Wounds Flashcards
What is a laceration?
Sharply cut tissue
Lacerations can vary in depth and location.
Define abrasion.
Superficial skin layer is removed, variable depth
Abrasions typically affect the outermost layers of skin.
What characterizes a contusion?
Injury caused by forceful blow to the skin and soft tissue; entire outer layer of skin intact, yet injured
Contusions are commonly known as bruises.
What is an avulsion?
Skin and soft tissue forcefully separated from deeper structures, potentially compromising blood supply or resulting in full detachment (amputation)
Avulsions can lead to severe complications if not treated promptly.
Describe puncture wounds.
Cutaneous opening relatively small as compared with depth (e.g. needle), including bite wounds
Puncture wounds can introduce bacteria deep into tissues.
What are crush injuries?
Injuries caused by compression
Crush injuries can lead to significant tissue damage.
List the types of burns.
Thermal, chemical, electrical
Each type of burn requires different treatment approaches.
What are ulcers?
Open sores on the skin or mucous membranes
Ulcers can result from various factors, including pressure and poor circulation.
What local factors influence wound healing?
Mechanical trauma, blood supply, technique and suture materials, retained foreign body, infection
Local factors can significantly impact the healing process.
What general factors influence wound healing?
Age, nutrition, tobacco smoking, alcohol consumption, chronic illness, immunosuppression, genetic predisposition
General factors can affect the overall healing capacity of an individual.
Fill in the blank: _______ affects the healing rate of wounds.
Age
Older individuals may experience slower healing rates.
True or False: Venous hypertension can influence wound healing.
True
Venous hypertension can lead to poor circulation and delayed healing.
What are some chronic illnesses that affect wound healing?
Diabetes mellitus, cancer, dyslipidemia, renal failure, stroke
These conditions can impair various aspects of the healing process.
What is the role of nutrition in wound healing?
Nutrition supports cellular repair and immune function
Adequate nutrition is essential for optimal healing.
What is the impact of immunosuppression on wound healing?
It can delay healing and increase the risk of infection
Immunosuppressive therapies, such as steroids and chemotherapy, can compromise the healing response.
List some factors that can lead to abnormal healing.
Genetic predisposition, hypertrophic scarring, keloid scarring, collagen vascular disease
These factors can result in complications during the healing process.
Fill in the blank: _______ can increase the infection rate in wounds.
Hematoma/seroma
Retained fluid can create an environment conducive to infection.
What is the effect of tobacco smoking on wound healing?
It can impair blood flow and oxygen delivery to tissues
Smoking is known to negatively affect wound healing outcomes.
What role do growth factors play in wound healing?
They are released by tissues and play an important role in the healing process.
Growth factors orchestrate various phases of healing, including collagen production.
How long does it typically take for a scar to mature?
1-2 years.
Scar maturation is completed after the final stage of wound healing.
What is the duration of the Inflammatory Phase of wound healing?
Days 1-10.
This phase limits damage and prevents further injury.
What are the main processes involved in the Inflammatory Phase?
- Hemostasis
- Chemotaxis
- Inflammatory response
Neutrophils: cell debris and pathogen cleanser
macrophages: cell cleaner and releases collagen 3
and platelets: clot formation
Cytokines
Proinflammatory: TNF-alpha, IL-1, PDGF
What is the role of neutrophils in the Inflammatory Phase?
They clear debris and organisms within the first 24-48 hours.
Neutrophils are part of the body’s initial response to injury.
What is the primary role of macrophages in wound healing?
They orchestrate growth factors for collagen production.
Macrophages play a critical role in the healing process.
What is the duration of the Proliferative Phase of wound healing?
Day 4 to Week 3.
This phase includes key processes like collagen synthesis and angiogenesis.
What are the key processes in the Proliferative Phase?
- Collagen synthesis (mainly type III)
- Angiogenesis
- Epithelialization
These processes are essential for tissue repair.
Lymphocytes – Protectors
Fibroblasts – Builders -> collagen
Cytokines:
PDGF: platelets derived growth factor
FGF: fibroblast growth factor
EGF: epidermal growth factor
VEGF: vascular endothelial growth factor
When does tensile strength begin to increase during wound healing?
At 4-5 days.
This marks the transition into the stronger phases of healing.
What is the duration of the Remodeling Phase of wound healing?
