Wound Management
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What are adnexia?
Glands, hair etc. present in healthy skin tissue
What is the objective of care of accidental wounds?
• convert an open wound to a surgically clean than can be closed (ideally within 6-12hours) • minimal scarring, normal function and no infection
What are the 2 broad categories of wound? What else should be thought about?
> Closed - crushing and contusion injuries eg. mm. avulsion, fx > Open - skin lacerations or loss - duration - degree of contamination - aetiolgogy - depth of tissue damage
Why is duration of wound exposure important?
bacteria multiply quickly - “golden period” after which wound cannot be sutured as clean
What are the classes of wound duration?
• clean lcerations 0-6 hours with minimal contamination • wounds 6-12hrs duration with significant contamination • wounds 12hrs + with gross contamination AND bite wounds even if fresh
What are the majority of wounds classified as?
2
How is degree of contamination defined?
• clean • clean contaminated • contaminated • dirty
What is a dirty wound defined as in a lab?
> 10^5 organisms per gram of tissue
What are potential wound aetiologies?
• abrasion • avulsion/degloving • incision • laceration • puncture • crushing • burns
What may discolouration around a seemingly small wound indicate?
underlying trauma
What trauma are we most worried about with neck wounds?
laryngeal and tracheal trauma
How should accidental wounds be managed first aid
• control haemorrhage using pressure not tourniquet • fresh steril pressure bandage • topical Abx (tetracycline or neomycin &bacitracin in 0.9% saline) • chlorhexidine v dilute 0.05% can be sued but is damaging to fibroplasia
What is the first thing that should be done to accidental wounds?
DO NOT PROBE • fill with KY jelly • clip hair around wound • prepare aseptically • irrigate
Should accidental wounds be lavaged under pressure?
No • effect is proportional to volume • do not drive debris further into tissues • no need for ABx added
What guage needle should be used to prevent too much pressure being applied when lavaging a wound?
19G
How may wounds be debrided?
• surgery gold standard • bandages - wet-dry, dry-dry, wet-wet (adjubnct to surgery or when debridement not possible) • Hydrogel and enzymes improve effects of debriding bandage
How can you decide which muscles to remove when debriding a wound?
if it does not twitch or bleed when touched it can go
What are the 2 main types of dressings?
> passive - adherent/absorbent/non-adherent/vapour permeable/barrier films - protection and environment to support healing active - hydrocolloids/hydrogels/alginates/collagens/skin substitutes - provide cytokines and alter wound environment to ^ healing
When is vacuum assisted wound closure commonly used?
abdo and thoracic wounds ^ quality of granulation tissue
What are the advantages of adherent passive dressings?
• excellent debridement • wide mesh allows dessication and tissue adherence • good at combatting infection • cheap
What are the disadvantages of adherent passive dressings?
• painful to remove • changed frequently q24hrs • delay fibroplasia and epithelialisation • detrimental if used after debridement period
What are the differnet types of adherent passive dressings called? When are they indicated?
dry - dry (if wound effusive) wet - dry
What sare the different wound closure options?
> 1* intention (incisions) delayed 1* closure (leave 24-48hrs for necrosis then debride and close) 2* closure (leave granulation tissue to form then remove all) 2* intention (contraction and epithelialisation) - may need a combination and can change your mind
If in doubt,should you close the wound?
No