What are the six goals of wound care?
- Reduce ecchymoses
- Reduce dead space
- Prevent hematoma and seroma formation
- Prevent infection
- Preserve function
- Preserve appearance
What are the eight complications of wound healing?
- Ecchymoses
- Hematomas
- Seromas
- Infection
- Wound dehiscence
- Bad scarring
- Loss of function
- Nerve and/or vascular damage
What are the causes of ecchymoses?
- Blood leaks into the skin and, often, into the subcutaneous fat
How can we reduce the severity of ecchymoses?
- Carefully handle tissue during surgery and repair
- Avoid using excessive amount of local anesthesia
- Apply proper pressure bandaging for 24 hours - tight enough to prevent oozing of blood in the tissue, but not to cut off normal circulation
- Apply intermittent ice packs for 2-3 days
What causes hematomas?
- Post-op sustained capillary bed leakage
- Venous/arterial bleeding from the raw surface of a surgical site or within a traumatic lesion
What pre-operative steps can be taken to reduce the occurrence of hematomas?
- Assess each patient’s general health status and history of coagulopathies
- Identify any history of significant bleeding during prior low-risk surgical or dental procedures
- Identify common medical problems that may affect healing - renal dysfunction, hypertension, liver disease, and abnormal coagulation
- Screen for alcohol abuse - impairs coagulation of platelets and decreases vasoconstriction
- Identify all daily and prn medications and the last date taken
Have aspirin, Alka-Seltzer, ibuprofen, and clopidogrel (Plavix) been shown to increase the risk of hemorrhage more than warfarin?
- Yes
- Also fish oil, gingko biloba, garlic, ginseng, ginger, feverfew, vitamin E, and saw palmetto
Should all prescribed and non-prescribed anticoagulants be stopped 1 week prior to dermatologic surgery?
- Conflicting opinions…
- Best to delay surgery for three days after the last dose of aspirin
- Avoid use of non-medically necessary supplements and anticoagulants for 1 week
- Continue warfarin or clopidogrel (Plavix) to avoid thrombotic events
- Weigh out pros/cons of increased risk of bleeding vs lower but potentially life-threatening risk of a thrombotic event if anticoagulant is temporarily discontinued
What intra-operative steps can be taken to reduce bleeding and hematomas?
- Produce careful hemostasis
> Use figure-of-8 sutures or suture ligation to tie off bleeders
> Use quilting sutures (interrupted deep stitches) in a large wound to reduce dead space –> reduced hematoma formation - Place drains or suction drains when there is increased risk of hematoma formation
What post-op management steps can reduce bleeding and hematomas?
- Pressure bandaging - for 24 hours post-op/repair hold in place 2 twice-folded 4x4s with a pressure bandage of hypoallergenic paper tape or elastic wrap
- Apply ice packs over the dressing for 20 minutes every hour for six hours for patients on anticoagulants or who have had excessive bleeding during surgery
What are the differences in the treatments of expanding or clotted hematomas vs fluctuant ones?
Expanding or clotted
- Partially or completely re-open the surgical wound
- Identify any oozing vessels
- Stop bleeding by suture ligation or electrosurgery
- Insert a drain/suction if indicated
- Do a full-layer re-closure
- If there is a high risk of more bleeding or the wound is contaminated the best choice may be to let the wound heal by secondary intention
Fluctuant
- Aspirate with sterile procedure
- Repeat every 1-2 days until hematoma stops forming
- Continue using pressure bandage
What causes seromas?
- Small blood vessels rupture and blood plasma seeps out
- Trauma causes tissue fluid leakage that does not fully subside
- Inflammation cause by dying injured cells
- Particularly common after major surgeries - breast, abdominal, and reconstructive
How can you prevent/treat seromas?
Prevent
- Careful tissue handling to reduce trauma
- Thorough wound irrigation and debridement
- Quilting (interrupted deep stitches) in a large wound to reduce dead space
- Pressure bandaging to reduce fluid collection
Treatment
- Usually low-risk
- Usually resolve spontaneously within days to weeks (but can be months to years)
- Avoid blood-thinning analgesics
- Consider homeopathic bryonia, silica, or sepia
- Rest/elevate affected part
- Intermittent ice packs
- Use alternating hot/cold after a few days
- Consider fine needle aspiration if it persists
> Controversial procedure
> Only for excessive amounts of fluid collection
> Increased risk of infection
> May only need one aspiration, or may take several
Does prophylaxis with antibiotics for routine or elective minor surgery generally lower the risk of infection?
- No, actually increases the risk of infection
What are the current guidelines for withholding antiplatelet drugs and other anticoagulants?
- Best to delay surgery for three days after the last dose of aspirin
- Avoid use of non-medically necessary supplements and anticoagulants for 1 week
- Continue warfarin or clopidogrel (Plavix) to avoid thrombotic events
- Weigh out pros/cons of increased risk of bleeding vs lower but potentially life-threatening risk of a thrombotic event if anticoagulant is temporarily discontinued
In what three situations are prophylactic antibiotics indicated in patients with traumatic wounds?
- Wounds that are obviously infected
- Contaminated wounds that are closed primarily
- Lymphedematous patients with traumatic wounds
What are the arguments against using antibiotics in traumatic wounds?
- Limited indications for the routine use of antibiotics in lacerations
- A single reliable study showed an advantage to prophylactic oral penicillin for intraoral wounds
- Clean, properly debrided early traumatic wounds in patients that are not immune compromised do not require prophylactic antibiotics
Can wounds dehisce when sutures are in place?
- Yes
What are the four things that can typically cause wound dehiscence?
- Too much tension on newly sutured tissue - damages the tissue and interferes with circulation and healing
- Too little tension - wound edges too loosely apposed to allow proper healing
- Inappropriate suture material (wrong size or material) –> breakage and/or a tissue reaction
- Poor tissue quality (poor nutritional status, chronic disease, chemotherapy, etc.) –> tissue failure and poor healing
Can both cryotherapy and full-thickness lacerations/incisions/excisions carry a risk of nerve and vascular damage?
- Yes
What must always be assessed in all traumatic wounds before injection of anesthesia and repair of the wound?
- Sensation
- Vascular integrity
- Active and passive ROM
What can result from the skin being cut or damaged via hyfrecation, radiosurgery, lift and snips, shaves, or cryotherapy?
- The color of the skin may never return to normal
- There may be permanent hypo/hyperpigmentation
Will scars resulting from any surgery or traumatic laceration regain color?
- No, they will remain colorless
What are the six causes of hypertrophic scars and keloids?
- Genetics
- Body site (esp. upper chest, back, shoulders)
- Quality of the surgery
- Skin tension (worse with more tension)
- Skin types
- The patient’s health status at the time
