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3. Cat & Dog > Wound management > Flashcards

Wound management Flashcards

1
Q

Wound Classification Based On The Degree of Contamination

A
  • Clean
  • Clean-Contaminated
  • Contaminated
  • Dirty / Infected
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2
Q

clean wound criteria

A
  • Non traumatic (surgical) uninfected wound
    0
  • No communication with:
  • Oropharynx
  • Respiratory tract
  • Gastrointestinal tract
  • Urogenital tract
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3
Q

Clean Contaminated criteria

A
  • Operative wounds involving oro-pharynx, digestive, respiratory or urogenital tract without major contamination (no spill)
  • Operative wounds with minor contamination due to minor break in aseptic technique (punctured glove)
  • Recent clean wound with minor contamination (<6h)
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4
Q

Contaminated wound criteria

A
  • Open traumatic wounds
  • Operative wounds with major break in sterile technique
  • Incision made in area of acute, non purulent inflammation
  • Wound into the colon
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5
Q

Dirty / Infected wound criteria

A
  • Older traumatic wounds
  • Purulent wounds
  • Wound with perforated viscera / peritonitis
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6
Q

Timeline and Wound Classification
> golden period

A

“The Golden Period”
* It takes approximately 6 hours to go from 100 to >100 000 bacteria per gram of tissue
* Wound goes from clean-contaminated or contaminated…to infected
* May not always be accurate. Use common sense but the sooner you intervene, the better… and after that, likely need to treat as contaminated or infected

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7
Q

Stages of Wound Healing

A

Inflammatory phase (Days 0 to 5)
* Acute inflammation, attraction of PMN’s and Macrophages
* Debridement phase

Repair phase (Days 4-12)
* Capillary ingrowth, granulation tissue formation
* Fibroblasts migration / proliferation / contraction
* Epithelial proliferation / migration

Maturation phase (months)

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8
Q

Initial Assessment for wounds

A
  • Assess all systems for more serious problems (pneumothorax, fractures, etc.)
  • Cover any wounds with a clean or sterile dressing as soon as possible to prevent further contamination and hemorrhage
  • Assess & treat covered wounds ASAP
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9
Q

The cause of a wound may affect what?

A

The cause may affect the level of contamination, guide treatment and may affect prognosis
* Cause: bite wound vs laceration
* Contamination: soil, grass, hair, oil, etc.
* Will typically slow down healing

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10
Q

Early surgical closure of a contaminated wound will likely lead to…

A

infection and dehiscence (break-down)…

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11
Q

Initial Wound Management 101
- considerations right off the bat
- protecting the wound
- Reduce Future Contamination

A
  1. Sedation & analgesia (painful)
    **General anesthesia may be necessary
    for initial wound assessment (if patient is stable)
  2. Attire: surgical cap, mask + sterile gloves - to prevent nosocomial infections
  3. Cover the wound with sterile aqueous based lubricant / wet gauze
    * Prevent further contamination from adjacent skin and fur
  4. Clip liberally (>10cm) around the wound
    * Anything that will be included in bandage
    * 360 degrees for limbs
    * No hair should touch the wound
  5. Skin preparation
    * Standard surgical skin prep on periphery of wound
    * No alcohol in or close to the wound
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12
Q

Sterilely Probe Puncture Wounds to…

A

Assess Dead Space and Tissue Trauma

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13
Q

Immediate Wound Care - how to irrigate and why

A
  • Irrigation: reduce microbial burden and wound contaminants
    > Large amount
    > Low Pressure
  • Tap Water is good initially
    > Inexpensive so can use a lot
  • Pressure 7-8 PSI
    > IV bag under 300 mmHg pressure and 18G needle
    > Perforated 500ml saline bottle
    > 35 cc syringe with 18G needle or catheter
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14
Q

sterile wound irrigation - how to? what not to do?

A

Sterile Saline or LRS
* By itself or with:
> Povidone Iodine 0.1% (1/10 of the 1% solution) or
> Chlorhexidine 0.05% (1/40 of the 2% solution)
* Good for small wounds or as a finishing solution for large wounds
* Do not use sterile water, distilled water, alcohol or hydrogen peroxide: Cytotoxic!

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15
Q

Debridement - what is it? purpose?

A

Removal of gross debris
& necrotic tissues (instruments / lavage / gauze / adherent bandage)
* Decrease inflammation
* Minimize bacterial growth
* Speed healing
How aggressive depends on:
* Location, superficial or deep wound, amount of trauma / debris
* Wound to remain open allowing further debridement later or closed at 1st surgery?

