wound management
DESCRIPTION
wound treatment / wound managementTRANSCRIPT
![Page 1: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/1.jpg)
Wound ManagementDr Sumer Yadav
![Page 2: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/2.jpg)
• “the primary goal of wound care is not the technical repair of the wound; it is providing
optimal conditions for the natural reparative processes of the wound to proceed”
• – Richard L. Lammers (Roberts and Hedges)
![Page 3: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/3.jpg)
plastic surgeon consultation (a) the acute wound where the final
appearance may be the principal concern, (b) the wound in a patient
whose medical status and/or mode of injury predisposes her to wound
healing difficulties and the threat of a problem wound, or (c) the
established chronic wound refractory to past interventions.
![Page 4: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/4.jpg)
GOALS of wound care
• Facilitate hemostasis• Decrease tissue loss• Promote wound healing• Minimize scar formation
![Page 5: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/5.jpg)
TYPES of Wound Healing1.) Healing by first intention (aka. primary wound healing or primary
closure)• wound closed by approximation of wound margins or by placement of
a graft or flap, or wounds created and closed in the operating room.• Best choice for wounds in well-vascularized areas• Indications -recent (<24h old)
-clean-viable tissue-tension-free
• treated within 24 h, prior to development of granulation tissue.• epithelialize within 24 to 48 h. Water barrier function restored can
shower or wash.
![Page 6: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/6.jpg)
2.) Healing by second intention (aka. secondary wound healing or spontaneous healing)
• wound left open and allowed to close by epithelialization and contraction.
• Commonly : management of contaminated or infected wounds.• without surgical intervention.• Unlike primary wounds, approximation of wound margins occurs
via reepithelialization and wound contraction by myofibroblasts.• Presence of granulation tissue.• Complications -late wound contracture
-hypertrophic scarring
![Page 7: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/7.jpg)
• 3.) Healing by third intention (aka. tertiary wound healing or delayed primary closure)
• wounds that are too heavily contaminated for primary closure but appear clean and well vascularized after 4-5 days of open observation.
• Inflammation reduced bacterial concentration (“debribe”) allow safe closure.
• Indications :- infected or unhealthy wounds with high bacterial content,
-wounds with a long time lapse since injury, or -wounds with a severe crush component with significant tissue devitalization.
• Wound edges are approximated within 3-4 days• tensile strength develops as with primary closure.
![Page 8: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/8.jpg)
Factors that affect wound healing
• In general, remember “DIDN'T HEAL”• D = Diabetes: -diminishing sensation and arterial
inflow ++ acute loss of diabetic control diminished cardiac output, poor peripheral perfusion, and impaired polymorphonuclear leukocyte phagocytosis.
• I = Infection: -potentiates collagen lysis. Bacterial contamination + susceptible host + wound environment = wound infection. Foreign bodies (including sutures) potentiate wound infection.
![Page 9: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/9.jpg)
DIDN’T HEAL
• D = Drugs: Steroids and antimetabolites impede proliferation of fibroblasts and collagen synthesis.
• N = Nutritional problems: Protein-calorie malnutrition and deficiencies of vitamins A (collagen synthesis, antioxidant), C (collagen synthesis), and zinc (fibroblast proliferation ).
• Malnutrition- Impaired organ function, Impaired collagen synthesis, Impaired immune function, Reduced antioxidant activity
• T = Tissue necrosis, from local or systemic ischemia or radiation injury. Blood supply is important.
![Page 10: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/10.jpg)
DIDN’T HEAL
• H = Hypoxia: -esp the distal extent of the extremities. Blood volume deficit, unrelieved pain, or hypothermia sympathetic overactivity local vasoconstriction Inadequate tissue oxygenation.
• E = Excessive tension on wound edges local tissue ischemia and necrosis.
![Page 11: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/11.jpg)
DIDN’T HEAL
• A = Another wound: Competition for the substrates required for wound healing.
• L = Low temperature: (relatively) distal aspects of the upper and lower extremities (a reduction of 1-1.5°C [2-3°F] from normal core body temperature) is responsible for slower healing of wounds at these sites.
