Wound Healing Flashcards
This is a cut or a wound intentionally produced by cutting with a sharp instrument. It is produced with wound healing in mind. Considered a “clean” cut.
Surgical Incision
This is a wound where the skin is “torn” partially or fully away. It tends to bleed.
Avulsion
How do you approach a partial avulsion?
Debrided and sutured in place, if viable.
How do you approach a total avulsion?
Generally not replaceable except as a skin graft after the fat is removed
When is microsurgery an option for an avulsion?
If the avulsed part contains an adequate single artery and a vein (>0.4 mm).
This is a wound or hole in the skin and deeper tissue layers caused by a sharp object such as a nail, stick, or piece of metal.
Puncture
Management of a puncture
- Should not be closed
- Assess for damage to underlying vital structures and examining for a foreign body.
This is a wound that is described as a superficial loss of the epithelial tissue layer.
Abrasion
What is the management for an abrasion?
- Usually only cleaning of the wound is required because the remaining epithelial cells regenerate and migrate to the wound.
- Careful cleaning to prevent traumatic tattooing
- Pain meds/sedation or general anesthesia may be needed to clean for large abrasions
- Abx ointment
This is a wound caused by a sharp object producing edges that may be jagged, dirty, or bleeding. Most commonly affects skin, but any tissue may be affected including SQ fat, tendon, muscle, or bone.
Laceration
Treatment for a Laceration
Primary or secondary closure
This is a wound that occurs when a body part is subjected to a high degree of force or pressure, usually after being squeezed between two heavy or immobile objects. Usually associative injuries including laceration, bruising, fractures, compartment syndrome.
Crush
This is an area of soft tissue swelling and hemorrhage without violation of the skin (bruise).
Contusion
Treatment/Management of a Contusion
- Evacuation of a hematoma with aspiration may be required.
- Application of cold compresses early to minimize swelling, followed by the application of warm, moist compresses for the absorption of blood.
Identify the Stage of (Pressure) Ulcer:
Intact skin with non-blancheable redness of a localized area usually over a bony prominence darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Stage I
Identify the Stage of (Pressure) Ulcer:
- Full thickness tissue loss
- SQ fat may be visible but bone, tendon, or muscle are not exposed
- Slough may be present but does not obscure the depth of tissue loss
- May include undermining and tunneling.
Stage III
Identify the Stage of (Pressure) Ulcer:
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed.
Unstageable
Identify the Stage of (Pressure) Ulcer:
- Full thickness tissue loss with exposed bone, tendon or muscle.
- Slough or eschar may be present on some parts of the wound bed
- Often include undermining and tunneling
Stage IV
Identify the Stage of (Pressure) Ulcer:
- Partial Thickening loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough – may also present as an intact or open/ruptured serum-filled blister.
Stage II
What phase of wound healing is this?
Occurs approximately over 4 days. The wound is edematous (tumor) and erythematous (rubor). It may be difficult to distinguish from early signs of infection. It continues indefinitely until the wound surface is closed by epithelium of the skin or mucosa in the gut. PMNs and macrophages are mainly involved. PMNs appear quickly and remain for approximately 48 hours and may be the origin of inflammatory mediators such as kallikrein. Monocytes enter the wound in 24 hours after PMNs and evolve into macrophages.
Inflammatory Phase
Also called the lag or exudative phase.
What are the main cells involved in wound debridement? Why are they important?
Macrophages
Important producer of growth factors such as TGF-B (stimulates fibroblasts), interleukin-1 (induces fever, promotes homeostasis enhances fibroblasts and activates T-cells).
What phase of wound healing is this?
This is the second stage of healing and is characterized by the production of collagen in the wound. The fibroblast is the primary cell that produces collagen which is the primary structural protein in the body. The wound scar may be raised, red, and hard.
Proliferative Phase
What phase of wound healing is this?
This is the third and final stage of wound healing also known as the maturation phase. It is characterized by the maturation of collagen. The wound scar gradually flattens and becomes less prominent, more pale, and supple.
Remodeling Phase
Factors that Affect Wound Healing
- The amount of tissue trauma (laceration vs. crush vs. avulsion)
- Hematoma
- Bacterial Contamination
- DM
- Steroids
- Nutritional Status
What are some Pharmacologic Impairments to Wound Healing?!
