Wounds

Question 1

List and define the wound types.

Answer 1

Incision = clean straight line e.g. surgical procedure
Laceration = jagged edges, cuts to skin surface
Abrasion = damage to epithelial surface e.g. graze
Contusion = bruising
Puncture = deep, penetrating, infectious e.g. cat bite

Question 2

Describe the wound classifications.

Answer 2

Class 1 = 0-6hrs, minimal contamination
Class 2 = 6-12hrs, microbial burden has not reached critical level
Class 3 = 12hrs+, wound infection (do not want to surgically close these!)

Question 3

What considerations should we have when a patient presents with an open wound?

Answer 3

History, pre-existing conditions
Medications e.g. steroids
Breed, species, age
Position, type, cause of wound
Time since incident
First aid? Haemorrhage?
Owner compliance
Cost/insurance
Practice resources and expertise

Question 4

List the stages of wound healing.

Answer 4

Inflammatory phase (0-5 days)
Debridement phase (day 0+)
Repair/proliferation phase (day 3 - 4 weeks)
Remodelling phase (day 20+)

Question 5

Describe the inflammatory phase of wound healing.

Answer 5

Haemorrhage, vasodilation, increased vascular permeability

Question 6

Describe the debridement phase of wound healing.

Answer 6

Phagocytosis, migration of WBCs, removal of cellular debris

Question 7

Describe the repair/proliferative phase of wound healing.

Answer 7

Fibroblasts proliferate, collagen synthesis, epithelialisation and contraction

Question 8

Describe the remodelling phase of wound healing.

Answer 8

Wound contraction and remodelling of collagen fibres

Question 9

Why do we carry out wound lavage?

Answer 9

Reduce bacterial load - for every hour earlier lavaged, bacterial load halved!
Allows for visualisation of underlying tissues

Question 10

How do we carry out wound lavage?

Answer 10

Use 35/40ml syringe and 19G needle
Too much pressure can penetrate debris further into tissues!
Use isotonic saline to avoid damage to cells (never chlorhex!)

Question 11

What options do we have for allowing a wound to heal?

Answer 11

Primary wound closure (first intention)
Delayed primary closure (third intention
Contraction and epithelialisation (second intention)

Question 12

What considerations should we have when deciding to allow a wound to heal by second intention?

Answer 12

Topical agents?
Dressings
Types of bandage material
Client compliance
Cost
Expertise

Question 13

Why would we consider using negative pressure wound therapy (NPWT)?

Answer 13

Reduced oedema and exudate accumulation
Elimination of strikethrough because wound fluid is evacuated into collection canister
increased central wound perfusion and vascularisation
Rapid contraction and wound healing
Reduction in dressing changes

Question 14

Why do we use manuka honey in practice?

Answer 14

Broad spectrum antimicrobial activity
Anti-inflammatory properties
Shown to be effective against MRSA and Pseudomonas

Question 15

What considerations should we have when using honey for wound healing?

Answer 15

Higher level of exudate so consider dressings
Consider initial use to aid granulation then switch to hydrogel
Great for granulation but must stop using when sufficient to avoid over-granulation (excess scar tissue)

Question 16

Describe the use of silver in wound healing.

Answer 16

Topical agent in various forms e.g. creams/dressings
Primary benefit is antimicrobial effects - indicated for inflammatory phase

Question 17

Why would we use a wet-to-dry dressing?

Answer 17

Useful for debridement
Wet swabs on wound surface removed at change debrides surface of wound

Question 18

What are the cons of wet-to-dry dressings?

Answer 18

Environmental bacteria
Strikethrough
Discomfort
Gauze fibres left behind

Question 19

Describe hydrogel dressings.

Answer 19

E.g. Intrasite gel, GranuGel
Water-based, amorphous, cohesive
Applied to wound bed and covered with secondary, non-absorbent dressing

Question 20

Describe hydrocolloid dressings.

Answer 20

E.g. Aquacel, Granuflex, Hydrocoll
Carboxymethylated cellulose, pectin, gelatine
Forms a non-adherent gel on contact with wound
Not commonly used in open wound management

Question 21

Describe vapour-permeable films/membranes.

Answer 21

E.g. Primapore, Melolin
Sheet of absorbent material between two thin layers of film that contain small pores for movement of gas and fluid

Question 22

Describe foam dressings.

Answer 22

E.g. Kendall Foam, Allevyn, ActivHeal Foam
Hydrophilic dressings made of polyurethane foam
Adhesive or non-adhesive
With or without breathable film backing

Question 23

What considerations should we have when bandaging a wound?

Answer 23

Patient comfort
Patient interference
Secondary bandage concerns
How often to change
Position/area of wound

Question 24

What kind of bandaging can we do for expansive, body wounds?

Answer 24

Tie-over dressings

Question 25

Why might a wound not be healing?

Answer 25

Take pictures/measurements to record progression Microbial presence? Culture for antibiotics Patient/client factors

Question 26

What are some possible surgical reconstruction techniques?

Answer 26

Simple closure Subdermal plexus flap Axial pattern flap Free skin graft

Question 27

When is simple suturing most appropriate?

Answer 27

Primary/delayed primary closure

Question 28

What wounds are most appropriate for simple suturing?

Answer 28

Fresh wound, clean/clean-contaminated Shallow, not much skin loss E.g. sharp incisional injury Minimal surgical debridement

Question 29

What cons/complications can occur from simple suturing?