![Page 12: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/12.jpg)
Basics
• Wound evaluation and history• Wound preparation and closure• Optimize systemic parameters• Debride nonviable tissue• Reduce wound bioburden• Optimize blood flow• Reduce edema• Use dressings appropriately• Use pharmacologic therapy• Close wounds with suturing/grafts/flaps as indicated
![Page 13: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/13.jpg)
Wound Evaluation -HISTORY• identify all extrinsic and intrinsic factors that
jeopardize healing and promote infection– mechanism of injury– time of injury (accelerated growth phase of
bacteria starts at 3 hours post wound)– environment in which wound occurred
potential contaminants, foreign bodies
– species of animal if bite wound– pt’s medical problems (allergies to medication) / immune status
• tetanus immunization status
![Page 14: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/14.jpg)
Wound assessment
• Examine for:– amount of tissue destruction– degree of contamination– damage to underlying structures
![Page 15: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/15.jpg)
•Body Location –Proximity to Other Structures –Joints –Nerves –Tendons–Vasculature –Test integrity of each structure
•Assess laxity/muscle and tendon function•Assess 2-point discrimination•Assess vascular supply
![Page 16: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/16.jpg)
Physical examination
• Wound Location– importance in the risk of infection– high endogenous bacterial counts in hairy
scalp, forehead, axilla, groin, foreskin of penis, vagina, mouth, nails
– wounds in areas of high vascularity moreeasily resist infection (scalp, face)
![Page 17: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/17.jpg)
Wound Preparation - Anesthesia• Topical
– Solution or paste– LET– TAC– EMLA
• Local– Direct infiltration– 1% lidocaine with or without epinephrine– Bupivicaine or sensorcaine for longer acting anesthesia
• Regional Block– Local infiltration proximally in order to avoid tissue disruption– Smaller amount of anesthesia required
![Page 18: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/18.jpg)
Local anestheticDrug Max Dose Onset Duration
Cocaine 6.6 mg/kg Rapid 1 hour
Procaine 10-15 mg/kg Rapid 30min-1hr
Tetracaine 1.5 mg/kg Moderate 2 hours
Lidocaine 5 mg/kg 5-30 min 2 hours
(with Epi) 7 mg/kg 5-30 min 2-3 hours
Bupivacaine 2 mg/kg 7-30 min > 6 hours
![Page 19: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/19.jpg)
Epinephrine
• Vasoconstrictive –Increases Duration of Action–Promotes Hemostasis–Avoid end-arterial blood supply areas–May increase pain (low pH)
![Page 20: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/20.jpg)
Wound Preparation - Hemostasis• Direct Pressure–Usually best choice • Ligatures
– Use a tourniquet• Chemicals
–Epinephrine–Gelfoam–Oxycel–Actifoam
• Cautery
![Page 21: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/21.jpg)
Debridement & Reduction of Bioburden
• Surface irrigation with saline.• Debridement: surgical, enzymatic (papain with urea,
collagenase), mechanical (pressurized water jet), autolytic, maggots.
• Antibiotics: cellulitis, decreased rate of healing, increased pain, straw colored oozing from skin, contaminated wounds, mechanical implants.
• Removal of FB.
![Page 22: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/22.jpg)
Wound Preparation – Foreign Body Removal
• Suspect with point tenderness• Visual inspection (to the apex)• Imaging
– Glass, metal, gravel fragments >1mm should be visible on plain radiographs
– Organic substances and plastics are usually radiolucent
• Always discuss and document possibility of retained foreign body
![Page 23: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/23.jpg)
Wound preparation : CLEANING• high pressure irrigation (Normal Saline)• min 100-300 ml with continued irrigation• at least 8 psi force to the wound the irrigation fluid
dislodges foreign bodies, contaminants, and bacteria.• A simple device setup 30-60 ml syringe and an 14-gauge angiocatheter.
![Page 24: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/24.jpg)
Hair removal
• Shaving –Increases risk of infection X 10 !• Clip Hair with Scissors • Matt Hair with Ointment
• Never shave eyebrows ( may not regrow )
![Page 25: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/25.jpg)
Wound Preparation – Debridement
• Removes devitalized tissue• Creates sharp wound edge• Excision with elliptical shape• Respect skin lines
![Page 26: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/26.jpg)
Wound closure in relation to time
• Primary closure– Suture, staple, adhesive, or tape– Performed on recently sustained lacerations: <12 hours
generally and <24 hours on face
• Secondary closure– Secondary intent– Allowed to granulate
• Tertiary closure– Delayed primary (observed for 3-4days)
![Page 27: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/27.jpg)
SUTURE TECHNIQUES
• Deep layer approximation– Absorbable sutures– Buried knot– Serves two purposes
• Closes potential spaces• Minimizes tension on the wound
margins
![Page 28: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/28.jpg)
Skin Closure
• Key – wound edge eversion• “Approximate, don’t strangulate”• Anticipate wound edema• Choose appropriate size of suture for location
of laceration
![Page 29: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/29.jpg)
Other devices in wound closure• Staples
– Quick, poor aesthetic result– where scar is less of an issue (hairy scalp)
• Adhesives– Dermabond– clean, sharp edges, clean nonmobile areas, laceration
less than 5 cm in length• Tape
– Steri-strips– superficial, straight laceration under little tension
![Page 30: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/30.jpg)
After care•Wound Dressings • Maintain moist –24 –48 hours
–Augments reepithelialization •“Water-Tight” after 48 hours•Bandages–Soft-splint–Absorb exudates–Protects Wound–Protects knots
![Page 31: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/31.jpg)
Optimize systemic parameters
• Age: cannot be reversed, usage of growth factors, aggressive optimization of systemic parameters & supplementation.
