SEMINAR PRESENTATION ON WOUND:

CLASSIFICATION,HEALING AND PRINCIPLES OF MANAGEMENT BY

DEBELA URGESSA

C –I

AMBO UNIVERSITY COLLEGE OF MEDICINE AND HEALTH SCIENCE DEPARTMENT OF MEDICINE

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OUTLINE

ObjectivesDefinitionClassificationWound healingManagement principlesComplicationsReferances

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OBJECTIVE

At the end of this session students are expected to :•Define wound•Classify wound •Explain steps of wound healing•Explain general management of wound•Identify the complications of wound healing

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WOUND

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DEFINITION

Wound is defined as a break in the normal continuity of a tissue. It is caused by a transfer of any form of energy into the body which can be either to an externally visible structure like the skin or deeper structures like muscles, tendons or internal organs

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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 fasciaMuscle layer

Base of the wound

Wound edge

Surface ofthe wound

Woundcavity

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CLASSIFICATION OF WOUNDS

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1. Based on the origin

I. Mechanical: 1. Abraded wound 2. Punctured wound 5. Bite wound 3. Incised wound 6. Shot wound 4. Crush wound

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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Mechanical wounds

1) Abraded wound •Superficial part of the epidermal layer•Good wound healing

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Mechanical wounds

2) Punctured wound Sharp-pointed objectSeems negligibleBUTAnaerobic infectionInjury of big vessels and nerves

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Mechanical wounds

3) Incised wound Sharp objectBest healing

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Mechanical wounds

5) Crush wound Blunt forcePressure injuryBleeding

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Mechanical wound

6) Shot wound Close - burn injuryForeign materials

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Mechanical wounds

7) Bite wound Crushed tissueInfectionBone fracture

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Chemical:

1. Acid

2. Base

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Wounds caused by radiation

Symptoms and severity depend on:Amount of radiationLength of exposure Body part that was exposed

Symptoms may occur immediately, after a few days, or even as long as months.

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Wounds caused by thermal forces

1.) Burning1st degree – superficial injury (epidermis)2nd degree –partial or deep partial thickness (epidermis+superficial or deep dermis)3rd degree – full thickness (epidermis + entire dermis)4th degree – (skin + subcutaneous tissue + muscle and bone)

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Wounds caused by thermal forces

2.) Freezingmild, moderate, severe (redness, bullas,

necrosis)

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Special wounds

Exotic, poisonous animals

Toxins, venom - toxicologistSkin necrosis

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2. According to the bacterial contamination

1. clean Wound: Operative incisional wounds that follow nonpenetrating (blunt) trauma.2. Clean-Contaminated Wound: uninfected wounds in which no inflammation is encountered but the respiratory, gastrointestinal, genital, and/or urinary tract have been entered.

3. Contaminated Wound: open, traumatic wounds or surgical wounds involving a major break in sterile technique that show evidence of inflammation.4. Infected Wound: old, traumatic wounds containing dead tissue and wounds with evidence of a clinical infection (e.g., purulent drainage).

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SuperficialPartial thicknessFull thicknessDeep wound

3. Depending on the depth of injury

+ bone, opened cavities, organs…etc.

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WOUND HEALING

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Wound healing

• It is a mechanism whereby the body attempts to restore the integrity of the injured part.

The disruption in the integrity of tissues, whether

surgical or traumatic, stimulates a series of events that attempts to restore the injured tissue to a normal state.

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The wound healing

steps: Inflammation Proliferation Remodelling

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The main steps of the wound healing

1.Inflammatory phaseThe inflammatory phase begins immediately after woundingand lasts 2–3 days.

It is recognized at the skin level by the cardinal signs of inflammation—which result from changes in the microcirculation.

Polymorphonuclear leukocytes (PMNs) are the dominant inflammatory cells in the wound for the first 24 to 48 hours,

-Phagocytize foreign material -Release cytokines

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2. proliferationfibroblast migrationcollagen depositionangiogensisgranulation tissue formationepithelializationcontraction

3. Remodellingregression of many capillariesphysical contraction – myofibroblastscollagen degeneration and synthesizationnew epitheliumtensile strength

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Types of wound healing

Healing by Primary Intention:All Layers are closed. The incision that heals by first intention

does so in a minimum amount of time, with no separation of the wound edges, and with minimal scar formation.

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healing by secondary intention:Deep layers are closed but superficial layers are left to heal

from the inside out. Healing by second is appropriate in cases of infection, excessive trauma, tissue loss, or imprecise approximation of tissue.

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Healing by tertiary intention:• Also referred to as delayed primary closure• Wound initially left open• is a useful option for managing wounds that are too heavily

contaminated for primary closure but has appearance of clean wound.

