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Endo > Wound healing > Flashcards

Wound healing Flashcards

1
Q

Describe an abrasion and give common causes

A
  • Loss of epidermis and some dermis
  • Blunt trauma/shearing
  • Skin rubbed along surface most common e.g. RTA case
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2
Q

Describe an avulsion and give common causes

A
  • Tearing of tissues from attachments
  • On limbs
  • e.g degloving injury, stake injury
  • Torn skin and underlying tissues
  • Can also be bite injuries
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3
Q

Describe an incision wound and give common causes

A
  • Created by sharp object
  • Minimal trauma
  • Usually associated with surgery
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4
Q

Describe a laceration wound

A

Tearing wound creating irregular defect

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5
Q

Describe a puncture wound and give common causes

A
  • Penetrating wound
  • Often do not show full extent of damage i.e. superficial damage often minimal, deep substantial
  • Projectile injury, shot, stab, bite
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6
Q

What are the stages of wound healing?

A
  • Haematosis and inflammation
  • Proliferation (fibroplasia)
  • Maturation
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7
Q

Describe the inflammatory phase of wound healing

A
  • Transient vasoconstriction prevent bleeding
  • Followed by vasodilation to increase capillary permeability
  • Activation of intrinsic and extrinsic clotting cascade
  • Removal of clot to allow influx of inflam. ells
  • Chemotaxis of inflam cells
  • Neutrophils to macrophages
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8
Q

Describe the fibroplasia phase of wound healing

A
  • Cessation of inflammatory phase
  • Fibroblast migration - contact inhibition removed, produce and secrete proteoglycans, collagen and elastin
  • Wound contraction
  • Epithelialisation (contact inhibition removed)
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9
Q

Describe the mauration/remodelling phase in wound healing

A
  • Matrix synthesis and matrix degradation
  • Cross linking of colalgen
  • Increase in tensile strength
  • Weeks to months
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10
Q

What is the function of collagen in wound healing?

A

Improve tensile strength of wound

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11
Q

List factors that affect wound healing

A
  • Age
  • Nutrition
  • Co-morbidities
  • Medication
  • Radiation
  • Vascular supply
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12
Q

Describe the basic vascular supply of the skin

A
  • 3 layers
  • Deep (subdermal)
  • Middle and superficial in dermis
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13
Q

Describe the vascular supply to the skin in cats and dogs

A
  • Subdermal plexus
  • Major network
  • Supplied directly by cutaneous artery
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14
Q

Explain how the subdermal plexus in dogs and cats is useful in wound healing

A
  • Can move an area of skin around and know that it will have blood supply
  • As long as arterial supply to that plexus is kept in tact
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15
Q

What is the effect of steroids on wound healing?

A

Delay healing

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16
Q

Give the important features of a wound assessment in order to decide on management of acute wounds

A
  • Type of wound
  • Wound age
  • Level of contamination
  • Lavage +/- debridement
  • Then management
  • Also asses other injuries and stabilise
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17
Q

Outline the importance of assessing type of wound in terms of its management

A
  • Type of wound relates to level of contamination
  • Degree of tissue damage
  • Depth of wound
  • Vital structures that may have been damaged e.g. bones, joints, nerves, tendons
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18
Q

Outline the importance of wound age in terms of management

A
  • Golden period 6-8 hours
  • Time take from wound occuring to when it will be contaminated/colonised
  • Earlier dealt with reduces bacterial contamination and can prevent becoming a colony and causing infection
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19
Q

Outline the assessment and importance of the level of contamination in terms of wound management

A
  • Linked to type/cause of wound
  • Whether or not will have large bacterial inoculum
  • Presence of foreign material, devitalised tissue
  • Golden period as guideline
  • Affected by vascular supply
  • Swabbing and send off for culture
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20
Q

Outline lavage and/or debridement in management of acute wounds

A
  • Gross contamination removed with tap water
  • Sterile solution followign water (lactated Ringer’s)
  • Avoid pushing bacteria deeper into wound (20-50ml synringe and 18G needle ideal)
  • No added antiseptics
  • Debridement using dressings or surgical
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21
Q

What are the 3 types of management for acute wounds?

