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MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Burn and wound managementBurn and wound management
C Balakrishnan, MDC Balakrishnan, MDAssociate ProfessorAssociate Professor
Division of Plastic SurgeryDivision of Plastic SurgeryWayne State UniversityWayne State UniversityDetroit, Michigan, USADetroit, Michigan, USA
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Burn care and Wound careBurn care and Wound care
No financial interestNo financial interest
Aim: Principles of Wound care principles, Aim: Principles of Wound care principles, Burn care and Reconstruction and Burn care and Reconstruction and rehabilitation following burn injuriesrehabilitation following burn injuries
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Burn care and Wound careBurn care and Wound care
Burn care and wound care – what is in Burn care and wound care – what is in common?common?Skin is the largest organ in the bodySkin is the largest organ in the bodyLocal and systemic changes are best Local and systemic changes are best studied for burnsstudied for burnsAmerican Burn Association, Am Academy American Burn Association, Am Academy of Wound management, American College of Wound management, American College of certified Wound specialists (CWS, of certified Wound specialists (CWS, FCCWS)FCCWS)
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Types of woundsTypes of wounds
Acute wounds:Acute wounds:
Acute thermal injuries (Burns, Frostbite)Acute thermal injuries (Burns, Frostbite)
Traumatic injuries Traumatic injuries
Chronic wounds:Chronic wounds:
Pressure soresPressure sores
Radiation injuriesRadiation injuries
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Cold injuriesCold injuries
Frost biteFrost bite
Trench feetTrench feet
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
American Burn Association criteria for American Burn Association criteria for transfer to Burn unittransfer to Burn unit
Major burnsMajor burns
Burns associated with inhalation injuryBurns associated with inhalation injury
Burns of specific areas of the body – face, Burns of specific areas of the body – face, hand, feet, perineumhand, feet, perineum
Chemical injuriesChemical injuries
Electrical injuriesElectrical injuries
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Etiology of BurnsEtiology of Burns
Causes : Causes :
Flame - damage from superheated, oxidized air Flame - damage from superheated, oxidized air
Scald - damage from contact with hot liquids Scald - damage from contact with hot liquids
Contact - damage from contact with hot or cold Contact - damage from contact with hot or cold solid materials solid materials
Chemicals - contact with noxious chemicals Chemicals - contact with noxious chemicals
Electricity - conduction of electrical current through Electricity - conduction of electrical current through tissues tissues
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Etiology of BurnsEtiology of Burns
Incidence of work related burn injuries – Incidence of work related burn injuries – 26.4 per 10,000 workers (26.4 per 10,000 workers (Islam et al J T 2000Islam et al J T 2000))
Male – Construction and mechanicalMale – Construction and mechanical
Women – Service industryWomen – Service industry
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Work force involvedWork force involved
WeldersWelders
CooksCooks
LaborersLaborers
Food serviceFood service
MechanicsMechanics
ElectricianElectrician
Fire fightersFire fighters
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Area involvedArea involved
Hand, wrist – hot liquidHand, wrist – hot liquid
Eyes – chemicalEyes – chemical
Face flame, hot liquidFace flame, hot liquid
Contact burnsContact burns
Firefighters – face and posterior neckFirefighters – face and posterior neck
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
EtiologyEtiology
Age groups - Younger cooks and food Age groups - Younger cooks and food service personnelservice personnel
Depth – 1.3 per 10,000 deepDepth – 1.3 per 10,000 deep
Associated trauma – Inhalation injury, Associated trauma – Inhalation injury, Fractures, Crush injuriesFractures, Crush injuries
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Psychological problems associated with Psychological problems associated with work related Burn injurieswork related Burn injuries
DepressionDepression
PTSDPTSD
Anxiety disordersAnxiety disorders
Workers with electrical injuries had higher Workers with electrical injuries had higher psychological sequlae (19%)psychological sequlae (19%)
JBCR 2011
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Depth of injuryDepth of injury
First degree - Injury localized to the epidermis First degree - Injury localized to the epidermis
Superficial second degree - injury to the Superficial second degree - injury to the epidermis and superficial dermis epidermis and superficial dermis
Deep second degree - injury through the Deep second degree - injury through the epidermis and deep into the dermis epidermis and deep into the dermis
Third degree - full-thickness injury through the Third degree - full-thickness injury through the epidermis and dermis into subcutaneous fat epidermis and dermis into subcutaneous fat
Fourth degree - injury through the skin and Fourth degree - injury through the skin and subcutaneous fat into underlying muscle or bone subcutaneous fat into underlying muscle or bone