• the wound will be well vascularized after 4 to 5 days of open observation so that the cutaneous edges can be approximated at that time

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Factors affecting wound healing

Local factors: Ischemia Infection Foreign body

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Cont…………

Systemic factors: Age Stress Ischemia Diseases Medication Alcoholism and smoking Immunocompromised conditions Nutrition

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PRINCIPLES OF WOUND MANAGEMENT

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General principles of wound management

The primary goal of wound management is: To aid the natural body process To produce optimal functional and cosmetic result.

Management of acute wounds begins with obtaining a careful history of the events surrounding the injury.

The history is followed by a meticulous examination of the wound. Examination should assess:

The depth and configuration of the wound,The extent of nonviable tissue, and The presence of foreign bodies and other contaminants.

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Mx contin…….

Examination of the wound may require: Irrigation and debridement of the edges of the wound, and is facilitated by

use of local anesthesia. Antibiotic administration and tetanus prophylaxis may be needed, and planning the type and timing of wound repair should take place.After completion of the history, examination, and administration of tetanus prophylaxis, the wound should be meticulously anesthetized.

Lidocaine (0.5 to 1%) or bupivacaine (0.25 to 0.5%) combined with a 1:100,000 to 1:200,000 dilution of epinephrine provides satisfactory anesthesia and hemostasis.

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Mx contin…….

Epinephrine should not be used in wounds of the:Fingers ToesEarsNose orpenis due to the risk of tissue necrosis secondary to

terminal arteriole vasospasm in these structures

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Mx contin…….

Injection of these anesthetics can result in significant initial patient discomfort, and this can be minimized by:

Slow injection, Infiltration of the subcutaneous tissues, and Buffering the solution with sodium bicarbonate.

Care must be observed in calculating the maximum dosages of lidocaine to avoid toxicity-related side effects.

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Mx contin…….

Irrigation to visualize all areas of the wound and remove foreign material is best accomplished with normal saline .

High-pressure wound irrigation is more effective in achieving complete debridement of foreign material and nonviable tissues.

Iodine, povidone-iodine, hydrogen peroxide, and organically based antibacterial preparations have all been shown to impair wound healing due to injury to wound neutrophils and macrophages, and thus should not be used.

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Mx contin…….

After the wound has been anesthetized, explored, irrigated, and débrided, the area surrounding the wound should be cleaned, inspected, and the surrounding hair clipped.

The area surrounding the wound should be prepared with povidone-iodine or similar solution and draped with sterile towels.

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Mx contin…….

Having ensured hemostasis and adequate débridement of nonviable tissues and removal of any remaining foreign bodies, irregular, macerated, or beveled wound edges should be débrided in order to provide a fresh edge for reapproximation. Initial sutures that realign the edges of these different tissue types will speed and greatly enhance the aesthetic outcome of the wound repair.

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Mx contin…….

In general, the smallest suture required to hold the various layers of the wound in approximation should be selected in order to minimize suture-related inflammation.

In areas with significant superficial tissue loss, split-thickness skin grafting may be required.This will speed formation of an intact epithelial barrier to fluid loss and infection.

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Mx contin…….

After closing deep tissues and replacing significant tissue deficits, skin edges should be reapproximated for:

Cosmesis and To aid in rapid wound healing.

Skin edges may be quickly re approximated with stainless steel staples or non absorbable monofilament sutures.

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Mx contin…….

Failure to remove the sutures or staples by 7 to 10 days

after repair will result in a cosmetically inferior wound.

When wound cosmesis is important, the above problems may be avoided by placement of buried dermal sutures using absorbable braided sutures.

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Antibiotics

Antibiotics should be used only when there is an obvious wound infection. Most wounds are contaminated or colonized with bacteria. Signs of infection to look for include :

Erythema, Cellulitis,Swelling, and Purulent discharge.

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Antibiotics can also be delivered topically as part of irrigations or dressings, although their efficacy is questionable.Indiscriminate use of antibiotics should be avoided to prevent emergence of multidrug-resistant bacteria.

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DRESSING

The main purpose of wound dressings is to provide the ideal environment for wound healing.

The dressing should facilitate the major changes taking place during healing to produce an optimally healed wound. Covering a wound with a dressing mimics the barrier role of epithelium and prevents further damage. In addition, application of compression provides hemostasis and limits edema.

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Desired Characteristics of Wound Dressings

Promote wound healing Pain controlOdor controlNon allergenic and nonirritatingPermeability to gasSafetyNon traumatic removalCost-effectiveness

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Occlusion of a wound with dressing material helps:Healing by controlling the level of hydration and oxygen

tension within the wound. It also allows transfer of gases and water vapor from the

wound surface to the atmosphere. Occlusion affects both the dermis and epidermis, and it has been shown that exposed wounds are more inflamed and develop more necrosis than covered wounds.

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As it may enhance bacterial growth, occlusion is contraindicated in infected and highly exudative wounds.Many types of dressings exist and are designed to achieve certain clinically desired endpoints. These includes:

Absorbent Dressings Non adherent dressings Medicated Dressings Occlusive and Semi occlusive Dressings,

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Absorbent Dressings

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Accumulation of wound fluid can lead to maceration and bacterial overgrowth.