A
  • Primary intention
  • Secondary intention healing (takes time)
  • Tertiary intention (delayed primary closure)
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22
Q

Outline primary closure

A
  • Immediate suture
  • Used for clean or clean-contaminated
  • Most likely with surgery, elective surgical procedure
  • Make wound and then close it again
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23
Q

Outline delayed primary closure

A
  • Used for clean-contaminated to contaminated wounds
  • Reduces incidence of infection
  • Closure after 3-5 days
  • Leave wound open for period of time, systemic and local treatment until fit state for closure
  • Usually requires debridement, lavage, culture and wet-to-dry dressings
  • Gradual
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24
Q

Outline secondary intention healing

A
  • Allowing wound to close itself
  • Granulation tissue, wound contraction and epithelialisation
  • Suitable dressings required at each stage
  • Time consuming
  • Careful management
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25
Q

What are the disadvantages of secondary intention healing?

A
  • Careful management to ensure healing does not stop
  • Often get granulation response, won’t move on from there
  • Often hospitalised to ensure correct care
  • Need to reduce movement
  • Regular changing of dressings to support stage of healing
  • Risk of “proud flesh”
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26
Q

Why might granulation stop in healing?

A
  • Co-morbidities

- Movement

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27
Q

What factors affect prognosis of wound healing?

A
  • Level and type of contamination
  • Vascular compromise
  • Viability of tissues
  • Types of tissues
  • Foreign material
  • Patient status
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28
Q

What are the basic aims of wound management?

A
  • Promote healing
  • Convert contaminated into clean
  • Control infection
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29
Q

What are the advantages of secondary intention healing?

A
  • Optimum wound drainage
  • Local infection control
  • Initially cheaper (but likely to become expensive as treatment progresses)
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30
Q

Explain what is meant by “proud flesh”

A
  • Exuberant granulation tissue
  • Contact inhibtion of cells coming together to produce single layer ineffective
  • End up with chronic granulation tissue that epithelium cannot form over
  • Will roll under granulation tissue
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31
Q

Outline the control of infection to promote wound healing

A
  • Local agents with antimicrobial effects
  • Systemic antibodies with care
  • Establish what bacteria are and use specific antibiotics
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32
Q

Outline the role of wound lavage in wound healing

A
  • Dilutes bacteria
  • Removes foreign bodies
  • Encourages healing
  • Isotonic solutions best
  • Culture after lavage
  • Swab before or after, unlikely to clean to extent where will get no results
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33
Q

Outline the role of surgical debridement in wound management

A
  • Removal of foreign material
  • Aspetic technique sharp incision, removal of nectroic material
  • Often repeat
  • Aim to save as much as possible
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34
Q

Give examples of non-surgical debridement

A
  • Use dressings: wet-to-dry or dry-to-dry
  • Both act to draw away purulent and necrotic material
  • Both need external protection
35
Q

Describe wet-to-dry dressings

A
  • Sterile swabs
  • Moisten with sterile isotonic solution
  • Place on wounds, dry swabs on top
  • Fluid drawn from wet to dry, wound fluid drawn into dressing by capillary action
  • Dressing will dry out, removal of dressing also has mechanical properties orf removal
36
Q

Describe tie-over (bolus) dressings

A
  • Useful for hard to dress areas
  • Loops of sutures around wound
  • Apply dressing
  • Hold in place using umbilical tape passing through suture loops (like shoe-laces)
37
Q

What are the indications for use of surgical drains?

A
  • Removal of fluid accumulation

- To eliminate dead space

38
Q

Why eliminate dead space?

A
  • Can fill with fluid = seroma (mostly fill with serum, not blood)
  • Prime inoculum site for bacteria
  • Remove surgically or insert drain to remove fluid
39
Q

What are the advantages of drains in wound healing?

A
  • Increase healing capacity
  • Remove contaminated fluid
  • Reduce tension formed by seroma
40
Q

What are the disadvantages of drains in wound healing?

A
  • Introduction of foreign bodies

- Introduction of infection

41
Q

What are the different types of drains used in wound healing?

