Wounds and wound process. Treatment of clean wounds. Purulent

wounds. Infected and purulent wounds.

Docent Docent of the Surgery chair of the Surgery chair of the Dentistry departmentof the Dentistry department

Ryziuk M. D.Ryziuk M. D.

Ivano-Frankivsk National Medical UniversityIvano-Frankivsk National Medical University

PLANE OF LECTURE

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1.1. DETERMINATION AND CLINICDETERMINATION AND CLINIC

2.2. HISTORY OF TREATMENT OF WOUNDSHISTORY OF TREATMENT OF WOUNDS. .

3.3. CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

4.4. PATHOGENESIS OF THE WOUNDSPATHOGENESIS OF THE WOUNDS

5.5. TREATMENT OF WOUNDSTREATMENT OF WOUNDS

ACTUALITY OF THEMEACTUALITY OF THEME

Physiology of Wound Healing

Blood leaksBlood leaksWounWound d

occursoccursSTOPSTOP EpithelialEpithelial

cellscells

Scab Scab causes causes

obstructionobstruction

Thickening and returnThickening and return to normal stateto normal state

DETERMINATION AND CLINICDETERMINATION AND CLINICWOUND (WOUND (Vulnea)Vulnea) is the damage of integrity of skin or is the damage of integrity of skin or

mucus membrane,deep tissues and the inner organs.mucus membrane,deep tissues and the inner organs.Symptoms of wound Symptoms of wound (local):(local):

• bleeding;bleeding;• hiatus;hiatus;• pain.pain.

HISTORY OF TREATMENT OF WOUNDSHISTORY OF TREATMENT OF WOUNDS

HipokratHipokrat

M.I. PirogovM.I. Pirogov Ambruas PareAmbruas Pare

History of Wounds

• Herbal balms and ointments• Initially, wounds were left open• Oldest suture 1100BC• Primary and secondary closure 2000 yrs

ago• Middle ages: pus thought necessary• Recent wound closure less that 200 yrs old

HISTORY OF TREATMENT OF WOUNDSHISTORY OF TREATMENT OF WOUNDS

Classification of wounds

І. І. According to the characterAccording to the character Різані рани (Різані рани (vulnus incisium)vulnus incisium);; Рубані раниРубані рани (vulnus caesum) (vulnus caesum);; Колоті раниКолоті рани (vulnus punctum) (vulnus punctum);; Забійні раниЗабійні рани (vulnus contusum) (vulnus contusum);; Рвані раниРвані рани (vulnus laceratum) (vulnus laceratum);; Розчавлені Розчавлені (vulnus conquassatum)(vulnus conquassatum);; Укушені раниУкушені рани (vulnus morsum) (vulnus morsum);; Отруєні раниОтруєні рани (vulnus venenatum) (vulnus venenatum);; Вогнепальні Вогнепальні (vulnus(vulnus sclopetarium)sclopetarium);; Зсаднені рані Зсаднені рані ((vulnus excoriatum)vulnus excoriatum);; Царапині рани Царапині рани (vulnus scarificatum)(vulnus scarificatum);; Змішані раниЗмішані рани (vulnus mixtum) (vulnus mixtum)..

In according to the damage of tissues the wounds are In according to the damage of tissues the wounds are distinguished:distinguished:

Cut wound – incisumCut wound – incisum

CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

Incision

CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

- Stab wound – punctum- Stab wound – punctum

- - Sabre or slash wound – caecumSabre or slash wound – caecum

Puncture Wounds

CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

- Lacerated wound – laceratumLacerated wound – laceratum

- Contused wound – contusumContused wound – contusum

Laceration

Degloving injury

CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

- - Scalped woundScalped wound

Avulsion

Avulsion

Avulsion (complete/amputation)

Avulsion Treatment

• Control bleeding• Clean and dress• Seek physician evaluation• Watch for infection• If complete avulsion (amputation), take avulsed

tissue to physician for reattachment!