Ideally, the dressing should absorb without getting soaked through, as this would permit bacteria from the outside to enter the wound.

The dressing must be designed to match the exudative properties of the wound and may include cotton, wool, and sponge.

Non adherent Dressings

Non adherent dressings are impregnated with paraffin, petroleum jelly, or water-soluble jelly for use as non adherent coverage.

A secondary dressing must be placed on top to seal the edges and prevent desiccation and infection.

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Occlusive and Semi occlusive Dressings

Occlusive and semi occlusive dressings provide a good environment for clean, minimally exudative wounds.

These film dressings are waterproof and impervious to microbes, but permeable to water vapor and oxygen.

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Absorbable Materials

Absorbable materials are mainly used within wounds as hemostats and include collagen, gelatin, oxidized cellulose, and oxidized regenerated cellulose.

Medicated Dressings Medicated dressings have long been used as a drug-delivery

system.Agents delivered in the dressings include benzoyl peroxide, zinc

oxide, neomycin, and bacitracin-zinc. These agents have been shown to increase epithelialization by

28%.

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Skin Replacements

All wounds require coverage in order to prevent evaporative losses and infection and to provide an environment that promotes healing.

Both acute and chronic wounds may demand use of skin replacement, and several options are available.Skin grafts have long been used to treat both acute and chronic wounds.

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MANAGING CHRONIC WOUNDS

A chronic ulcer, unresponsive to dressings and simple treatments, should be biopsied to rule out neoplastic change.

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PRESSURE SORESThese can be defined as tissue necrosis with ulceration due to pro-longed pressure. Less preferable terms are bed sores, pressure ulcers and decubitus ulcers. They should be regarded as preventable but occur in approximately 5% of all hospitalised patients.

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Staging of pressure soresStage 1 : Non-blanchable erythema without a breach in the epidermisStage 2 : Partial-thickness skin loss involving the epidermis and dermisStage 3 : Full-thickness skin loss extending into the subcutaneous tissue but not through underlying fasciaStage 4 : Full-thickness skin loss through fascia with extensive tissue destruction, maybe involving muscle, bone, tendon or joint.

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Prevention is obviously the best treatment with good skin care, special pressure dispersion cushions or foams, the use of low air loss and air-fluidised beds and urinary or faecal diversion in selected cases. Pressure sore aware-ness is vital, and the bed-bound patient should be turned at least every 2 hours.

Surgical management of pressure sores follows the same principles involved in acute wound treatment.

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Complications of wound healingI. Early complications

SeromaHematomaWound disruptinSuperficial wound infectionDeep wound infectionMixed wound infection

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Early complications of wound healing

1. Seroma Filled with serous fluid, lymph or blood Fluctuation, swelling, rednessa nd

tenderness.

TREATMENT: Sterile punture and compression Suction drain

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2. HematomaBleeding, short drainage time, anticoagulantRisk of infectionSwelling, fluctuation, pain, redness

TREATMENTSterile punctureSurgical exploration

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Early complications of wound healing

3.) Wound disruptionSurgical errorIncreased intraabdominal pressureWound infection

TREATMENT:U-shaped sutures

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Early complications of wound healing4. Superficial wound infection

1. DiffuseLocated below the skin

TREATMENTResting positionAntibioticDermatological consultation

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2. LocalizedAnywhereTREATMENTSurgical explorationDrainageX-ray examinationEg. abscess

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Early complications of wound healing5.Deep wound infection

1. DiffuseTREATMENTSurgical explorationOpen therapyH2O2 and antibioticse.g. anaerobic necrosis

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2. Localized

Inside the tissues or body cavities

TREATMENTsurgical explorationdrainage

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Early complications of wound healing

6. Mixed wound infectione.g. gangrenenecrotic tissuesanaerobic infectiona severe clinical picture

TREATMENTaggresive surgical debridement effective and specified (antibiotic) therapy

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Complications of wound healingII. Late complications

Hyperthrophic scarKeloid formationNecrosisInflammatory infiltrationAbscessesForeign body containing abscesses

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Late complications

1. Hypertrophic scarDevelop in areas of thick choriumNon-hyalinic collagen fibres and fibroblastsConfine to the incision lineTREATMENTRegress spontaneously(1-2 yrs)

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2. Keloid scarMostly African and Asian populationWell-defined edgeEmerging, tough structureOverproliferation of collagen fibers in the subcutaneous tissueSubjective complainsTREATMENTPostoperative radiationCorticosteroid + local anaesthetic injection

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Referances

Bailey and loves, short practice of surgery, 26th edition.

Schwartzs, principles of surgey, 8th edition.

Surgery lecture note for health officers.

Sabiston, textbook of surgery, 18th edition.

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