Flashcards in Principles of wound management Deck (60)
Possible complications of larger wounds - 3
compromise of limb function necessitating amputation
What type of wound may heal by secondary intention?
wounds without major tissue loss
free of large areas of necrotic tissue
confined to non-vital areas
open to drainage
not overwhelmed by pathogens and contaminants
List the 4 main aims of wound management
achieve a healed wound
minimise scar formation
What are the main steps of wound management? 5
manage open wound
What can you cover a wound with to prevent further contamination? 3
(rarely is a tourniquet required)
Why might a tourniquet be a disadvantage?
may cause more trauma through ischaemia (especially if applied by lay personnel)
How should the wound be assessed? 6
degree of contamination
rest of affected region examined
THORAX: pleural and peritoneal space integrity
LIMBS: underlying bones, joints, neruovascular structures
How often should open wounds be assessed?
every 12-24 hours (serial assessments)
wound progression to be monitored
What is the 'golden period' in terms of wound contamination?
< 6 hours after injury, a contaminated wound may be cleaned and closed primarily without development of infection
BUT, factors other than time are more important:
bacterial numbers and virulence
wound factors predisposing to infection
integrity of host IR
AB use - prophylactic or therapeutic
What are the logical steps in promoting the development of healthy granulation tissue? 7
protect wound from dessication and contamination
preparation and clipping
removal of FB and contaminants (lavage)
provision of adequate wound drainage
promotion of a viable vascular bed
selection of appropriate method of closure
When are topical treatments to prevent contamination redundant?
when GT has formed because of its resistance to infection
How can you prevent wound contamination before GT formation?
saline-soaked gauze swabs
water-soluble AB solutions/ointments or antiseptics (0.1% poivdone iodine, 0.05% chlorhexidine diacetate)
animals should be sedated or anaesthetised for this
If conscious - use local/regional anaesthetic techniques (local application, infiltration, ring block, regional block)
How can a wound be protected during clipping?
KY jelly or saline-soaked swabs or temporarily closed (sutures or towel clips)
How should you clip round a wound?
clip from wound margins and move towards the periphery
clip a generous margin round the wound to allow exploration
hair removed with vacuum cleaner
keep blades moist and hair moistened
How is the area around the wound prepared aseptically?
start at wound margin and move to the periphery (keep antiseptic out of wound)
What is the most common cause of delayed wound healing?
How can you debride a wound? 3
Which is the most common?
scalpel (sharp debridement, most common)
adherent dressing (wet-to-dry, dry-to-dry)
hydrogel dressings and enzymes (trypsin and chymotrypsin)
How should a surgeon not debride a wound?
ligating large pedicles
excessive retraction or dissection
What should be done with areas of questionable viability?
excised (if not essential to normal function, SC fat)
staged debridement (tissue is essential for normal function, tendons)
How should muscle be debrided?
excise (until bleeds/contracts) but preserve function
How is tissue vaibility assessed?
Simple measurements: colour, warmth, pain sensation, bleeding
Complex measurement: doppler ultrasound, transcutaneouus pO2, fluorescein injection, scintigrpahy
May change ofr the better or worse over the first 5 days and staged daily assessment of the wound to let the tissue 'declare itself' may be appropriate.
Define 'layered debridement'
begine at wound margins
thus each layer considered separately
surgeon can be selective in what is removed
Define 'en bloc' debridement
complete excision of the wound (as though it was a tumour) with no entry into the wound.
wound may be closed or packed with swabs to facilitate
result if a clean wound which may be closed primarily
but a larger wound
damage to surrounding vital structures
How do you deal with gross contamination of tissue that is not redundant?
mechanical removal followed by pressure lavage will remove most contaminants left after the initial debridement
What can you use for wound lavage?
18 guage needle attached to a 20ml syringe and a baf of fluids via a giving set and a 3-way tap
generally performed daily after changing the dressing
What liquid can you use to lavage a wound?
grossly contaminated tissue where high volume needed - tap water via shower head initially
definitive lavage - sterile isotonic fluid (Hartmann's solution or saline)
Add ABs (ampicillin, cefazolin, neomycin) or antiseptic (chlorhexidine, povidone iodine) sometimes but my be irritating, may inhibit GT formation and may cause sytemic toxicity
What is the best way of keeping a wound drained?
leave wound open
How can you increase wound drainage when you close the wound? 4
leaving part of wound open
fenestration of part of the covering skin surface (meshed free skin grafts)
physiologic implant (omentum)
synthetic implant (surgical drain)
How may the problem that 'exposed areas of bone dended of periosteum may not support a GT bed' be overcome?
drill small holes into cancellous bone (forage) to promote the coverage of cortical bone or by using a muscle flap to cover the bone