Care of the avulsed tissue

• Wrap tissue in clean cloth

• Put wrapped tissue in plastic bag

• Put plastic bag in a bag of ice

Crushed wound – conqvassatumCrushed wound – conqvassatum

CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

Crush injury

CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

-Excoriation wound – excoriatumExcoriation wound – excoriatum

- - Scratch wound – scarificatumScratch wound – scarificatum

Abrasion

Scrapes

-Bite wound – morsumBite wound – morsum

- - Poisoned wound – venenatumPoisoned wound – venenatum

CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

Gunshot wound – sclopetariumGunshot wound – sclopetarium

CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

In according to depth of the wounds they are In according to depth of the wounds they are distinguished:distinguished:- superficial wounds;superficial wounds;- deep wounds.deep wounds. In relation to cavities of body the woundsIn relation to cavities of body the wounds are are distinguished:distinguished: - - unpenetrable;unpenetrable; - - penetrable.penetrable.In according toIn according to reason the woundsreason the wounds areare distinguish:distinguish:- operative woundsoperative wounds;;- accidental woundsaccidental wounds..

In relation to the bodily cavities:In relation to the bodily cavities:

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penetrativepenetrativedo not penetrativedo not penetrative

CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

According to the level of According to the level of infection :infection :

- clean (aseptic) wounds;clean (aseptic) wounds;

- conditionally clean wounds;conditionally clean wounds;

- muddy (contaminated) muddy (contaminated) wounds;wounds;

- infected wounds;infected wounds;

- purulent wounds.purulent wounds.

Classification of wounds

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Depending on the cause:

surgical, or asepticsurgical, or aseptic accidental, or casualaccidental, or casual

CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

According to the origin wounds are distinguished:According to the origin wounds are distinguished:

-- fresh woundsfresh wounds ( (from 1 till 24 hourfrom 1 till 24 hour););

- later woundslater wounds ( (after 24 hour)after 24 hour)According to the method of healing of the wounds According to the method of healing of the wounds

they arethey are::

- - primary tensionprimary tension (per primum)(per primum);;

- secondary tensionsecondary tension (per secundam);(per secundam);

- reparation under the crust.reparation under the crust.

Superficial Wounds

• Involve epidermis only

• No breach of basement membrane

• No bleeding• Can be painful• Ex- sunburn, “rug

burn”

Arterial Wounds

• Inadequate arterial flow– Tissue lacks nutrients

and oxygen to maintain• Causes: peripheral

vascular disease, diabetes, embolism

• Often located on tips of toes and fingers

Venous Wounds

• Inadequate venous drainage

• Causes: vein valve disfunction, post vein removal, DVT, vein dilation

• Often located LE, above ankle

• Weepy wound

Pressure Wounds

• Aka- “bedsore”• Excessive or

unrelieved pressure• Often over bony

prominences• Impaired mobility

Neuropathic Wounds

• Wound develops in area with impaired sensation

• Commonly on foot• Often patients with

diabetes, s/p chemothepy, neurodegenerative diseases, nerve compression

• Often lead to amputation

Acute Surgical Wounds

• Often sutured or stapled and heals quickly

• Left open due to swelling

• Infection, poor nutrition can lead to chronic wound

Atypical Wounds

• Dermal disease– dermatitis, pemphigus, autoimmune, fungal

infection• Trauma• Malignancy• Necrotizing fasciitis

PATHOGENESIS OF THE WOUNDSPATHOGENESIS OF THE WOUNDSWOUND PROCESSWOUND PROCESS – – it is a large complex of the it is a large complex of the

biological reactions which develops as a result of the biological reactions which develops as a result of the

damage of the tissues and will be finishing of its healing damage of the tissues and will be finishing of its healing

as a rule.as a rule.

