Wounds and wound process.
Treatment of clean wounds. Purulent
wounds. Infected and purulent
wounds.
Docent of the Surgery chair
of the Dentistry department
Ryziuk M. D.
Ivano-Frankivsk National Medical University
PLANE
OF LECTURE
1. DETERMINATION AND CLINIC
2. HISTORY OF TREATMENT OF WOUNDS.
3. CLASSIFICATION OF THE WOUNDS
4. PATHOGENESIS OF THE WOUNDS
5. TREATMENT OF WOUNDS
Ivano-Frankivsk National Medical University
ACTUALITY OF THEME
Physiology of Wound Healing
Woun
Woun
dd
occurs
occurs
Blood leaks
Thickening and return
to normal state
STOP
Epithelial
cells
Scab
Scab
causes
causes
obstruction
obstruction
DETERMINATION AND CLINIC
WOUND ( Vulnea) is the damage of integrity of skin
or mucus membrane,deep tissues and the inner
organs.
Symptoms of wound (local):
• bleeding;
• hiatus;
• pain.
HISTORY OF TREATMENT OF WOUNDS
Hipokrat
M.I. Pirogov
Ambruas 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 WOUNDS
Classification of wounds
І. According to the character
 Різані рани (vulnus incisium);
 Рубані рани (vulnus caesum);
 Колоті рани (vulnus punctum);
 Забійні рани (vulnus contusum);
 Рвані рани (vulnus laceratum);
 Розчавлені (vulnus conquassatum);
 Укушені рани (vulnus morsum);
 Отруєні рани (vulnus venenatum);
 Вогнепальні (vulnus sclopetarium);
 Зсаднені рані (vulnus excoriatum);
 Царапині рани (vulnus scarificatum);
 Змішані рани (vulnus mixtum).
CLASSIFICATION OF THE WOUNDS
In according to the damage of tissues the wounds are
distinguished:
Cut wound – incisum
Incision
CLASSIFICATION OF THE WOUNDS
- Stab wound – punctum
- Sabre or slash wound – caecum
Puncture Wounds
CLASSIFICATION OF THE WOUNDS
-
Lacerated wound – laceratum
-
Contused wound – contusum
Laceration
Degloving injury
CLASSIFICATION OF THE WOUNDS
- Scalped 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
CLASSIFICATION OF THE WOUNDS
Crushed wound – conqvassatum
Crush injury
CLASSIFICATION OF THE WOUNDS
-Excoriation wound – excoriatum
- Scratch wound – scarificatum
Abrasion
Scrapes
CLASSIFICATION OF THE WOUNDS
-Bite wound – morsum
- Poisoned wound – venenatum
CLASSIFICATION OF THE WOUNDS
Gunshot wound – sclopetarium
CLASSIFICATION OF THE WOUNDS
In according to depth of the wounds they are
distinguished:
- superficial wounds;
- deep wounds.
In relation to cavities of body the wounds are
distinguished:
- unpenetrable;
- penetrable.
In according to reason the wounds are distinguish:
- operative wounds;
- accidental wounds.
In relation to the bodily cavities:
do not penetrative
penetrative
Ivano-Frankivsk National Medical University
CLASSIFICATION OF THE WOUNDS
According to the level of
infection :
-
clean (aseptic) wounds;
- conditionally clean wounds;
- muddy (contaminated)
wounds;
- infected wounds;
- purulent wounds.
Classification of wounds
Depending on the cause:
surgical, or aseptic
accidental, or casual
Ivano-Frankivsk National Medical University
CLASSIFICATION OF THE WOUNDS
According to the origin wounds are distinguished:
- fresh wounds (from 1 till 24 hour);
- later wounds (after 24 hour)
According to the method of healing of the wounds
they are:
- primary tension (per primum);
- secondary tension (per secundam);
- 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 WOUNDS
WOUND PROCESS – it is a large complex of the
biological reactions which develops as a result of the
damage of the tissues and will be finishing of its healing
as a rule.
The first phase – INFLAMMATION (ALTERATION,
HYDRATION, CLEARNING) – 1-5 DAY
The second phase– PROLIFFERATION (DEHYDRATION,
REGENERATION, GRANULATION) – 6-14 DAY
The third phase – FORMATION AND REORGANIZATION
OF THE SCAR –15 DAY – 6 MONTH
PHASE OF INFLAMMATION
- duration 1-4 days
(depending on a trauma);
- destroying of tissues;
- spasm of vessels;
- swelling;
- hypoxia and acidosis;
- infection;
- cleaning from dead tissues
(enzymes).
