Wounds Flashcards
Name 2 immediate complications of wounds
• blood loss
• underlying neurovascular structures damage
Name 5 delayed complications of wounds
• Cellulitis
• bacteremia
• osteomyelitis
• pseudo-aneurysm
• Septic arthritis
Name 5 late complications of wounds
• Endocarditis
• heterotopic bone formation
• sinus tract/abscess
• keloids
• Squamous cell carcinoma
How should a wound be examined?
Location, size
TIME OVS
Tissue margin: viability devitalized or necrotic; specific characteristics of tissue surrounding wound, hyper or hypo pigmented
Inflammation/infection - floor of ulcer
Moisture: moisture balance; is wound macerated? (soggy) - floor of ulcer
Edge: assess for re-epithelialization vs non-advancing or nonhealing edges; blood supply, raised and rolled (rodent ulcer basal cell ca),raised and everted (scc), sloping (trauma healing), undermined (tb ulcers), punched out(syphilis)
Oedema (control by compression and elevation)
Vascular blood supply
Skin surrounding wound
And underlying structures -base of ulcer
Periph structures eg pulses,lymph may cause ascending infection etc
What is the benefit of doing skin grafts? (2)
• Prevent fluid and electrolyte loss
• reduce bacterial burden and infection
Benefit of using foams for wound dressing? (2)
• Pull exudate from wound
• maintain moist environment
3 advantages of using hydrocolloids as wound dressing
• Autolytic wound debridement
• maintain moist
• promote granulation (new vascular development)
Limitation of using hydrocolloids for wound dressing
Can’t use with heavy exudate
3 advantages of using hydrogels for wound dressing
• Autolytic
• promote moist healing environment
• fill dead space
Limitation of using hydrogels for wound dressing
Can’t use with high exudates
4 advantages of using films for wound dressing
• Semi-permeable to water vapour and oxygen
• impermeable to bacteria and liquid.
• conforming, inexpensive
• retain moisture
What dressing should be used for epithelialising wounds?
• Low/non-adherent dressing: extra thin hydrocolloid !
• May be left exposed. Consider moisturiser
What dressing should be used for granulating wounds? (3)
• hydrogel ( if dry) or absorbent (if exudative) (eg foams, alginates)
Silicone mesh is a light absorbent that will protect granulating tissue. Clean first.
What dressing should be used for sloughy wounds? (2)
Must debride first! Won’t heal until Slough removed - enzymatic debriding agents eg iruxol
If little exudate: hydrogel or honey (anti microbial)
High exudate: absorbent eg foam , alginate
What dressing should be used for necrotic wounds?
Must debride first! Hydrogel or honey if good perfusion. If poor perfusions , do not debride but focus on revascularisation surgically and keep dry.
Define wound
Disruption of skin integrity with division of blood vessels
Name a protective, non adherent wound dressing
Silicone mesh (mepitel)
Gauze
Mesh and ointment (jelonet)
Name a wound dressing that adds moisture
Hydrogels eg novogel, honey
Name 2 wound dressing that absorbs moisture
•Foam (allevyn) (also control odor)
• alginates (kaltostat)
Composite, cellulose promote healing, capillary dressings
Name 2 wound dressing that retains moisture
•Films (tegaderm)
• hydrocolloids (granuflex)
Name a wound dressing that controls excess moisture most efficiently
Vacuum dressing eg negative pressure wound therapy
Name 3 wound dressing that are antimicrobial
• Honey (l-mesitran)
• silver based (silvercel)
• iodine based (betadine)
• chlorexidine based (bactigras)
Topical eg bactroban
Name a wound dressing that controls odour
Activated charcoal
What dressing can be used for infected wet wound?
Iodine based
What dressing can be used for infected dry wound?
