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GYRGYI SZABA S S I S T A N T P R O F E S S O R
DEPARTMENT OF SURGICALRESEARCH AND TECHNIQUES
Classification and management ofwound, principle of wound healing,haemorrhage and bleeding control
Basic Surgical Techniques, Faculty of Medicine, 3rd year2021/13 Academic Year, Second Semester
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WOUND
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What is a wound?
It is a circumscribed injury which is caused by an external
force and it can involve any tissue or organ.
surgical, traumatic
It can be mild, severe, or even lethal.
Simple wound
Compound wound
Acute
Chronic
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Parts of the wound
Wound edge Woundcorner
Surface of
the wound
Base of the wound
Cross section of a simple wound
Skin surface
Subcutaneus tissue
Superficial fascia
Muscle layer
Base of the wound
Wound edge
Surface of
the wound
Wound
cavity
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The ABCDE in the injured assessment
The mnemonic ABCDE is used to remember the orderof assessment with the purpose to treat first that killsfirst.
A:Airway and C-spine stabilization
B:Breathing
C:Circulation
D:Disability
E:Environment and Exposure
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Classification of the accidental wounds1. Based on the origine
I. Mechanical: 1. Abraded wound (vulnus abrasum) 2. Puncured wound (v. punctum) 3. Incised wound (v. scissum) 4. Cut wound (v. caesum) 5. Crush wound (v. contusum) 6. Torn wound (v. lacerum) 7. Bite wound (v. morsum) 8. Shot wound (v. sclopetarium)
II. Chemical: 1. Acid
2. Base III. Wounds caused by radiation IV. Wounds caused by thermal forces:
1. Burning 2. Freezing
V. Special
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1.) Abraded wound
(v. abrasum)
1.) Abraded wound
(v. abrasum)
2.) Punctured wound
(v. punctum)
2.) Punctured wound
(v. punctum)
Superficial part of the epidermallayer
Good wound healing
Sharp-pointed object
Seems negligible
BUT Anaerobic infection
Injury of big vessels and nerves
Mechanical wounds7
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3.) Incised wound
(v. scissum)
3.) Incised wound
(v. scissum)4.) Cut wound(v. caesum)4.) Cut wound(v. caesum)
Sharp object
Best healing
Sharp object + blunt additionalforce
Edges - uneven
Mechanical wounds8
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5.) Crush wound
(v. contusum)
5.) Crush wound
(v. contusum)
6.) Torn wound
(v. lacerum)
6.) Torn wound
(v. lacerum)
Blunt force Pressure injury
Edges uneven and torn Bleeding
Great tearing or pulling
Incomplete amputation
Mechanical wounds9
(v. lacerocontusum)
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7.) Shot wound(v. scolperatium)7.) Shot wound(v. scolperatium)
Close - burn injury
Foreign materials
Mechanical wound10
unijured tissuenecrobiotic zonenecrotic zoneforeign bodies
aperture
slot tunel
output
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8.) Bite wound(v. morsum)8.) Bite wound(v. morsum)
Ragged wound
Crushed tissue
Torn
Infection
Bone fracture
Prevention of rabies Tetanus profilaxis
Mechanical wounds11
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DistalDistal ProximalProximal
The wound healing is good
The direction of the flap12
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1.) Acid1.) Acid 2.) Base2.) Base
in small concentration irritate
in large concentration coagulation necrosis
colliquative necrosis
Chemical wounds13
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Symptoms and severitydepend on:Symptoms and severitydepend on:
Amount of radiation Length of exposure Body part that was exposed
Symptoms may occur immediately,after a few days, or even as longas months.
