Wound Management: MacPhail Flashcards
open wound care philosophy
õMost wounds can be managed with simple care õFollow fundamental basic principles
õUnderstand phases of wound healing
õUnderstand wound healing is dynamic õUnderstand every wound is different
simple open wound management
õAlways wear gloves
õIsotonic saline lavage using pressure bag; no antiseptics
õInteractive wound dressing in early stages of healing
õTie-over bandage for wound contact, mild tension relief, and patient comfort
õ õ
Active drainage preferred over passive
Bite wounds: explore or leave open; avoid early closure
what kind of circulation do dogs and cats have? how is this advantageous?
they have direct cutaneous artery/vein: this is very specific and you know where those vessels are and what they supply. advantageous because you can move large flaps of skin (axial pattern flaps) because it has specific, direct supply
what kind of circulation do pigs and humans have?
musculocutaneous artery/vein
blood supply distributes within skeletal muscle
pros and cons of dog wound healing
pros: better cutaneous perfusion, higher wound breaking strength
cons: faster contraction and epithelialization
cat wound healing unique features
- slower paler granulation tissue
- extensive delay in healing with loss or debridement of subcutaneous tissue
what can cause impaired wound healing?
õHealth of the patient
õNutritional intake
õHypoproteinemia
õUremia
õInfection
õEndocrinopathies
õImmunosuppressive drugs
steps in wound care
õPrioritize
õPrevent further contamination
õRemove foreign material and necrotic tissue
õEncourage healthy wound bed
õDecide most appropriate method for closure
what do you prioritize when assessing a wound?
õVital signs
õShock
õThoracic trauma
õNeurologic injury
õOrthopedic injury
õAnalgesia
why are bite wounds significant conern?
- multiple wounds common
- crush pressure of canine jaw: 150-450psi
- significant infection
- mortality > 10%
- iceberg principle: what’s on surface is not an indication of what is underneath!
- bite and crush vs bite anad tear
what are sources of trauma?
- abrasion/laceration
- vehicular: low velocity vs high velocity
- penetrating: projectile, sticks, bites
- burns
what if your bite wound patient has cavity involvement?
- abdominal surgical exploration is next step!
- thoracic surgical exploration debatable
- imaging may underestimate amount of body wall or internal trauma
how can you prevent further contamination?
- cover the wound
- WEAR FREAKING GLOVES
- sterile contact layer
- barrier precautions: changing scrubs, new gown etc
- culture?
- antimicrobial therapy: source of trauma?
what are factors you need to consider when dealing with an infection?
- when to culture: don’t culture right away: culturing a HBC patient is just culturing the road
- empirical abx therapy
- smell your bandages
- wear gloves
- wear STERILE gloves- contact layer
how can you remove foreign material and necrotic tissue?
- LAVAGE LAVAGE LAVAGE
- excise necrotic tissue
- avoid early aggressive debridement
- use measures of tissue viability
lavage details
- goal: 6-8psi
- 35cc syringe + 19 g needle?
- pressure bag: 1 L saline, 300mmHg, any needle size, 7psi
saline vs LRS vs tap water
how do you debride wounds?
- surgical
- autolytic: moist wound envmt
- mechanical: adherent dressings
- enzymatic
- biosurgical: maggots
how do you encourage a healthy wound bed?
- use all previous steps
- appropriate wound contact layer
- promote granulation tissue
what are the typical contact layers (order from inflammation/debridement to repair)
- hypertonic saline: use cautiously
- wet-to-dry: saline soaked sponges over time they dry, then when you take them off you are mechanically debriding
- calcium alginate
- COPA: hydrophilic foam
- hydrogel
what is the best closure method for a primary wound?
within 6 hours
what is the best closure method for a delayed primary wound?
before granulation tissue
what is the best closure method for a secondary wound?
after granulation tissue
what factors lead you to decide to close a wound NOW
- fresh, clean wound!!
- healthy granulation bed
- continuous source of contamination
- risk of nosocomial infection
- convenience
what factors lead you to decide to close a wound LATER
- grossly infected
- large amount of dead space
- bite wounds
- need time to plan
- owner patience and finances
how to close a wound?
- simple reapposition of skin edges
- regional tissue mobilization: undermining, local flaps
- advanced reconstruction: flaps, graft
- drain or no drain??
wound drainage options
- open wound
- passive: penrose drain: conduit, gravity dependent
- active: closed system, suction
principles of passive drain replacement
- most dependent position- gravity!!!
- exit site SEPARATE from primary incision
- drain not directly under incision
- keep exit site COVERED: potential for ascending infx
- remove in 3-5 days
principles of active drain replacement
- exit site can be anywhere
- closed system
- allow fluid quantitation and analysis
- decreases risk of ascending infection
- “Jackson-Pratt” or “JP” drain
butterfly drains
- 18-g butterfly catheter
- red top tube
- for active drainage of small spaces
bandage layers
- primary: contact layer, sterile dressing
- secondary: absorptive, support
- tertiary: protective, bandage art
what if you have a difficult area to bandage?
tie-over!!!
HEAVY gauge suture, healthy tissue
big loops, sterile contact layer
secondary padding layer
umbilical tape
bandage layers of the limb?
- stirrups
- padded layer
- compressive layer
- support: splint, cast
- protective layer