The first phaseThe first phase – – INFLAMMATIONINFLAMMATION ( (ALTERATIONALTERATION, ,

HYDRATIONHYDRATION, , CLEARNINGCLEARNING)) – – 1-5 DAY1-5 DAY

The second phaseThe second phase– – PROLIFFERATION PROLIFFERATION ((DEHYDRATIONDEHYDRATION,,

REGENERATIONREGENERATION, , GRANULATIONGRANULATION)) – – 6-14 DAY6-14 DAY

The third phaseThe third phase – – FORMATION AND REORGANIZATION FORMATION AND REORGANIZATION

OF THE SCAR –OF THE SCAR –15 DAY – 6 MONTH15 DAY – 6 MONTH

PHASE OF INFLAMMATIONPHASE OF INFLAMMATION

- duration 1-4 days - duration 1-4 days

(depending on a trauma);(depending on a trauma);

- destroying of tissues;- destroying of tissues;

- spasm of vessels;- spasm of vessels;

- swelling;- swelling;

- hypoxia and acidosis;- hypoxia and acidosis;

- infection;- infection;

- cleaning from dead tissues - cleaning from dead tissues

(enzymes).(enzymes).

PHASE OF REGENERATIONPHASE OF REGENERATION

- lasts from 3-4 days lasts from 3-4 days tilltill ................

- decrease of the swellingdecrease of the swelling;;

- decrease of the decrease of the inflammationinflammation;;

- normalization of normalization of рН;рН;

- decrease of the secrete decrease of the secrete from the woundfrom the wound;;

- wound process fills by wound process fills by granulative tissuegranulative tissue..

GRANULATTIVE TISSUEGRANULATTIVE TISSUE

GRANULATION GRANULATION - this is the special - this is the special kind of connective tissue, which forms kind of connective tissue, which forms only during heal of the wound by only during heal of the wound by second tension and has 6 layers:second tension and has 6 layers:1. 1. Superficial leukocytic-necrotic Superficial leukocytic-necrotic layers.layers. 2. 2. Layer of the band vesselsLayer of the band vessels. . 3. 3. Layer of the vertical vesselsLayer of the vertical vessels. . 4. 4. Mature layer of fibroblastsMature layer of fibroblasts. . 5. 5. Layer of Layer of horizontal horizontal fibroblasts.fibroblasts. 6. 6. Fibrous layerFibrous layer..

PHASE OF FORMATION AND PHASE OF FORMATION AND REORGANIZATION OF THE STICHREORGANIZATION OF THE STICH

- beginsbegins inin 2-4 2-4 weeksweeks and and

goes on tillgoes on till 6 6 monsmons;;

- active forms of the active forms of the

collagen and elastic collagen and elastic

fibersfibers;;

- take place the process of take place the process of

the epithelization.the epithelization.

PHASE OF FORMATION AND PHASE OF FORMATION AND REORGANIZATION OF THE STITCHREORGANIZATION OF THE STITCH

PHASE OF FORMATION AND PHASE OF FORMATION AND REORGANIZATION OF THE STITCHREORGANIZATION OF THE STITCH

TYPES OF REPARATIONTYPES OF REPARATION

REPARATION BY REPARATION BY PRIMARY PRIMARY TENSIONTENSION

TYPES OF REPARATIONTYPES OF REPARATION

REPARATION BY REPARATION BY SECONDARY SECONDARY

TENSIONTENSION

TYPES OF REPARATIONTYPES OF REPARATION

REPARATION REPARATION UNDER THE UNDER THE

CRUSTCRUST

Acute Wound Healing

Hemostasis/Coagulation

• Goals:– Control bleeding

• Clotting cascade– Begins immediately upon injury– Activate platelets

Hemostasis/CoagulationCellular component

• The Platelet– Activates to form

fibrin clot– Stems blood flow– Release cytokines

• PDGF• TGF-ß• EGF

Hemostasis/CoagulationCytokines

• Platelet derived growth factor (PDGF)– Directs collagen

expression– Released with platelet

activation– Neutrophil, macrophage

chemotaxis

• TGF-ß– Directs collagen

expression

Inflammatory Phase

• 0-3 days• Begins with clotting cascade and platelets• Characterized by:

– Rubor (redness)– Turgor (swelling)– Calor (heat– Dolar (pain)