What part of the body is
most sensitive duringradiation sickness?
bone marrowgastrointestinal tract
Wounds caused by radiation14
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1.) Burning1.) Burning 2.) Freezing2.) Freezing
a normal skin
1 - 1stdegreesuperficial injury(epidermis)
2 2nddegreepartial or deep partialthickness (epidermis+superficial or deepdermis)
3 3rd degreefull thickness (epidermis
+ entire dermis)
4 4thdegree(skin + subcutaneoustissue + muscle and bone)
Wounds caused by thermal forces15
Metabolic change! - toxemia mild, moderate, severe orclassification in 4 degree
rewarm not only the frozen areabut the whole body
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Exotic, poisonous animalsExotic, poisonous animals
Toxins, venom - toxicologist
Skin necrosis
Special wounds16
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Classification of the wounds2. According to the bacterial contamination
Clean wound
Clean-contaminated wound
Contaminated wound
Heavily contaminated wound
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Superficial
Partial thickness
Full thickness
Deep wound
Classification of the wounds2. Depending on the depth of injury
+ bone, opened cavities, organsetc.
18
source: http://www.funscrape.com/Search/1/skin+layers.html
http://www.google.hu/url?sa=i&rct=j&q=layers+of+the+skin&source=images&cd=&cad=rja&docid=Cg_uivrO1fzKtM&tbnid=0K48hs2TB54nJM:&ved=0CAUQjRw&url=http://www.nonsurgicalskincare.com/laser-skin-treatments-new-weapons-in-the-fight-on-ageing/&ei=frETUYDdLcyFtQbHp4HYDw&bvm=bv.42080656,d.bGE&psig=AFQjCNFqm7U4f__CnozHxlTdArQRDBuJUw&ust=13603314693047528/12/2019 Gyorgyi Szabo Classification and Management of Wound
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Applied wound management -colour continuum
black black-yellow yellow yellow-red red red-pink pink
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source: Applied wound management supplement
www.wounds-uk.com
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Applied wound managementinfection continuum
contaminationcolonisation infectionsterility
critical colonisation
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the quantity and diversity of microbes
source: Applied wound management supplement
www.wounds-uk.com
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Applied wound managementexudate continuum
volume high - 5 medium - 3 low - 1
high - 5
medium -3
low - 1
Viscosity
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source: Applied wound management supplement www.wounds-uk.com
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The wound managemanet
Temporary wound management (first aid) clean, hemostasis, covering
Final primary wound management clean, anaesthesis, excision, sutures
ALWAYS:thoracic cavity, abdominal wall or dura mater injury
NEVER:war injury, inflammation, contamination, foreignbody, special jobs,
bite, shot, deep punctured wound
Primary delayed suture (3-8 days) clean, wash saline, cover
excision of wound edges, sutures
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The wound managemanet23
Early secondary wound closure (2 weeks)
after inflammation, necrosis proliferation
anesthesia, refresh wound edges, suturing and draining
Late secondary wound closure (4-6 weeks) anesthesis, scar excision, suturing, draining
greater defect plastic surgery
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The surgical wound
Surgical incision
Stretch and fix
Handling the scalpel
Langer lines
Skin edges
Vessels and nerves
HemostasisLanger lines
The wound edges
Handling the scalpel
24
source: http://www.med-
ars.it/galleries/langer.htm
http://www.google.hu/url?sa=i&rct=j&q=langer+lines&source=images&cd=&cad=rja&docid=3GUNPeEPL60e-M&tbnid=gom5noe33-xiTM:&ved=0CAUQjRw&url=http://www.med-ars.it/galleries/langer.htm&ei=XLgTUeSEH4ndswbCwoGoCw&bvm=bv.42080656,d.bGE&psig=AFQjCNFt9WVJX9KUIsWzQuOON1hzAd_VtQ&ust=13603331339230418/12/2019 Gyorgyi Szabo Classification and Management of Wound
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Tissue unifying and dressing the wound
Skin: Stiches
Clips
Steri-Strips
Tissue glues
Fascia and subcutaneous layers:
Interrupted stiches
Fat fat necrosis!
