WOUND AND MANAGEMENT

MAUNG MAUNG KYAW

WO U N D A N D M A N AG E M E N T- D E F

• Wound - Breach in continuity of skin (usually trauma)

• To promote/ optimize the natural/ physiological repair process

• To reduce the complications – infection, delayed/ non-healing, deformity etc…

• To restore normal function and reasonable aesthetic results

WO U N D A N D M A N AG E M E N T- T Y P E S

• Surgical, Traumatic

• Chronic – failed to heal despite all efforts to promote healing

• - usually associated with underlying disease such as DM, vascular

insufficiency, mobility issue/ prolong pressure

WO U N D A N D M A N AG E M E N T- T Y P E S

• TYPES OF WOUND

• 1. CLEAN - sterile, clean environment - Hernia, Breast, thyroid, Laparoscopic procedure

• 2. CLEAN CONTAMINATED – wound involving normal but colonized tissue, elective

bowel operations, urinary tract

• 3. CONTAMINATED – a wound containing foreign or infected materials, bowel perforation

• 4. INFECTED – wound with frank infection, purulent fluid, pus

WO U N D A N D M A N AG E M E N T – 4 P H A S E S O F H E A L I N G

• Healing is a systematic process - 4 overlapping classic phases:

• 1. Hemostasis - Platelets play keyrole

• 2. Inflammatory phase - Inflammatory cells débride injured tissue .

• 3. Proliferative phase - Epithelialization, fibroplasia, and angiogenesis occur .

Granulation tissue forms and the wound begins to contract.

• 4. Maturation phase (Remodeling) - collagen forms tight cross-links to other

collagen and with protein molecules, increasing the tensile strength of the scar.

WO U N D A N D M A N AG E M E N T

Hemostasis Inflammatory Proliferative maturation

Platelets inflammatory cells Angiogenesis remodeling

Blood clot macrophage Granulation collagen

fibroblast wound contract Scar formation

WO U N D A N D M A N AG E M E N T- P H A S E S O F H E A L I N G

WO U N D A N D M A N AG E M E N T – H E A L I N G P RO C E S S

• Primary Healing (Healing by Primary Intension)

• Secondary Healing (Healing by Secondary Intension)

• Delayed Primary Healing

WO U N D A N D M A N AG E M E N T

WO U N D A N D M A N AG E M E N T – P R I M A RY I N T E N T I O N

- suture, clips/ staples, glue, skin tapes

- suture techniques – simple

interrupted, continuous, mattress,

dermal, subcuticular

- layers closure

WO U N D A N D M A N AG E M E N T – I N I T I A L M A N AG E M E N T

• ABCDE

• General assessment – life threatening, limb threatening

• Assessment of the wound

• Haemostasis

• Wound debridement – GA, Local

• Method of closure

• Dressing and follow up advice

• Analgesia, Tetanus Toxoid, Antibiotics

WO U N D A N D M A N AG E M E N T - H A E M O S TA S I S

• HAEMOSTASIS

• Pressure and Packing – direct / indirect

• Elevation – may be associated with fracture

• Tourniquet

• Surgical techniques – sutures, clips,

WO U N D A N D M A N AG E M E N T- D E B R I D E M E N T

• WOUND DEBRIDEMENT – G A, LOCAL ANAETHESIA

• Remove FB, dirt

• Wash/ irrigate/ syringing thoroughly – saline/ sterile water/ diluted betadine

• Lacerated wound – trimmed minimal – less skin loss

• Gentle handling of the tissue

• Abscess – open all locules

• Curette

WO U N D A N D M A N AG E M E N T

PRIMARY INTENSION SECONDARY INTENSION

WOUND EDGES APPROXIMATED

WITHOUT TENSION – elective, trauma

Clean wound

Plan – incision, good surgical access, less

trauma

Cosmetically appealing scar, blend with

surrounding skin with time

Normal function restore without any

complications

Less complications

WOUND – UNABLE TO CLOSE

Elective, Emergency, Trauma

Clean contaminated W

Contaminated W

Infected W

Heal by granulation tissue

Longer time to heal

Larger unsightly scar

Infection, complications

WO U N D A N D M A N AG E M E N T – P R I M A RY A N D S E C O N DA RY I N T E N S I O N

A . S I M P L E I N T E R RU P T E D H O R I Z O N TA L M AT T E R E S S V E RT I C A L M AT T R E S SB . RU N N I N G S T I T C HC . S U B C U T I C U L A R

WO U N D A N D M A N AG E M E N T – T R A U M A TO C H I N , A F T E R C L O S U R E

Most of the wounds achieve better results with closure.