Inflammatory Phase

• Goals:– Destroy pathogens

• White blood cells– Clean wound site

• Breakdown cellular and extracellular debris– Signal cells of repair

• Cytokines, growth factors,

Inflammatory PhaseCellular Component

• Neutrophils– Migrate into wound within 24

hours• Initially largest proportion of

WBCs– Remain 6 hours to 4 days– Called to wound by presence of

fibrinogen, fibrin degradation products

– Move into wound from vasculature by diapedesis

Inflammatory PhaseCellular Component

• Macrophages– Most active in late

inflammatory phase– Main regulatory cell of

inflammation– Remain through

proliferative and remodeling phases

Inflammatory PhaseCellular Component

• Macrophages– Phagocytize bacteria and exogenous debris– Secrete collagenases to remove damaged

extracellular matrix– Release nitric oxide to kill bacteria– Release fibronectin to recruit fibroblasts– Can stimulate angiogenesis

Inflammatory PhaseMolecular Component

• Compliment– Immunology course– Bacterial destruction

• Opsization• Bacterial lysis

– Chemotactic factors• Phagocytic cells, neutrophils, macrophages

Inflammatory PhaseMolecular ComponentMacrophage Derived

• PDGF• TNF-

ProinflammatoryInduce MMPs

• IL-1– Proinflammatory– Stimulates NO synthesis– Amplifies inflammatory

response

– IL-6• Proinflammatory

– G-CSF• proinflammatory

– CM-CSF• ECM degradation

Proliferative Phase

• Overlaps inflammatory phase

• Begins 3-5 days post injury

• Length of phase dictated by wound size (~3 weeks for closed surgical wounds)

• Includes angiogenesis, re-epithelialization, fibroplasia

Proliferative PhaseAngiogenesis

• Neovascularization• Granulation tissue

– Buds of new capillaries• Does not occur if

ECM absent• Stimulated by FGF,

VEGF, TGF-ß, EGF, wound angiogenesis factor

Proliferative PhaseMatrix Formation

• Aka- fibroplasia• Begins 48-72 hours post injury• Fibroblasts secrete collagen (type III) and

ground substance • Maximally secretes for 5-7 days• Forms scaffold for endothelial migration• Binds cytokines, growth factors

Wound Extracellular Matrix• Composed of collagen

and ground substance• Produced by

fibroblasts• Provide structure for

cells and tissues• Bind growth factors,

helps create gradient

Ground Substance

• Amorphous viscous gel produced by fibroblasts• Comprised of glycosaminoglycans (GAGs) and

proteoglycans• Occupies space between cells and fibers• Allows medium for diffusion of nutrients and

wastes

Ground Substance• Major GAGs- hyularonic acid, chondroitin

sulfate• Composition varies by age and location

– Decreased water with age– GAGs increased in wounds, weight bearing

surfaces

Collagen and Wounds

• Normal surgical wound has 15% tensile strength of non-injured tissue after 3 weeks.

• Increases to 70-80% in two years• Wound recurrence: gravity, swelling, poor closure

Proliferative PhaseRe-epithelialization

• Resurfaces wound• Restores integrity of epithelium• Keratinocytes migrate into and proliferate

over wound bed– Inhibited by scabs

• REQUIRES basement membrane

Proliferative PhaseRe-epithelialization

• Begins within 24 hours of injury• Closed surgical wounds complete in 48-72

hours• New skin tensile strength ~15% of original

skin• After remodelling tensile strength only 70-

80%

Remodeling Phase

• Begins during proliferative phase• Continues 1-2 years post injury• Scar tissue/ECM remodeled• Increases tensile strength of scar

– Type III collagen replaced by type I

TREATMENT OF WOUNDSTREATMENT OF WOUNDS

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

PRIMARY SURGICAL TREATMENT OF THE PRIMARY SURGICAL TREATMENT OF THE WOUNDWOUND is the first surgical operation, provided is the first surgical operation, provided

in aseptic conditions, with anesthesia, which in aseptic conditions, with anesthesia, which contains the following stages.contains the following stages.