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16
Q

Surgical Debridement - how to? what if wound cant be closed?

A
  • Often repeated over several days
  • Begin at the skin edges and work inward
  • If the wound can’t be closed (not enough tissue or too dirty), don’t debride the edges, and
    only remove tissues that are
    obviously necrotic (black, grey or
    white, non pliable & cool, non bleeding)
  • Red or purple tissue may still live so wait and reassess at next bandage change, usually in 24h
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17
Q

Surgical Debridement - what if the wound communicates with the chest or abdomen?

A

If the wound communicates with the chest or abdomen (deep wound) this is your only chance because you will need to close so remove anything that looks suspicious

18
Q

type of surgical debridement

A

Layered Debridement vs en-block

19
Q

when to use En-Bloc Surgical Debridement

A
  • Area with a lot of skin / tissues (thorax, neck, abdomen)
  • Remove all the contaminated tissues en-bloc
  • Might allow to close primarily but is rarely possible…
20
Q

Now that you lavaged and debrided the question is: should you close? consider:

A
  1. Time elapsed ? Golden period???
  2. Etiology ?
  3. Residual necrotic tissue ?
  4. Communication with cavity**
  • If the wound is superficial, you debrided and lavaged within 3-6 hours or less and no necrotic, dirty, or suspicious tissue was left in the wound bed - you can probably perform primary closure +/- drain
  • If communicates with cavity – will need to close
21
Q

which wounds to Treat as Open Wounds?

A
  • Severely traumatized tissues
  • Contaminated wounds
  • Wounds older than 6 hours
  • Infected wounds
  • Wounds that can’t be closed…
    … Treat as open wounds to allow sequential débridement and decrease bacterial numbers, it might only take 24hrs to be good enough to close but it could also take days or weeks…
22
Q

second intention healing considerations for cats

A
  • Second intention healing is slow for cats and they have a lot of skin to close wounds with!
23
Q

Open Wound Management

A

Initially:
1. Daily bandage changes (‘sterile’ conditions) 2. Daily lavage & debridement (if required) 3. Daily assessment to determine the next step 4. Re-apply sterile wound dressing
- Repeat over several days providing an environment for proliferation and then reduce the frequency of bandage changes or, if appropriate, proceed with surgical closure

24
Q

Non-Surgical Debridement - when to use, how to / options

A

For less contaminated wounds or for extra debridement following surgical debridement in an open wound

  • “Wet to Dry” (Mechanical)
    >Dries and adheres to wound and is then removed
    > Non-selective debridement
    > Destroys healthy epithelium and granulation tissue
  • Hyper-osmotic dressings (Autolytic)**
    > honey, sugar
  • Enzymatic
    > Papain, Trypsine, Urea, Collagenase
    > Expensive, rarely used
  • Maggots (Biotherapeutic)
25
Q

Wet-to-dry* non-surgical debridement - how to

A

Terminology refers to the condition of the dressing when it is applied and at the time it is removed
* Adherent bandage - Aids mechanical débridement
* Apply to dirty / necrotic wound
– usually after initial débridement and lavage
* Saline moistened sterile 4X4 directly on the wound
* Cover with thick absorbent layer in order to dry out
* Wet layer adheres to wound and must dry out before next bandage change to be effective (12-24h)**
> Removal of debris & necrotic tissue when pull away (out of favor in people due to drying effect…)

26
Q

Wet-to-Dry Adherent Dressing
> advantages

A
  • Inexpensive
  • Technically easy
  • Effective ONLY if used appropriately
27
Q

Wet-to-Dry Adherent Dressing
> Disadvantages

A
  • Will impede healing if used incorrectly
  • Painful to remove when very dry so may require sedation
  • (Deeper tissues may desiccate if too dry or macerate if too wet…)
28
Q

Wet-to-Dry - when to stop this debridement method and why?

A

Stop using a Wet-to-Dry or any type of adherent bandage once granulation tissue appears (3-5 days) … or you will compromise wound healing by removing healing cells

29
Q

Hyper-Osmotic Dressings
- suger - how does it work? and what does it do?