Silver based
Name 5 advantages negative pressure wound therapy
• Increased oxygen tension in wound bed
• reduce wound bacterial load
• reduce excess exudate and tissue slough
• limit repeated wound trauma - change dressing every 3-5 days
• enhance granulation tissue formation
• reduce pain (immobilise wound)
. Facilitates preparation of wound for skin graft or tissue flap closure
• reduced costs of care
Name 4 classifications of surgical wounds
Class 1 - clean
Class 2 - clean-contaminated
Class 3- contaminated
Class 4- dirty/ infected
Define primary closure
Direct apposition of skin edges after appropriate wound prep eg by staples, sutures, skin glues
Name 6 indications for antibiotic prophylaxis in trauma wounds
• Contaminated wounds - tears/bruises/contusions, contam with soil/dirt/faeces/mineral oil/foreign bodies
• penetrating wounds eg puncture, bite
• abdominal trauma, esp with crush injuries
• compound (open) #
• wounds with devitalised tissue eg edge diastasis
•Maxillofacial trauma (open fracture type)
• intercostal drain insertion prior to incision single dose for 24h
• high risk anatomical sites eg hand, foot (poorly vascularised and dirty)
Define delayed primary closure
Skin edge apposition occurs following interval of wound management.
Wound heals open in moist dressing for about 5 days, then once blood supply restored, sutured.
Commonly done in patients shocked at time of surgery, significant contamination or necrosis wound
What are the 6 principles of wound treatment
Well vascularised
Free of devitalised tissue (debride)
Clear of infection
Moist
Control oedema
Control systemic diseases eg diabetes,Ht
Name and classify the 6 wound debridement techniques (6)
Invasive methods
-surgical
-sharp
-mechanical.
Minimally invasive
-autolytic
-enzymatic
-biological eg honey, maggots
- chemical eg iuroxol, ascerbine
Name 9 types tetanus prone wounds that need tetanus treatment
Sustained more than 6 hours before surgical treatment
Show one or more:
-puncture type wound
-significant degree devitalised tissue
-clin evidence sepsis
-contamination with soil/manure likely to contain tetanus
-burns
-frostbite
-high velocity missile injuries
-open fracture
Tetanus prophylaxis in patients over 10 years and follow up
Active immunisation with tetanus toxoid or with tetanus and diphtheria vaccine
1 dose (0.5 ml) by IM or deep subcutaneous injection
Follow up at 6 weeks and 6 months
Tetanus prophylaxis in patients under 10 years and follow up
Diphtheria and tetanus vaccine
0.5 ml by IM or deep subcutaneous injection.
Follow up at 4 and 8 weeks.
Which patients have highest risk of wound infection? (4)
Age more than 65
Immunocompromised eg steroid treatment, immunosuppressants, HIV, splenectomised
Vascular disease
Diabetic
Which antibiotics should be given for human bite and when? (4)
Co-amoxiclavulanic acid or quinolone, NOT cephalosporin (E corrodens very resistant).
ONLY if bite on hand or feet, or completely penetrate epidermis, or involve joint or cartilage
Treatment of human bite? (7)
-copious irrigation with isotonic NaCl or dilute povidone-iodine (betadine) or dilute hydrogen peroxide with 10ml syringe and 18 gauge angiocatheter. Irrigate particulate matter and clots.
-avoid injection of tissues, prevent additional trauma. Except anaesthesia
-debride devitalised tissue
-DO NOT CLOSE hand wounds, puncture wounds, infected wounds or wounds more than 12 hours old. Heal by secondary intention. Head and neck wounds may be closed if less than 12 hours old and not obviously infected. If suture, make sure it’s not water tight - allow drainage
-antibiotic prophylaxis if penetrate epidermis, on hands or feet, involve cartilage or joints
- hep B immunoglobulin and accelerated course vaccination
- HIV prophylaxis
Which kinds of wounds should not be sutured/heal by primary intention? ( 4)
-hand wounds
-puncture wounds
-infected wounds
-wounds more than 12 hours old
Consult surgery
Which antibiotics should be given for animal bites and why?
Co-amoxiclavulanic acid or fluoroquionolone plus clindamycin if penicillin allergy. To cover staph, strep, anaerobes, PasteurElla
Give for 3-5 days prophylaxis
Describe class 1 surgical wounds and risk of surgical site infection
“Clean” wound involving skin and soft tissues eg breast surgery, hernias.
