Wound Triage and Bandaging

Question 1

describe an open wound; give and describe the 2 kinds

Answer 1

open wounds have breaks in or actual losses of protective skin or mucous membrane coverings; can be

contaminated: traumatic wounds without purulent discharge; time lapse since trauma is short

infected: traumatic wounds that have purulent discharge, wound has been present long enough for microorganisms to establish growth

Question 2

what is often required before you begin treating an open wound?

Answer 2

sedation!

use opiods and benzodiazepines (safer) and avoid alpha-2 agonists and acepromazine until cardiovascular status is known

or regional anesthesia! local block or epidural

but general anesthesia is often required initially bc these are hella painful

Question 3

what are the 7Cs and Abs?

Answer 3

the same simple steps each time you treat an open wound to get the wound as clean as possible; do after you’ve treated pain

1. clip
2. clean
3. copious lavage
4. cut- debridement
5. consider culture
6. cover
7. coaptation

antibiotics

Question 4

describe the clip step (2)

Answer 4

1. place sterile KY jelly in the wound prior to clipping to prevent further contamination
2. clip the entire area that will be under the bandage

Question 5

describe the clean step

Answer 5

scrub AROUND the wound NOT in it; scrub products are very cytotoxic to cells inside the wound

Question 6

describe the copious lavage step (5)

Answer 6

1. lavage wound with warm (NOT room temp) sterile saline or lactated ringer’s solution
2. tap water is not ideal bc it is hypotonic and will cause cell lysis (some freedom taken for large animals)
3. use large volumes- liters, not ml
4. if wound highly contaminated, may add a dilute antiseptic solution (know numbers for exam!)
   -povidone iodine: marketed at a 10% solution but desired concentration for wound lavage is 0.1-1% so dilute 1:10 with LRS or saline
   -chlorhexidine: marketed as a 2% solution, but desired concentration for wound lavage is 0.05% so dilute 1:40 with LRS or saline but if put in LRS it will precipitate
   -neither of these solutions should be left in the wound, used only for irrigation
5. most efficient and effective method is using a 35ml or 60ml syringe attached to a 3-way stopcock and a liter bag of fluids, attach an 18G needle to provide 7-8psi of pressure

Question 7

describe the cut-debride step (4)

Answer 7

1. removal of devitalized tissue
2. fat, SQ tissue, and muscle can be liberally and aggressively debrided, there is plenty of it and it’s not critical
3. skin, tendon, and nerve should be debrided cautiously; conserve skin for wound closure
4. this step usually does not happen all at one time, just take out the obviously dead stuff, wait, recheck, and repeat (give time for wound to declare itself)

Question 8

describe the consider culture step (2)

Answer 8

1. culture of fresh wounds is often unrewarding, many bacteria are in there but may not be set up or colonized yet
2. usually only consider culture if wound 3-4 days old and inflamed

Question 9

describe the cover step

Answer 9

depends on what phase of wound healing!

contact layer: what you put against the wound; 4 types
1. wet to dry bandage: used on fresh wounds still in debridement phase to provide further debridement; sterile saline soaked gauze sponges covered by dry gauze allows moisture to wick away as gauze is removed since contact layer adheres to bandage as it dries

2. wet to wet: sterile saline soaked sponges, helps break up viscous exudate
3. dry to dry: dry sterile sponges used against wound surface are covered with additional dry sponges, used when a wound is effusive but not viscous
4. nonadherent: used when no further debridement is necessary after granulation tissue is present; includes release, telfa, adaptic

Question 10

describe the coaptation step

Answer 10

many open wounds have concurrent orthopedic injuries and will require immobilization/stabilization of wound via robert jones bandage or spica splint

Question 11

when do you administer systemic antibiotics? (2)

Answer 11

1. when there is an obvious active infection (purulent exudate)
2. if the wound has devitalized tissue remaining

Question 12

list and describe 6 topical products administered to wounds

Answer 12

1. silver: several MOAs and resistance is unlikely, can be expensive, short half life so must be applied BID
2. tricide: direct action on bacterial cell wall, punches holes in it; can be combined with antibiotics and is frequently used as a wound lavage in a wet to dry bandage
3. silvalon or silvaklenz: wound cleaner and moisturizer made of potentiated silver compounds; very effective topically against resistant bacteria and can be applied to bandages for long lasting effect; very economical silver option!
4. alginate dressings: nonocclusive to semiocclusive; seaweed derivatives that are highly absorbent so used in very effusive wounds; form a gel as the wound fluid is absorbed, often used with silver and can leave on for 2-3days
5. honey: anti-bacterial, anti-inflam, anti-oxidant, but high variability as this product is not very regulated so must use medical grade honey to avoid clostridium contamination
6. sugar: antibacterial via being hella osmotic, osmotic activity will also draw fluid out of the wound; inexpensive and effective but osmosis = hella bandage changes

Question 13

describe bandaging strategy in the repair phase

Answer 13

1. focus on maintain a healthy environment for the very resistant-to-infection granulation tissue
2. help the fibroblasts do their job and don’t hurt the innocent epithelial cells! (use NONadherent contact layers now!!)

Question 14

what are the 2 types of nonadherent contact layers?

Answer 14

1. semiocclusive:
   -petroleum impregnated wide mesh gauze; use early in repair phase to increase wound contraction and delay epithelialization (may be painful to remove)
   -polyethylene glycol: release or telfa pads, not painful at removal
2. occlusive: absorbs wound fluid and forms a gel
   -hydrocolloid dressings
   -hydrogel dressings

Question 15

describe the layers/steps of a modified robert jones bandage (8)

Answer 15

1. stirrups
2. nonadherent layer
3. cast padding: overlap by at least 50% to prevent tourniquet, want same diameter/size across bandage, immobilizes the limb
4. kling: compresses and holds in place; be HELLA careful to overlap by at least 50% to avoid tourniquet, can overdo the tension easily
5. stirrups attach to kling to hold the bandage up
6. splint if you need it
7. more kling to hold the splint in place
8. vet wrap it all together

Question 16

describe a tie over bandage (3)

Answer 16

1. used in hard to bandage places
2. suture loops around the wound
3. use umbilical tape to hold the contact layer on the wound

Question 17

describe a vacuum assisted closure (VAC) bandage (4)

Answer 17

1. non-invasive active therapy using localized subatmospheric pressure to promote wound healing
2. facilitates wound coverage; is a closed system with less maintenance than other bandages
3. provides active drainage and the ability to analyze and measure trends
4. need open cell polyurethane foam for drainage, an adhesive drape of ioban or tegaderm, suction tubing, and a suction device with a reservoir

Question 18

what are the advantages of a VAC bandage? (6)

Answer 18

decreases wound healing time by

1. increasing blood flow
2. increasing production of granulation tissue
3. decreasing bacteria levels
4. decreasing edema
5. enhancing epithelial migration
6. stimulating cell mitosis and the wound margin

Question 19

what are the contraindications/precautions of a VAC bandage?

Answer 19

1. malignancy in the wound
2. exposed blood vessels or organs
3. necrotic tissue
4. untreated osteomyelitis
5. active bleeding
6. patients on anticoagulatns
7. difficult wound hemostasis