wounds-wound healing & care
DESCRIPTION
WOUNDS-WOUND HEALING & CARE. Begashaw M . Layers of Skin. DEFINITION. Wound - break in normal continuity of a tissue cause - transfer of any form of energy. WOUND HEALING. is a complex biologic process of restoring normal tissue continuity - PowerPoint PPT PresentationTRANSCRIPT
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WOUNDS-WOUND HEALING & CARE
Begashaw M
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Layers of Skin
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DEFINITION• Wound - break in normal continuity of a
tissue • cause - transfer of any form of energy
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WOUND HEALING• is a complex biologic process of
restoring normal tissue continuity• integrated sequences of events leading
to cellular proliferation and remodeling• starts immediately following the event of
wounding
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Wound Healing
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Phases of healing1-Coagulation phase• first phase • is induced immediately following injury• characterized by vaso-constriction, clot
formation and release of platelets
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2- Inflammatory phase
• takes place from time of wounding up to 3 days
• Characterized: inflammatory response vasodilatation and pouring out of fluid migration of inflammatory cells and
leukocytes rapid epithelial growth
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3- Proliferative Phase
• phase of fibroplasia• starts around the 3rd day of injury• stays for about 3 weeks• is characterized -fibroblast, epithelial and endothelial
proliferation -Collagen synthesis & ground substance -blood vessel production
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4- Maturation phase
• phase of remodeling• takes the longest period - up to 1 yr• Equilibrium between protein synthesis
and degradation occurs • with cross linking of collagen bundles
leading to slow and continuous increase in tissue strength
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Stages of Wound Healing
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Stages of wound healing
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Cells in Wound Healing
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Clinical types of healing• Healing by first intention - clean wound closed primarily - healing by epithelialization - minimal scar - <6 hours, longer with facial• Healing by Second intention- in wide, contaminated wounds- not primarily closed- healing by granulation tissue formation- tissue contraction and epithelialization- inferior cosmetic result
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Healing by third intention:-left open initially -closed later-delayed primary closure-In contaminated -long time lapse since initial injury-severe crush wound
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Factors affecting healing Local factors-Ischemia -decreased oxygen
tension-foreign bodies-tension-Infection-Irradiation
Systemic factors-Systemic diseases-
DM, cirrhosis, renal failure, malignancy
-malnutrition-immunosupression-Drug- steroids,
cytotoxic agents
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WOUND ASSESSMENT AND CLASSIFICATION
Assessment History• Mechanism of injury• Time• Place and circumstance• past and current medical• immunization history
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physical examination
• Extent of skin loss• Degree of circulation• soft tissue injury• The degree of contamination• foreign body • tissue necrosis
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Classification of wounds• Closed wound- an intact epithelial
surface- skin cover not
completely breeched
e.g Contusion Bruise Hematoma
• Open wounds- complete break of
the epithelial protective surface
E.g Abrasion Laceration Puncture Bites
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Open woundsTidy• Incised• Clean• Healthy tissue• Seldom tissue
loss
Untidy• crushed• Contaminated• Devitalised
tissue• Often tissue loss
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Classification of Wounds
ClassificationCriteriaRisk (%)
Clean Elective, not emergency, non traumatic, primarily closed; no acute inflammation; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered
< 2
Clean-contaminated
Urgent or emergency case that is otherwise clean; elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g., appendectomy) not encountering infected urine or bile; minor technique break
< 10
Contaminated Non purulent inflammation; gross spillage from gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique; penetrating trauma < 4 hours old; chronic open wounds to be grafted or covered
~ 20
Dirty Purulent inflammation (e.g., abscess); preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract; penetrating trauma > 4 hours old
~ 40
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Classification of Surgical Wounds
• Clean(no viscus opened)• Clean-contaminated(viscus opened
minimal spillage)• Contaminated(open viscus with
gross spillage or inflammatory ds)• Dirty(pus or perforation or incision
via abscess)
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WOUND MANAGEMENT-Priority: ABC-Stabilize-correct life threatening conditions• history & P/E -associated injuries• Assess wound• treatment• Follow up
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Proper wound care:• stop bleeding• irrigation• debridement• decision -to close -leave the wound open• antibiotics• tetanus prophylaxis • correcting systemic disease
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primary wound closure
• Clean wounds• Clean-contaminated wounds -if they
can be converted into clean wounds• all missile wounds, animal & human
bites should never be primarily closed • in wounds within 6-8 hours
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Delayed primary closure
• for traumatic or contaminated wounds• within 3 days
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Secondary closure
• wound left open to heal spontaneously
• contraction (myofibroblasts) and granulation
• requires dressing change• inferior cosmetic result• indication: when 1° closure not
possible or indicated
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Specific management
• Bruises -Superficial-no specific
management -local compress-analgesics
• Hematoma • collection of
extravasated blood• Management:- absorbed spontaneously - Local compress to
alleviate pain- aspiration-very large/
over a cosmetic area
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Abrasion• is rubbing or scraping of skin or mucous
membrane -variable depth• affect only a part or full layer of skin• Management- Cleanse using scrubbing brushes- Use antiseptic or clean tap water and soap- Analgesic
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Punctures• involve deeper structures• opening relatively small as compared with
depth (e.g. needle)• Management:- Evaluate the depth- Remove- Excise damaged tissue- Cover with antibiotics- Tetanus prophylaxis
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Lacerations- open wounds - knife, or glass- cut or torn tissue• Management:- cleansing- Closure- wound debridement - antibiotic - Tetanus Prophylaxis- Analgesics
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Laceration
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Crush and avulsion wounds
complicated wounds have more extensive damage caused by compression Management:- life threatening conditions- debridement- Early skin cover- late graft- wound left open if contaminated- antibiotics- Tetanus Prophylaxis- Analgesics
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Crush & avulsion
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Debridement
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Missile injuries• compound , complicated• excessive tissue damage• high degree of contamination• severe life threatening• Management- stabilize - debridement- Antibiotics- Tetanus Prophylaxis - analgesics - avoid primary closure
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Human bites• heavily contaminated • due to polymicrobial-Staph> a-hemolytic Strep
> Eikenella corrodens >Bacteroides• Management- culture - Scrubbing- irrigation with saline - debridement- Leave wound open- Broad-spectrum antibiotic-augmentin- Tetanus Prophylaxis
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Dog bites• can transmit the rabies virus• animal observation for 10 days Local- irrigation and repeated swabbing - flushing -soap & water/ antiseptics- anti-rabies serum infiltration- leave wound open Systemic- Post exposure anti rabies prophylaxis (1ml, IM) on the
1st, 3rd, 7th, 14th and 28th day- Tetanus prophylaxis- Antibiotics
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Dog bite
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Snake Bites• First aid :- irrigation- pressure bandage proximally- Immobilize- Transport to hospital
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Hospital Measures- Identify species- lab- hemoglobin, renal function- Anti-venom injection- Supportive care- Rest- IV-infusions to combat shock- Antibiotics- Blood transfusion- Tetanus Prophylaxis- Wound excision- Fasciotomy for compartment syndrome
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WOUND COMPLICATIONS• Local- Hematoma- Seroma- Infection- Dehiscence- Granuloma- Scar - Contracture
• systemic - shock -massive
bleeding- bacteremia & sepsis- death
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Hypertrophic Scar
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Hypertrophic Scars
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Keloid
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Keloids
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Questions?