Answer 29

Relies on accurate wound assessment - can lead to breakdown Infection, non-viable tissue left behind, excess tension, inappropriate suturing

Question 30

How can we carry out simple suturing?

Answer 30

GA / sedation and LA Basic surgical kit only Can consider using staples on skin only wounds +/- bandage post-op

Question 31

What is the theory behind a subdermal plexus flap?

Answer 31

Generous plex of small arteries/veins in subdermal tissue under skin Skin elevated and dissected away, vessels preserved, skin elasticity allows skin to be moved to a larger defect

Question 32

What are the two named subdermal skin flaps?

Answer 32

Flank fold flap - inguinal wounds Elbow fold flap - axillary wounds

Question 33

When are subdermal flaps most appropriate?

Answer 33

Primary / delayed primary / secondary closure

Question 34

What are the pros of a subdermal plexus flap?

Answer 34

Simple yet versatile Good for medium-sized wounds Reduces tension

Question 35

What wounds are most appropriate for subdermal plexus flaps?

Answer 35

Fresh/bandaged for a while Clean or contaminated/dirty Any area, medium-sized, reduces tension Significant surgical debridement

Question 36

What are the cons/complications of subdermal plexus flaps?

Answer 36

Relies on accurate wound assessment, size limitations, damage to plexus possible Infection, non-viable tissue left behind Too big a flap = blood supply inadequate = vascular necrosis Poor technique = plexus damage = vascular necrosis

Question 37

What is the theory behind an axial pattern flap?

Answer 37

Incorporate direct cutaneous artery and vein in skin flap raised to cover large areas Less chance of breakdown due to vascular necrosis

Question 38

When is an axial pattern flap most appropriate?

Answer 38

Secondary closure

Question 39

What are the pros of an axial pattern flap?

Answer 39

Come with good blood supply Longer and wider flaps possible than subdermal Can offer rapid healing of chronic wound

Question 40

What wounds are most appropriate for axial pattern flaps?

Answer 40

Wound bandaged for a while Must be 'clean' at time of surgery Specific sites on body, large defects

Question 41

What are the cons/complications of an axial pattern flap?

Answer 41

Steep learning curve, catastrophic flap necrosis, good post-op care vital, cosmetic result?

Question 42

What is the theory behind free skin grafts?

Answer 42

Need healthy bed of granulation tissue and skin to 'grow' into tissue Sheet (creates a primary wound) / punch biopsy Useful for distal limbs where other closures not an option

Question 43

When are free skin grafts most appropriate?

Answer 43

Only for secondary closure

Question 44

What are the pros of free skin grafts?

Answer 44

Punch grafts simple Sheet grafts good for large extremity defects Offer rapid healing of chronic wound

Question 45

What wounds are appropriate for free skin grafts?

Answer 45

Need healthy bed of granulation tissue Useful for extremities where other closures not an option

Question 46

What are the cons/complications of free skin grafts?

Answer 46

Advanced procedure Good post-op care vital Partial/complete failure not uncommon

Question 47

Give some examples of open wounds.

Answer 47

Abrasion Avulsion Burn Degloving Incision Laceration Pressure sore Puncture Shearing

Question 48

Give some examples of closed wounds.

Answer 48

Contusion Crush injury Haematoma Hygroma

Question 49

How can casts/bandages cause wounds?

Answer 49

Open/closed Overly tight, inadequate padding, excess exercise, wet/dirty

Question 50

What initial considerations should we have before surgical reconstruction of a wound?

Answer 50

What wound have we got here? What cause/trauma have we got? What patient have we got here? When is this likely to go to surgery? Where is the wound?

Question 51

What are the three stages of skin healing?

Answer 51

Inflammation Proliferation Maturation

Question 52

What client factors affect surgical management of wounds?

Answer 52

Cost - bandaging may not be cheaper than surgery! Compliance - revisits, bandage management, medications Practicalities - more trips for bandaging than surgery? Distance to practice?

Question 53

What does TIME stand for?

Answer 53

Tissue Infection/Inflammation Moisture Epithelialisation

Question 54

What considerations should we have for removing non-viable tissue?

Answer 54

Viability assessment Timing of debridement Method of debridement

Question 55

How do we describe wounds that are too wet?

Answer 55

Macerated Excoriated

Question 56

How do we describe wounds that are too dry and how can we help these?

Answer 56

Desiccated - add moisture Eschar (scab) present - debride

Question 57

How can we assess epithelialisation of wounds?

Answer 57

Wound edges - pink smooth vs dark red uneven Measurements - length/width/depth Photos, drawings Tissue around wound - cellulitis, oedema, skin

Question 58

Why do we carry out wound lavage?

Answer 58

Rehydrate necrotic tissue Remove foreign material Reduce bacterial contamination Remove toxins/cytokines

Question 59

How can we carry out surgical debridement?

Answer 59

Sharp dissection to remove all contaminated/necrotic tissue Avoid damage to normal tissue

Question 60

How can we carry out non-surgical debridement?

Answer 60

Physical - using adherent dressings that remove tissue when dressing is removed Chemical - using chemical substances to remove dead tissue

Question 61

Why do we bandage open wounds?

Answer 61

Protect - self-trauma, contamination/environment, desiccation Provide - pain relief, immobilisation, pressure, topical medications Debridement - chemical/physical Moisture - keep moisture in/take excess moisture away