Wound ManagementDr Sumer Yadav

• “the primary goal of wound care is not the technical repair of the wound; it is providing

optimal conditions for the natural reparative processes of the wound to proceed”

• – Richard L. Lammers (Roberts and Hedges)

plastic surgeon consultation (a) the acute wound where the final

appearance may be the principal concern, (b) the wound in a patient

whose medical status and/or mode of injury predisposes her to wound

healing difficulties and the threat of a problem wound, or (c) the

established chronic wound refractory to past interventions.

GOALS of wound care

• Facilitate hemostasis• Decrease tissue loss• Promote wound healing• Minimize scar formation

TYPES of Wound Healing1.) Healing by first intention (aka. primary wound healing or primary

closure)• wound closed by approximation of wound margins or by placement of

a graft or flap, or wounds created and closed in the operating room.• Best choice for wounds in well-vascularized areas• Indications -recent (<24h old)

-clean-viable tissue-tension-free

• treated within 24 h, prior to development of granulation tissue.• epithelialize within 24 to 48 h. Water barrier function restored can

shower or wash.

2.) Healing by second intention (aka. secondary wound healing or spontaneous healing)

• wound left open and allowed to close by epithelialization and contraction.

• Commonly : management of contaminated or infected wounds.• without surgical intervention.• Unlike primary wounds, approximation of wound margins occurs

via reepithelialization and wound contraction by myofibroblasts.• Presence of granulation tissue.• Complications -late wound contracture

-hypertrophic scarring

• 3.) Healing by third intention (aka. tertiary wound healing or delayed primary closure)

• wounds that are too heavily contaminated for primary closure but appear clean and well vascularized after 4-5 days of open observation.

• Inflammation reduced bacterial concentration (“debribe”) allow safe closure.

• Indications :- infected or unhealthy wounds with high bacterial content,

-wounds with a long time lapse since injury, or -wounds with a severe crush component with significant tissue devitalization.

• Wound edges are approximated within 3-4 days• tensile strength develops as with primary closure.

Factors that affect wound healing

• In general, remember “DIDN'T HEAL”• D = Diabetes: -diminishing sensation and arterial

inflow ++ acute loss of diabetic control diminished cardiac output, poor peripheral perfusion, and impaired polymorphonuclear leukocyte phagocytosis.

• I = Infection: -potentiates collagen lysis. Bacterial contamination + susceptible host + wound environment = wound infection. Foreign bodies (including sutures) potentiate wound infection.

DIDN’T HEAL

• D = Drugs: Steroids and antimetabolites impede proliferation of fibroblasts and collagen synthesis.

• N = Nutritional problems: Protein-calorie malnutrition and deficiencies of vitamins A (collagen synthesis, antioxidant), C (collagen synthesis), and zinc (fibroblast proliferation ).

• Malnutrition- Impaired organ function, Impaired collagen synthesis, Impaired immune function, Reduced antioxidant activity

• T = Tissue necrosis, from local or systemic ischemia or radiation injury. Blood supply is important.

DIDN’T HEAL

• H = Hypoxia: -esp the distal extent of the extremities. Blood volume deficit, unrelieved pain, or hypothermia sympathetic overactivity local vasoconstriction Inadequate tissue oxygenation.

• E = Excessive tension on wound edges local tissue ischemia and necrosis.

DIDN’T HEAL

• A = Another wound: Competition for the substrates required for wound healing.

• L = Low temperature: (relatively) distal aspects of the upper and lower extremities (a reduction of 1-1.5°C [2-3°F] from normal core body temperature) is responsible for slower healing of wounds at these sites.

Basics

• Wound evaluation and history• Wound preparation and closure• Optimize systemic parameters• Debride nonviable tissue• Reduce wound bioburden• Optimize blood flow• Reduce edema• Use dressings appropriately• Use pharmacologic therapy• Close wounds with suturing/grafts/flaps as indicated

Wound Evaluation -HISTORY• identify all extrinsic and intrinsic factors that

jeopardize healing and promote infection– mechanism of injury– time of injury (accelerated growth phase of

bacteria starts at 3 hours post wound)– environment in which wound occurred

potential contaminants, foreign bodies

– species of animal if bite wound– pt’s medical problems (allergies to medication) / immune status

• tetanus immunization status

Wound assessment

• Examine for:– amount of tissue destruction– degree of contamination– damage to underlying structures

•Body Location –Proximity to Other Structures –Joints –Nerves –Tendons–Vasculature –Test integrity of each structure

•Assess laxity/muscle and tendon function•Assess 2-point discrimination•Assess vascular supply

Physical examination

• Wound Location– importance in the risk of infection– high endogenous bacterial counts in hairy

scalp, forehead, axilla, groin, foreskin of penis, vagina, mouth, nails

– wounds in areas of high vascularity moreeasily resist infection (scalp, face)

Wound Preparation - Anesthesia• Topical

– Solution or paste– LET– TAC– EMLA

• Local– Direct infiltration– 1% lidocaine with or without epinephrine– Bupivicaine or sensorcaine for longer acting anesthesia

• Regional Block– Local infiltration proximally in order to avoid tissue disruption– Smaller amount of anesthesia required

