Wound Management Flashcards
1
Q
Avulsion
A
- Tearing away of body tissue due to shear
- Degloving injury
- Flaps of tissue
- Avulsed part may be attached by flap of skin
2
Q
What is the golden period in regards to timing of injury?
A
- Within 6 hours of injury - this is when bacterial numbers are still low
- Beyond 6 hours of injury, bacterial growth reach numbers that risk infection (105 per gram of tissue)
- The earlier you can get to a wound, the better you can close it off without it becoming infected
3
Q
Degree of Contamination: clean, clean contaminated, contaminated, dirty/infected
A
- Clean: surgically created, no hollow viscous opened
- Clean contaminated: minimal contamination; contamination can be effectively removed; includes surgery of hollow viscus (intestines, stomach, etc)
- Contaminated: open traumatic wounds; break in aseptic technique
- Dirty/infected: Old traumatic wounds; perforated viscus; clinical infection (open abdomen where there is already peritonitis)
4
Q
Will the presence of bacteria alone cause an infection in a wound?
A
No, you need more than just some bacteria on a wound to cause an infection. Usually there is some compromised effect of local immunity, it depends on the blodo supply and the amoutn of traumatized tissue, and the amoutn/type of foreign debris present. Patient age also plays a role.
5
Q
When to culture and what to culture
A
- When to culture:
- BEFORE anitbiotics if possible
- When there is gross evidence of infection - not useful to culture a fresh wound
- What to culture
- Deep tissue layer, NOT the surface
6
Q
Acute Wound Management Goals
A
- Remove obvious devitalized tissue
- Remove foreign bodies/debris
- Reduce bacterial numbers to as close to zero as possible
- Wound closure at earliest appropriate time
7
Q
Acute Wound Treatment - Lavage
A
- Can remove up to 90% of bacteria
- Large quantities - moderate pressure
- 35 mL syringe + 18 g needle = 7-8 psi
- 1 L plastic bag within a 300 mmHg pressurized cuff
- Main thing - deliver 7-8 psi
- Contraindication in puncture wounds b/c fluid can’t get back out, and results in iatrogenic tissue edema!!
8
Q
Most common lavage solution:
A
Normal saline
9
Q
Two antiseptic lavage solutions:
A
- 0.05% Chlorhexidine
- any more will cause too much damage to fibroblasts in the wound
- 0.1% povidone-iodine
10
Q
Pros and Cons of tap water with lavage:
A
- Pros
- GROSS contamination
- Cheap
- Available
- Ease of application
- Cons
- Hypotonic
- Cytotoxic trace elements
- Not antimicrobial
11
Q
Pros and cons of using electrolyte solutions with lavages
A
- Pros:
- Isotonic
- Least cytotoxic
- Cons
- Not antimicrobial
12
Q
pros and cons of using normal saline in lavage
A
- Pros - isotonic
- Cons
- More acidic than LRS
- Not antimicrobial
13
Q
How to make 0.05% Chlorhexidine
A
- Stock (2%) added to sterile water - 1:40 dilution
- 25 mL per liter of sterile water
- DO NOT USE SALINE to mix - liquid will become foamy!
14
Q
Pros and cons of using 0.05% chlorhexidine in lavage
A
- Pros
- Wide antimicrobial spectrum
- Residual activity - increases when repeated
- Minimally inactivated by organic matter
- Cons
- Slows granulation and contraction in some rat models
- Proteus, Pseudomonas, Candida resistance
- Corneal toxicity
15
Q
How to make 0.1% povidone-iodine
A
- Stock (10%) added to sterile water, LRS, or saline … 1:100 dilution
- 10 mL per liter of water/LRS/saline
16
Q
Pros and Cons of 0.1% povidone-iodine in lavage
A
- Pros
- Wide antimicrobial spectrum
- Short residual activity (4-6 hours)
- More effective/active when more dilute - because the more free iodine is released!
