Wound Management

Question 1

Avulsion

Answer 1

• Tearing away of body tissue due to shear
• Degloving injury
• Flaps of tissue
• Avulsed part may be attached by flap of skin

Question 2

What is the golden period in regards to timing of injury?

Answer 2

• Within 6 hours of injury - this is when bacterial numbers are still low
• Beyond 6 hours of injury, bacterial growth reach numbers that risk infection (10⁵ per gram of tissue)
• The earlier you can get to a wound, the better you can close it off without it becoming infected

Question 3

Degree of Contamination: clean, clean contaminated, contaminated, dirty/infected

Answer 3

• Clean: surgically created, no hollow viscous opened
• Clean contaminated: minimal contamination; contamination can be effectively removed; includes surgery of hollow viscus (intestines, stomach, etc)
• Contaminated: open traumatic wounds; break in aseptic technique
• Dirty/infected: Old traumatic wounds; perforated viscus; clinical infection (open abdomen where there is already peritonitis)

Question 4

Will the presence of bacteria alone cause an infection in a wound?

Answer 4

No, you need more than just some bacteria on a wound to cause an infection. Usually there is some compromised effect of local immunity, it depends on the blodo supply and the amoutn of traumatized tissue, and the amoutn/type of foreign debris present. Patient age also plays a role.

Question 5

When to culture and what to culture

Answer 5

• When to culture:
  
  • BEFORE anitbiotics if possible
  • When there is gross evidence of infection - not useful to culture a fresh wound
• What to culture
  
  • Deep tissue layer, NOT the surface

Question 6

Acute Wound Management Goals

Answer 6

• Remove obvious devitalized tissue
• Remove foreign bodies/debris
• Reduce bacterial numbers to as close to zero as possible
• Wound closure at earliest appropriate time

Question 7

Acute Wound Treatment - Lavage

Answer 7

• Can remove up to 90% of bacteria
• Large quantities - moderate pressure
  
  • 35 mL syringe + 18 g needle = 7-8 psi
  • 1 L plastic bag within a 300 mmHg pressurized cuff
  • Main thing - deliver 7-8 psi
• Contraindication in puncture wounds b/c fluid can’t get back out, and results in iatrogenic tissue edema!!

Question 8

Most common lavage solution:

Answer 8

Normal saline

Question 9

Two antiseptic lavage solutions:

Answer 9

1. 0.05% Chlorhexidine
   
   1. any more will cause too much damage to fibroblasts in the wound
2. 0.1% povidone-iodine

Question 10

Pros and Cons of tap water with lavage:

Answer 10

• Pros
  
  • GROSS contamination
  • Cheap
  • Available
  • Ease of application
• Cons
  
  • Hypotonic
  • Cytotoxic trace elements
  • Not antimicrobial

Question 11

Pros and cons of using electrolyte solutions with lavages

Answer 11

• Pros:
  
  • Isotonic
  • Least cytotoxic
• Cons
  
  • Not antimicrobial

Question 12

pros and cons of using normal saline in lavage

Answer 12

• Pros - isotonic
• Cons
  
  • More acidic than LRS
  • Not antimicrobial

Question 13

How to make 0.05% Chlorhexidine

Answer 13

• Stock (2%) added to sterile water - 1:40 dilution
• 25 mL per liter of sterile water
• DO NOT USE SALINE to mix - liquid will become foamy!

Question 14

Pros and cons of using 0.05% chlorhexidine in lavage

Answer 14

• Pros
  
  • Wide antimicrobial spectrum
  • Residual activity - increases when repeated
  • Minimally inactivated by organic matter
• Cons
  
  • Slows granulation and contraction in some rat models
  • Proteus, Pseudomonas, Candida resistance
  • Corneal toxicity

Question 15

How to make 0.1% povidone-iodine

Answer 15

• Stock (10%) added to sterile water, LRS, or saline … 1:100 dilution
• 10 mL per liter of water/LRS/saline

Question 16

Pros and Cons of 0.1% povidone-iodine in lavage

Answer 16

• Pros
  
  • Wide antimicrobial spectrum
  • Short residual activity (4-6 hours)
  • More effective/active when more dilute - because the more free iodine is released!
• Cons
  
  • Inactivated by organic matter
  • Cytotoxic >1%
  • Contact hypersensitivity
  • Thyroid disorder if absorbed

Question 17

Debridement

Answer 17

Removal of dead or damaged tissue, foreign material, microorganisms

Question 18

Surgical Debridement

Answer 18

• Selective debridement
• Layered (MC)
  
