Wounds Flashcards

Question

Abdomen injuries

Answer 1

Careful palpation will often help to decide whether abdominal wall has been fully penetrated Abdominocentesis can help but changes take several hours (esp if a small penetration) Often just monitor for CS of peritonitis e.g. colic, pyrexia, high HR If large wound and risk evisceration, plug hole with damp gamgee pads and wrap with belly bandage before referral

Answer 2

If referring a horse with a tendon laceration, splinting of the leg (dorsal cortices aligned) and broad spectrum antibiosis are indicated prior to transport. Postoperative external coaption for a prolonged period is likely to be involved in the treatment after surgical repair

Answer 3

in the absence of synovial sepsis of the extensor tendon sheath are frequently managed without primary surgical repair of the tendon. Splinting should be applied for the first few days until the animal learns to accommodate for its gait deficit.

Answer 4

Fractures Foot penetrations - radiograph with nail still in place Osteomyelitis - old wounds Foreign bodies - if radiopaque Gas opacity to determine if wounds tracking near joints or bon

Answer 5

Gas opacity from wound often inhibits use, but occasionally useful Soft tissue damage - i.e. wound over flexor tendon Foreign bodies Gas opacity to determine if wounds tracking near joints or bones

Answer 6

Clean wounds with minimal contamination are good candidates. Will give fastest healing time + best cosmetic result. Partial closure can be used for large wounds and often speeds healing whilst allowing drainage. Necrotic tissue should be debrided. Upwards pointing 'V' skin flap often poorly vascularised, even if it subsequently dies it acts as a biological dressing - like a full thickness skin graft. If wound edges are under tension, tension relieving suture patterns e.g. vertical or horizontal mattress or cruciates should be used. Stent-supported sutures provide extra tension relief of the wound margin but not often needed. Immobilisation with a bandage cast or splint will also help to stabilise the suture line in wounds that are closed under tension. Degloving wound has good primary closure: proximal limb bandage placed to protect flap during transport.

Answer 7

Polypropylene is the least reactive suture material available and is therefore the best for equine skin, but other synthetic materials are also suitable (nylon, PDS).

Answer 8

fractious horse, ££, other structures involved e.g. joints

Answer 9

your experience and comfort level, suspected/confirmed synovial sepsis/fracture etc., complexity of repair AND aftercare.

Answer 10

up to 5 days after the injury a good option for contaminated wounds which are unsuitable for closure at the first visit. Skin retraction usually occurs making it difficult to completely close wound.

Answer 11

(after 5 days post injury i.e. after granulation tissue formed) rarely used apart from certain areas e.g. heel bulbs– often skin is adherent to underlying granulation bed. Granulation tissue is cut back and the skin is reapposed where possible. Skin retraction occurs as above.

Answer 12

very common - for all contaminated wounds or if large amounts of tissue loss/devitalised tissue. Heals primarily by proliferative/repair phase of wound healing – granulation then epithelisation and contraction. Exudate is common and NORMAL. Wound is usually bandaged during secondary intention healing (unless site is difficult to bandage .e.g. head, upper body)

Answer 13

Hydrogel preparations Silver sulfadiazine (gram negative bacteria and pseudomonas, contraindicated in pregnant animals) Topical antibiotics: aminoglycoside (gram negative), soluble antibiotics lie penicillin, gentamycin etc. Caustic agents (none proven to work) Corticosteroids (reduces granulation tissue) Manuka honey (contaminated/devitalised/non-healing wounds)

Answer 14

Adherent or non-adherent dressing

Answer 15

these dressings stick to the wound surface and thus debride the surface when removed – often painful to remove – e.g. wet to dry swabs. Not used much these days.

Answer 16

Cotton cellophane (melonin) Polyurethane foam (advasorb, allevyn, biatain) Polyurethane sheet (opsite) Hydrocolloids (Tegasorb, replicare) Petroleum impregnated gauze (vaseline) Calcium alginate (algisate, algiderm) Activated charcoal

Answer 17

Melolin Cotton, coated with perforated polyethylene which is non-adherant. Not very absorptive but when removed -> minimal trauma to the wound surface.

