Wound management Flashcards
(42 cards)
Wound Classification Based On The Degree of Contamination
- Clean
- Clean-Contaminated
- Contaminated
- Dirty / Infected
clean wound criteria
- Non traumatic (surgical) uninfected wound
0 - No communication with:
- Oropharynx
- Respiratory tract
- Gastrointestinal tract
- Urogenital tract
Clean Contaminated criteria
- Operative wounds involving oro-pharynx, digestive, respiratory or urogenital tract without major contamination (no spill)
- Operative wounds with minor contamination due to minor break in aseptic technique (punctured glove)
- Recent clean wound with minor contamination (<6h)
Contaminated wound criteria
- Open traumatic wounds
- Operative wounds with major break in sterile technique
- Incision made in area of acute, non purulent inflammation
- Wound into the colon
Dirty / Infected wound criteria
- Older traumatic wounds
- Purulent wounds
- Wound with perforated viscera / peritonitis
Timeline and Wound Classification
> golden period
“The Golden Period”
* It takes approximately 6 hours to go from 100 to >100 000 bacteria per gram of tissue
* Wound goes from clean-contaminated or contaminated…to infected
* May not always be accurate. Use common sense but the sooner you intervene, the better… and after that, likely need to treat as contaminated or infected
Stages of Wound Healing
Inflammatory phase (Days 0 to 5)
* Acute inflammation, attraction of PMN’s and Macrophages
* Debridement phase
Repair phase (Days 4-12)
* Capillary ingrowth, granulation tissue formation
* Fibroblasts migration / proliferation / contraction
* Epithelial proliferation / migration
Maturation phase (months)
Initial Assessment for wounds
- Assess all systems for more serious problems (pneumothorax, fractures, etc.)
- Cover any wounds with a clean or sterile dressing as soon as possible to prevent further contamination and hemorrhage
- Assess & treat covered wounds ASAP
The cause of a wound may affect what?
The cause may affect the level of contamination, guide treatment and may affect prognosis
* Cause: bite wound vs laceration
* Contamination: soil, grass, hair, oil, etc.
* Will typically slow down healing
Early surgical closure of a contaminated wound will likely lead to…
infection and dehiscence (break-down)…
Initial Wound Management 101
- considerations right off the bat
- protecting the wound
- Reduce Future Contamination
- Sedation & analgesia (painful)
**General anesthesia may be necessary
for initial wound assessment (if patient is stable) - Attire: surgical cap, mask + sterile gloves - to prevent nosocomial infections
- Cover the wound with sterile aqueous based lubricant / wet gauze
* Prevent further contamination from adjacent skin and fur - Clip liberally (>10cm) around the wound
* Anything that will be included in bandage
* 360 degrees for limbs
* No hair should touch the wound - Skin preparation
* Standard surgical skin prep on periphery of wound
* No alcohol in or close to the wound
Sterilely Probe Puncture Wounds to…
Assess Dead Space and Tissue Trauma
Immediate Wound Care - how to irrigate and why
- Irrigation: reduce microbial burden and wound contaminants
> Large amount
> Low Pressure - Tap Water is good initially
> Inexpensive so can use a lot - Pressure 7-8 PSI
> IV bag under 300 mmHg pressure and 18G needle
> Perforated 500ml saline bottle
> 35 cc syringe with 18G needle or catheter
sterile wound irrigation - how to? what not to do?
Sterile Saline or LRS
* By itself or with:
> Povidone Iodine 0.1% (1/10 of the 1% solution) or
> Chlorhexidine 0.05% (1/40 of the 2% solution)
* Good for small wounds or as a finishing solution for large wounds
* Do not use sterile water, distilled water, alcohol or hydrogen peroxide: Cytotoxic!
Debridement - what is it? purpose?
Removal of gross debris
& necrotic tissues (instruments / lavage / gauze / adherent bandage)
* Decrease inflammation
* Minimize bacterial growth
* Speed healing
How aggressive depends on:
* Location, superficial or deep wound, amount of trauma / debris
* Wound to remain open allowing further debridement later or closed at 1st surgery?
Surgical Debridement - how to? what if wound cant be closed?
- Often repeated over several days
- Begin at the skin edges and work inward
- If the wound can’t be closed (not enough tissue or too dirty), don’t debride the edges, and
only remove tissues that are
obviously necrotic (black, grey or
white, non pliable & cool, non bleeding) - Red or purple tissue may still live so wait and reassess at next bandage change, usually in 24h
Surgical Debridement - what if the wound communicates with the chest or abdomen?
If the wound communicates with the chest or abdomen (deep wound) this is your only chance because you will need to close so remove anything that looks suspicious
type of surgical debridement
Layered Debridement vs en-block
when to use En-Bloc Surgical Debridement
- Area with a lot of skin / tissues (thorax, neck, abdomen)
- Remove all the contaminated tissues en-bloc
- Might allow to close primarily but is rarely possible…
Now that you lavaged and debrided the question is: should you close? consider:
- Time elapsed ? Golden period???
- Etiology ?
- Residual necrotic tissue ?
- Communication with cavity**
- If the wound is superficial, you debrided and lavaged within 3-6 hours or less and no necrotic, dirty, or suspicious tissue was left in the wound bed - you can probably perform primary closure +/- drain
- If communicates with cavity – will need to close
which wounds to Treat as Open Wounds?
- Severely traumatized tissues
- Contaminated wounds
- Wounds older than 6 hours
- Infected wounds
- Wounds that can’t be closed…
… Treat as open wounds to allow sequential débridement and decrease bacterial numbers, it might only take 24hrs to be good enough to close but it could also take days or weeks…
second intention healing considerations for cats
- Second intention healing is slow for cats and they have a lot of skin to close wounds with!
Open Wound Management
Initially:
1. Daily bandage changes (‘sterile’ conditions) 2. Daily lavage & debridement (if required) 3. Daily assessment to determine the next step 4. Re-apply sterile wound dressing
- Repeat over several days providing an environment for proliferation and then reduce the frequency of bandage changes or, if appropriate, proceed with surgical closure
Non-Surgical Debridement - when to use, how to / options
For less contaminated wounds or for extra debridement following surgical debridement in an open wound
- “Wet to Dry” (Mechanical)
>Dries and adheres to wound and is then removed
> Non-selective debridement
> Destroys healthy epithelium and granulation tissue - Hyper-osmotic dressings (Autolytic)**
> honey, sugar - Enzymatic
> Papain, Trypsine, Urea, Collagenase
> Expensive, rarely used - Maggots (Biotherapeutic)