  • Devitalized
  • Black, green, white
  • if in doubt, leave it
  • Debris
• En bloc - closing wound over gauze and excising it - risk removing a lot of healthy tissue, but gives you opporutinity to close wound immediately

Question 19

Autolytic Debridement

Answer 19

• Selective debridement
• Letting the wound do its thing
• Moist wound environment
• Protective bandage
• Needs minimal/no surgical debridement

Question 20

Enzymatic Debridement

Answer 20

• Semi-selective debridement
• Needs minimal surgical debridement
• good for poor anesthetic candidates
• Good for “Debris” surrounding vital structures for reconstruction
• Not effective on: burns, necrotic bone, connective tissue
• Example - granulex V

Question 21

Three components of granulex V

Answer 21

• Trypsin
  
  • Debridement
  • Liquiefies protein
• Balsam of Peru
  
  • Stimulates circulation
  • Stimulates granulation
• Castor oil
  
  • Prevents dessication
  • Improves epithelialization

Question 22

Bandage Debridement

Answer 22

• Non-selective debridement
• Bandage adheres to debris/tissue
• Strips superficial wound layer every time
• Wet-to-dry: put gauze in wet, exudates come up and the gazue dries with the exudate in it
• Dry-to-dry: in luiqidy, non-viscous wounds, put gauze in dry and it will get wet right away once in the wound
• Discontinue ASAP (proliferative stage) - when we see nice, healthy, granulation tissue

Question 23

Primar closure vs delayed primary closure vs seoncdary closure vs second intention

Answer 23

• Primary closure
  
  • Immediate suturing to appose skin edges
• Delayed primary closure
  
  • Delayed for up to 3 days to allow control of local infection or for damaged tissue to declare itself
• Secondary closure
  
  • Closure is delayed until after a bed of granulation tissue has formed
• Healing by second intention - nonclosure
  
  • Occurs by granulation tissue formation, wound contraction, and epitheliaization
  • natural

Question 24

Contact (primary) layer of bandage

Answer 24

• Sterile
• Conforms to wound/body contours
• Allows fluid to pass to secondary layer
• Non-toxic, non-irritating
• Minimize pain
• Adherent vs non-adherent
  
  • Use adherent for more traumatic wounds to remove debris - can take healthy tissue with it, painful, serves as bacterial media
  • Non-adeherent can promote healing by allowing enough fluid to circulate out, but still protect it in a moist enivonrment. We wnat to use non-adherent material when we have healthy granulation tissue

Question 25

Intermediate (secondary) laye of bandage

Answer 25

* Absorb and hold drainage * Support/immobilization * Splint/cast incorporation * Pressure - to obliterate dead space * Control hemorrhage * Reduce edema * Can incorporate splints into second layer

Question 26

Outer (tertiary) layer of bandage

Answer 26

* Secures first 2 layers * Stretch gauze * Prous tape * Vetwrap * Apply with even pressure

Question 27

When to use drains

Answer 27

* Large dead space that can't be closed * When fluid accumulation is likely

Question 28

Drain rules

Answer 28

1. Only when necessary - avoid in oncological surgery 2. Never exit through incision 3. Do not place directly under skin suture line 4. Always bandage passive drains - if stuff can come out, bugs can go in 5. Don't tack with burried sutures 6. Remove ASAP - when there is decreased fluid production, and discharge becomes serous/serosanguinous

Question 29

Passive vs Active Drains

Answer 29

* Passive - gravity dependent * Penrose * Exits via separate stab in dependent region * Greater risk for infection * Drains **AROUND** drain * Active/closed suction * Jackson-Pratt * May enhance healing * Less infection * Obstruction possible, but uncommon * Drains **through** drain

Question 30

Vacuum-Assisted Wound Closure

Answer 30

* Open-cell foam\* * Subatmospheric pressure * Pulls fluid through wound * Decreases swelling * Increased perfusion, granulation, infection resistance, flap survival * \*wound is continually being bathed with it's own tissue juices - good

Question 31

Bite wounds

Answer 31

* Crushing, tearing, avulsion * Infection - worse with cat bite than dog bite * Worry about Pasteurella * Leave open or bandage - delayed primary or secondary closure * If thoracic/abdominal penetration - emergency surgery if abdominal * Extremity may be managed with surface lavage and sytemic antibiotics

Question 32

Do we use drains with abscesses?

Answer 32

* NO! Treat abscess like an open wound - it itself is the drain

Question 33

Thermal Burn Medical Therapy

Answer 33

* Topical cream * Aloe vera * Silver sulfadiazine * Systemic antibiotics * Fluoroquinolones