Wound Managment Flashcards
What are the four stages of wound healing?
Inflammatory
Debridement
Repair
Maturation/remodeling
** significant degree of overlap, more than one stage can occur at a time
What is the lag phase os wound healing?
In the first 3-5days
There is not sufficient inflammation and debridement yet
What is a protective response initiated by tissue damage?
Inflammatory phase
What are characteristics of the inflammatory phase of wound healing?
Increased permeability of local blood vessels
Recruitment of circulatory cells
Release of growth factors and cytokines
Activation of neutrophils, lymphocytes, fibroblasts, and macrophages
What is the pathophysiology of the inflammatory phase of wound healing?
Hemorrhage
Vasoconstriction (5-10mins) - control hemorrhage with clot
Vasodilation -> increased vascular permeability and release of inflammatory mediators
Leukocyte response - macrophages (1st responders) and T lymphocytes
Platelets - coagulation plus production of cytokines and growth factors
When does the inflammatory phase occur?
0-5 days
What is the debridement phase of wound healing?
In wound bed, development of rich exudate rich in WBC
Arrival of neutrophils and monocytes
T/F: monocytes and neutrophils are essential for wound healing
False
Only Monocytes are essential
What is the function of macrophages in debridement?
Secrete collagenase- remove necrotic tissue, bacteria, and foreign material
Secrete chemotatic and growth factors
Recruit mesenchymal cells, stimulate angiogenesis and modulate matrix production in wounds
What factor promotes angiogenesis, granulation, and epithelialization via migration of epithelial cells, fibroblasts, and keratinocytes
Basic fibroblast growth factor
From macrophages/MC/Tlymphs
What factor simulates fibroblasts to secrete collagenase to degrade the matrix during the remodeling phase?
Epidermal growth factor
From platelets and macrophages
What factor stimulates keratinocytes migration, differentiation, and proliferation?
Keratinocyte growth factor
From fibroblasts
What factor attracts neutrophils/macrophages, and promotes collagen and proteoglycan synthesis?
Platelet derived growth factor
From platelets/macrophage/endothelial cells
What factor attracts neutrophils/macrophages, promotes angiogenesis, up regulates collagen production, and inhibits degradation.
Transforming growth facto r
From macrophages/platelet/lymphs/hepatocytes
What factor promotes angiogenesis during tissue hypoxia?
Vascular endothelial cell growth factor
From endothelial cells
When does the repair phase occur?
3-5days up to 2-4weeks
What are the main cells present in the repair phase?
Macrophages and fibroblasts
What is the role of fibroblasts in wound healing?
Originate from undifferentiated mesenchymal cells inn surrounding CT —> migrate into wound along fibrin strands
Synthesize and deposit collagen, elastin, and proteoglycans —> fibrous CT
During what phase does angiogenesis occur?
Repair phase
A combination of fibroblasts, new capillaries, and fibrous tissue development forms a bright red tissue called ??
Granulation tissue
-> filled defects and protects wounds
T/F: granulation tissue provides an barrier to infection
True
What type of cells come from granulation tissue and help in wound contraction?
Myofibroblasts
What is epithelization?
Mobilization, proliferation, and differentiation of epithelial cells
Migration guided by collagen fibers
In what time frame does epithelialization occur in sutured wounds vs open wound?
Sutured wounds: 24-48hours
Open wounds: 4-5days
T/F: epithelialization occurs faster in a moist environment and will cover non-viable tissue
False
Occurs faster in almost environment, but will NOT occur over non-viable tissue
What is wound contraction?
Size of wound is reduced d/t fibroblasts, reorganizing collagen in granulation tissue and myofibroblasts contraction at the wound edge
-occur simultaneously with granulation and epithelialization
What things can inhibit wound contraction?
If skin around wound is…
- fixed
- inelastic
- under tension
OR
Myofibroblasts are inadequate (ie insufficient granulation tissue)
—> iatrogenic= anti-inflammatory steroids, anti-microtubular dugs, and local application of smooth muscle relaxants
What occurs the maturation/remodeling phase of wound healing?
Strengthening of wound- scar formation
Collagen fibers remodel with alteration of orientation and increased cross-linking
Increase in type I collagen and decreased in type III
What is a class I wound?
Within 0-6hours of wounding
Minimal contamination or tissue damage
Within the “golden period”
What is the “golden period” for wounds?
