WOUND CARE

the primary goal of wound care is not the technical repair of the wound; it is providing optimal conditions for the natural reparative processes of the wound to proceed Richard L. Lammers (Roberts and Hedges)

GOALS of wound care

Facilitate hemostasis Decrease tissue loss Promote wound healing Minimize scar formation

INTRODUCTION

Wound healing : PATHOPHYSIOLOGY

1.) Inflammatory Phase

Initial response (Day 1-4 post injury) rubor, tumor, dolor, calor Platelet aggregation and activation Leukocyte (PMNs, macrophages) migration, phagocytosis and mediator release Venule dilation Exudative a biologic debridement In wounds closed by primary intention, lasts 4 days

 2.) Proliferative Phase Day 4-42 macrophage-released growth factors Fibroblast proliferation Increased rate of collagen synthesis Granulation tissue and neovascularization Gain in tensile strength

 3.) Remodeling Phase 6wks-1 year Intermolecular cross-linking of collagen via vitamin C-dependent hydroxylation Characterized by increase in tensile strength Type III collagen replaced with type I Scar flattens

TYPES of Wound Healing

1.) Healing by first intention (aka. primary wound healing or primary closure) wound closed by approximation of wound margins or by placement of a graft or flap, or wounds created and closed in the operating room. Best choice for wounds in well-vascularized areas Indications -recent (<24h old) -clean -viable tissue -tension-free treated within 24 h, prior to development of granulation tissue. epithelialize within 24 to 48 h. Water barrier function restored can shower or wash.

2.) Healing by second intention (aka. secondary

wound healing or spontaneous healing) wound left open and allowed to close by epithelialization and contraction. Commonly : management of contaminated or infected wounds. without surgical intervention. Unlike primary wounds, approximation of wound margins occurs via reepithelialization and wound contraction by myofibroblasts. Presence of granulation tissue. Complications -late wound contracture -hypertrophic scarring

 3.) Healing by third intention (aka. tertiary wound

healing or delayed primary closure) wounds that are too heavily contaminated for primary closure but appear clean and well vascularized after 4-5 days of open observation. Inflammation reduced bacterial concentration (debribe) allow safe closure. Indications :- infected or unhealthy wounds with high bacterial content, -wounds with a long time lapse since injury, or -wounds with a severe crush component with significant tissue devitalization. Wound edges are approximated within 3-4 days tensile strength develops as with primary closure.

 wound preparation (debridement,cleansing, etc.) dress with saline soaked fine mesh gauze follow up in 72-96 hours for debridement repeat cleansing and closure if no evidence of infection

Factors that affect wound healing

Patient factor :Age Immunocompromising
-DM -renal failure -AIDS -splenectomy Medications systemic steroids/ other immunocompromising drugs increased infection rates Wound Characteristics -Time, Location, Etiology , Mechanism of injury, Laceration width

Factors that affect wound healing

In general, remember DIDN'T HEAL D = Diabetes: -diminishing sensation and arterial inflow ++ acute loss of diabetic control diminished cardiac output, poor peripheral perfusion, and impaired polymorphonuclear leukocyte phagocytosis. I = Infection: -potentiates collagen lysis. Bacterial contamination + susceptible host + wound environment = wound infection. Foreign bodies (including sutures) potentiate wound infection.

DIDNT HEAL
D = Drugs: Steroids and antimetabolites impede proliferation of fibroblasts and collagen synthesis. N = Nutritional problems: Protein-calorie malnutrition and deficiencies of vitamins A, C, and zinc. T = Tissue necrosis, from local or systemic ischemia or radiation injury. Blood supply is important.

DIDNT HEAL
H = Hypoxia: -esp the distal extent of the extremities. Blood volume deficit, unrelieved pain, or hypothermia sympathetic overactivity local vasoconstriction Inadequate tissue oxygenation. E = Excessive tension on wound edges local tissue ischemia and necrosis.

DIDNT HEAL
A = Another wound: Competition for the substrates required for wound healing. L = Low temperature: (relatively) distal aspects of the upper and lower extremities (a reduction of 1-1.5C [2-3F] from normal core body temperature) is responsible for slower healing of wounds at these sites.