THE MAIN STAGESTHE MAIN STAGES::1.1. Disinfection of the operative field.Disinfection of the operative field.2.2. AnesthesiaAnesthesia..3.3. Cutting of the wound.Cutting of the wound.4.4. Revision of the wound channel.Revision of the wound channel.5.5. Removing of the margins, walls and bottom of the Removing of the margins, walls and bottom of the

wound.wound.6.6. Hemostasis.Hemostasis.7.7. Rehabilitation of injured organs and structures.Rehabilitation of injured organs and structures.8.8. Applying of stitches on the wound with leaving ofApplying of stitches on the wound with leaving of drainages (according to indications)drainages (according to indications)

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

Full and partial treatment of the Full and partial treatment of the woundwound..

Primary and secondary treatment of Primary and secondary treatment of the woundthe wound..

Early, delayed and later treatment of Early, delayed and later treatment of the woundthe wound. .

Wound Preparation

• Removal of hair

– Not eyebrow

• Scrubbing the wound

• Irrigation with saline

– Avoid peroxide,

betadine, tissue toxic

detergents

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

Cutting of the wound and removing of Cutting of the wound and removing of margins, walls and bottom of the woundmargins, walls and bottom of the wound..

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

CUTTING OF APONEVROSISCUTTING OF APONEVROSIS

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

REMOVING OF THE NECROTIC TISSUESREMOVING OF THE NECROTIC TISSUES

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

REVISION OF ZONE OF SPEADING OF WOUND CHANNEL REVISION OF ZONE OF SPEADING OF WOUND CHANNEL AND CHARACTER OF INJURYAND CHARACTER OF INJURY

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

WASHING OF THE WOUNDWASHING OF THE WOUND

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

DRAINAGES OF THE WOUNDDRAINAGES OF THE WOUND

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

PASSIVE DRAINAGE OF THE WOUNDPASSIVE DRAINAGE OF THE WOUND

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

ACTIVE DRAINAGE OF THE WOUNDACTIVE DRAINAGE OF THE WOUND

REDONS SET OF REDONS SET OF DRAINAGINGDRAINAGING

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

WASHING DRAINAGES OF THE WOUNDWASHING DRAINAGES OF THE WOUND

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

SEWING OF THE WOUNDSEWING OF THE WOUND

PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

ACCORDING TO THE TIME OF APPLYING OF THE STITCHES:ACCORDING TO THE TIME OF APPLYING OF THE STITCHES:

1.1. PrimarilyPrimarily..

2.2. Primarily delayedPrimarily delayed..

3.3. Early secondaryEarly secondary..4.4. late secondarylate secondary..

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PRIMARY SURGICAL TREATMENT OF PRIMARY SURGICAL TREATMENT OF THE WOUNDTHE WOUND

SEWING OF THE WOUNDSEWING OF THE WOUND

SURGICAL TREATMENT OF THE SURGICAL TREATMENT OF THE PURULENT WOUNDPURULENT WOUND

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Ideal Wound Closure

• Allow for meticulous wound closure• Easily and readily applied• Painless• low risk to provider• Inexpensive• Minimal scarring• Low infection rate

Sutures

• Non-absorbable sutures– Tinsel strength 60 days– Non-reactive– Outermost closure

Sutures• Absorbable sutures

– Synthetic > natural– Synthetic increases wound

tinsel strength– Deeper layers– Avoid in highly

contaminated wounds– Avoid in adipose tissue– Synthetic & monofilament

> natural & braided

Staples

• More rapidly placed• Less foreign body

reaction• Scalp, trunk,

extremities• Do not allow for

meticulous closure

Adhesive Tapes

• Less reactive than staples

• Use of tissue adhesive adjunct (benzoin)

• Poor outcome in areas of tension

• Seldom used for primary closure

• Use after suture removal

Tissue Adhesives• Dermabond, Ethicon• Topical use only• Outcome equal to 5-0

and 6-0 facial repairs• Less pain and time• Slough off in 7-10 days• Act as own dressing• No antibiotic ointment

Post-procedural Care• Dressing for 24-48 hours• Topical antibiotics• Start cleansing in 24 hours• Suture/staple removal

