Wound Management Flashcards
What are adnexia?
Glands, hair etc. present in healthy skin tissue
What is the objective of care of accidental wounds?
- convert an open wound to a surgically clean than can be closed (ideally within 6-12hours)
- minimal scarring, normal function and no infection
What are the 2 broad categories of wound? What else should be thought about?
> Closed - crushing and contusion injuries eg. mm. avulsion, fx > Open - skin lacerations or loss - duration - degree of contamination - aetiolgogy - depth of tissue damage
Why is duration of wound exposure important?
bacteria multiply quickly
- “golden period” after which wound cannot be sutured as clean
What are the classes of wound duration?
- clean lcerations 0-6 hours with minimal contamination
- wounds 6-12hrs duration with significant contamination
- wounds 12hrs + with gross contamination AND bite wounds even if fresh
What are the majority of wounds classified as?
2
How is degree of contamination defined?
- clean
- clean contaminated
- contaminated
- dirty
What is a dirty wound defined as in a lab?
> 10^5 organisms per gram of tissue
What are potential wound aetiologies?
- abrasion
- avulsion/degloving
- incision
- laceration
- puncture
- crushing
- burns
What may discolouration around a seemingly small wound indicate?
underlying trauma
What trauma are we most worried about with neck wounds?
laryngeal and tracheal trauma
How should accidental wounds be managed first aid
- control haemorrhage using pressure not tourniquet
- fresh steril pressure bandage
- topical Abx (tetracycline or neomycin &bacitracin in 0.9% saline)
- chlorhexidine v dilute 0.05% can be sued but is damaging to fibroplasia
What is the first thing that should be done to accidental wounds?
DO NOT PROBE
- fill with KY jelly
- clip hair around wound
- prepare aseptically
- irrigate
Should accidental wounds be lavaged under pressure?
No
- effect is proportional to volume
- do not drive debris further into tissues
- no need for ABx added
What guage needle should be used to prevent too much pressure being applied when lavaging a wound?
19G
How may wounds be debrided?
- surgery gold standard
- bandages - wet-dry, dry-dry, wet-wet (adjubnct to surgery or when debridement not possible)
- Hydrogel and enzymes improve effects of debriding bandage
How can you decide which muscles to remove when debriding a wound?
if it does not twitch or bleed when touched it can go
What are the 2 main types of dressings?
> passive
- adherent/absorbent/non-adherent/vapour permeable/barrier films
- protection and environment to support healing
active
- hydrocolloids/hydrogels/alginates/collagens/skin substitutes
- provide cytokines and alter wound environment to ^ healing
When is vacuum assisted wound closure commonly used?
abdo and thoracic wounds
^ quality of granulation tissue
What are the advantages of adherent passive dressings?
- excellent debridement
- wide mesh allows dessication and tissue adherence
- good at combatting infection
- cheap
What are the disadvantages of adherent passive dressings?
- painful to remove
- changed frequently q24hrs
- delay fibroplasia and epithelialisation
- detrimental if used after debridement period
What are the differnet types of adherent passive dressings called? When are they indicated?
dry - dry (if wound effusive)
wet - dry
What sare the different wound closure options?
> 1* intention (incisions)
delayed 1* closure (leave 24-48hrs for necrosis then debride and close)
2* closure (leave granulation tissue to form then remove all)
2* intention (contraction and epithelialisation)
- may need a combination and can change your mind
If in doubt,should you close the wound?
No
Which wound should you specifically not close early?
Puncture wounds, infected wounds, under tension
What causes impairment of granulation tissue formation?
- necrotic/devitalised tissue in wound
- infection
- movement
- poor blood supply
- mechanical abrasion
Tx of granulation tissue
- further debridements
- excision of old granulationtissue bed
- enhance blood supply (mm. omentum, vascular skin)
- reconstruct using tissue with good blood supply
- support and immobilisation (as with bone healing)
What causes impairment of epithelialisation?
- necrotic tissue
- infection
- eschar
- movement
- poor bloodsupply
- mechanimal abrasion surface trauma
Tx of delayed epithelialisation
- debridement
- tx infection
- enhance blood supply
- protection
What causes inhibition of contraction? Tx?
- tension
- lack of local skin
- restrictive fibrsosis
- tight bandages
> excise restrictive scar
> reconstruct with skin flap or graft
Tx of indolent pocket wounds?
- ID cause
- control infection
- excise wound
- tension free closure
- manage dead space
- enhance local vascular supply (omentalisation)