- Chemotherapy
- Steroids
What drug has been approve for the use of reversing the inhibitory effects of glucocorticoids on wound healing?
Vitamin A!!!
Other Barriers to Wound Healing
- Ischemia
- Smoking or nicotine patches
- Radiation
- Edema
- DM
- Neuropathy
- Other Local Conditions
Why is ischemia a barrier to wound healing?
Because O2 is needed to clear bacteria and also for proline and lysine hydroxylation to form stable collagen cross links.
Why are Smoking or Nicotine Patches barriers to wound healing?
Because they inhibit O2 delivery via sympathomimetic vasoconstriction. It also elevates carboxyhemoglobin levels in the blood causing a leftward shift, decreasing O2 delivery.
Why is Radiation a barrier to wound healing?
Because radiation injury leads to arteriolar fibrosis and impaired O2 delivery. In addition, thee is progressive obliteration of blood vessels in the radiated area over time.
also causes intranuclear and cytoplasmic damage to fibroblasts, and this change appears to limit the proliferation potential.
Irradiated wounds often require a flap for successful closure
Why is Edema a barrier to wound healing?
Impairs local O2 delivery.
Often assc with inc. venous pressure, which can lead to obstruction and perfusion pressure will decrease resulting in ischemia.
It also can lead to protein extravasation and pericapillary cuffing.
Why is DM a barrier to wound healing?
Due to local wound ischemia. If pt is well controlled with normal perfusion, then the wound should heal and there should be no infection.
Why is Neuropathy a barrier to wound healing?
Neuropeptides promote healing. When there is a decrease or absence in these with spinal cord injury or DM neuropathy, this might affect healing. No treatment that is effective currently.
Why are Other Local Conditions a barrier to wound healing?
Peripheral Arterial Occlusive Dz secondary to atherosclerosis can be a primary cause of impaired healing and may also be a cofactor with the other conditions discussed.
Conditions such as vasculitis, prolonged pressure, lower leg venous insufficiency, and tissue fibrosis affect wound healing through the mechanism of local tissue ischemia.
This type of wound closure is by direct approximation of the wound edges.
It includes primary suturing, stapling, gluing, pedicled flaps, and skin grafts.
The wound is pink and the tissue is fragile.
The purpose is to protect and promote tissue growth and maintain a moist environment
Primary Intention
What do you do for dressings with a Primary Intention Closure?
- Consider low or non-adherent dressing due to fragile skin
- Irrigate gently with warmed NaCl 0.9% to remove debris when changing dressing
This type of wound closure is also called a delayed primary closure.
The wound is left open for a time and then sutured at a later date
Suturing interrupts the secondary healing process
Often used with grossly contaminated wounds.
Tertiary Intention
This type of wound closure is also know as spontaneous wound closure. The wound is left open and allowed to heal by process of wound contraction and epithelialization at a rate of 1 mm/day.
Most often for infected and packed open wounds
Secondary Intention
Secondary Intention Wound Healing - Inflammatory Phase
Inflammatory phase continues in the middle of an open wound.
Prolonged = Granulation tissue (proud flesh), which consists of inflammatory cells and a proliferation of capillaries.
Closure by Secondary Intention
- Granular in appearance, glossy red and bleeds easily
- Irrigate with warmed NaCl 0.9%
- Wet to dry dressing changes, VAC dressings or hydrocolloid
- Slough is the formation of a viscous yellow layer of tissue
- Debridement and Accuzyme (Collagenase)
This is used for healing acute and chronic wounds. It uses continuous negative pressure distributed over the wound surface.
Vacuum Assisted Closure (VAC)
Pros of VAC
- Decreased wound edema
- Increased local tissue perfusion
- Continual Removal of wound exudates and reduction of wound bacterial burden
- Accelerates wound contraction
- Microdeformation places in cells in the wound bed is though to upregulate growth factor production
Steps in Wound Care
- Sterile prep and draping
- Admin of local anesthetic
- Irrigation and Debridement
- Hemostasis
- Closure in layers
- Dressing and Bandage
Proper Wound Debridement and Irrigation
- Use sharp debridement to remove clots, debris, and necrotic tissue
- Irrigate with copious normal saline
- Evacuate hematoma
- Hemostasis is achieved with cauterization, absorbable ligature, or pressure