Wound Evaluation -HISTORY

identify all extrinsic and intrinsic factors that jeopardize healing and promote infection mechanism of injury time of injury (accelerated growth phase of bacteria starts at 3 hours post wound) environment in which wound occurred
potential contaminants, foreign bodies

species of animal if bite wound pts medical problems (allergies to medication) / immune status tetanus immunization status

history
Immunocompromised Bleeding disorder.Prolonged bleeding-. Hematoma can serve as culture medium for wound infection. Peripheral vascular disease

Mechanism of injury
FORCE
shear

OBJECT
Sharp

DAMAGE
Minimal

WOUND
Linear

compression Blunt Right angle

tensile

Moderate (+) Stellate Jagged

Blunt Moderate (+) Triangular Oblique angle Flap

TYPES of wound
Abrasions Superficial layer of tissue is removed Avulsions A section of tissue is torn off (partially or totally)

Lacerations Tissue is cut or torn. Sharply demarcated borders. Puncture Small opening and of indeterminate depth.

Contusion forceful blow, outer layer of skin intact ; minimal wound care ; evaluate for possible hematoma Combination wound

Wound assessment
Examine for: amount of tissue destruction degree of contamination damage to underlying structures

Body Location Proximity to Other Structures Joints Nerves TendonsVasculature Test integrity of each structure
Assess laxity/muscle and tendon function Assess 2-point discrimination Assess vascular supply

Physical examination
Wound Location importance in the risk of infection high endogenous bacterial counts in hairy scalp, forehead, axilla, groin, foreskin of penis, vagina, mouth, nails wounds in areas of high vascularity more easily resist infection (scalp, face)

WOUND PREPARATION

Wound Preparation - Anesthesia

Topical
Solution or paste LET TAC EMLA

Local
Direct infiltration 1% lidocaine with or without epinephrine Bupivicaine or sensorcaine for longer acting anesthesia

Regional Block
Local infiltration proximally in order to avoid tissue disruption Smaller amount of anesthesia required

Topical anesthesia
Solely / with local infiltration Most effective : face and scalp (high vascularity) LET (lidocaine, epinephrine, tetracaine) TAC (tetracaine, adrenaline/epinephrine, cocaine ) cotton ball soaked with 35ml applied to the open wound for at least 10 minutes

Local anesthetic
Drug Max Dose Onset Duration

Cocaine
Procaine Tetracaine Lidocaine

6.6 mg/kg
10-15 mg/kg 1.5 mg/kg 5 mg/kg

Rapid
Rapid Moderate 5-30 min

1 hour
30min-1hr 2 hours 2 hours

(with Epi)
Bupivacaine

7 mg/kg
2 mg/kg

5-30 min
7-30 min

2-3 hours
> 6 hours

Epinephrine
Vasoconstrictive Increases Duration of Action Promotes Hemostasis Avoid end-arterial blood supply areas May increase pain (low pH)

Local infiltration
reduce the pain of anesthetic infiltration
1. Premedicate the wound with a topical anesthetic (described above) or ice. 2. Buffer anesthetic with sodium bicarbonate (1 ml/ 10 ml ) less painful anesthetic. 3. Needle size : smallest diameter needle. A 30-gauge needle is preferred. 4. Inject slowly (10sec), as pain results when the soft tissue stretches.

Wound Preparation - Hemostasis

Direct PressureUsually best choice Ligatures
Use a tourniquet

Chemicals Epinephrine Gelfoam Oxycel Actifoam Cautery

Wound Preparation Foreign Body Removal

Suspect with point tenderness Visual inspection (to the apex) Imaging
Glass, metal, gravel fragments >1mm should be visible on plain radiographs Organic substances and plastics are usually radiolucent

Always discuss and document possibility of retained foreign body

Hair removal
Shaving Increases risk of infection X 10 ! Clip Hair with Scissors Matt Hair with Ointment

Never shave eyebrows ( may not regrow )

Wound preparation : CLEANING

high pressure irrigation (Normal Saline) min 100-300 ml with continued irrigation at least 8 psi force to the wound the irrigation fluid dislodges foreign bodies, contaminants, and bacteria. A simple device setup 30-60 ml syringe and an 14-gauge angiocatheter.

