Download - WOUND AND MANAGEMENT
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WOUND AND MANAGEMENT
MAUNG MAUNG KYAW
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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
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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
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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
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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.
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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
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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
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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
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WO U N D A N D M A N AG E M E N T
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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
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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
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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,
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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WO U N D A N D M A N AG E M E N T – D M U L C E R
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WO U N D A N D M A N AG E M E N T - V E N O U S
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WO U N D A N D M A N AG E M E N T - A RT E R I A L
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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
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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