A
  • Active

- Passive

42
Q

Give an example of a passive drain

A

Penrose drain

43
Q

Describe Penrose drains

A
  • Latex rubber tube
  • Work using gravity and capillary action
  • Place lower down wound for support from gravity
  • Do not exit wound directly
  • Do not use “ingress/egress” method i.e. drain either side
  • Cover to avoid risk of ascending infection
44
Q

Describe active suction drains

A
  • Closed system
  • Negative pressure applied
  • More expensive
  • 2 readily available: grenade and concertina
  • grande: rigid tube into wound site, empty grenade tray, made of elastic material that wants to expand so is applying constant mild negative pressure, sucking out wound
45
Q

Outline Topical Negative Pressure (TNP) therapy

A
  • Chronic non-healing wounds
  • Produces negative suction pressure
  • Removes exudate and bacterial colonisation
  • Promotes granulation response, better perfusion, better epithelialisation closer to wound more rapidly than otherwise
  • Increases rate of cell mitosis
  • Increases wound perfusion
46
Q

Describe the wound healing continuum model

A
  • Different wounds have different colours associated
  • Can use to decide what stage and thus what management
  • Aim for left to right movement along continuum
47
Q

Describe the wound healing progression model

A
  • Different wounds have different colours and different moisture levels
  • Shown in relation to the optimum moisture and so know whether management should involve addition or removal of moisture
48
Q

Outline how wound tension affects prognosis in wound management

A
  • Circulatory compromise
  • Reduced wound healing
  • Dehiscence
  • Skin necrosis
49
Q

How can wound tension be reduced?

A
  • Patient positioning
  • Undermining of skin
  • Suture patterns
  • Relaxing incision
  • Advancement flaps
  • Understanding of tension lines
50
Q

Explain how patient positioning affects skin tension

A
  • Skin trapped by animal’s own weight

- Weight of skin dragging it down e.g. lying on back

51
Q

Outline the use of skin undermining in reduction of wound tension

A
  • Makes use of natrual elasticity
  • Increases dead space and seroma
  • Takes tension of wound as removing elastic attachment undeneath
  • Skin can move more freely where needed
52
Q

What are important considerations in skin undermining?

A
  • Skin with panniculus, undermine below
  • Skin withouth panniculus, undermine in deep fascia
  • Aim to preserve direct cutaneous arteries using atraumatic technique
53
Q

Outline the use of walking sutures

A
  • After skin undermined
  • Distribution of skin tension
  • Advance skin towards wound site
  • Pull skin forward in increments
  • Sutures within fascia/muscle layer
  • Pull skin forward (max 2-3cm), place suture, repeat
  • Cumulative effect of multiple sutures
54
Q

Outline the use of relaxing incision in wound tension

A
  • Incisions parallel to wound
  • Debride edges of primary wound
  • Undermine bipedicle flap
  • Allows stretch of primary wound, but leaves secondary wound (however this is clean and so will heal)
  • Can also use 2 large relaxing incisions, or multiple smaller ones
55
Q

When might relaxing incisions be used?

A
  • Closing of chronic non-healing wounds
  • To close wounds exposing essential tendons, ligaments and nerves
  • Protection of surgical implants
  • Areas susceptible to external trauma
56
Q

Outline the use of multiple relaxing incisions as opposed to one

A
  • Describe for lower extremities
  • Multiple stab incisions parallel to long axis where there is too much lateral tension
  • Staggered
  • Not as much advancement possible
  • Risk of circulatory compromise and infection
  • However easier to heal
57
Q

What types of skin flaps can be used in advanced wound closure?

A
  • Vascularised

- Non-vascularised

58
Q

Describe the use of vascularised skin flaps

A
  • Resistance to infection
  • Any tissue bed
  • May withstand radiation therapy
  • Rapid healing (single procedure)
59
Q

Describe the use of non-vascularised skin flaps

A
  • Technically relatively simple, covers large tissue defects
  • Requires vascularised tissue bed
  • Poor resistance to infection or radiation
60
Q

Describe the blood supply in vascularised skin flaps

A
  • May be subdermal plexus
  • Terminal branch of direct cutaneous arteries
  • Within panniculus and subcutis
  • Own inherent blood supply or not i.e. is there a subdermal plexus
  • More risky in species other than cat and dog where there is no subdermal plexus, cannot guarantee blood supply
61
Q

Name the different types of subdermal plexus flaps

A
  • Rotation
  • Transpositional
  • Single pedicle advancement
  • Distant
62
Q

Describe rotation subdermal plexus flaps

A
  • Undermine panniculus layer below
  • Move and rotate skin into wound site
  • Allows good cosmetic results
63
Q

Describe transpositional subdermal plexus flaps

A
  • Brad flap, rotate into wound
  • 90degree, 45 degree
  • Harvest skin along line of tension, rotate along least line of tension
  • Can easily close subsequent defect as the line of tension is running the other way
  • Produces Y shape
64
Q