– Face 3-5 days– Non-tension areas 7-10 days– Tension areas 10-14 days

Choosing Your Suture

• 6-0– Face

• 5-0– Chin– Low tension/detail

• 4-0– Large laceration– Moderate tension

• 3-0– Significant tension

The Interrupted Stitch

The Interrupted Stitch

• Instrumentation– Hemostat– Scissors– Forceps with teeth– Plain forceps– Control syringe– Tub for saline– Gauze– Sterile towels– Syringe and splash shield

Anesthesia of the Laceration

• Lidocaine with/out epi, marcaine• TAC• Local vs regional• Mechanisms to reduce pain

The Interrupted Stitch• Finger tip grip• Palm grip• Grip needle one-third of way from thread

The Interrupted Stitch• Curl needle into dermis of 1st side

The Interrupted Stitch• Curl needle into dermis of 1st side• Curl needle trough parallel opposite subcutaneous side

The Interrupted Stitch• Curl needle into dermis of

1st side• Curl needle trough parallel

opposite subcutaneous side• Tie square knot with at least

two braids

The Interrupted Stitch

• Curl needle into dermis of 1st side

• Curl needle trough parallel opposite subcutaneous side

• Tie square knot with at least two braids

• Repeat three to four throws

Points to Remember

• Specific points affecting wound healing

• Evaluation of laceration and neurovascular assessment

• Types of sutures• Staples• Adhesive tapes• Tissue adhesives

Points to Remember

• Advantages vs disadvantages• Post procedure care• Choosing your suture• Instruments• Be able to perform interrupted

suture for lab final

Suture PatternsInterrupted

– simple– horizontal mattress– vertical mattress

Running (continuous)– simple– subcuticular

Simple Interrupted

Simple Interrupted

Horizontal Mattress

Vertical Mattress

Simple Continuous

Simple Subcuticular

Corner/flap

PRINCIPELS OF THE LOCAL PRINCIPELS OF THE LOCAL TREATMENT OF THE WOUNDTREATMENT OF THE WOUND

1.1. During the first phase of the wound processDuring the first phase of the wound process::

- - immobilization of the woundimmobilization of the wound; ; - - use of the proteolytic fermentsuse of the proteolytic ferments; ; - - use of antisepsis use of antisepsis solutionssolutions..

2.2. During the second phase of the wound processDuring the second phase of the wound process ::

- - treatment bandagingtreatment bandaging;;

- - stimulation of the grows of granulative tissuesstimulation of the grows of granulative tissues;;

- - the bandages are conducted rarelythe bandages are conducted rarely. .

USE OF PROTEOLYTIC FERMENTS USE OF PROTEOLYTIC FERMENTS FOR THE TREATMENT OF THE FOR THE TREATMENT OF THE

WOUNDWOUND

Before Before treatmenttreatment

One week after One week after beginning of the beginning of the

treatmenttreatment

PRINCIPELS OF THE GENERAL PRINCIPELS OF THE GENERAL TREATMENT OF THE WOUNDTREATMENT OF THE WOUND

1.1. Antibacterial therapyAntibacterial therapy..

2.2. Desintoxication therapyDesintoxication therapy..

3.3. Immune correcting therapyImmune correcting therapy..

4.4. Correction of the haemostasisCorrection of the haemostasis..

5.5. AnalgeticsAnalgetics..

Moist Wound Healing

• DRY IS DEAD!

• Moist environment allows:– Cell function– Diffusion of chemical factors– Migration of cells– Autolytic debridement

Moist Wound HealingDressings

• Gauze is bad

• Absorb or give moisture

• Antimicrobial• Conform to wound• Limit dressing

changes

Chronic Wounds

• Wound “fails to proceed through an orderly and timely process to produce anatomic and functional integrity, or proceeded through the repair process without establishing a sustained anatomic and functional result”

• No definitive amount of time to be considered chronic

Chronic Wounds

• Wound gets “stuck” in one phase of healing• Causes can be intrinsic, extrinsic or iatrogenic