Answer 18

Advasorb, Allevyn, Biatain waterproof but gas permeable. More absorptive than cotton cellophane and ideal for use with a hydrogel.

Answer 19

Opsite Transparent adhesive film which is semi-occlusive, allowing passage of gases but not fluid. Very little capacity for absorption therefore maintain a moist wound environment and promote epithelisation of partial thickness wounds or incisions which can not be easily bandanged e.g. on rump or thorax.

Answer 20

Tegasorb, Replicare contain gel-forming agents, such as sodium carboxymethylcellulose (NaCMC) and gelatin. In many products, these are combined with elastomers and adhesives and applied to a carrier - usually polyurethane foam or film, to form an absorbent, self adhesive, waterproof wafer. Hydrocolloids absorb liquid and form a gel, which may be cohesive. Expensive and do not stick to haired skin.

Answer 21

Vaseline These allow passage of exudates into the secondary layer of the bandage. May have antibiotics included in the dressing. Innert and non-irritating but slow the rate of re-epithelisation.

Answer 22

Algisite, Algiderm has haemostatic properties and is highly absorbent therefore suitable for exudative wounds. Should not be used on dry wounds as will dessicate the site.

Answer 23

designed primarily to control odour and absorb bacteria (especially burns patients). Reported to have an inhibitory effect on granulation tissue.

Answer 24

Cotton wool/gamgee with a stretchy woven bandage on top Can repeat the compressive layer several times -> more immobilisation, stabilisation and absorbtion if wound v exudative

Answer 25

Vet wrap , Elastoplast top and bottom

Answer 26

Infection/contamination Excess tension on suture line Loss of blood supply Dead space (poor drainage) Excessive motion

Answer 27

Discolored granulation tissue Oedema in and around the wound Purulent exudate Odor Increased lameness and pain on palpation around the wound

Answer 28

if large dead space when closing wound then use a drain. ○ Penrose drain most common in 1st opinion practice. Prevent skin scalding at drainage site - vaseline ○ Mesh the skin to allow drainage, pressure bandage - only for areas where will not compress important structure like the flexor tendons

Answer 29

Infection/necrotic tissue Tension/motion Poor vascular supply Exuberent granulation tissue Foreign body Sequestrum Large skin defect

Answer 30

>10^5 bacteria/gram of tissue

Answer 31

'proud flesh' Limbs >> trunk wounds, Horses >> ponies Once granulation tissue protrudes higher than wound edge, v. difficult for epithelium to grow over it Due to inefficient acute inflammatory phase and protracted chronic inflammatory response -> too much granulation tissue produced

Answer 32

Chronic inflammation ◊ Infection - common cause Motion Bandages and casts Size of horse

Answer 33

Use treatments for excess motion, infection etc. as appropriate plus ◊ Bandage with moderate pressure ◊ Topical steroids Excision of excess granulation tissue ◊ Can usually be done with sedation + local anaesthesia ◊ Bleeds a lot - cut from distal to proximal

Answer 34

due to exposed desiccated bone – may have lost some periosteum in original injury Initial injury traumatises bone or blood supply to bone (periosteum stripped) Stripping of periosteum + loss of blood supply -> necrosis of superficial bone -> walled off from the healthy intact bone Suspect when see mature granulation bed but with a cleft or draining tract ('cloaca') Take radiographs

Answer 35

Has to be quite severe to affect wound healing PPID (high endogenous cortisol) Protein/nutrient deficient

Answer 36

Reactive bone forms around the necrotic portion

Answer 37

Draining tract to the skin connects with an opening to the sequestrum

Answer 38

Too large (to suture or heal by secondary intention) Slow healing

Answer 39

Pedicle graft - vasular and nerve supply Free graft - devoid of vascular and nerve supply, full thickness or split thickness

