T1 Lecture 2: Fundamentals of Wound Management (classification of wounds)

Question 1

How do we classify wounds?

Answer 1

class 1 is within 0-6 hours of wounding

Class 2 –Within 6-12 hours of wounding

Class 3 - > 12 hours of wounding

Question 2

How do we classify class 1?

Answer 2

Within 0-6 hours of wounding

– Minimal contamination or tissue damage

– “Golden Period” = Insufficient microbial replication to cause infxn. &
can usually manage w/ 10 closure

Question 3

How do we classify class 2?

Answer 3

Within 6-12 hours of wounding

– Microbial replication to critical level possible but “Gldn. Period” still in
play

Question 4

How do we classify class 3?

Answer 4

> 12 hours of wounding

– Microbial replication at critical level allowing for infection
• >105 bacteria/g tissue

Question 5

What are the types of wound closures?

Answer 5

• Primary Closure (1st Intention)
• Delayed Primary
• Secondary Closure
• Second Intention Healing

Question 6

State the type of closure:

– Class 1 (& some 2) wounds

Answer 6

Primary Closure 1st intention

most common

Question 7

State the type of closure:

– Appositional closure before
granulation tissue develops
• W/in 3-5 days of wounding

– Good for Class 2 wounds

Answer 7

Delayed Primary

Question 8

State the type of closure:

– Appositional closure after
granulation tissue has developed
• > 3-5 days after wounding

Answer 8

Secondary Closure

Question 9

State the type of closure:

– Healing by
contraction/epithelialization

– Open wound management (OWM)

Answer 9

Second Intention Healing

Question 10

Name the 8 points of the algorithm for fundamentals of wound management

Answer 10

GPAL Puts dedicated swimming plans

1. Global patient assessment
2. Prevent nosocomial contamination (cover the wound)
3. Aseptically” clip & scrub area
4. Lavage, Lavage…Lavage
5. Procure culture of wound
6. Debridement
7. Select appropriate surgical closure method
8. Provide drainage if necessary

Question 11

When you assess the patient what do you address first?

Answer 11

life threatening problems first

Question 12

Describe the phase?

• Thorough history from owner
– How did injury happen – Polytrauma?
– Likelihood of severe contamination
• Hx of other systemic disease or medications?
– Age  Start thinking about how they can heal
• Global prognosis
– Be realistic w/ the owner up front if it’s real bad
• How will analgesia be maintained throughout
the assessment & management period?

Answer 12

Assess the Patient

Question 13

le patient’s that are wounded but not acting painful are _____ _____

Answer 13

STILL PAINFUL

Question 14

What kind of anesthesia for evaluation and closure does Dr. C Like?

Answer 14

Local analgesia

Question 15

Some form of protective bandage w/ or w/out rigid stabilization
indicated for ____ ____ on entry to hospital

– If stable do not place pet in cage unless it has bandage!

Answer 15

all wounds

Question 16

When aseptically clipping the scrub area, how do you initially protect the wound?

Answer 16

Protect wound w/ sterile lubricant or saline soaked sponges

Question 17

Hair may be clipped from the wound margin w. scissors dipped in ____ ___ to
prevent hair from falling into the wound

Answer 17

mineral oil

Question 18

Can you use alcohol in an open wound to initially get rid of material

Answer 18

Alcohol damages open tissue = Never use

Question 19

Scrub the on the wound or around the wound? Why?

Answer 19

Around the wound,

– Detergents in antiseptic scrubs cause irritation, toxicity
& pain in exposed tissue & may potentiate wound infection

Question 20

What must you do and make sure of when aseptically clipping and scrubbing?

Answer 20

Make sure patient is stable before transitioning to

this step. Often requires sedation or anesthesia

Question 21

Describe what is taking place during lavage and why we do it?

Answer 21

Initial wound mgt. begins w/ removal of gross contaminants & copious lavage

– Reduces bacterial numbers mechanically by loosening and flushing away bacteria & associated necrotic
debris

Question 22

What is the preferred lavage solution?

Answer 22

Sterile isotonic saline or a balanced electrolyte solution (i.e. LRS) (TEST)

Question 23

Antibiotics or antiseptics (e.g., chlorhexidine or povidone-iodine) in the lavage solution reduce bacterial numbers but what must they do before they are used?

Answer 23

These agents may damage tissue – Must dilute appropriately!!!

Question 24

Do antiseptics work in an active infection?

Answer 24

No! Little effect

Question 25

Would you rather lavage or scrub the wound with tissues? Why or why not?

Answer 25

Lavaging = Preferred to scrubbing the wound w/ sponges – Sponges inflict tissue damage that impairs the wound’s ability to resist infection & allows residual bacteria to elicit an inflammatory response

Question 26

What is the ideal percentage and ratio for chlorhexidine solution and povidone iodine solution?

Answer 26

• 0.05 % Chlorhexidine solution (1:40) • 0.1 % povidone-iodine solution (1:100)

Question 27

Describe the use of tap water for gross contamination as an lavage?

Answer 27

Use of running, luke warm tap water for initial cleaning of a heavily contaminated sheering wound ** Tap water is effective & less detrimental than distilled or sterile water, although it causes some hypotonic tissue damage (cellular & mitochondrial swelling)**

Question 28

What are the 4 main goals of lavage?

Answer 28

• Remove particulate debris and bacteria via mechanical contact, inertial forces & fluid dynamic forces * Remove exudates from infected wounds * Dilute & remove toxins associated w/ infection * The forces that must be overcome to remove bacteria from wound beds include capillary, molecular & electrostatic adhesive forces generated by the bacteria

Question 29

Describe what the new gold standard is for evaluation of fluid pressure of common wound flushing techniques

Answer 29

1L Saline solution bag placed in a pressure cuff, at a cuff pressure of 300 mm Hg = most consistent technique for generation of 7 to 8 psi 👍 *Size of needle does not matter*

Question 30

Why can't we use the bottle method as a wound flushing technique?

Answer 30

Highest pressure generated w/ the bottle was 3.90 ± 1.30 psi (mean ± SD) w/ a 16-ga needle & full 1-L bottle Might be sufficient to flush bacteria out of a musculoskeletal wound but is not sufficient to flush out foreign material Failed to produce pressures of 7 to 8 psi b/c bottles were too difficult to squeeze efficiently **Not recommended for highly contaminated wound lavage**

Question 31

How much should you flush

Answer 31

* Available studies indicate amounts between 200-500 mL/wound * Wound surface area-based protocols = ~50 mL of fluid/cm3 of wound * Based on this clinical variation  500 mL of fluid for an average wound = Adequate * Use judgment = Wounds that have high levels of debris contamination, high bioburden debris (i.e. feces) or that occur in immunocompromised patients should be more aggressively irrigated * Amount of irrigant & type of irrigation used should always be documented in the medical record

Question 32

What do you do with Minimally/moderately contaminated wounds < 6 to 8 hrs old?

Answer 32

Clean & close w/out culture or use of prophylactic | abx

Question 33

What do you do with Severely contaminated, crushed/infected wounds, or wounds > than 6 - 8 hours? When do you take these?

Answer 33

Culture – Samples can be obtained from the wound during the initial wound exploration or during initial debridement – Clip, clean & lavage wound prior to procuring culture – If antimicrobial flush solutions are employed = Collect samples before these solutions are used

Question 34

Culture from _____ ____ is preferred (why?)

Answer 34

Culture from initial debridement = Preferred – Superficial contaminants removed = Sample more representative of the level of infection & the organisms involved – Procure block of tissue for sample = Higher diagnostic yield