WO U N D A N D M A N AG E M E N T – I N J U RY TO F I N G E R , A F T E R C L O S U R E

WO U N D A N D M A N AG E M E N T – L O C A L A N E S T H E S I A

• Lidocaine(Lignocaine)

• quicker onset, up to 1 – 2 hours

• +/- adrenaline 1: 100,000 , vasoconstriction – less bleeding

• Do not use in - Distal digital block, ear lobule, nose, penis

• 4 – 5 mg /kg (adrenaline – 7mg/kg)

• Bupivacaine – adults (0.25% - 25 mg in 10ml / 0.5% - 50mg in 10 ml)

• 2mg/kg

• Long acting up to 3 -5 hours

WO U N D A N D M A N AG E M E N T – L O C A L A N E S T H E T I C

• Half life – Lidocaine – 90 minutes

• Bupivacaine – 200 – 250 minutes

• Decline rapidly after peak concentration, within maximum 30 minutes

• Side effects - common

• Perioral numbness, metallic taste

• Dizziness, Agitation, Drowsiness

• Cardiac arrhythmia

• Respiratory arrest

• Hypersensitivity

WO U N D A N D M A N AG E M E N T – T Y P E S O F S U T U R E S

NON-ABSORBABLE

SYNTHETIC

- ETHILON

- NYLON

- PROLENE

NATURAL

- SILK

- STEEL

- COTTON

ABSORBABLE

SYNTHETIC

- MONOCRYL

-VICRYL

- PDS

NATURAL

- COLLAGEN

WO U N D A N D M A N AG E M E N T - S U T U R E S

Round body needle – use anywhere except

skin

Cutting needle – skin

Absorbable suture – anywhere except

cardio-vascular operation

Non-absorbable – skin closure,

if fixing the implant/ mesh/ prosthesis

should well covered not to contact with

skin

WO U N D A N D M A N AG E M E N T- C L E A N C O N TA M I N AT E D, C O N TA M I N AT E D, I N F E C T E D

CLEAN CONTAMINATED WOUNDS - more than 6 - 8 h – delayed primary closure

• Wound debridement and dressing

• Second look 48H

• Can be closed if clean

CONTAMINATED AND INFECTED WOUNDS – do not close

• healed by secondary intention

• injudicious closing – infection – delayed healing

• Wounds better healed by secondary intention -

concave surface of the face – nasal ala, pre-auricular sulcus, temple,

• Human bite, animal bites

WO U N D M A N AG E M E N T- FAC TO R S E F F E C T I N G T H E H E A L I N G

• Infection / Foreign body

• Malnutrition

• DM – microvascular disease, reduced O2, immunity, prone to infection

• Anemia - tissue hypoxia

• Smoking – direct toxic effect, vasoconstriction by nicotine

• Previous radiotherapy

WO U N D A N D M A N AG E M E N T - C O M P L I C AT I O N S

• Infection , stitch abscess, stitch granuloma

• Delayed healing

• Non healing

• Hyper granulation

• Hypertrophic scar

• Keloid

H Y P E RT RO P H I C S C A R K E L O I D

- are characterized by an accumulation of excess collagen with decreased lysis

H Y P E RT RO P H I C S C A R

Stay within the limit of original wound

May regress spontaneously

Occur soon after injury

Tends to associated with contracture

across the joint

K E L O I D

Can occur one year after the scar formation

May be continuation from the hypertrophic scar

continue to grow beyond the boundary of the scar

Usually not regress spontaneously

Deltoid area, ear lobule, chest

Dark skin individuals

Recurrence – very high

WO U N D A N D M A N AG E M E N T- H Y P E RT RO P H I C S C A R , K E L O I D

• Conservative

• Pressure garment

• Steroid injection

• Radiotherapy

• Laser therapy

WO U N D M A N AG E M E N T – C H RO N I C WO U N D ( U L C E R )

• Wounds failed to heal/ respond to initial management

• Often associated with underlying diseases such as DM, Lack of mobility/ stroke,

Vascular insufficiency, other like HF

• Pressure sore

• Diabetic ulcer

• Vascular ulcer (Venous/ Arterial)

WO U N D A N D M A N AG E M E N T – P R E S S U R E S O R E

WO U N D A N D M A N AG E M E N T – D M U L C E R

WO U N D A N D M A N AG E M E N T - V E N O U S

WO U N D A N D M A N AG E M E N T - A RT E R I A L

WO U N D M A N AG E M E N T – C H RO N I C WO U N D

• Regular wound care and dressing

• Correction/ optimization of the underlying diseases

• Surgical intervention – after careful consideration – wound debridement

• Amputation, skin graft/ flap

WO U N D A N D M A N AG E M E N T

• BASIC PRINCIPLES

• 1. HAEMOSTASIS

• 2. CLEANING OF THE WOUND

• 3. SKIN CLOSURE

• 4. DRESSING AND FOLLOW UP ADVICES

• 5. ANALGESIA / ANTIBIOTICS