Week 3 to Year 1.
This phase focuses on the organization of collagen and scar remodeling.
What happens to collagen during the Remodeling Phase?
Type I collagen replaces Type III until a normal 4:1 ratio is achieved.
This transition strengthens the scar tissue.
What is the peak tensile strength of the scar and when is it achieved?
80% of pre-injury strength at 60 days.
This reflects the scar’s capacity to withstand stress.
What is the main goal of the Remodeling Phase?
To remodel the scar and increase tensile strength.
This phase is crucial for restoring skin integrity.
True or False: Lymphocytes play a well-defined role in the Inflammatory Phase.
False.
The role of lymphocytes is poorly defined in this phase.
What is Primary (1°) Healing?
Wound closure by direct approximation of edges within hours of wound creation
Examples include using sutures, staples, or skin grafts.
What is the indication for Primary (1°) Healing?
Recent wounds (6-8 hours old, longer for facial wounds)
This type of healing is most effective shortly after the injury occurs.
What are the contraindications for Primary (1°) Healing?
- Animal/human bites
- Crush injuries
- Infection
- Long time lapse since injury (>6-8 hours)
- Retained foreign body
These factors can complicate the healing process.
What is Secondary (2°) Healing?
Wound left open to heal spontaneously with epithelialization, contraction, and granulation
Epithelialization occurs at 1 mm/day from wound margins.
What are the key cells responsible for wound contraction in Secondary (2°) Healing?
Myofibroblasts
These specialized cells play a critical role in the healing process.
What is the indication for Secondary (2°) Healing?
When Primary (1°) closure is not possible or indicated
This could be due to the nature of the wound or other health factors.
What is Tertiary (3°) Healing?
Intentionally interrupting the healing process, then closing the wound primarily after granulation tissue has formed
This occurs at 4-10 days post-injury.
What are the indications for Tertiary (3°) Healing?
- Contaminated wounds (high bacterial count)
- Long time lapse since initial injury
- Severe crush component with significant tissue devitalization
- Closure of fasciotomy wounds
This method helps manage infection risk and promotes healing.
What is the importance of prolonging the inflammatory phase in Tertiary (3°) Healing?
Decreases bacterial count and lessens chance of infection after closure
This is crucial for successful wound healing.
What is a Hypertrophic Scar?
A scar that remains within the boundaries of the original scar, characterized by being red, raised, widened, and frequently pruritic.
Common sites include the back, shoulder, and sternum.
What are the treatment options for Hypertrophic Scars?
- Scar massage
- Pressure garments
- Silicone gel sheeting
- Corticosteroid injection
- Surgical excision if other options fail
Recurrence may still occur even after surgical excision.
What is a Keloid Scar?
A scar that grows outside the boundaries of the original scar, characterized by being red, raised, widened, and frequently pruritic.
Highest rates occur in Black and Asian individuals.
What factors contribute to the formation of Keloid Scars?
- Genetic factors
- Excess tension on the wound
- Delayed closure
Common sites include the central chest, back, shoulders, deltoid, ear, and angle of the mandible.
What are the treatment options for Keloid Scars?
- Multimodal therapy
- Pressure garments
- Silicone gel sheeting
- Corticosteroid injection
- Fractional carbon dioxide ablative laser
- Surgical excision if radiation is to be performed within the next 48 hours
Surgical excision is typically very unsuccessful, and recurrence is common.
What characterizes a Spread Scar?
It has the same order of collagen fibers as normal scars and is typically flat, wide, and often depressed.
Treatment usually involves surgical excision and closure.
What defines a Chronic Wound?
A wound that fails to achieve primary wound healing within 4-6 weeks.
Common types include diabetic, pressure, and venous stasis ulcers.
What is the treatment approach for Chronic Wounds?
Addressing the underlying cause of chronicity, which may include infection, ischemia, metabolic conditions, immunosuppression, or radiation.
All chronic wounds should be biopsied to rule out Marjolin’s ulcer.
What is Marjolin’s ulcer?
A squamous cell carcinoma that arises in a chronic wound secondary to genetic changes caused by chronic inflammation.
All chronic wounds should be biopsied to rule out this condition.
Whats the critical depth of scar formation ?
0.5 cm or 33% of skin thickness
Compare between keloid and hypertrophic scar:
What are the two categories of efficacy in scar management?