Answer 40

Most common type of grafting in horses Purpose is to increase area of epidermis from which epithelization proceeds Implanting grafts in the granulation bed, rather than applying them to surface, is better Punch: full-thickness plugs of skin harvested with skin biopsy tool, and implanted into granulation tissue using another skin biopsy tool, one size smaller Pinch: small discs of skin harvested by hand using scalpel blade Elevate skin with hypodermic needle with bent tip

Answer 41

Neck beneath mane Ventral abdomen (thick skin here) Perineum

Answer 42

Useful for large skin defects § Highly mobile sites § Sites that are difficult to bandage □ Thorax/abdomen/gluteal Technically simple Donor site = neck, leaves more of a scar than pinch/punch

Answer 43

Very painful to harvest Needs specialist equipment (dermatome) Technically difficult but higher % 'take'

Answer 44

Not accepted as readily as split-thickness grafts □ Have fewer exposed vessels available for imbibition or inosculation □ Requirement for nourishment is greater Epidermis usually sloughs

Answer 45

potentially fatal in horses and must be treated as an emergency. Survival rate (to discharge from hospital)= 89% , return to previous athletic function = 69% If synovial contamination has occurred, immediate parental antibiotics (penicillin + gentamicin) should be administered and the horse should be for arthroscopic lavage under general anaesthesia.

Answer 46

Joints Tendon sheaths – lower rate of return to athletic function -circa 50% Bursae

Answer 47

Traumatic wound (most common) Iatrogenic i.e. after joint injection (or inadvertent puncture of joint during nerve block) or after joint surgery (arthroscopy) Haematogenous (rare in adult horse, common in foal)

Answer 48

Contamination of synovial cavity Marked inflammatory response = marked lameness § Fibrin accumulates + bacteria + inflammatory cells -> synovial thickening/pannus § Continues inflammatory process may lead to irreversible articular cartilage, tendon and/or subchondral bone damage/infection

Answer 49

Penetrating traumatic injury - most common in adults Haematogenous spread - most common in foals Iatrogenic infection Extension of local infection

Answer 50

Lameness typically acute and severe Open joints/acute wounds with synovial involvement may initially be mildly/not lame Osteomyelitis in foals may present first with mild, intermittent lameness Synovial effusion and/or periarticular oedema TPR ○ Adults typically WNL ○ Foals typically febrile, but not always

Answer 51

Synoviocentesis § Collection of synovial fluid § Number 1 test for diagnosis no matter the aetiology § Fluid analysis (gross and microscopic) – WBC count, % of neutrophils and TP most important § Culture and sensitivity – takes days to get result – often not performed Synovial distension/pressure leak test § Sterile saline injected into joint under pressure to see if any communication present with wound § Always collect joint fluid if possible before distending joint

Answer 52

Aseptic prep Aseptic technique using landmarks to enter Collection/aspiration of synovial fluid (for analysis and C/S) If wound present enter at a different site and do leak test

Answer 53

straw yellow, translucent, viscous WBC: <10 x 109/L, Total Protein: <10 g/L, usually <15% neutrophils, but can increase after e.g. joint injection up to 50-60%

Answer 54

Varies (Florescent yellow-cream coloured, serosanguinous), turbid or flocculent material, decreased viscosity WBC: >20 x 109/L , Total Protein: >30 g/L >90% neutrophils

Answer 55

Rapid (ideally <24hrs) and aggressive Synovial lavage Antibiotics (penicillin and gentamycin systemically, Aminoglycosides locally) Additional treatments e.g. stall rest, NSAIDs, bandaging

Answer 56

Good for vast majority of horses with prompt treatment (<24 hrs) Excellent for survival (90%) Good for athletic use (50-70% reported—lower with foals) Prognosis decreases with: ○ increased time from inoculation to lavage ○ degree of damage to sheath /joint, surrounding structures, or infection into the bone ○ Specific synovial structures known to have worse outcomes than others OA is a sequellae to septic arthritis—especially if prolonged treatment