Wounds

Question 1

Wound infection

Answer 1

5-7d post-op

Organisms: Staph. aureus and Coliforms

Question 2

Wound infection classification

Answer 2

• Clean: incise uninfected skin w/o opening viscus
• Clean/Cont: intra-op breach of viscus (not colon)
• Contaminated: breach of viscus + spillage or opening of colon
• Dirty: site already contaminated – faeces, pus, trauma

Question 3

Pre-operative risk Factors for wound infection

Answer 3

• ↑ Age
• Comorbidities e.g. DM
• Pre-existing infection e.g. appendix perforation
• Pt. colonisation e.g. MRSA

Question 4

Operative risk factors for wound infection

Answer 4

• Op classification and wound infection risk
• Duration
• Pre-op Abx, asepsis technique

Question 5

Post-operative risk factors for wound infection

Answer 5

• Contamination of wound from staff

Question 6

Presentation of wound dehiscence

Answer 6

Occurs approx 10days post-op

• Preceded by discharge from wound

Question 7

Pre-Operative Factors for wound dehiscence

Answer 7

• ↑ age
• Smoking
• Obesity, malnutrition, cachexia
• Comorbdities e.g. DM, uraemia, chronic cough, Ca
• Drugs - steroids, chemo, radio

Question 8

Operative Factors for wound dehiscence

Answer 8

• Length and orientation of incision
• Closure technique
• Suture material

Question 9

Post-operative Factors for wound dehiscence

Answer 9

• Increased intra - abdominal pressure - e.g. prolonged ileus causing distension
• Infection
• Haematoma / seroma formation

Question 10

Jenkin’s Rule

Answer 10

6:1 - suture length: wound length as the optimal ratio in abdominal closure

Question 11

Mx of full wound dehiscence

Answer 11

• Swabs
• Replace abdominal contents and cover with sterile soaked gauze
• IV Abx: cef+met
• Opioid analgesia
• Call senior and arrange theatre
• Repair in theatre
• Wash bowel
• Debride wound edges
• Close with deep non-absorbable sutures (e.g. nylon)

• May require VAC dressing or grafting

Question 12

Mx of superficial dehiscence

Answer 12

Open wound and examine the sheath to ensure it has not dehisced

Washing out the wound with saline and simple wound care

Will heal by secondary intention - takes several weeks

Question 13

Clinical features of wound infections

Answer 13

Spreading erythema
Localised pain
Pus or discharge from the wound
Wound dehiscence
Persistent pyrexia

Question 14

Investigations of wound infections

Answer 14

Wound swabs - culture

Blood test

Question 15

Mx of wound infections

Answer 15

Any sutures or clips removed, -drainage of pus and wound packing if required.

Empirical antibiotic

Monitor for sepsis

Question 16

Pre-Operative prevention of wound infections

Answer 16

Prophylactic abx if indicated - prosthesis, clean-contaminated surgery, or contaminated surgery

Do not remove hair routinely

Patient advice:

• shower prior to surgery
• weight loss
• optimised nutrition
• good diabetic control
• smoking cessation

Question 17

Keloids

Answer 17

Abnormal proliferation of scar tissue and projects beyond original wound margins

• does not regress

Question 18

Risk factors for keloid scars

Answer 18

Ethnicity – Black and Asian populations

Age –20-30yrs

Cause of injury – burns

Anatomical site – commonly occur in scars on the ear lobe, shoulders, and sternal notch

Previous keloid formation

Question 19

Pathophysiology of keloid scars

Answer 19

Excess fibroblast activity

Question 20

Mx of keloid scars

Answer 20

Intralesional steroids

Silicone gel

Radiation therapy