High efficacy, Low efficacy
Name three methods for scar prevention (high efficacy)
- Silicone
- Tension reduction
- wound edge eversion
What are two technologies used in scar prevention? (Low efficacy)
- Pulsed-dye laser
- Pressure garments
Onion extract
Scar massage
List two treatments for scars.
- Silicone
- Pulsed-dye laser
CO2 laser, corticosteroids
What is an adjunct treatment for keloid excision?
- Corticosteroid
Radiotherapy + mitomycin
Fill in the blank: _______ is used in scar treatment alongside corticosteroids and fat grafting.
[Onion extract]
What is a common method for managing keloids?
- Radiation
Which treatments are associated with low efficacy in scar management?
- 5-FU
- Bleomycin
- Scar massage
Onion extract
Fat grafting
Name a surgical adjunct used in keloid management.
- Mitomycin C
True or False: Scar massage is only effective for scar treatment.
False
What is the primary focus of evidence-based scar management?
Improve results with technique and technology
Scar management
Scar management
Factors that delays wound healing ?
What are the grades of pressure ulcer?
What are the grades of pressure ulcer?
How to treat pressure ulcer?
Types of dressings:
Initial managment:
1. Stabilise the patient: ABCDE + inspection + look for signs of inhalation therapy.
- airway and breathing: any sign of inhalation injury + RDS => intubation
- circulation: fluid resuscitation (parkland formula) to prevent hypovolemic shock => insert two large pores of IV line (ringers lactate).
- pain management: IV opioids
- wound care: cover wounds with clean dry dressing.
- insert a Foley catheter: to monitor the urine output
Confirming the inhalation injury:
1. Facial burns
2. Hoarseness of the voice or stridor and carbonaceous sputum
3. Bronchoscopy => visualise airway damage
4. Measure the carboxyhemoglobin levels to asses for carbon monoxide exposure
Whats the treatment: provide 100% oxygen Nina non rebreather mask or intubation.
Whats the initial rate for administering fluids?
The formula for fluid resuscitation in burn patients: 4ml x TBSA% x body weight (kg).
For this patient: 4 x (40%) x 80 kg => 12,800 ml (total for 24 hours)
In the first 8 hours administer half of the amount and the remaining half over next 16 hours.
(Adjust the fluid rates based on urine output aiming 0.5/1ml/kg/hr
Next day in ICU:
Acute respiratory distress syndrome and acute kidney injury => result from systemic inflammatory response syndrome resulting from excessive burn and inhalation injury.
ARDS: ventilators support + PEEP
AKI: fluid resuscitation or renal support therapy (dialysis)
Initial managment:
1. Stabilise the patient: ABCDE + inspection + look for signs of inhalation therapy.
- airway and breathing: any sign of inhalation injury + RDS => intubation
- circulation: fluid resuscitation (parkland formula) to prevent hypovolemic shock => insert two large pores of IV line (ringers lactate).
- pain management: IV opioids
- wound care: cover wounds with clean dry dressing.
- insert a Foley catheter: to monitor the urine output
Confirming the inhalation injury:
1. Facial burns
2. Hoarseness of the voice or stridor and carbonaceous sputum
3. Bronchoscopy => visualise airway damage
4. Measure the carboxyhemoglobin levels to asses for carbon monoxide exposure
Whats the treatment: provide 100% oxygen Nina non rebreather mask or intubation.
Whats the initial rate for administering fluids?
The formula for fluid resuscitation in burn patients: 4ml x TBSA% x body weight (kg).
For this patient: 4 x (40%) x 80 kg => 12,800 ml (total for 24 hours)
In the first 8 hours administer half of the amount and the remaining half over next 16 hours.
(Adjust the fluid rates based on urine output aiming 0.5/1ml/kg/hr
Next day in ICU:
Acute respiratory distress syndrome and acute kidney injury => result from systemic inflammatory response syndrome resulting from excessive burn and inhalation injury.
ARDS: ventilators support + PEEP
AKI: fluid resuscitation or renal support therapy (dialysis)
Answer
What is contamination in the context of infected wounds?
The presence of non-replicating microorganisms within a wound
Contamination does not lead to infection.
Define colonization in infected wounds.
The presence of replicating microorganisms within a wound
Colonization can lead to infection if not controlled.