Dressing: sterile, moist, antibiotic-containing, non-allergic,non-adhesive
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The wound healing
Hemostasis-inflammation Granulation-proliferation
Remodelling
capillariesfibroblasts
lymphocytes
macrophages
neutrophyl gr.
thrombocytes
0 1 2 3 4 5 6 7 8 9 10 11 10 13 14 15
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source: internet
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The main steps of the wound healing
1. Hemostasis-inflammationvasoconstiction, fibrin clot formationproinflammatory citokines andgrowth factors releasingvasodilatation
infiltration PMNs, macrophagescytokines releasing
2. Granulation-proliferationfibroblasts and endothelial cellsangiogenesis, collagen formation,
granulation tissue formationECM
3. Remodellingregression of many capillaries,physical contraction
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http://www.pilonidal.org/aftercare/wound_healing_indepth.php
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Types of wound healing
Healing by primary
intention
Healing by secondary
intention
Healing by tertiary
intention
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source: http://quizlet.com/13665246/chapter-3-tissue-renewal-regeneration-and-repair-flash-cards/
http://www.google.hu/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=09ewcRTqZp0Q0M&tbnid=2tLkfIyPPDGPEM:&ved=0CAUQjRw&url=http://www.studyblue.com/notes/note/n/tissue-injury-and-repair/deck/1472496&ei=RMIUUZ6ZM9DktQbhyYGAAQ&psig=AFQjCNHxd5-Hlu2BczTkKmnniG3M70uLWw&ust=13604012604854138/12/2019 Gyorgyi Szabo Classification and Management of Wound
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Factors affecting wound healing
Local Ischemia Infection Foreign body Edema, elevated
tissue pressure
Systemic Age and gender Sex hormones Stress Ischemia Diseases Obesity Medication Alcoholism and smoking Immunocompromised
conditions Nutrition
Hyperbaric oxygentreatment
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infection
ischemiaforeign
bodies
edema/
elevated
tissue
pressure
IMPAIREDHEALING
C li i f d h li
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Complications of wound healingI. Early complications
Seroma
Hematoma
Wound disruptin Superficial wound infection
Deep wound infection
Mixed wound infection
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1.) Seroma 2.) Hematoma1.) Seroma 2.) Hematoma
Filled with serous fluid, lymphor blood
Fluctuation, swelling, redness,tenderness, subfebrility
TREATMENT:
Sterile punture andcompression
Suction drain
Early complications of wound healing31
Bleeding, short drainage time,anticoagulant
Risk of infection
Swelling, fluctuation, pain,redness
TREATMENT Sterile puncture
Surgical exploration
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3.) Wound disruption3.) Wound disruption A. partial dehisceneceB. complete - disruptionA. partial dehisceneceB. complete - disruption
Surgical error
Increased intraabdominal
pressure
Wound infection
Hypoproteinaemia
TREATMENT: U-shaped sutures
Early complications of wound healing32
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1.) Diffuse1.) Diffuse 2.) Localized2.) Localized
Located below the skin
TREATMENT Resting position Antibiotic Dermatological consultation
Anywhere
TREATMENT Surgical exploration
Drainage
X-ray examination
Early complications of wound healingSuperficial wound infection
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e.g. erysipelas e.g. abscess
E l li ti f d h li
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1.) Diffuse1.) Diffuse 2.) Localized2.) Localized
TREATMENT
Surgical exploration Open therapy
H2O2and antibiotics
e.g. anaerobic necrosis
Inside the tissues or body cavities
TREATMENT surgical exploration drainage
Early complications of wound healingDeep wound infection
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C li i f d h li
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Mixed wound infectionMixed wound infection
e.g. gangrene necrotic tissues putrid and anaerobic
infection a severe clinical picture
TREATMENT aggresive surgical
debridement effective and specified
(antibiotic) therapy
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Complications of wound healingI. Early complications
l f d h l
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Complications of wound healingII. Late complications
Hyperthrophic scar