• Avoidance of ischemia & malnutrition.• Correction of diabetes, removal of FB.• Avoidance of steroids, alcohol, smoking.• Avoidance of reperfusion injury: total contact
casting, compression therapy.
![Page 32: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/32.jpg)
Optimize systemic parameters-nutrition
• Glucose -give energy for angiogenesis and the deposition of new tissue.
• Fatty acids-essential for cell structure and have an important role in the inflammatory process.
• Protein deficiency-contribute to poor healing rates with reduced collagen formation and wound dehiscence.
• Vitamins- vitamins A (collagen synthesis, antioxidant), C (collagen synthesis), and zinc (fibroblast proliferation )..
![Page 33: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/33.jpg)
Optimize blood flow & oxygen supply
• Warmth• Hydration• Surgical revascularization• Hyperbaric O2 therapy: limb salvage.
![Page 34: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/34.jpg)
Reduce edema
• Elevation • Compression• Negative pressure wound therapy: removes
pericellular transudate & wound exudate as well as deleterious enzymes. Cannot be used in ischemic, badly infected or inadequately debrided wounds or in malignancy.
![Page 35: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/35.jpg)
Indications for systemic antibioticfor traumatic wounds
• Injury 6 hours old on the extremities• Injury 24 hours old on the face and scalp• Tendon, joint, or bony involvement• Cartilage involvement• Mammalian bite• Co-morbidity (diabetes mellitus, extremes of age,
steroid use, morbid obesity)• Puncture wound• Complex intraoral wound
![Page 36: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/36.jpg)
Wound preparation -Tetanus prophylaxis
• Clean wounds– Incompleted immunization toxoid– >10 years, then give toxoid
• Tetanus prone wound– Incompleted immunization Toxoid &
immunoglobulin– > 5 years, give toxoid
![Page 37: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/37.jpg)
Dressings
• Absorption characteristics: none – films, low – hydrogels, moderate - hydrocolloids, high – foams, alginates, collagen.
• Hydrogels (eg. starch) rehydrate wounds (benefit in small amounts of eschar, infected wounds).
• Hydrocolloids promote wound debridement by autolysis.
• Antimicrobial dressings: silver, cadexomer iodine, mupirocin, neomycin.
![Page 38: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/38.jpg)
Suture removal guidelines
• Anatomic location Days (average)face 3-5arm 7
anterior trunk 7back 10-14feet and hand 10-14joint 10-14 scalp 10-14
![Page 39: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/39.jpg)
Skin Substitutes• Autologous keratinocyte sheets.• Biobrane• Oasis• Alloderm• Integra (sites prone to contracture, coverage of
tendons, bone, surgical hardware)• TransCyte• Dermagraft• Orcel
![Page 40: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/40.jpg)
Collagen & chondroitin sulphate : Integra
Apligraftrade: skin substitute containing collagen and seeded cells
Alloderm: immunologically inert, nonliving, allogenic, acellular dermal matrix with intact basement membrane prepares wound bed for grafting
![Page 41: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/41.jpg)
Tegaderm
Used for simple shallow wound dressing Protects from water loss mechanical injury and drying
![Page 42: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/42.jpg)
TransCyte (ECM matrix generated by allogenic human dermal fibroblasts serves as a matrix for neodermis generation
ORCEL: Composite cultured skin. Fibroblasts, keratinocytes seeded on opposite sides of bilayered matrix of bovine collagen
![Page 43: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/43.jpg)
Dermagraft living allogenic dermal fibroblasts grown on a degradable scaffold. Good resistance to tearing
![Page 44: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/44.jpg)
Pharmacologic therapy
• Antimicrobials• PDGF- becaplermin- US-FDA approved –
dibetic foot ulcers• EGF- under trial• VEGF- under trial• Vit A: steroid use• Absolutely of no use in normally healing
wounds
![Page 45: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/45.jpg)
Flaps & Grafts
• Radiation wounds require flaps.• Chronic nonhealing ulcers.• Extensive areas of ulceration.• Major soft tissue loss.• Other therapies: electrical stimulation for
recalcitrant ulcers.