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Depth of injuryDepth of injury
IncinerationIncineration Fourth degreeFourth degree
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Physiology of depth of injuryPhysiology of depth of injury
Three zones: Three zones:
zone of coagulation zone of coagulation
zone of stasis zone of stasis
zone of hyperemiazone of hyperemia
This is similar for a pressure ulcerThis is similar for a pressure ulcer
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Aim of managementAim of management
To limit the injure to zone of coagulationTo limit the injure to zone of coagulation
To prevent injury to zone of stasis To prevent injury to zone of stasis
Management actually aims at preventing a Management actually aims at preventing a second degree or first degree burn to second degree or first degree burn to becoming a deeperinjury becoming a deeperinjury
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Burn sizeBurn size
Rule of nineRule of nine
ChartsCharts
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Chemical burnsChemical burns
Hydrofluoric acidHydrofluoric acid
PhenolPhenol
PhosphorusPhosphorus
- Calcium gluconate- Calcium gluconate
- Ethylene glycol- Ethylene glycol
- Copper sulfate- Copper sulfate
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Chemical burnsChemical burns
Phenol – chemical peelPhenol – chemical peel Cardiac toxicityCardiac toxicity
Monitor EKG Monitor EKG
Ethylene glycolEthylene glycol
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Electrical injuriesElectrical injuries
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Electrical injuriesElectrical injuries
Muscle injury without skin damageMuscle injury without skin damage
Myoglobinuria – treat to prevent renal Myoglobinuria – treat to prevent renal failurefailure
Cardiac arrhythmiaCardiac arrhythmia
Tetany, rupture of tendonsTetany, rupture of tendons
Neurological deficitNeurological deficit
Saliva good conductor of electricitySaliva good conductor of electricity
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Electrical InjuriesElectrical Injuries
Impaired attention spanImpaired attention span
Memory problems (especially for short-term Memory problems (especially for short-term anterograde verbal informationanterograde verbal information
Persistent distress and frustrationPersistent distress and frustration
Mood disorders - often characterized by Mood disorders - often characterized by psychosocial difficulty and violent behavioral psychosocial difficulty and violent behavioral outbursts, accompanied by a background of outbursts, accompanied by a background of generalized depressiongeneralized depression
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Electrical injuriesElectrical injuries
Survivors of severe electrical injury have Survivors of severe electrical injury have been noted to exhibit abnormal been noted to exhibit abnormal neuropsychologic findingsneuropsychologic findings several several years after trauma. years after trauma.
Late evaluation of patients with significant Late evaluation of patients with significant electrical injury has suggested a common electrical injury has suggested a common constellation of symptoms involving both constellation of symptoms involving both cognitive and affective disturbancescognitive and affective disturbances..
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Systemic response to BurnsSystemic response to Burns
Inflammation and edema Inflammation and edema
Altered hemodynamics Altered hemodynamics
Immunosuppression Immunosuppression
Hyper metabolism Hyper metabolism
Decreased renal flow Decreased renal flow
Increased gut mucosal permeability Increased gut mucosal permeability
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Principles of managementPrinciples of management
Burn ResuscitationBurn Resuscitation
Early managementEarly management
Wound careWound care
Surgical managementSurgical management
Management of complicationsManagement of complications
Management of Psychosocial issuesManagement of Psychosocial issues
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Parkland formulaParkland formula
Parkland 4 ml/kg per % TBSA burn Total Parkland 4 ml/kg per % TBSA burn Total fluid =4 x body wt x BSA fluid =4 x body wt x BSA
½ of which is given in first 8 hours from the ½ of which is given in first 8 hours from the point of injury point of injury
Next half is given in the next 16 hours Next half is given in the next 16 hours
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Wound managementWound management
EscharotomyEscharotomy
ExcisionExcision
Skin graftsSkin grafts
FlapsFlaps
OthersOthers
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
EscharotomyEscharotomy
IndicationsIndications - Improve circulation- Improve circulation
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Wound careWound care
Silver sulfadiazineSilver sulfadiazine
Mefenate acetateMefenate acetate
Silver dressingsSilver dressings
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Wound careWound care
Biological dressingsBiological dressings Allograft (cadaver skin)Allograft (cadaver skin)
XenograftXenograft
Placental membranePlacental membrane
Bilayered Bilayered
Cultured epidermal cellsCultured epidermal cells
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Wound healing PrinciplesWound healing Principles
Burn wounds are potentially contaminated Burn wounds are potentially contaminated and needs debridement.and needs debridement.
