damage to muscles, tendons, or other tissues must be treated before wound closure
management of degloving injuries
usually requires bandaging
management of puncture wounds
leave open
explore? possibility of underlying trauma
managemnet of abscesses
establish draining
lavage copiously
warm compresses
antibiotics?
management of open fractures
rapid wound care and culture
bandage/splint
antibiotics
analgesics
surgery consultation ASAP
complications – seroma
layered wound closure
drains
complications – infection
debridement
antimicrobials
+/- supportive care
complications – dehiscence
tissue viability
closure technique
complications – failure to heal
patient status
closure method