Describe advancement subdermal plexus flaps

A
  • Move local skin utilising subdermal plexus to maintain blood supply
  • e.g. single pedicle advancement flap
  • Makes rectangle shape/H shape
65
Q

Describe axial/inguinal flank fold subdermal plexus flaps

A
  • Can be used as transposition flap
  • Skin in fold loose
  • Rotate into nearby wound
  • However if desensitised due to severed nerve supply then have tendency to self traumatise
66
Q

Describe distant subdermal plexus flaps

A
  • Pouch
  • Site with wound into pouch made at another site e.g. flank
  • Will have inherent blood supply
  • However takes long time and is uncomdortable
67
Q

Describe axial pattern flaps

A
  • Supplied by named direct cutaneous artery/vein
  • Mobilise large areas of skin if certain of blood supply
  • More blood supply than subdermal plexus
  • e.g. caudal superficial axial pattern flap
68
Q

Describe punch/pinch grafts used in wound healing

A
  • Non-vascularised
  • names after artery supplying that portion of skin
  • Take portion of skin using scalpel or skin punch
  • Remove core and defat
  • Place in area of lesion
  • Narrows the gap that epithelium needs to vocer
69
Q

Describe non-vascularised skin grafts

A
  • Free skin grafts partial/full thickness, meshed/non-meshed
  • LArge areas of skin from one part to another
  • Remove fat
  • Attach to healthy granulation bed
  • rely on skin drawing nutrients and blood suply from underlyiing granulation bed
  • No nerve supply so no risk of no danger of self-traumatisation
70
Q

Outline some complications with using skin flaps to support wound healing

A
  • Partial thickness necrosis
  • Full thickness necrosis
  • Desensitisation and self trauma
71
Q

Describe the ideal healing environment

A
  • Optimum moisture (may need to add or remove moisture)
  • Free of infection and debris
  • Free of toxic chemicals, particles or fibres
  • Warm
  • New tissue undisturbed
  • Adequate gas exchange
  • Minimal contamination to and from wound using dressings
72
Q

Describe alginate dressing

A
  • Seaweed
  • Sterile pads, ribbons, rops
  • Non-occlusive, non-adherent
  • Autolytic debridement to soften and remove necrotic tissue
  • Stimulates granulation tissue
  • Become jelly like when absorb moisute, can be used to maintain moisture levels
73
Q

Describe foam dressings

A
  • Absorbent, sponge like polymer dressings
  • Provide thermal insulation
  • Moist wound environment maintained
74
Q

Give examples of contact layer dressings

A
  • Knitted viscose
  • Silicone mesh
  • Paraffin gauze
75
Q

Describe contact layer dressigns

A
  • Woven or perforated material
  • Lie directly on wound’s surface
  • Holes to allow drainage to pass through to secondary dressing
  • Remains in place during dressing changes to minimise trauma
76
Q

Describe hydrogel dressings

A
  • Water or glycerin base
  • Hydrate wounds, soften necrotic tissue
  • Limited absorption
  • Sheet or gel
  • Good for hydration of wounds
77
Q

Describe antimicrobial dressings

A
  • Ingredients: silver, iodine, polyhexamethylene
  • Protect against bacteria
  • Various forms (gauze, foam, absorptive fillers)
  • Some provide moist environment
78
Q

Describe honey for use in in dressings

A
  • Autolytic debridement (pH 3.7)
  • Draws fluid from wound area
  • Alternative to hydrogels
  • Impregnanted gauze, alginate, tube
  • Cover with secondary absorbent dressing
  • Osmotic action of honey draws fluid out, antibacterial properties
79
Q

Describe the use of silver sulphadiazine in dressings

A
  • Antibacterial and antifungal
  • No known resistance
  • Effective against Gram -ve organsism e.g. Pseudomonas
  • Effective against MRSA
80
Q

Outline the use of maggots in wound healing

A
  • Stage 1 larvae only eat liquid protein (so only eat necrotic)
  • Accurate and efficient debridement
  • Reduce risk of infection
  • Difficult to ensure do not escape from wound site
81
Q

In what wound healing stage does moisture need to be removed?

A

Sloughy

82
Q

In what wound healing stage does moisture need to be added?

A

Granulating

83
Q

What wound healing stage required debridement?

A

Necrotic

Endo (30 decks)

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