Wafer Aldulaimi

Wash the wound

Sumerians used beer and oil to the wound

Oil –bacteria grow poorly in oil and dressings become non adherent

Honey: Now known to be antibacterial

Grease (animal fat): Barrier to bacteria

Wound edges were held together with thorns or linen strips soaked in gum (steri strips!) or ant pincers

Also bound ulcerating lesions with figs that contain papain( proteinase)

 

Hippocrates (2500 years ago) wrote of:

Washing wound with wine and vinegar (acetic acid)

Relieving pressure to avoid cutaneous wounds (pressure ulcers)

Described surgical drainage of pus with piece of tin pipe

Aurelius Celsus :Described four cardinal signs of inflammation Rubor, Calor, Dolor and Tumor

Believed in keeping wound moist so wound would close

Wound cavities were filled with sea sponges ,sometimes soaked in wine or vinegar

Pare’ was official royal surgeon to kings Henry II.

Pare’ –cauterized amputation’s with red-hot iron or oil.

 

Alexander Fleming : penicillin in 1929

Topical products :Hydrocolloids , Hydrogels ,Calcium alginates/hydrofibers , Foams , Starch dressings , Enzymatic debriders

Antibiotics

Surgical debridement

Renewed interest in ancient remedies → honey

Renewed interest in maggots (“Biosurgery” )

Ultraviolet light

Laser

Hydrotherapy

Electrical stimulation

Ultrasound

Growth factors impregnated dressings

Skin substitutes → synthetic and biologic

Growth factor revolution –actively manipulate wound healing → angiogenesis

Gen therapy

Nanotechnology : Drugs directed to specific aspects of wounds , Manipulating of angiogenesis

By time of healing

By morphology

By etiology

Acute

An acute wound is an injury to the skin that occurs suddenly rather than over time.

It heals at a predictable and expected rate according to the normal wound healing process

Examples:

Surgical wounds (surgical)

Traumatic wounds (puncture wounds, cuts, abrasions, burns, frostbite, chemical burns , radiation etc.)

Infection-related wounds

Chronic Wounds

A chronic wound develops when any acute wound fails to heal in the expected time frame for that type of wound, which might be a couple of weeks or up to 12 weeks in some cases.

The black, yellow and red wound

Black necrotic wound

Yellow wound

Red wound

Decubitus (pressure ulcers / sores)

Venous ulcer (venous-related wounds)

Arterial ulcer (ischaemic wounds)

Arterio-venous ulcer cruris (mixed wounds)

Diabetic ulcers (ulcers caused by diabetes mellitus)

• Infected wounds

• Immunological wounds

• Cancer wound

Etiology

In 1860, Florence Nightingale wrote :“If he has a bedsore, it is generally the fault not of the disease but of the nursing.” 

The main cause is unrelieved pressure to a location of skin on the body. This constant pressure inflicts damage by decreasing the area’s blood supply and traumatizing the skin.

• Stages

• Treatment

 – Debridement of all necrotic tissue

 – Maintenance of a favorable moist wound

environment

 – Relief of pressure

 – Addressing host issues such as nutritional,

metabolic, and circulatory status

• Venous ulcers are the most common type of ulcers occurring in the lower limbs.

• Venous insufficiency leakage of :

– Fibrinogen perivascular cuffing that affects oxygen exchange loss of subcutaneous fat

– Leakage of hemoglobin brownish pigmentation

This combination lead to characteristic skin changes called lipodermatosclerosis

 

Treatment

Compression therapy + wound care

• Symptoms of peripheral ischemic changes :

– Intermittent claudication– Rest pain – Night pain – Diminished or absent pulses, – Decreased ankle-brachial index

Poor formation of granulation tissue – Dryness of skin – Hair loss ,Scaling – Pallor – The wound itself usually is shallow with smooth

margins, and a pale base and surrounding skin

Ankle brachial pressure index = 0.9 - 1,2

Treatment

Revascularization + Wound care

• These ulcers cause considerable pain and distress for patients and pose a difficult wound-management problem for health professionals.

• Many patients have significant oedema due to venous insuficiency that needs to be controlled but also have some degree of arterial disease (atherosclerosis) where compression bandaging is contraindicated.

Treatment

• Reduced compression strength

• No compression when ankle pressure below 80 mmHg or ABI below 0.7

• If the ankle pressure is below 60 mmHg or the ABI is below 0.5, revascularization is recommended.

• Wound care

Etiology

• 60 to 70% are due to neuropathy

• 15 to 20% are due to ischemia 

• 15 to 20% are due to a combination of both

• The neuropathy is both sensory and motor, and is secondary to persistently elevated glucose levels

• The loss of sensory function allows unrecognized injury to occur from ill-fitting shoes, foreign bodies, or other trauma

 

• The motor neuropathy or Charcot foot leads to collapse or dislocation of the tarsometatarsal or metatarsophalangeal joints

• There is also severe micro- and macrovascular circulatory impairment

 

Charcot foot

Treatment

 

• Adequate blood sugar levels

• Wound care

• Charcot foot: splinting and non weight bearing

• Prevention: regular check , non compressing shoe , etc.

Traditionally, wound microbiology has been described in three phases:

– Contamination refers to the presence of bacteria that are not multiplying.

– Colonization refers to bacteria which are growing within the wound but not causing tissue damage.

Infection : Bacteria causing tissue damage and clinical signs of infection.

Treatment

• Debridment

• Antibiotics

• Consider biofilm !

Biofilm

• It is an aggregate of microorganisms embedded within a self-produced matrix of extracellular polymeric substance (EPS).

• Bacteria embedded within biofilms are resistant to both immunological and non- specific defence mechanisms of the body.

• Treatment is by mechanical removal

• Vasculitis

• Pyoderma gangraenosum

Treatment

1. Corticosteroids and immune modulators

2. Gentle wound care

3. Avoid surgery ! It make it worse !

Either from a primary skin cancer or as metastasis

Treatment

1. Elective Surgery

2. Elective Radiation

3. Elective chemotherapy

4. Wound care