What does critical colonization indicate?
Increasing bacterial burden; have delayed healing
Critical colonization may lead to infection if not addressed.
When is a wound considered infected?
The presence of >10^5 microorganisms in a wound without intact epithelium
Infection is characterized by delayed healing and classic signs.
What are the classic signs of infection?
- Redness
- Swelling
- Pain
- Clinically unwell
These signs indicate a possible infection in the wound.
What is the first step in the management of acute contaminated wounds?
Cleanse and irrigate the open wound with at least 150 cc of physiologic solution
Use sufficient pressure (4 to 15 PSI) for effective cleansing.
What is the purpose of debridement?
Removal of foreign material, devitalized tissue, and old blood
Always take a swab if infection is suspected.
Describe serous drainage.
Thin, clear or light yellowish fluid
Indicates a normal healing process without infection.
What does sanguineous drainage indicate?
Fresh blood; bright red in color
This type of drainage may suggest active bleeding.
Its normal in the early healing phases but should decrease over time
Excessive saguineous drainage indicate uncontrolled bleeding
Sudden increase in sanguineous drainage after decrease could suggest reopening of blood vessels due to wound dehiscence (opening)
What is serosanguineous drainage?
A mix of blood and serous fluid; thin and watery, pale red to pink
Commonly seen during the healing process.
What characterizes purulent drainage?
Thick and opaque; white, yellow, or pale green
Typically indicates an infection.
List risk factors for infection in wounds.
- Wound >8 h
- Severely contaminated
- Immunocompromised host
- Involvement of deeper structures (e.g., joints, fractures)
These factors increase the likelihood of infection.
What should be done if wound cultures are positive and there are signs of infection?
Use systemic antibiotics; tailor antibiotics as cultures return
This approach helps to effectively manage the infection.
What is the management for late contaminated wounds (>24 h)?
- Tetanus prophylaxis
- Irrigation and debridement
- Systemic antibiotics if there are clinical signs of infection
- Closure options: secondary intention, delayed wound closure, skin graft, or flap
Late management aims to reduce infection risk and promote healing.
What are the characteristics of a wound that is considered tetanus-prone?
- Time since injury >6 h
- Depth of injury >1 cm
- Mechanism of injury: crush, burn, gunshot, puncture
- Devitalized tissue present
- Contamination (e.g., soil, dirt, saliva, grass) present
- Retained foreign body present
These factors significantly increase the risk of tetanus infection.
What characteristics define a wound that is not tetanus-prone?
- Time since injury <6 h
- Depth of injury <1 cm
- Mechanism of injury: sharp cut (e.g., clean knife, clean glass)
- No devitalized tissue
- No contamination (e.g., soil, dirt)
- No retained foreign body
Such wounds carry a lower risk of tetanus infection.
the presence of bacteria within a wound may be divided into 4 categories:
■ contamination: the presence of non-replicating microorganisms within a wound
■ colonization: the presence of replicating microorganisms within a wound
■ critical colonization: increasing bacterial burden; have delayed healing
■ infection: the presence of >10(5) microorganisms in a wound without intact epithelium or small
amounts of a very virulent organism (e.g. GBS); have delayed healing and exhibit classic signs of infection
When there’s injury you need to control and evaluate?
Control bleeding, irrigation, debridement (take a swab if you suspect infection).
Evaluate the injury (skin, muscles, nerves, vessels, tendons, bones)
Managment of acute contaminated wound < 24 hours
Managment of contaminated wound more than 24 hours ?
True or false: The proliferative wound healing phase is delayed in individuals with copper and vitamin C deficiency.
True
———————-
Zinc deficiency can delay wound healing because the collagenases responsible for collagen remodeling require zinc to function properly.
Definition: Hypertrophic scar
Hypertrophic scar
Cutaneous condition characterized by high (fibroblast proliferation and collagen production) that leads to a raised scar that does not grow beyond the boundaries of the original lesion.
Keloid is known to be claw-like” appearance, true or false
True
Hemorrhage control in wounds?
- Mechanical hemostasis: local pressure over the wound, packing the wound, or application of a tourniquet proximal to the site of bleeding.
- Pharmacological hemostasis: local hemostatic agents (e.g., epinephrine or fibrin) or systemic antifibrinolytics (e.g., tranexamic acid)
- Hemorrhagic shock: Resuscitate with blood products.