Clean wound with out coagulum heals Clean wound with out coagulum heals faster.faster.
Epithlialization occurs from the cells Epithlialization occurs from the cells remaining in the dermis.remaining in the dermis.
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Wound therapyWound therapy
Management of burn wounds can be Management of burn wounds can be divided into three stages: assessment, divided into three stages: assessment, management, rehabilitation. management, rehabilitation.
Rehabilitation starts early in managementRehabilitation starts early in management
Positioning and splinting Positioning and splinting
Stretching of jointsStretching of joints
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Surgical managementSurgical management
Primary excisionPrimary excision
Early excisionEarly excision
Excision with Skin graftingExcision with Skin grafting
Excision with allograftExcision with allograft
Excision with skin substitutesExcision with skin substitutes
Excision – Integra – Skin graftingExcision – Integra – Skin grafting
Excision with flap coverageExcision with flap coverage
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Surgical managementSurgical management
Immediate excisionImmediate excision
Primary excisionPrimary excision
Early excisionEarly excision
Delayed excisionDelayed excision
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Excision and grafting of the Burn woundExcision and grafting of the Burn wound
Early excision vs delayedEarly excision vs delayed
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Outcome in BurnsOutcome in Burns
Early, aggressive resuscitation regimens Early, aggressive resuscitation regimens including early excision and wound including early excision and wound coverage have improved survival rates coverage have improved survival rates dramatically. dramatically.
By decrease in Sepsis and Multi organ By decrease in Sepsis and Multi organ failure failure
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
OutcomeOutcome
Hypertrophic scarHypertrophic scar
Burn contracturesBurn contractures
AmputationsAmputations
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Prevention of contractures!!!!Prevention of contractures!!!!
Think neck and chest are a single unit Think neck and chest are a single unit when it comes to contracturewhen it comes to contracture
Hand splintsHand splints
Position elbows and axillaPosition elbows and axilla
Knee braceKnee brace
Prevent foot dropPrevent foot drop
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Pressure garmentsPressure garments
Pressure garments appear to help in :Pressure garments appear to help in :reduce scar thickness/lumpiness reduce scar thickness/lumpiness
reduce scar redness reduce scar redness
reduce swelling reduce swelling
relieve itching relieve itching
protect newly healed skin/graft protect newly healed skin/graft
prevent contractures/ maintain contoursprevent contractures/ maintain contours
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Silicone gel sheetsSilicone gel sheets
The exact mechanism of action of silicone The exact mechanism of action of silicone in the prevention and management of in the prevention and management of hypertrophic scars is unclear.hypertrophic scars is unclear.
Influences the collagen remodeling phase Influences the collagen remodeling phase of wound healing of wound healing
Soften, flatten and blanch the scar, making Soften, flatten and blanch the scar, making it comfortable and improves appearance it comfortable and improves appearance
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Custom Compression Custom Compression GarmentsGarments
25 mm of Hg25 mm of Hg
Constant useConstant use
Clear masks for faceClear masks for face
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Management of contracturesManagement of contractures
Serial castingSerial casting
Surgical releaseSurgical release
Post operative splintingPost operative splinting
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Lip deformity secondary to neck contractureLip deformity secondary to neck contracture
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Complications of Hand BurnsComplications of Hand Burns
Burn associated neuropathyBurn associated neuropathy
Reflex sympathetic dystrophyReflex sympathetic dystrophy
Pain syndromePain syndrome
Amputations and loss of partsAmputations and loss of parts
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Hand burns - PrinciplesHand burns - Principles
Early excision and wound coverageEarly excision and wound coverage
Excision and skin graftingExcision and skin grafting
Flap coverage of exposed bones and Flap coverage of exposed bones and jointsjoints
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Cross finger flapCross finger flap
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Radial forearm flapRadial forearm flap
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
DISTANT FLAPS -Abdominal flapDISTANT FLAPS -Abdominal flap
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Amputation of digits / Fusion
DIPJs, PIPJs and possibly the middle phalanges. – Try to preserve length
Both for toes as well as fingers.
The thumb amputation deformity is treated either by pollicization or toe transfer.
