Wound Management

Question 1

What are adnexia?

Answer 1

Glands, hair etc. present in healthy skin tissue

Question 2

What is the objective of care of accidental wounds?

Answer 2

• convert an open wound to a surgically clean than can be closed (ideally within 6-12hours)
• minimal scarring, normal function and no infection

Question 3

What are the 2 broad categories of wound? What else should be thought about?

Answer 3

> Closed - crushing and contusion injuries eg. mm. avulsion, fx
> Open - skin lacerations or loss 
- duration
- degree of contamination
- aetiolgogy
- depth of tissue damage

Question 4

Why is duration of wound exposure important?

Answer 4

bacteria multiply quickly

- “golden period” after which wound cannot be sutured as clean

Question 5

What are the classes of wound duration?

Answer 5

1. clean lcerations 0-6 hours with minimal contamination
2. wounds 6-12hrs duration with significant contamination
3. wounds 12hrs + with gross contamination AND bite wounds even if fresh

Question 6

What are the majority of wounds classified as?

Answer 6

2

Question 7

How is degree of contamination defined?

Answer 7

• clean
• clean contaminated
• contaminated
• dirty

Question 8

What is a dirty wound defined as in a lab?

Answer 8

> 10^5 organisms per gram of tissue

Question 9

What are potential wound aetiologies?

Answer 9

• abrasion
• avulsion/degloving
• incision
• laceration
• puncture
• crushing
• burns

Question 10

What may discolouration around a seemingly small wound indicate?

Answer 10

underlying trauma

Question 11

What trauma are we most worried about with neck wounds?

Answer 11

laryngeal and tracheal trauma

Question 12

How should accidental wounds be managed first aid

Answer 12

• 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

Question 13

What is the first thing that should be done to accidental wounds?

Answer 13

DO NOT PROBE

• fill with KY jelly
• clip hair around wound
• prepare aseptically
• irrigate

Question 14

Should accidental wounds be lavaged under pressure?

Answer 14

No

• effect is proportional to volume
• do not drive debris further into tissues
• no need for ABx added

Question 15

What guage needle should be used to prevent too much pressure being applied when lavaging a wound?

Answer 15

19G

Question 16

How may wounds be debrided?

Answer 16

• 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

Question 17

How can you decide which muscles to remove when debriding a wound?

Answer 17

if it does not twitch or bleed when touched it can go

Question 18

What are the 2 main types of dressings?

Answer 18

> 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

Question 19

When is vacuum assisted wound closure commonly used?

Answer 19

abdo and thoracic wounds

^ quality of granulation tissue

Question 20

What are the advantages of adherent passive dressings?

Answer 20

• excellent debridement
• wide mesh allows dessication and tissue adherence
• good at combatting infection
• cheap

Question 21

What are the disadvantages of adherent passive dressings?

Answer 21

• painful to remove
• changed frequently q24hrs
• delay fibroplasia and epithelialisation
• detrimental if used after debridement period

Question 22

What are the differnet types of adherent passive dressings called? When are they indicated?

Answer 22

dry - dry (if wound effusive)

wet - dry

Question 23

What sare the different wound closure options?

Answer 23

> 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

Question 24

If in doubt,should you close the wound?

Answer 24

No

Question 25

Which wound should you specifically not close early?

Answer 25

Puncture wounds, infected wounds, under tension

Question 26

What causes impairment of granulation tissue formation?

Answer 26

• necrotic/devitalised tissue in wound
• infection
• movement
• poor blood supply
• mechanical abrasion

Question 27

Tx of granulation tissue

Answer 27

• 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)

Question 28

What causes impairment of epithelialisation?

Answer 28

• necrotic tissue
• infection
• eschar
• movement
• poor bloodsupply
• mechanimal abrasion surface trauma

Question 29

Tx of delayed epithelialisation

Answer 29

• debridement
• tx infection
• enhance blood supply
• protection

Question 30

What causes inhibition of contraction? Tx?

Answer 30

• tension
• lack of local skin
• restrictive fibrsosis
• tight bandages
  > excise restrictive scar
  > reconstruct with skin flap or graft

Question 31

Tx of indolent pocket wounds?

Answer 31

• ID cause
• control infection
• excise wound
• tension free closure
• manage dead space
• enhance local vascular supply (omentalisation)