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Flashcards in Principles of wound management Deck (36):
1

aims of wound management

achieve a healed wound
minimise scar function
preserve function
prevent infection

2

wound management steps

initial management
assessment of patient
assessment of wound
manage open wound
closure of wound

3

initial management

wound should be covered to prevent contamination + trauma + help haemostasis - dry gauze, linen or sterile dressing
tourniquet rarely needed + can cause trauma
support fractures to reduce pain, prevent soft tissue injury + reduce contamination of deeper tissue from movement of fracture fragments in open fractures

4

assessment of the patient

airways, breathing + circulation followed by PE
general health + history should be taken
aetiology of wound + treatment
BCS
appropriate analgesia

5

assessment of the wound

aetiology, location, nature, extent + degree of contamination
rest of affected region exam
thorax wound - integrity of pleural + peritoneal space established
limb wound - bone, joint + neuro damage

6

wound contamination, infection + aseptic technique

all traumatic wounds dirty/contaminated
most contaminants in wounds are from hospital - strict aseptic technique needed
sample after debridement + lavage
antibiotics can be prophylactic or therapuetic but not neeeded once granulation tissue is formed - resistant to infection

7

"golden period"

6 hours after injury a contaminated wound may be cleaned + closed primarily without development of infection

8

definitive wound management

protect wound from desiccation + contamination
preparation + clipping
debridement of necrotic tissue
removal of foreign material + contaminants - lavage
provision of adequate wound drainage
promotion of viable vascular bed
selection of appropriate method closure

9

prevention of further wound conamination

on admission wound protected from further contamination, trauma or drying by dressing
saline-soaked swabs good for debridement
antibiotics/antiseptics can be added to the dressing but these are questionable
animals should be sedated/anaesthetised for adequate wound preperation
in concious animal, local or regional anaesthetic techniques can be used

10

wound protection

wound protected with KY jelly or slain swabs
if animal is v.dirty animal may be bathed

11

tissue handling

shouldn't be handles atraumatically
shouldn't probe wound before preperation
shouldn't replace bone fragments into wound

12

clipping of the hair

should begin at wound margins + move towards periphery
clip generous margin around wound to allow for exploration

13

surgical preperation

KY jelly/swabs replaced to cover wound + skin around wound prepared aseptically
antiseptic kept out of the wound

14

debridement - define

removal of necrotic tissue from a wound

15

debridement

all necrotic tissue should be removed
*inadequate debridement is most common cause of delayed wound healing
done with scalpel, adherent dressings, hydrogel dressings + enzymes
scalpel used most commonly - initial phases
dressing used for 1st few days
enzymes not used often - good for pocket wounds
avoid use of diathermy, ligating large pedicles + excessive retraction or dissection

16

debridement - skin + subcutis

excise liberally, back to bleeding tissue
preserve vessels

17

debridement - fat + facia

excise liberally

18

debridement - muscle

excise but preserve function

19

debridement - tendon/ligament

staged debridement
preserve function
anastomosis

20

debridement - nerves + vessels

preserve if possible
ligate damaged vessels

21

debridement - bone

preserve if vascularised
remove if unattached + small

22

debridement - joints

lavage + remove small loose fragments
close if possible

23

tissue viability

colour, warmth, sensation, bleeding
complex measurement - doppler ultrasound, transcutaneous pO2, flourescein injection
may change for better or worse over 1st 5 day

24

layered debridement

beginning at wound margins + progressing deeper into the wound
allows each layer to be assessed serperately

25

en bloc debridement

complete excision of wound with no entry to the wound
wound may be closed/packed with swabs
simple technique with gives clean wound which can be closed primarily
removes more tissue + results in larger wound + may be damage to surrounding vital tissue

26

lavage - aims

remove foreign material + keep tissue hydrated
necrotic tissue, debris + micro-organisms promote infection + delay healing
can be couple with debridement

27

lavage

simple + cheap apparatus for lavage in 18 gauge needle attached to 20ml syringe + bag of fluid via giving set + 3-way tap
wound edges elevated to examine deeper fascial planes
asses wound infection
generally performed daily after changing wound dressings
antibiotics/antiseptics can be given

28

establish drainage

fluid in wound impairs immune response, incr bacterial growth + decr blood supply
open wounds drain best
when closing a wound allow drainage - leave part of wound open, fenestration of part of skin surface, use phsiologic/synthetic implant

29

promote development of a viable vascular bed

debridement, drainage + protect from trauma + contamination
ideally circulation can support granulation tissue formation
exposed area of bone denuded of periosteum may not - drill small holes into cancellous bone to promote coverage of cortical bone by using muscle flap to cover bone

30

reasons for closing a wound

can convert to clean wound
no tension
not crush wound
not infected
granulating wound
won't heal by 2nd intention

31

reasons for not closing a wound

puncture wound
can't debride + lavage
infected
tension on closure

32

primary closure

direct apposition of skin edges
clean/clean-contaminated wounds
restores normal function quick
needs general anaesthesia + leads to problems if used inappropriately

33

delayed primary closure

apposition of skin edges 2-5 days after injury
wound covered with sterile dressing
contaminated wounds
decr infection
used when contamination can't be removed, judgement of tissue viability, definitive debridement cant't be done initially

34

secondary closure

closure in presence of granulation tissue
can be combined with reconstructive techniques to avoid tension
for superficial contamination, invasive infection + wounds closed by primary that get infected
5-10 days after injury
direct apposition of granulating surfaces or excision of granulation tissue + primary close
excision of granulation tissue may decr infection + better cosmetics but takes longer + is more traumatic
healing is rapid after closure as wound is already in prolifererative phase of healing
delay in closure + decr tissue pliability may make closure difficult

35

second intention healing

healing by contraction + epithelialisation
contraction normally successful in small animals due to abundant, elastic skin
generally reserved for dirty wounds which can't be closed by other techniques
large defects - not enough skin to closure so left to heal
laxity in adjacent skin + tension assessed

36

disadvantages of second intention healing

expensive in many bandage changes, hospital visits + medications
healing is prolonged
healing be not complete - chronic non-healing
cosmetic result is relatively poor
recurrent wound breakdown may occur if fragile epithelium present over large area
recurrent wound breakdown may occur if fragile epithelium present over large area
stenosis/impairment of function or orifices may occur with adjacent wounds
decr range of motion of limb may occur with wounds near joints