Insufficient microbial replication to cause infection and usually can manage with primary closure
What is a class II wound?
Within 6-12 hours of wounding
Microbial replication to critical level is possible but still within golden period
What is a class III wound?
> 12hours of wounding
Microbial replication is at critical level for infection
What are the types of wound management?
Primary closure (1st intention)
Secondary closure
Delayed primary
Secondary intention healing
What types of local anesthetics can you use for wound management?
Injectable opioids
NSAIDS (after blood work)
Amantadine/gapapentin/tramadol/trazadone
T/F: bandaging is indicated for ALL wounds
True
Prevent nosocomial contamination
How should you clip and scrub a wound?
ASEPTICALLY
Protect wound with sterile lubricant or saline soaked sponges
WIDE clip
Scrub area around wound
- detergents in antiseptic scrubs can cause irritation , toxicity and pain in exposed tissue and may potentiated infection
T/F: alcohol is used to to scrub the area around a wound
False
NEVER use
What is the preferred lavage solution?
Sterile isotonic saline or a balanced electrolyte solution (LRS)
**least cytotoxic **
T/F: antibiotics or antiseptics can be used in lavage solution
True
Can cause tissue damage - must be diluted properly
Solutions can be used in lavage?
LRS Normal saline 0.05% chlorohxidine solution (1:40) 0.1% povidone-iodine solution (1:100) Tap water
What lavage solution is effective and less detrimental than distilled/sterile water, but can cause some hypotonic tissue damage?
Tap water
Has some cytotoxic trace elements
Why do you lavage?
Remove debris and bacteria via mechanical contact and dynamic fluid force
Remove exudate
Dilute and remove toxins associated with infection
What is the ideal pressure for wound lavage ?
What is the best way to achieve this pressure?
7-8psi
1L saline solution bag placed in an pressure cuff at 300mmHg
Needle size does not matter
How much fluid should you use when flushing a wound?
500mL is usually adequate for an average wound
Wounds with high levels of debris, high bioburden, or in immunocompromised should be more aggressively irrigated
When would you culture a wound?
Severely contaminated, crushed/infected wounds
Wounds > 6-8hours old
What type of samples would you collect to culture a wound?
Samples from initial wound exploration or during initial debridement
-> remove superficial contaminants
Clip, clean, and lavage wound prior to procuring culture
Collect before antimicrobial flush solutions are used
What are the advantages of topical antimicrobial selection??
Selective bacterial toxicity
Efficacy in presence of organic material and combined efficacy with systemic antibiotics
What are the disadvantages to topical antimicrobal selection??
Expense Narrower antimicrobal spectrum Potential for bacterial resistance Creation of “super infections” Systemic or local toxicity Hypersensitivity and increased nosocomial infections
What topical antimicrobial is effective against most gram positives, gram negatives, fungi, and pseudomonas?
Silver sulfadizine
What is the drug of choice to treat burn wounds?
Silver sulfadiazine
What is in triple antibiotic ointment?
Bacitracin, neomycin, and Polymixin
What is the process of removing dead/damaged tissue, foreign material and microorganisms form a wound?
Debridement
-healing is delayed if necrotic tissue is left in the wound
What are the methods of surgical debridement?
Layered -> devitalized tissue removed in layers
En bloc- entire wound excised if there is sufficient healthy tissue surrounding and vital structures are preserved
T/F: contaminated SQ should be liberally excised
True
- is easily devascularized and harbors bacteria
In what speices would you avoid extensive debridement of SQ ?
Cats
What is autolytic debridement?
Creation of a moist wound environment to allow endogenous enzymes to dissolve nonviable tissue
When would you opt for autolytic debridement over surgical debridement?
In wounds with questionable tissue viability
—> highly selective for devitalized tissue ONLY
What is biosurgical debridement?
Maggot therapy - best suited to necrotic, infectious or chronic non-healing wounds
What factors do you consider when deciding to close a wound?
Time lapse since injury? - golden period?
Degree of contamination - cause of wound?
Amount of tissue damage
Blood supply status
Ability to decontaminate
Systemic status
Tension/dead space/location
Client logistics
If there is any level of contamination, potential for deep tissue injury, viability, or vascular compromise how should you proceed with closing the wound?
Delay closure