Risk SSI <5%
Describe class 2 surgical wounds and risk of surgical site infection (6)
“Clean-contaminated” involving, git, respiratory or urinary tract, ICD insertion
Risk SSI less than 15%
Describe class 3 surgical wounds and risk of surgical site infection
“Contaminated” with non-purulent inflammation, minor spillage git content, necrotic bowel, other necrotic tissues, major break in surgical technique
Risk SSI 20-30%
Eg open cholecystectomy for cholecystitis
Describe class 4 surgical wounds and risk of surgical site infection
“Dirty/infected” with pre-existing infection, major git spillage or fecal contamination, traumatic wound or laceration presenting after more than 4 hours, open fractures >4h, devascularized tissues
Risk SSI > 50%
Name and describe the 3 classifications of surgical site infection
• Superficial: skin and subcut tissue eg superficial wound abscess
• deep: infection extend to fascial compartment and deep muscles
• cavity or organ space: infection extend into body cavity eg abdominal abscess, pleural empyema
Name the most common organisms responsible for infection from skin (3)
• Staphylococcus aureus
• S epidermis
• MRSA
Name the most common organisms responsible for infection from intestines (2)
Enterococcus species - Also most Common overall
Bacteroïdes
Name the most common organisms responsible for infection from colon (4)
Escherichia coli
Pseudomonas
Klebsiella
Yeast - candida
Name the most common organisms responsible for infection from saliva
Bacteroides species
Name the most common organisms responsible for infection from oesophagus, stomach and vagina
Yeast-candida
Name the most common organisms responsible for infection from health care providers and hospital surfaces (4)
-MRSA
-CRE (carbapenem resistant enterobacterales) eg E. coli, klebsiella
-ESBL (extended spectrum beta lactamase) producing organisms eg e-coli, klebsiellia
-yeasts
Name 7 clinical features of surgical site infection
-erythematous, hot wound
-severe pain
-skin oedema, induration, necrosis
-foul smelling purulent or faeculent discharge from wound or drains
-wound breakdown -look for abscess
-paralytic ileus (abdominal cavity organ space SSI)
-signs systemic infection including fever, tachycardia, dehydration, organ fail, septic shock
Name 8 strategies to reduce the incidence of SSI
-adequate antibiotic prophylaxis
-meticulous surgical technique
-limited use cavity drains
-aggressive control haemorrhage and fecal contam
-early revascularisation of dead tissues and removal foreign bodies
-early debride and stabilise open fractured WITHIN 6 HOURS
-careful use blood transfusions
How manage established wound SSI? (8)
-lay open and drain wound ASAP
-surgical debride and remove foreign material including sutures and implants
-obtain cultures from tissues, urine, sputum or blood. NOT PUS
-exclude anastomotic breakdown and intestinal fistula formation by CT contrast and or re-explore abdo
-initiate empiric broad spectrum antibiotics targeting bacteria commonly found in affected area; IV fluids and analgesia
-de-escalate antibiotics to prevent resistance
-initiate NPWT dressings
-plan for late wound closure: secondary closure, split skin graft, tissue flap…
Name 10 common risk factors for necrotising soft tissue infection/necrotising fasciitis
-delayed ID and manage of deep and organ space SSI
-delayed/incorrect manage class 3 and 4 wounds
-complications intestinal stomas (colostomy/iliostomy/urostomy)
-anastomotic breakdown (especially colonic) and entero-cutaneous fistula formation
-open fractures
-penetrating injuries involving intestines, esp GSW
-perineal injuries and sepsis (ie ischio-rectal abscess)
-limb vascular injuries
-diabetic pts
-industrial and farm accidents
Name 5 clinical features necrotising soft tissue infection
-EXPANSION UNDER NORMAL LOOKING SKIN (pathopneumonic)
-signs systemic infec, septic shock common
-area involved usually induration, pain, erythema or pallor, pitting oedema and subcut crepitus if anaerobic and gas forming organism present (gas gangrene)
-areas skin necrosis
-limited ROM in affected limb
General Management of necrotising soft tissue infection. (4)
-organ support: IV fluids, intubate and ventilate, vasopressors, inotropes, hemodialysis etc
-IV analgesia
-systemic broad spectrum antibiotics with good soft tissue penetration: semi-synthetic penicillins (amoxicillin clavulanate, piperacillin tazobactam) AND second/3rd gen cephalosporins OR carbapenems OR metronidazole OR clindamycin.