Local anestheticDrug Max Dose Onset Duration

Cocaine 6.6 mg/kg Rapid 1 hour

Procaine 10-15 mg/kg Rapid 30min-1hr

Tetracaine 1.5 mg/kg Moderate 2 hours

Lidocaine 5 mg/kg 5-30 min 2 hours

(with Epi) 7 mg/kg 5-30 min 2-3 hours

Bupivacaine 2 mg/kg 7-30 min > 6 hours

Epinephrine

• Vasoconstrictive –Increases Duration of Action–Promotes Hemostasis–Avoid end-arterial blood supply areas–May increase pain (low pH)

Wound Preparation - Hemostasis• Direct Pressure–Usually best choice • Ligatures

– Use a tourniquet• Chemicals

–Epinephrine–Gelfoam–Oxycel–Actifoam

• Cautery

Debridement & Reduction of Bioburden

• Surface irrigation with saline.• Debridement: surgical, enzymatic (papain with urea,

collagenase), mechanical (pressurized water jet), autolytic, maggots.

• Antibiotics: cellulitis, decreased rate of healing, increased pain, straw colored oozing from skin, contaminated wounds, mechanical implants.

• Removal of FB.

Wound Preparation – Foreign Body Removal

• Suspect with point tenderness• Visual inspection (to the apex)• Imaging

– Glass, metal, gravel fragments >1mm should be visible on plain radiographs

– Organic substances and plastics are usually radiolucent

• Always discuss and document possibility of retained foreign body

Wound preparation : CLEANING• high pressure irrigation (Normal Saline)• min 100-300 ml with continued irrigation• at least 8 psi force to the wound the irrigation fluid

dislodges foreign bodies, contaminants, and bacteria.• A simple device setup 30-60 ml syringe and an 14-gauge angiocatheter.

Hair removal

• Shaving –Increases risk of infection X 10 !• Clip Hair with Scissors • Matt Hair with Ointment

• Never shave eyebrows ( may not regrow )

Wound Preparation – Debridement

• Removes devitalized tissue• Creates sharp wound edge• Excision with elliptical shape• Respect skin lines

Wound closure in relation to time

• Primary closure– Suture, staple, adhesive, or tape– Performed on recently sustained lacerations: <12 hours

generally and <24 hours on face

• Secondary closure– Secondary intent– Allowed to granulate

• Tertiary closure– Delayed primary (observed for 3-4days)

SUTURE TECHNIQUES

• Deep layer approximation– Absorbable sutures– Buried knot– Serves two purposes

• Closes potential spaces• Minimizes tension on the wound

margins

Skin Closure

• Key – wound edge eversion• “Approximate, don’t strangulate”• Anticipate wound edema• Choose appropriate size of suture for location

of laceration

Other devices in wound closure• Staples

– Quick, poor aesthetic result– where scar is less of an issue (hairy scalp)

• Adhesives– Dermabond– clean, sharp edges, clean nonmobile areas, laceration

less than 5 cm in length• Tape

– Steri-strips– superficial, straight laceration under little tension

After care•Wound Dressings • Maintain moist –24 –48 hours

–Augments reepithelialization •“Water-Tight” after 48 hours•Bandages–Soft-splint–Absorb exudates–Protects Wound–Protects knots

Optimize systemic parameters

• Age: cannot be reversed, usage of growth factors, aggressive optimization of systemic parameters & supplementation.

• Avoidance of ischemia & malnutrition.• Correction of diabetes, removal of FB.• Avoidance of steroids, alcohol, smoking.• Avoidance of reperfusion injury: total contact

casting, compression therapy.

Optimize systemic parameters-nutrition

• Glucose -give energy for angiogenesis and the deposition of new tissue.

• Fatty acids-essential for cell structure and have an important role in the inflammatory process.

• Protein deficiency-contribute to poor healing rates with reduced collagen formation and wound dehiscence.

• Vitamins- vitamins A (collagen synthesis, antioxidant), C (collagen synthesis), and zinc (fibroblast proliferation )..

Optimize blood flow & oxygen supply

• Warmth• Hydration• Surgical revascularization• Hyperbaric O2 therapy: limb salvage.

Reduce edema

• Elevation • Compression• Negative pressure wound therapy: removes

pericellular transudate & wound exudate as well as deleterious enzymes. Cannot be used in ischemic, badly infected or inadequately debrided wounds or in malignancy.

Indications for systemic antibioticfor traumatic wounds

• Injury 6 hours old on the extremities• Injury 24 hours old on the face and scalp• Tendon, joint, or bony involvement• Cartilage involvement• Mammalian bite• Co-morbidity (diabetes mellitus, extremes of age,

steroid use, morbid obesity)• Puncture wound• Complex intraoral wound

Wound preparation -Tetanus prophylaxis

• Clean wounds– Incompleted immunization toxoid– >10 years, then give toxoid

• Tetanus prone wound– Incompleted immunization Toxoid &

immunoglobulin– > 5 years, give toxoid

Dressings

• Absorption characteristics: none – films, low – hydrogels, moderate - hydrocolloids, high – foams, alginates, collagen.