PHASE OF REGENERATION
- lasts from 3-4 days
till ........
- decrease of the swelling;
- decrease of the
inflammation;
- normalization of рН;
- decrease of the secrete
from the wound;
- wound process fills by
granulative tissue.
GRANULATTIVE TISSUE
GRANULATION - this is the
special kind of connective tissue,
which forms only during heal of the
wound by second tension and has 6
layers:
1. Superficial leukocytic-necrotic
layers.
2. Layer of the band vessels.
3. Layer of the vertical vessels.
4. Mature layer of fibroblasts.
5. Layer of horizontal fibroblasts.
6. Fibrous layer.
PHASE OF FORMATION AND
REORGANIZATION OF THE STICH
-
begins in 2-4 weeks and
goes on till 6 mons;
- active forms of the
collagen and elastic
fibers;
- take place the process of
the epithelization.
PHASE OF FORMATION AND
REORGANIZATION OF THE STITCH
PHASE OF FORMATION AND
REORGANIZATION OF THE STITCH
TYPES OF REPARATION
REPARATION
BY PRIMARY
TENSION
TYPES OF REPARATION
REPARATION
BY
SECONDARY
TENSION
TYPES OF REPARATION
REPARATION
UNDER THE
CRUST
Acute Wound Healing
Hemostasis/Coagulation
• Goals:
– Control bleeding
• Clotting cascade
– Begins immediately upon injury
– Activate platelets
Hemostasis/Coagulation
Cellular component
• The Platelet
– Activates to form
fibrin clot
– Stems blood flow
– Release cytokines
• PDGF
• TGF-ß
• EGF
Hemostasis/Coagulation
Cytokines
• 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 Phase
Cellular 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 Phase
Cellular Component
• Macrophages
– Most active in late
inflammatory phase
– Main regulatory cell of
inflammation
– Remain through
proliferative and
remodeling phases
Inflammatory Phase
Cellular 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 Phase
Molecular Component
• Compliment
– Immunology course
– Bacterial destruction
• Opsization
• Bacterial lysis
– Chemotactic factors
• Phagocytic cells, neutrophils, macrophages
Inflammatory Phase
Molecular Component
Macrophage Derived
• PDGF
• TNF-α
Proinflammatory
Induce 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, reepithelialization,
fibroplasia
Proliferative Phase
Angiogenesis
• Neovascularization
• Granulation tissue
– Buds of new capillaries
• Does not occur if
ECM absent
• Stimulated by FGF,
VEGF, TGF-ß, EGF,
wound angiogenesis
factor
Proliferative Phase
Matrix 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 noninjured tissue after 3 weeks.
• Increases to 70-80% in two years
• Wound recurrence: gravity, swelling, poor closure
Proliferative Phase
Re-epithelialization
• Resurfaces wound
• Restores integrity of epithelium
• Keratinocytes migrate into and proliferate
over wound bed
– Inhibited by scabs
• REQUIRES basement membrane
Proliferative Phase
Re-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 7080%
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 WOUNDS
PRIMARY SURGICAL TREATMENT OF
THE WOUND
PRIMARY SURGICAL TREATMENT OF THE
WOUND is the first surgical operation, provided
in aseptic conditions, with anesthesia, which
contains the following stages.
THE MAIN STAGES:
1. Disinfection of the operative field.
2. Anesthesia.
3. Cutting of the wound.
4. Revision of the wound channel.
5. Removing of the margins, walls and bottom of the
wound.
6. Hemostasis.
7. Rehabilitation of injured organs and structures.
8. Applying of stitches on the wound with leaving of
drainages (according to indications)
PRIMARY SURGICAL TREATMENT OF
THE WOUND
Full and partial treatment of the
wound.
Primary and secondary treatment of
the wound.
Early, delayed and later treatment of
the wound.
Wound Preparation
• Removal of hair
– Not eyebrow
• Scrubbing the wound
• Irrigation with saline
– Avoid peroxide,
betadine, tissue toxic
detergents
PRIMARY SURGICAL TREATMENT OF
THE WOUND
Cutting of the wound and removing of
margins, walls and bottom of the wound.