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Primary amputationPrimary amputation
Electrical injuriesElectrical injuries
Contact burnsContact burns
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Complications of Hand BurnsComplications of Hand Burns
Loss of partsLoss of parts Adduction contractureAdduction contracture
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Prevention of contracture by early Prevention of contracture by early excision and soft tissue coverageexcision and soft tissue coverageSoft tissue coverage of the knee joint following Soft tissue coverage of the knee joint following burns. Canadian Journal of Plastic Surgery 2006; burns. Canadian Journal of Plastic Surgery 2006; 14:163.14:163.
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Axillary contractureAxillary contracture
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Psychological problems associated Psychological problems associated with work related Burn injurieswith work related Burn injuries
DepressionDepression
PTSDPTSD
Anxiety disordersAnxiety disorders
Workers with electrical injuries had higher Workers with electrical injuries had higher psychological problems (19%)psychological problems (19%)
JBCR 2011
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Occupational Burn injuriesOccupational Burn injuries
Preventable?Preventable?
Appropriate educationAppropriate education
Work place trainingWork place training
PPE (Personal Protective equipment)PPE (Personal Protective equipment)
Safe work place proceduresSafe work place procedures
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Worker trainingWorker training
Worker illness and Injury prevention Worker illness and Injury prevention programsprograms
Reporting all injuriesReporting all injuries
First aidsFirst aids
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Back to work programsBack to work programs
Can the worker return to previous Can the worker return to previous occupationoccupation
Is there any work place adjustments Is there any work place adjustments requiredrequired
RetrainingRetraining
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Classification of Chronic woundsClassification of Chronic wounds
Pressure ulcersPressure ulcers
Vascular insufficiencyVascular insufficiency
MetabolicMetabolic
InfectionsInfections
Inflammatory disordersInflammatory disorders
HematologicHematologic
MalignantMalignant
MiscellaneousMiscellaneous
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Pressure ulcersPressure ulcers
Decubitous ulcersDecubitous ulcers
Neuropathic ulcersNeuropathic ulcers
Contributing factors include Contributing factors include Pressure, Pressure, Immobility, Shear, Moisture, NutritionImmobility, Shear, Moisture, Nutrition
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Etiology - nomenclatureEtiology - nomenclature
Pressure sore, decubitus ulcer, bedsorePressure sore, decubitus ulcer, bedsore
Unrelieved pressureUnrelieved pressure, altered sensory , altered sensory perception, incontinence, exposure to perception, incontinence, exposure to moisture, altered activity and mobility, moisture, altered activity and mobility, friction, and shear force.friction, and shear force.
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Staging and risk factorsStaging and risk factors
Pressure Ulcer Staging (depth & tissue type)Pressure Ulcer Staging (depth & tissue type)– Stage IStage I Persistent redness (culturally Persistent redness (culturally
sensitive)sensitive)– Stage IIStage II Partial thickness skin lossPartial thickness skin loss– Stage IIIStage III Full thickness skin lossFull thickness skin loss
(subcutaneous)(subcutaneous)– Stage IVStage IV Full thickness skin loss (fascia)Full thickness skin loss (fascia)
Norton scale: Norton scale: Physical condition, mental condition, Physical condition, mental condition, activity, mobility, incontinence (score ≥ 12 is at risk)activity, mobility, incontinence (score ≥ 12 is at risk)
Norton scale: Norton scale: Activity, mobility, sensory perception, Activity, mobility, sensory perception, moisture, nutrition, friction, and shear moisture, nutrition, friction, and shear
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Vascular insufficiencyVascular insufficiency
Acute vascularAcute vascular
Chronic venousChronic venous
ArtherosclerosisArtherosclerosis
LymphedemaLymphedema
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Fx pelvis – SP embolozationFx pelvis – SP embolozation
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
MetabolicMetabolic
Diabetes mellitusDiabetes mellitus
GoutGout
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Infected woundsInfected wounds
BacterialBacterial
FungalFungal
ParasiticParasitic
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Bacterial infectionsBacterial infections
Necrotizing fascitis
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Bacterial infectionBacterial infection
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Inflammatory disordersInflammatory disorders
Pyoderma gangrenosaPyoderma gangrenosa
VasculitisVasculitis
Necrobiosis lipodica diabeticorumNecrobiosis lipodica diabeticorum