Chronic WoundsIntrinsic causes

• Age• Chronic disease• Perfusion/oxygenation• Immunosuppression• Neurologic impairments

Chronic WoundsExtrinsic causes

• Medication• Nutrition• Irration/chemotherapy• Psychophysiologic stress• Wound bioburden

Chronic WoundsIatrogeneic causes

• Local ischemia• Poor wound care• Trauma• Wound extent• Wound duration

Ischemic arterial ulcers

• Poor blood supply• Painful, usually distal• Shallow wound, • smooth margins, pale• S/Sx of PVD: intermittent claudication, rest

pain, color changes, ↓ pulses, ABI < 1, dry skin, pallor, hair loss

• Tx: revascularization, wound care

Venous stasis ulcers

• Incompetence of the deep vein perforators

• capillary leakage- polymerization of fibrin impairs oxygenation

• Painless, shallow ulcer with irregular margins, possible skin pigmentation (hemoglobin extravasation and breakdown)

• Tx: compression therapy (rigid or flexible)

Diabetic ulcers• 10-15% of DM pts develop ulcers• Causes: ischemia, neuropathy

(unrecognized injury,Charcot foot)• Poor healing• Tx: Tight blood glc control, abx, wide

debridement of necrotic/ infected tissue, relief of pressure via orthotics/casts, potentially: topical PDGF and GM-CSF, skin grafts

Decubitus/pressure ulcers• Localized tissue necrosis from

compression over a bony prominence, ↓ nutrients/O2

• ↑ by friction, moisture• 3-9% acute care, 2.4-23% in long-term

care facilities• Tx: debridement of all necrotic tissue,

relief of pressure, wound care (moist environ), surgical flap repair, nutrition

• 4 stages:– I. Non blanchable erythema, intact skin– II. Partial thickness skin loss of

epidermis/dermis– III. Full thickness skin loss, above

fascia– IV. Full thickness, involves muscle or

bone

Excess Dermal Scarring• Occur after trauma, may burn or be pruritic• Xs of collagen/glycoprotein deposition

• Hypertropic scars– Usu develop within 4 wks of trauma– Collagen bundles are wavy pattern– Stay within the original wound, elevated < 4mm– Occur across areas of tension/flexing– Often regress – Tx: excision + corticosteroids

• Keloids– 15x more common in pts with darker skin

pigmentation– Develop 3mos-years after trauma– Collagen fibers are larger, random/ not bundled– Expand beyond wound edges, can become large– Rarely regress– Excision alone (45-100% recurrence). Corticosteroids

then Excision + corticosteroid injections, topical silicone, external compression, xrt, IFN-γ, 5-FU, bleomycin

Dressings• Mimics epithelial barrier, protection of site• Compression provides hemostasis, decreases

edema• Occlusion controls hydration and allows for

oxygenation/gaseous diffusion• Occlusion stimulates collagen synth and epith cell

migration• Primary- directly on wound• Secondary- placed on a primary dressing

Skin Grafts• Split/partial thickness graft = epidermis + partial dermis

– Require less vascular supply• Full thickness = entire epidermis and dermis

– Greater mechanical strength, increased resistance to wound contraction, improved cosmesis

• Autograft – transplant from another site• Allograft – transplant from a living nonidentical donor or cadaver

– Subject to rejection, may contain pathogens• Xenograft – from another species

– Subject to rejection, may contain pathogens• Preparation of wound bed – debridement of necrotic/fibrinous

tissue, control of edema, minimizing exudate, revascularization of wound bed, ↓ bacterial load

Hydrocolloid : Indication

• For low to moderate exuding wounds• For clean, granulating, superficial

wounds• With safe surrounding skin

Hydrocolloids : Advantage• Require changing only every 3 -

7 days• Provide effective occlusion and

barrier (prevent the spread of Infection

• Cost effective • More effective than traditional

dressings

1 week1 week

21 days

Diabetic ulcer for 5 month

Hydrocolloid

loids

Hydrocolloid

Absorption base Absorption base dressingdressing

AlginateAlginate

HydrofibreHydrofibre

Moist woundMoist wound healinghealing

Alginate : Indication• For moderate to heavily exudating

wounds• Help to debride (in addition with

mechanical debridement)