• Hydrogels (eg. starch) rehydrate wounds (benefit in small amounts of eschar, infected wounds).

• Hydrocolloids promote wound debridement by autolysis.

• Antimicrobial dressings: silver, cadexomer iodine, mupirocin, neomycin.

Suture removal guidelines

• Anatomic location Days (average)face 3-5arm 7

anterior trunk 7back 10-14feet and hand 10-14joint 10-14 scalp 10-14

Skin Substitutes• Autologous keratinocyte sheets.• Biobrane• Oasis• Alloderm• Integra (sites prone to contracture, coverage of

tendons, bone, surgical hardware)• TransCyte• Dermagraft• Orcel

Collagen & chondroitin sulphate : Integra

Apligraftrade: skin substitute containing collagen and seeded cells

Alloderm: immunologically inert, nonliving, allogenic, acellular dermal matrix with intact basement membrane prepares wound bed for grafting

Tegaderm

Used for simple shallow wound dressing Protects from water loss mechanical injury and drying

TransCyte (ECM matrix generated by allogenic human dermal fibroblasts serves as a matrix for neodermis generation

ORCEL: Composite cultured skin. Fibroblasts, keratinocytes seeded on opposite sides of bilayered matrix of bovine collagen

Dermagraft living allogenic dermal fibroblasts grown on a degradable scaffold. Good resistance to tearing

Pharmacologic therapy

• Antimicrobials• PDGF- becaplermin- US-FDA approved –

dibetic foot ulcers• EGF- under trial• VEGF- under trial• Vit A: steroid use• Absolutely of no use in normally healing

wounds

Flaps & Grafts

• Radiation wounds require flaps.• Chronic nonhealing ulcers.• Extensive areas of ulceration.• Major soft tissue loss.• Other therapies: electrical stimulation for

recalcitrant ulcers.

beta-Glucan stimulates the macrophage activity and promotes rapid wound healing.

Beta-Glucan Collagen mesh or Glucan II (Beta-Glucan) mesh. . Rapid healing without dressing changes painless treatment.

BIOLOGIC DRESSINGS

HONEYSOFT

Natural dressingHoney-impregnated dressing Chronic unhealing wounds. Impregnated into a compress of EVA (ethylenevinylacetate) mesh

Honey cleans the wound without disturbing it Removing the dressing causes no damage no known side effects

NPWT/VAC

• expeditiously prepare a wound bed for surgical closure by tertiary intent.

• works through- relief of edema, improving interstitial diffusion of oxygen to cells, removes deleterious enzymes

• most wounds will heal optimally with a pressure of 125 mm Hg, other wounds may only tolerate a setting of 75 mm Hg before capillary flow is occluded.

NPWT/VAC

• Indications- lymphatic leaks, venous stasis ulcers, diabetic wounds, and wounds with fistulae , sternal wounds, orthopedic wounds, and abdominal wounds

• Some instances, it has enabled avoidance of free flaps can also be used to assist the neovascularization of skin grafts and tissue engineered skin substitutes

• Contraindications- malignancy, ischemia, inadequately debrided or badly infected wounds

Hyperbaric Medicine• (HBO) (typically, 100% O2saturation at 2 to 3 ATA)

raises the dissolved oxygen saturation in plasma from 0.3% to nearly 7%.

• • Stimulates angiogenesis and fibroblast migration,

enhances neutrophil and antibiotic killing action, and suppresses alpha toxin production in gas gangrene.

• if the periwound area/extremity demonstrates a rise in tcPO2when the patient inspires supplemental oxygen, the patient is likely to benefit from HBO.

• not benefit from HBO: those with a normal environmental perfusion, and those with ischemic limbs who need a bypass to restore blood flow to a limb

Patients with irradiated skin or steroid users

• Patients who are on steroids should receive vitamin A (25,000 IU daily by mouth or 200,000 IU topically t.i.d.).

• The progressive endarteritis obliterans and microvascular damage, along with fibrotic interstitial changes, results in a wound marked by ischemia, hampered by cellular senescence, and prone to infection.

• gingerly debrided, antimicrobial dressings, growth factors and even hyperbaric oxygen therapy, microvascular free flap.

Pressure sore care

• Should be aggressively nourished and receive vitamin supplementation.

• administration of growth hormone or anabolic steroids.

• Debridements• Dressings• air-fluidized beds, air mattresses, air flotation

and water flotation devices, and low air-loss beds.

Wound Care in Patients with Diabetes

• components of pressure necrosis, functional microangiopathy, and true neuropathic derangements.

• Selective debridement, control of glucose levels, pressure offloading.

• Revascularization• use of growth factors

Wound Care in Patients with Venous Stasis Ulcers

• Compression therapy is essential for venous stasis ulcers.

• stockings, elastic wraps, and multilayer wraps, Unna boot-paste dressings and low-stretch bandages.

• contraindicated in patients with an ABI <0.7• ideally the pressures exerted should be between 30

and 40 mm Hg• continued for several weeks following successful

closure of the wound.

“ God heals, and the doctor takes the fees ”

Benjamin Franklin(American Statesman, scientist, Philosopher)