-hyperbaric oxygen therapy in clostridial and anaerobic infec if possible
Local Management of necrotising soft tissue infection. (4)
-aggressive and repeated debridement devitalised tissues and drainage purulent collections NB! Excise until clean tissues seen and bleeding occurs
-wound tracts: wash, lay open, drain esp when involve intestines
-fecal and urinary diversion may be necessary in some cases
-NPTW for wound closure
-ALWAYS EXCLUDE ANASTOMOTIC BREAKDOWN
Define secondary closure or healing by secondary intention
Wound heal by formation of granulation tissue and eventual coverage by skin epithelium
Common in infected wounds and burns
Define tertiary closure or healing by tertiary intention
Healing following transplant (skin grafting)
Name the 7 steps of wound healing
- Coagulation and inflammation (first 3-4 days): macrophages clean, platelets and fibroblasts form mesh - thrombus
- Fibroblasts and collagen matrix deposition (5-7 days)
- Angiogenesis (start day 2)
- Epithelialization (weeks)
- Collagen maturation and lysis (wound remodelling)
- Wound contraction (months to years)
- Scar formation
What is the role of oxygen in wound healing. (5)
-activate inflammation
-kill bacteria
-angiogenesis
-epithelialisation
-matrix collagen deposition
How can oxygenation of a wound be improved? (4)
-prevent vasoconstriction
-restore circulating volume
-control pain
-avoid hypothermia
Name 10 local wound factors that impair healing
1 hypovolaemia
2 ischaemia
3 hypoxia
4 foreign bodies including surgical implants
5 necrotic tissue
6 desiccation (dry)
7 excess exudate and fibrin deposition
8 repeated trauma
9 improper surgical technique (tight sutures, rough tissue handle, poor haemostasis)
10 poor wound opposition (dead space)
Radiation injury
Abscess formation
Tissue oedema
Name 10 systemic patient factors that impair healing
-advanced age
- obesity
-smoking
-malnutrition and starvation (hypoproteinaemia)
-steroids and immunosuppressive
- Renal failure and uraemia
-hyperglycaemia and diabetes → cell starvation
-cancer and chemo drugs
-trauma and surgery stress response
-systemic infection eg Tb
-congestive or ischaemic hear disease
-periph arterial disease
-liver fail
-immobile
-systemic collagen diseases
Name 8 local factors that increase leak rate of intestinal anastomosis
-poor tissue handling
-anastomosis in areas with poor blood supply or watershed areas (ischaemic)
-oedema
-poor opposition Serosa (peritoneal) surface
-excessive fibrin deposition (ischaemia)
-distal obstruction
-tight sutures and staples causing ischaemia
-improper suture material
Which suture material should be used for intestinal anastomosis?
Small gauge (3-0/4-0) monofilament synthetic absorbable sutures with atraumatic needles eg PDS polydioxanone
Best antiseptic for wound cleaning?
Diluted povidone iodine
Name 6 causes why acute wound will convert to chronic wound
•Infection
• poor blood supply (hypoxia)
• dead tissue (necrosis, slough)
• metabolic eg diabetes
• inadequate initial management (contamination, sutured under tension )
• medication (anti-inflamm, steroids)
Name 5 procedures that will result in clean surgical wound
• Thyroidectomy
• neck dissection
• mastectomy
• joint replacement
• vascular surgery
No opening of resp, git, urinary. Closed primarily
Name 6 procedures that will result in clean contaminated surgical wound
• Bronchoscope
• cholecystectomy
• appendectomy
• small bowel resection
• TURP
• whipple
Respiratory, git, urinary tract opened but no contamination
Name 3 procedures that will result in contaminated surgical wound
• Appendectomy for inflamed appendix
. Cholecystectomy with bile spillage
• diverticulitis
Open fresh wound. Break in sterile technique, spillage, inflammation
Name 4 procedures that will result in dirty surgical wound
• I and D abscess
• myringotomy for otitis media
• perforated bowel
• peritonitis
Old wounds, devitalised tissue, open viscera, infection,
Management contaminated wound?
• Single dose antibiotic prophylaxis just before surgery
. Drain may be left in to guard against infection
Classification chronic wounds? (4)
• Necrotic (black or grey)
• infected or sloughy (yellow)
• granulating (red)
• epithelialising and healing (pink)
Define wound infection
> 10^6 per gram of tissue - load too much for body to handle
Antibiotic management options of wounds if necessary? (4)
• Empiric penicillin (most probable gram positive)
• Infection develop in hospital: cloxacillin, amoxil or augmentin (mrsa)
• offensive smell probably gram negative or anaerobes - aminoglycoside, with metronidazole or quinolone
• wound abdominal wall, pelvis, perineum, thighs to knees - enteric type: triple therapy penicillin, aminoglycocide,metronidazole
