Wound

Question 1

What are main types of wounds (3)?

*just name

Answer 1

• incisional
• lacerations
• burns

Question 2

What are incisional wounds caused by?

Answer 2

Shar objects e.g. knife (either traumatic or surgical)

Question 3

What causes laceration?

What happens in laceration?

Answer 3

Laceration

Cause: an injury with blunt objects -> skin tear

What happens: Stretch of the skin -> tear of the dermis and underlying vessels

Question 4

What’s degloving?

Answer 4

degloving -> It’s a type of laceration

Skin is removed from underlying fascia by a rotational force

Question 5

Types of burns (3)

Answer 5

Burns:

• thermal
• electrical
• chemical

Question 6

General approaches to the treatment of the burns:

A. superficial

B. deep

Answer 6

Superficial burns -> conservative management

Deep burns -> possibly specialist input

Question 7

What are Langer’s lines?

Answer 7

Langer’s lines are the areas of tension of the normal skin

* surgical incisions should be made along these lines

Question 8

What’s the deep wound?

What management do we need in case of deep wound?

Answer 8

Deep wound - cross dermis and pass into subdermis

Surgical closure is required in terms of deep wounds

Question 9

Two physiological ways that a wound can heal

Answer 9

Healing of the wound (physiological)

A. Primary intention -> two edges of skin are brought together -> healing occurs rapidly

B. Secondary Intention -> two wound edges cannot be brought together *or are left open for the purpose; the wound is kept clean and granulation tissue forms in the gap -> this fills the space and secondary intention healing occurs

*sepsis, swelling

Question 10

Factors that promote healthy wound healing (5)

Answer 10

• no infection
• no foreign body
• good blood supply
• appropriate skin apposition (alignment)
• no excess tension to the wound

Question 11

General types of sutures (2) - just mention what types and describe (advantages, disadvantages)

Answer 11

- absorbable -> biological; broken down by enzymes; they do not need to be removed although they provide support only for limited period of time

• non - absorbable -> are non-biological materials; they provide permanent wound support but need to be removed and there is also a potential for a foreign body reaction and infection

Question 12

When to remove:

• superficial sutures
• facial sutures

Answer 12

• superficial sutures (if on the limbs) -> remove after 10 days
• if on the face -> remove after 5 days

Question 13

Name an example (1) of absorbable sutures

Answer 13

Polyglactin

Question 14

What to use Steri-strips for?

Answer 14

Steri- strips

Used in closure of small skin wounds e.g. superficial arm wound and non-gapping scalp injuries

Question 15

What do we often use tissue glue for?

Answer 15

Superficial scalp wounds

Question 16

Metal clips

• what are they used for?
• how long for?

Answer 16

Metal clips - remain large metal staples

Use: large abdominal and thoracic surgery

• kept on for 10 days

Question 17

When the wound of the scalp can be managed with tissue glue and when with sutures?

Answer 17

If the wound will cross aponeurosis -> needs suture closure

*aponeurosis lies under the fat and fibrous layer

Question 18

What can delay wound healing?

Answer 18

• infection
• foreign body
• steroids -> as collagen synthesis and cytokine function is inhibited
• tissue hypoxia, bad blood supply and respiratory failure
• systemic disease: jaundice, DM, cancer and malnutrition
• previous radiation to damage area
• sepsis
• poor surgical technique

-

Question 19

Exogenous organisms causing wound infection (2)

Answer 19

• Staphylococcus aureus

- Staphylococcus epidermis

Question 20

Examples of endogenous organisms causing wound infection after bowel surgery

Answer 20

endogenous wound infection -> usually gut organisms after bowel surgery

• • E. coli*
• • Klebsiella*
• • Proteus*
• • Pseudomonas*
• • Bacteroides*
• • Clostridia spp.*
• -* anaerobic streptococci

Question 21

Examples of urinary pathogens causing wound infection after open urology (2)

Answer 21

• E. coli
• enterococci

Question 22

Examples of vaginal pathogens causing wound infection after gynaecological operations (2)

Answer 22

• anaerobic or aerobic streptococci
• yeats

Question 23

What is the management of infected surgical wounds?

Answer 23

Wounds should be:

• opened
• washed out with either surgical toilet or debridement
• dressings changed regularly
• antibiotics given in accordance to the wound swabs (culture and sensitivity)

Question 24

Wound dehiscence:

• following what types of surgery
• what happens
• risk factors

Answer 24

Wound dehiscence = rupture against the surgical incision

Types of surgery: 2- 10% abdominal wounds

What happens: wound breaks down completely

e.g. laparotomy wound dehiscence -> loop of bowel is exposed

Risk factors (when does it occur): wound infection, the suture may tear through the weak tissue (steroid use, elderly, malnutrition, malignancy)

Question 25

Management options for wound dehiscence

Answer 25

Patient must be returned to the theatre and either: - the wound would be **sutured** back - healing would be allowed by **secondary intention** (gap left for the granulation tissue to form) - **open laparotomy** -\> in cases of severe sepsis or fistula

Question 26

Incisional hernia - whan does it happen - what happens - risk factors

Answer 26

***Incisional hernia*** ## Footnote - it is late post-op complications - wound closure becomes infected -\> abdominal/ visceral content protrudes through the wound closure site - _risk factors:_ malnourished, elderly, obesity, poor surgical technique

Question 27

What is the purpose of drain?

Answer 27

**Drains:** - put out into surgical wounds at the end of the surgery **Aim:** to allow an excess of pus or blood to be drained out of the body -\> their accumulation and abscess formation is prevented

Question 28

Examples of the **closed-suction** drain? How do we need to position them?

Answer 28

- urinary catheter - chest drain - T - Tube connected to bile drain **Position**: the bottle is kept below the patient -\> fluid drains into gravity

Question 29

When do we remove the drain?

Answer 29

When it is draining **\<25 ml** per day \*patients may be allowed home with the drain attached to them -\> community nurse can remove them

Question 30

Two ways to assess if the drain is blocked

Answer 30

A. **Swing test:** drain is held and moved (swinged) from side to side -\> the fluid line in the tube should move (if not blocked) B. **The patient coughs** -\> increased pressure -\> fluid level in the drain should shift (performed for abdominal drains)