Wound Preparation Debridement

Removes devitalized tissue Creates sharp wound edge Excision with elliptical shape Respect skin lines

Indications for systemic antibiotic for traumatic wounds

Injury 6 hours old on the extremities Injury 24 hours old on the face and scalp Tendon, joint, or bony involvement Cartilage involvement Mammalian bite Co-morbidity (diabetes mellitus, extremes of age, steroid use, morbid obesity) Puncture wound Complex intraoral wound

Prophylactic Antibiotics
If Prescribed Duration 3 7 days Wound Recheck in 24 48 hours

Wound preparation -Tetanus prophylaxis

Clean wounds
Incompleted immunization toxoid >10 years, then give toxoid

Tetanus prone wound

Incompleted immunization Toxoid & immunoglobulin > 5 years, give toxoid

WOUND CLOSURE
Undermine the wound edges
Release tension

Wound closure in relation to time

Primary closure
Suture, staple, adhesive, or tape Performed on recently sustained lacerations: <12 hours generally and <24 hours on face

Secondary closure
Secondary intent Allowed to granulate

Tertiary closure
Delayed primary (observed for 3-4days)

Suture supply
needle drivers tissue forceps (or skin hook) Scissors sterile drapes sterile gloves suture materials sterile gauze

Suture Material
Absorbable
Chromic catgut ( natural monofilament) Vicryl (synthetic braided) PDS II (synthetic monofilament)

Non-Absorbable
Silk (natural braided) Ethilon (synthetic monofilament)

Monofilament (smooth but stiff) vs. Braided (has interstices = haven for bacteria)

Suture size
Skin Face 5/0 or 6/0 Hands and Limbs 3/0 or 4/0 Elsewhere 2/0 or 3/0

SUTURE TECHNIQUES
Deep layer approximation Absorbable sutures Buried knot Serves two purposes Closes potential spaces Minimizes tension on the wound margins

Skin Closure
Key wound edge eversion Approximate, dont strangulate Anticipate wound edema Choose appropriate size of suture for location of laceration

Suture Techniques
Simple Interrupted Used on majority of wounds Each stitch is independent

Suture Techniques
Simple Continuous
Useful in pediatrics
Rapid Easy removal

Provides effective hemostasis Distributed tension evenly along length Can also be locked with each stitch

Suture Techniques
Horizontal Mattress
Useful for single-layer closure of lacerations under tension

Suture Techniques
Vertical Mattress
Useful for everting skin edges Far-far-near-near

Suture Techniques
Purse-string
Useful for stellate lacerations

Suture Techniques
Instrument tie

Other devices in wound closure

Staples
Quick, poor aesthetic result where scar is less of an issue (hairy scalp)

Adhesives
Dermabond clean, sharp edges, clean nonmobile areas, laceration less than 5 cm in length

Tape
Steri-strips superficial, straight laceration under little tension

After care
Wound Dressings Maintain dry 24 48 hours Augments reepithelialization Water-Tight after 48 hours Bandages Soft-splint Absorb exudates Protects Wound Protects knots

Suture removal guidelines

Anatomic location face arm anterior trunk back feet and hand joint scalp Days (average) 3-5 7 7 10-14 10-14 10-14 10-14

Wounds appropriate for consultation/referral

Primary provider is unable to perform optimal repair Skill level does not match complexity of wound Practice setting is too busy to allow adequate time for repair Underlying injury Tendon ,Nerve, Vascular,Joint involvement or underlying fracture Eyelid: tarsal plate or lacrimal duct involvement

Patient requests specialist Operative repair necessary Skin grafting Flap creation or rotation

References

www.cme-ce-summaries.com/emergency-medicine/em2604.html www.medstudentlc.com www.emedicine.medscape.com www.proceduresconsult.com Essential Practice of Surgery : Basic Science and Clinical Evidence;2003;chapter7;pg77-88;H.Peter Lorenzo, Michael T. Longaker. Robbins Basic Pathology 8th edition;chapter3;pg70-8; Kumar, Abbas, Faustro, Mitchell. Essential Surgery : Problems, Diagnosis & Management ; chapter11;pg14958; H.G. Burkitt,C.R.G. Quick, J.B.Reed. Wound Management ; powerpoint presentation by UNC emergency medicine (Medical Student Lecture Series). Wound Management Principles ; powerpoint presentation by Donald J Sefcik and Nicole Y Ottens, FACOEP. Wound Management 2001 ; powerpoint presentation by Gavin Greenfield and Bob Johnston.

Practice Time!