- Cons
- Inactivated by organic matter
- Cytotoxic >1%
- Contact hypersensitivity
- Thyroid disorder if absorbed
17
Q
Debridement
A
Removal of dead or damaged tissue, foreign material, microorganisms
18
Q
Surgical Debridement
A
- Selective debridement
- Layered (MC)
- Devitalized
- Black, green, white
- if in doubt, leave it
- Debris
- En bloc - closing wound over gauze and excising it - risk removing a lot of healthy tissue, but gives you opporutinity to close wound immediately
19
Q
Autolytic Debridement
A
- Selective debridement
- Letting the wound do its thing
- Moist wound environment
- Protective bandage
- Needs minimal/no surgical debridement
20
Q
Enzymatic Debridement
A
- Semi-selective debridement
- Needs minimal surgical debridement
- good for poor anesthetic candidates
- Good for “Debris” surrounding vital structures for reconstruction
- Not effective on: burns, necrotic bone, connective tissue
- Example - granulex V
21
Q
Three components of granulex V
A
- Trypsin
- Debridement
- Liquiefies protein
- Balsam of Peru
- Stimulates circulation
- Stimulates granulation
- Castor oil
- Prevents dessication
- Improves epithelialization
22
Q
Bandage Debridement
A
- Non-selective debridement
- Bandage adheres to debris/tissue
- Strips superficial wound layer every time
- Wet-to-dry: put gauze in wet, exudates come up and the gazue dries with the exudate in it
- Dry-to-dry: in luiqidy, non-viscous wounds, put gauze in dry and it will get wet right away once in the wound
- Discontinue ASAP (proliferative stage) - when we see nice, healthy, granulation tissue
23
Q
Primar closure vs delayed primary closure vs seoncdary closure vs second intention
A
- Primary closure
- Immediate suturing to appose skin edges
- Delayed primary closure
- Delayed for up to 3 days to allow control of local infection or for damaged tissue to declare itself
- Secondary closure
- Closure is delayed until after a bed of granulation tissue has formed
- Healing by second intention - nonclosure
- Occurs by granulation tissue formation, wound contraction, and epitheliaization
- natural
24
Q
Contact (primary) layer of bandage
A
- Sterile
- Conforms to wound/body contours
- Allows fluid to pass to secondary layer
- Non-toxic, non-irritating
- Minimize pain
- Adherent vs non-adherent
- Use adherent for more traumatic wounds to remove debris - can take healthy tissue with it, painful, serves as bacterial media
- Non-adeherent can promote healing by allowing enough fluid to circulate out, but still protect it in a moist enivonrment. We wnat to use non-adherent material when we have healthy granulation tissue
25
Q
Intermediate (secondary) laye of bandage
A
- Absorb and hold drainage
- Support/immobilization
- Splint/cast incorporation
- Pressure - to obliterate dead space
- Control hemorrhage
- Reduce edema
- Can incorporate splints into second layer
26
Q
Outer (tertiary) layer of bandage
A
- Secures first 2 layers
- Stretch gauze
- Prous tape
- Vetwrap
- Apply with even pressure
27
Q
When to use drains
A
- Large dead space that can’t be closed
- When fluid accumulation is likely
28
Q
Drain rules
A
- Only when necessary - avoid in oncological surgery
- Never exit through incision
- Do not place directly under skin suture line
- Always bandage passive drains - if stuff can come out, bugs can go in
- Don’t tack with burried sutures
- Remove ASAP - when there is decreased fluid production, and discharge becomes serous/serosanguinous
29
Q
Passive vs Active Drains
A
- Passive - gravity dependent
- Penrose
- Exits via separate stab in dependent region
- Greater risk for infection
- Drains AROUND drain
- Active/closed suction
- Jackson-Pratt
- May enhance healing
- Less infection
- Obstruction possible, but uncommon
- Drains through drain
30
Q
Vacuum-Assisted Wound Closure
A
- Open-cell foam*
- Subatmospheric pressure
- Pulls fluid through wound
- Decreases swelling
- Increased perfusion, granulation, infection resistance, flap survival
- *wound is continually being bathed with it’s own tissue juices - good
31
Q
Bite wounds
A
- Crushing, tearing, avulsion
- Infection - worse with cat bite than dog bite
- Worry about Pasteurella
- Leave open or bandage - delayed primary or secondary closure
- If thoracic/abdominal penetration - emergency surgery if abdominal
- Extremity may be managed with surface lavage and sytemic antibiotics
32
Q
Do we use drains with abscesses?
A
- NO! Treat abscess like an open wound - it itself is the drain
33
Q
Thermal Burn Medical Therapy
A
- Topical cream
- Aloe vera
- Silver sulfadiazine
- Systemic antibiotics
- Fluoroquinolones