Alginate : Indication

•For moderate to heavily exudating wounds

• Help to debride (in addition with mechanical debridement

Hydrofibre : Aquacel• CMC fiber : gel formation• Same indications than

alginate• Non haemostatic

• For light to medium exuding wounds

• Granulating and epithelializating wounds

Foam dressing : Indication

For Cavity Wounds

Cavity Wounds(Healthy Granulation )

Silver DressingSilver Dressing

•SilverceSilvercell (Alginate+sliver) (Alginate+sliver)

•AquacelAquacel((Ag(hydrofibre+silvAg(hydrofibre+silver)er)

•ActicoatActicoat (Nanocrystalline (Nanocrystalline silver-based dressing)silver-based dressing)

Promogran™

• Growth factors protection

• Binding and inactivating proteases in excess

Promogran

Protease

Growth Factors

inactive

Post traumatic chronic ulcer

SKIN COVER:

The best dressing is the patients skin whether the wound be closed directly, or by skin graft or skin flap. Early cover means early healing and potential avoidance of infection and bad scarring

PLASTIK REPLACEMENT OF SKINPLASTIK REPLACEMENT OF SKIN

EASY CLOSURE WITHOUT TENSION:

Be aware of closing wounds under tension, the wound edges may slough, the wound may dehisce, and there is the potential for a bad scar (either hypertrophic, keloidal or stretched). Sometimes a flap or a graft may be required to reduce the tension in a wound.

Wound classification

• Aetiology is therefore important in your understanding of how a wound arose and what structures may also be damaged or require attention

• Although there are many causes of wounds, in practise, as part of your assessment prior to definite management, you will need to categorise a wound into “tidy” or “untidy”

Practical Classification of Wounds:

• TIDY • UNTIDY

Tidy wounds:

• Clean incision• Uncontaminated• Less than 6 hours old• Low energy trauma

Tidy wounds:

• Can be repaired immediately after adequate wound exploration , cleansing and haemostasis

• Are associated with a low incidence of wound infection post repair

Untidy wounds:

• Ragged edge,crush or burn• Contaminated• More than 12 hours old• High energy trauma

Untidy wounds:

• Need to be converted into tidy wounds• May require repeated debridements until

tissue viability is ensured• Never close an untidy wound unless it has

been made tidy• If in doubt, it is safer to leave the wound

unrepared (but not undebrided!) and reinspected at 48 hour intervals

Evacuate haematoma and obtain haemostasis

ANTIBIOTIC and ANTITETANUS

COVER

NECROTIC TISSUE REMOVED

DRAINS and

DEAD -SPACE OBLITERATION

Dead space will fill up with blood or serous fluid which is an ideal culture medium. Obliterate this dead space by drainage, suture or by healthy tissue.

Closure of Tidy Wounds:

• Tidy wounds should be closed primarily• All damaged structures should be repaired• Sutures are to oppose NOT necrose• Use monofilament materials

Closure of Untidy Wounds

• Only close primarily if can be converted to a tidy wound

• Doubtful tissue must be meticulously but ruthlessly excised

• Copious Levage “Dilution is the solution to pollution”

• If in doubt, don’t close• 48 hourly “second looks”

THE COMPLICATIONS AFTER LOCAL THE COMPLICATIONS AFTER LOCAL TREATMENT OF THE WOUNDTREATMENT OF THE WOUND

1.1. Development of the Development of the inflammatory infiltrateinflammatory infiltrate..

2.2. HaematomaHaematoma..

3.3. PusingPusing..

4.4. Marginal necrosisMarginal necrosis..

5.5. Kelloid and hypertrophical Kelloid and hypertrophical rupturesruptures..

6.6. Destroy the innervations Destroy the innervations and lymphodranages of and lymphodranages of the woundthe wound..

Practice Time!

•

Thank you for attention !Thank you for attention !Ivano-Frankivsk National Medical UniversityIvano-Frankivsk National Medical University