Keloid formation
Necrosis
Inflammatory infiltration
Abscesses
Foreign body containing abscesses
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Hypertrophic scar KeloidHypertrophic scar Keloid
Develop in areas of thickchorium
Non-hyalinic collagenfibres and fibroblasts
Confine to the incisionline
TREATMENT Regress spontaneously(1-2 yrs)
Late complications37
Mostly African and Asianpopulation
Well-defined edge
Emerging, tough structure Overproliferation of collagen
fibers in the subcutaneous tissue Subjective complains
TREATMENT Postoperative radiation Corticosteroid + local anaesthetic
injection
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BLEEDING AND HEMOSTASIS
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AnatomicalAnatomical DiffuseDiffuse
Arterial bright red,pulsate
Venous dark red,continuous
Capillary can becomeserious
Parenchymal
Bleeding39
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Bleeding
Severity of bleeding the volume of the lost blood andtime
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source: http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/
http://www.google.hu/url?sa=i&rct=j&q=classification+of+bleeding+Advanced+Trauma+Life+Support&source=images&cd=&cad=rja&docid=73ovbbTxf7EKVM&tbnid=2Znri-IvQJqRpM:&ved=0CAUQjRw&url=http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/&ei=qPclUf2GHcrTsgar_YCQCA&psig=AFQjCNEw0_7aGQ2V_mBGkWtIIzwpwaiujQ&ust=13615291165883718/12/2019 Gyorgyi Szabo Classification and Management of Wound
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The direction of hemorrage
External
Internal In a luminar organ (hematuria, hemoptoe, melena)
In body cavities (intracranial, hemothorax, hemascos,hemopericardium, hemarthros)
Among the tissues (hematoma, suffusion)
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Bleeding
Preoperative hemorrhage
Prehospital care! maintenance of the airways, ventillation and circulation
bandages, direct pressure, turniquets
Intraoperative hemorrhage
anatomical and/or diffuse
depending on the surgeon, the surgery, position,
the size of the vessel, pressure in the vessel
ANESTHESIA!
Postoperative bleeding
ineffective local hemostasis, undetected hemostatic defect, consumptive
coagulopathy or fibrinolysis
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LocalLocal GeneralGeneral
Hematoma, suffusion,ecchymosis
Compression in the pleuralcavity, in pericardium, in theskull
Functional disturbancies e.g.hyperperistalsis
Pale skin, cyanosis, decreasedBP. and tachycardia, difficultyin breeding, sweeting,decreased body temperature,unconsciousness, cardiac andlaboratory standstill, laboratorydisorders, signs of shock
Signs of the bleeding43
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Surgical hemostasis
Aim to prevent the flow of blood from the incised ortransected vessels
Mechanical methods
Thermal methods
Chemical and biological methods
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Thermal methods
Low temperature Hypothermia eg. stomach bleeding
Cryosurgery
dehidratation and denaturation of fatty tissue
decreases the cell metabolism
vasoconstriction
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Thermal methods
High temperature Electrosurgery electrocauterization
Monopolar diathermy
Bipolar diathermy
Laser surgery
coagulation and vaporization
for fine tissues
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Thermal methods
High temperature Electrocoagulation
Electrofulguration (A)
Electrodessication
Electrosection
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source: internet
Hemostasis with chemical and biological
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Hemostasis with chemical and biologicalmethods
vasoconstriction coagulation hygroscopic effect
Absorbable collagenAbsorbable gelatin
Microfibrillar collagenOxidizedcelluloze
OxytocinEpinephrine
ThrombinHemconQuikClot
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Hemostasis with chemical and biological
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Hemostasis with chemical and biologicalmethods
HemCon
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http://www.google.hu/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=uY5PlM_6vFCEsM&tbnid=f_64i7L9n8brTM:&ved=0CAUQjRw&url=http://www.recothrom.com/reconstitution-and-flexibility-of-use.html&ei=0JMsUfrpGYbctAaqpYDYDA&psig=AFQjCNEAmYpAQpVPQG2esJZKhcPKp6sOsw&ust=1361962265699082