![Page 46: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/46.jpg)
beta-Glucan stimulates the macrophage activity and promotes rapid wound healing.
Beta-Glucan Collagen mesh or Glucan II (Beta-Glucan) mesh. . Rapid healing without dressing changes painless treatment.
![Page 47: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/47.jpg)
BIOLOGIC DRESSINGS
![Page 48: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/48.jpg)
HONEYSOFT
Natural dressingHoney-impregnated dressing Chronic unhealing wounds. Impregnated into a compress of EVA (ethylenevinylacetate) mesh
Honey cleans the wound without disturbing it Removing the dressing causes no damage no known side effects
![Page 49: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/49.jpg)
NPWT/VAC
• expeditiously prepare a wound bed for surgical closure by tertiary intent.
• works through- relief of edema, improving interstitial diffusion of oxygen to cells, removes deleterious enzymes
• most wounds will heal optimally with a pressure of 125 mm Hg, other wounds may only tolerate a setting of 75 mm Hg before capillary flow is occluded.
![Page 50: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/50.jpg)
NPWT/VAC
• Indications- lymphatic leaks, venous stasis ulcers, diabetic wounds, and wounds with fistulae , sternal wounds, orthopedic wounds, and abdominal wounds
• Some instances, it has enabled avoidance of free flaps can also be used to assist the neovascularization of skin grafts and tissue engineered skin substitutes
• Contraindications- malignancy, ischemia, inadequately debrided or badly infected wounds
![Page 51: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/51.jpg)
Hyperbaric Medicine• (HBO) (typically, 100% O2saturation at 2 to 3 ATA)
raises the dissolved oxygen saturation in plasma from 0.3% to nearly 7%.
• • Stimulates angiogenesis and fibroblast migration,
enhances neutrophil and antibiotic killing action, and suppresses alpha toxin production in gas gangrene.
• if the periwound area/extremity demonstrates a rise in tcPO2when the patient inspires supplemental oxygen, the patient is likely to benefit from HBO.
• not benefit from HBO: those with a normal environmental perfusion, and those with ischemic limbs who need a bypass to restore blood flow to a limb
![Page 52: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/52.jpg)
Patients with irradiated skin or steroid users
• Patients who are on steroids should receive vitamin A (25,000 IU daily by mouth or 200,000 IU topically t.i.d.).
• The progressive endarteritis obliterans and microvascular damage, along with fibrotic interstitial changes, results in a wound marked by ischemia, hampered by cellular senescence, and prone to infection.
• gingerly debrided, antimicrobial dressings, growth factors and even hyperbaric oxygen therapy, microvascular free flap.
![Page 53: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/53.jpg)
Pressure sore care
• Should be aggressively nourished and receive vitamin supplementation.
• administration of growth hormone or anabolic steroids.
• Debridements• Dressings• air-fluidized beds, air mattresses, air flotation
and water flotation devices, and low air-loss beds.
![Page 54: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/54.jpg)
Wound Care in Patients with Diabetes
• components of pressure necrosis, functional microangiopathy, and true neuropathic derangements.
• Selective debridement, control of glucose levels, pressure offloading.
• Revascularization• use of growth factors
![Page 55: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/55.jpg)
Wound Care in Patients with Venous Stasis Ulcers
• Compression therapy is essential for venous stasis ulcers.
• stockings, elastic wraps, and multilayer wraps, Unna boot-paste dressings and low-stretch bandages.
• contraindicated in patients with an ABI <0.7• ideally the pressures exerted should be between 30
and 40 mm Hg• continued for several weeks following successful
closure of the wound.
![Page 56: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/56.jpg)
“ God heals, and the doctor takes the fees ”
Benjamin Franklin(American Statesman, scientist, Philosopher)
![Page 57: Wound management](https://reader035.vdocuments.site/reader035/viewer/2022062404/554b22a3b4c9055d098b555b/html5/thumbnails/57.jpg)