PRIMARY SURGICAL TREATMENT OF
THE WOUND
CUTTING OF APONEVROSIS
PRIMARY SURGICAL TREATMENT OF
THE WOUND
REMOVING OF THE NECROTIC TISSUES
PRIMARY SURGICAL TREATMENT OF
THE WOUND
REVISION OF ZONE OF SPEADING OF WOUND
CHANNEL AND CHARACTER OF INJURY
PRIMARY SURGICAL TREATMENT OF
THE WOUND
WASHING OF THE WOUND
PRIMARY SURGICAL TREATMENT OF
THE WOUND
DRAINAGES OF THE WOUND
PRIMARY SURGICAL TREATMENT OF
THE WOUND
PASSIVE DRAINAGE OF THE WOUND
PRIMARY SURGICAL TREATMENT OF
THE WOUND
REDONS SET OF
DRAINAGING
ACTIVE DRAINAGE OF THE WOUND
PRIMARY SURGICAL TREATMENT OF
THE WOUND
WASHING DRAINAGES OF THE WOUND
PRIMARY SURGICAL TREATMENT OF
THE WOUND
SEWING OF THE WOUND
PRIMARY SURGICAL TREATMENT OF
THE WOUND
ACCORDING TO THE TIME OF APPLYING OF THE STITCHES:
1. Primarily.
2. Primarily delayed.
3. Early secondary.
4. late secondary.
Ivano-Frankivsk National Medical University
PRIMARY SURGICAL TREATMENT OF
THE WOUND
SEWING OF THE WOUND
SURGICAL TREATMENT OF THE
PURULENT WOUND
Ivano-Frankivsk National Medical University
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 Patterns
Interrupted
– 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
TREATMENT OF THE WOUND
1. During the first phase of the wound process:
- immobilization of the wound;
- use of the proteolytic ferments;
- use of antisepsis
solutions.
2. During the second phase of the wound process :
- treatment bandaging;
- stimulation of the grows of granulative tissues;
- the bandages are conducted rarely.
USE OF PROTEOLYTIC FERMENTS
FOR THE TREATMENT OF THE
WOUND
Before
treatment
One week after
beginning of the
treatment
PRINCIPELS OF THE GENERAL
TREATMENT OF THE WOUND
1. Antibacterial therapy.
2. Desintoxication therapy.
3. Immune correcting therapy.
4. Correction of the haemostasis.
5. Analgetics.
Moist Wound Healing
• DRY IS DEAD!
• Moist environment allows:
–
–
–
–
Cell function
Diffusion of chemical factors
Migration of cells
Autolytic debridement
Moist Wound Healing
Dressings
• 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 Wounds
Intrinsic causes
•
•
•
•
•
Age
Chronic disease
Perfusion/oxygenation
Immunosuppression
Neurologic impairments
Chronic Wounds
Extrinsic causes
•
•
•
•
•
Medication
Nutrition
Irration/chemotherapy
Psychophysiologic stress
Wound bioburden
Chronic Wounds
Iatrogeneic 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 leakagepolymerization 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 week
Hydrocolloid
Hydroc
olloid
loids
Diabetic ulcer for
5 month
days 21
Moist wound healing
Absorption base
dressing
Alginate
Hydrofibre
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
Foam dressing : Indication
• For light to medium
exuding wounds
• Granulating and
epithelializating
wounds
For
Cavity Wounds
Cavity Wounds
(Healthy Granulation )
Silver Dressing
•Silvercel (Alginate+sliver)
•Aquacel(Ag(hydrofibre+silver)
•Acticoat (Nanocrystalline
silver-based dressing)
Promogran™
Post traumatic chronic ulcer
Growth Factors
Protease
Promogran
• Growth factors
protection
• Binding and
inactivating
proteases in
excess
inactive
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 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
TREATMENT OF THE WOUND
1. Development of the
inflammatory infiltrate.
2. Haematoma.
3. Pusing.
4. Marginal necrosis.
5. Kelloid and hypertrophical
ruptures.
6. Destroy the innervations
and lymphodranages of
the wound.
Practice Time!
•
Thank you for attention !
Ivano-Frankivsk National Medical University