What are the indications of Primary wound closure?
Recent wound
clean
uninfected wounds that have edges that can be easily approximated.
Consider secondary wound closure or tertiary wound closure for all other wounds:
infected, contaminated, wide or irregular edges, delayed presentation
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Consider skin grafting for wounds with extensive tissue loss.
How to manage closed wounds?
- Analgesia
- Treat the injuries (tendons, fractures)
- Monitor complications (compartment syndrome, rhambdomyolisis and deep vein thrombosis)
- POLICE:
P: protection from further harm.
OL: optimal loading
I: ice
C: compression
E: elevation (to promote venous return)
Purpose of skin graft?
- close wounds
- prevent fluid and electrolyte loss
- reduce bacterial burden and infection.
What are types of skin graft?
- Full thickness skin graft: Graft: epidermis and dermis (including dermal appendages), usually obtained from areas of redundant and pliable skin (e.g., groin, lateral thigh, lower abdomen, lateral chest)
- Partial thickness skin graft: epidermis and upper part (¼–¾) of the dermis (without dermal appendages)
What are indications of full thickness skin graft ?
- small
- uncontaminated
- well-vascularized wounds
What are the advantages and disadvantages of full thickness skin graft?
Advantages: good postoperative cosmetic outcome
Disadvantages: high risk of necrosis, secondary injury to the donor area
What are the indications, advantages and disadvantages of (split thickness skin graft)?
Indications: many uses; resurface large wounds and mucosal deficits, line cavities, close donor sites of flaps, treat large chronic wounds
Advantages: heals well, only superficial secondary defect in donor area, which does not have to be covered
Disadvantages: scar formation when graft heals, skin pigmentation change, tendency to contract, more fragile
What are complications of surgical incisions?
- Surgical site infection
- Intestinal fistula
- Wound dehiscence: the spontaneous separation of wound edges following surgical wound repair
Can be superficial (skin and subcutaneous tissue) or deep (fascial) - Hematomas and seromas
What are the common pathogens associated with dog and cat bites?
Pasteurella multocida, Staphylococcus aureus, Streptococcus viridans
These pathogens are often responsible for infections following animal bites.
What investigations should be conducted prior to therapy for animal bites?
Radiographs and culture for aerobic and anaerobic organisms, Gram stain
Radiographs help rule out foreign bodies or fractures.
What is the recommended treatment for dog and cat bites?
Clavulin® (amoxicillin + clavulanic acid) 500 mg PO q8 h started immediately
This antibiotic is effective against the pathogens typically involved in these bites.
When should rabies prophylaxis be considered for animal bites?
If the animal has symptoms of rabies or is of unknown status
Rabies Ig and rabies vaccines are part of the prophylaxis.
What is the mainstay of treatment for dog and cat bites?
Healing by secondary intention
This method allows for proper healing in most cases of bite wounds.
Under what circumstances is primary closure considered for bite wounds?
Only for large bite wounds on the face and done in the operating room
Primary closure is usually contraindicated for other locations.
What are the common pathogens associated with human bites?
Staphylococcus aureus > GAS > Eikenella corrodens > Bacteroides
The mouth has a high concentration of microorganisms that can lead to infections.
Why are human bites considered serious?
The mouth has 10^9 microorganisms/mL that can cause septic arthritis if trapped
This can happen when the fist unclenches and skin covers the area.
What investigations should be conducted prior to therapy for human bites?
Radiographs and culture for aerobic and anaerobic organisms, Gram stain
These tests help assess the extent of the injury and potential infections.
What is the treatment protocol if a joint is infected from a human bite?
Urgent surgical exploration, drainage, and debridement of infected tissue
This is critical to prevent further complications like septic arthritis.
What is the treatment for non-infected human bites?
I & D and antibiotic treatment in ER
This approach helps manage the wound effectively.
What antibiotic is used if the infection is due to MSSA?
Cefazolin 2 g IV q8h
Alternative treatment includes vancomycin for penicillin allergies or MRSA.
What is the management for a human bite injury if there’s a penicillin allergy?
Vancomycin 15 mg/kg IV q12h + secondary closure
This is an appropriate alternative to Cefazolin.
What supportive measure is recommended for human bite injuries?
Splint
A splint can help stabilize the affected area during healing.