A
  • Bactericidal d/t hyperosmolar effect
  • Reduces edema
  • Attracts macrophages
  • Source of energy for cells
  • Stimulation of granulation tissue
  • Reduces odors
  • No known side effects
30
Q

Hyper-Osmotic Dressings
- sugar - how to apply? possible problem

A

Must apply a lot!
* ~ 1cm thick
* Bandage changes…
1-2 x / day
* Sugar attracts fluids
> syrup (not bactericidal)
* Monitor patient hydration / protein /
* Need a thick absorbant layer
* Change often to avoid ‘Strike through’

31
Q

Hyper-Osmotic Dressings
- honey - what to use and how it works

A
  • Non pasteurized
  • Similar mechanism of action as sugar
  • Osmotic effect / reduces edema
  • Bactericidal

Additional MOA:
* Production of low level
(not toxic) hydrogen peroxide via glucose oxidase
* Chronic wounds often have a pH >7.4
* Acidity (pH 3.2-4.5) stimulate angiogenesis & fibroblasts
()
* Antibacterial effect even when diluted 10x and in the presence of bacterial biofilm
* Gram +, Gram -, aerobes and anaerobes
* Pseudomonas et MRSA
* No documented bacterial resistance

32
Q

MEDIHONEY® - what is this?

A
  • Medical grade Manuka Honey (NZ)
  • **Methylglyoxal
    > Kills bacteria on contact
  • Penetrates deep into the wound
  • Calcium alginate
    > Exudative wounds
  • Hydrocolloid
    > Non-exudative wounds
  • Hydrocolloid also in a tube
33
Q

how to use medihoney?

A
  • Once the wound is covered by granulation tissue, can apply & leave for several days before changing again
34
Q

how to perform Bandage Changes for honey

A
  • Every 12-24 hours initially
    > Sooner if the external layer is wet
    (‘strike through’)
  • After 3-5 days of wound care, you can typically reduce frequency to every 24-72 hours and once good bed of granulation tissue can go as long as 5-7 days
35
Q

when to change bandage no matter what

A
  • Bandage got wet or damaged
  • Bandage slipped
  • Animal suddenly appears intolerant
  • Lameness
  • Swelling of toes
  • Foul odour / discharge
  • Strike through
    Too soon is better than too late… Can be an emergency
36
Q

Wounds usually initially contaminated by what kind of bacteria? what antibiotics to use? what happens if we dont have proper wound care?

A
  • Wounds usually initially contaminated by gram +ve
    > Staphylococcus, Streptococcus, E Coli…
    > Empiric antibiotic choice
    ()
  • First generation cephalosporin
  • Amoxicillin / clavulanic acid
  • Combination for severe wounds
    > Ampicillin/Enrofloxacin
    ()
  • Culture and sensitivity (deep tissue) – adjust accordingly
    ()
  • Eventually colonized by resistant nosocomial bacteria
  • Importance of proper wound care
  • Do not abuse antibiotics / ointments
    >Minimize resistance
37
Q

when should we give antibiotics for a wound? can we replace proper wound care? how long do we administer for? when to stop?

A
  • Often initiated ASAP (unless clean surgical wound)
  • DOES NOT REPLACE proper wound care
  • Can usually stop after a few days
    > No longer necessary for most open wounds receiving adequate local treatment unless predisposing factors
  • Stop when granulation tissue covers the wound
  • Start again for 5-7 days if surgical closure is performed
38
Q

predisposing factors for wound antibiotics

A
  • Bite wounds or deep wounds with necrotic tissue
  • Burns
  • Open fractures / joints
  • Systemic signs of infection / inflammation
  • Immunosuppression…
39
Q

Bandage: Primary Layer
- types and properties

A
  • Adherent - Only for debridement!
  • Non-adherent – To promote healing
  • Semi-Occlusive or occlusive – to promote healing
    > Sterile
    > Non-cytotoxic
    > Affordable
    > Allow granulation and epithelialization
40
Q

Non-Adherent Dressings

A
  • Cotton with Polyethylene tetraphthalate
    (Teflon) coating: (TELFATM…)
  • Gauze impregnated with Petrolatum
    > (BactigrasTM, JelonetTM, Sofra-TulleTM,
    AdapticTM…)
  • Non–occlusive
    > Allow excess fluid to seep through and be absorbed by bandage
    > Maintain humid but not soaked environment
    > Protects tissue during bandage changes
    > Used on their own or with topical agent
41
Q

Occlusive Dressings
- types

A
  • Alginate dressings (AlgisiteTM)
  • Hydrocolloid dressings (TegaDermTM)
  • Hydrogel dressings (Derma gel TM )
42
Q

how do occlusive dressings work? pros and cons? when to use?

A
  • Retain moisture by occlusion and water retention ability (Highly hydrophilic)
  • Lower pH, maintain ideal environment for granulation tissue formation, epithelialization
  • Can remain in place several days
  • But :
    > Rarely adhere well in animals (designed for humans)
    > Not ideal for debridement or highly exudative wounds
    > Used in the granulation / epithelialization phase

3. Cat & Dog (33 decks)

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