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Hematologic disordersHematologic disorders
Sickle cell diseaseSickle cell disease
Polycythemia veraPolycythemia vera
Hypercoagulable statesHypercoagulable states
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Malignant ulcersMalignant ulcers
Marjolin’s ulcersMarjolin’s ulcers
Primary cutaneous neoplasmPrimary cutaneous neoplasm
Metastic Cutaneous neoplasmMetastic Cutaneous neoplasm
Kaposi’s sarcomaKaposi’s sarcoma
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Radiation associated woundsRadiation associated wounds
Poor granulationPoor granulation
Rule out CancerRule out Cancer
? Hyperbaric? Hyperbaric
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Radiation associated woundsRadiation associated wounds
Can develop AngiosarcomaCan develop Angiosarcoma
Diagnosis by biopsyDiagnosis by biopsy
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Toxic drug ulcersToxic drug ulcers
Extravasation injuryExtravasation injury
Paint gun injuriesPaint gun injuries
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Etiology of Chronic woundsEtiology of Chronic wounds
Nutritional deficiencyNutritional deficiency
Tissue hypoxiaTissue hypoxia
InfectionInfection
MetabolicMetabolic
Malignant changeMalignant change
Immune compromiseImmune compromise
Mechanical factorsMechanical factors
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Impaired wound healing – Intrinsic Impaired wound healing – Intrinsic factorsfactors
IschemiaIschemia
InfectionInfection
Foreign bodyForeign body
SmokingSmoking
Venous insufficiencyVenous insufficiency
Radiation fibrosisRadiation fibrosis
Repeated traumaRepeated trauma
MalignancyMalignancy
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Impaired wound healing - ExtrinsicImpaired wound healing - Extrinsic
Nutritional deficiencyNutritional deficiency
Diabetes mellitusDiabetes mellitus
Chronic renal sufficiencyChronic renal sufficiency
Steroids – reversed by Vit ASteroids – reversed by Vit A
ChemoChemo
Liver diseaseLiver disease
Old ageOld age
HeredityHeredity
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Hyperbaric oxygenHyperbaric oxygen
2.5 atmospheres for 2 hours2.5 atmospheres for 2 hours
Tissue oxygen measured transcutanously. Tissue oxygen measured transcutanously. Oxygen tension of 30 mmHg required for Oxygen tension of 30 mmHg required for normal cell division and wound healing. normal cell division and wound healing. Optimal oxygen requirement for nonhealing Optimal oxygen requirement for nonhealing wound is unknown.wound is unknown.
Reinisch suggested that the beneficial effect Reinisch suggested that the beneficial effect of hyperbaric oxygen is due to the of hyperbaric oxygen is due to the vasoconstructive property of oxygen, which vasoconstructive property of oxygen, which acts to close arteriovenous shunts and thus acts to close arteriovenous shunts and thus improves capillary circulationimproves capillary circulation
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Categories of wound dressingCategories of wound dressing
Absorbents – Absorbents – to control drainageto control drainage
Impregnated dressings - Impregnated dressings - AdapticAdaptic
Transparent dressing- Transparent dressing- OpsiteOpsite
FoamsFoamsHydrogels – Hydrogels – DuoDerm GelDuoDerm Gel
Xerogels – Xerogels – Alginates, SorbsanAlginates, Sorbsan
Hydrocolloids – Hydrocolloids – Cutinova, DuoDermCutinova, DuoDerm
Active dressing –Active dressing – hydrogel with antimicrobial hydrogel with antimicrobial
VAC system – VAC system – subatmospheric wound healingsubatmospheric wound healing
Biotherapy - Biotherapy - maggotsmaggots
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Fetal wound healing Fetal wound healing
Contain few granulocytesContain few granulocytes
Increased turn over of matrixIncreased turn over of matrix
Early gestation fetal skin heals by Early gestation fetal skin heals by regeneration or growth rather than scaring.regeneration or growth rather than scaring.
Extra cellular matrix rich in hyaluronic acidExtra cellular matrix rich in hyaluronic acid
Low hyaluronidase activity and increased Low hyaluronidase activity and increased fibronectin productionfibronectin production
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Fetal wound healing Fetal wound healing
Highly organized collagen architectureHighly organized collagen architecture
TGF – induces acute inflammation and TGF – induces acute inflammation and subsequent fibrosis in fetal woundsubsequent fibrosis in fetal wound
Collagen type III increasedCollagen type III increased
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
Gene therapyGene therapy
Two methods:Two methods:
- Genetically engineered keratinocyte or - Genetically engineered keratinocyte or fibroblast to over express growth factor fibroblast to over express growth factor genesgenes
- Transfer of DNA directly by gene gun or - Transfer of DNA directly by gene gun or direct subcutaneous injection of DNAdirect subcutaneous injection of DNA
MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan
TransplantationTransplantation
Research to realityResearch to reality
Partial vs total facePartial vs total face
ExtremityExtremity