wounds-wound healing & care

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WOUNDS-WOUND HEALING & CARE Begashaw M

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WOUNDS-WOUND HEALING & CARE. Begashaw M . Layers of Skin. DEFINITION. Wound - break in normal continuity of a tissue cause - transfer of any form of energy. WOUND HEALING. is a complex biologic process of restoring normal tissue continuity - PowerPoint PPT Presentation

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Page 1: WOUNDS-WOUND HEALING  &  CARE

WOUNDS-WOUND HEALING & CARE

Begashaw M

Page 2: WOUNDS-WOUND HEALING  &  CARE

Layers of Skin

Page 3: WOUNDS-WOUND HEALING  &  CARE

DEFINITION• Wound - break in normal continuity of a

tissue • cause - transfer of any form of energy

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WOUND HEALING• is a complex biologic process of

restoring normal tissue continuity• integrated sequences of events leading

to cellular proliferation and remodeling• starts immediately following the event of

wounding

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Wound Healing

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Phases of healing1-Coagulation phase• first phase • is induced immediately following injury• characterized by vaso-constriction, clot

formation and release of platelets

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2- Inflammatory phase

• takes place from time of wounding up to 3 days

• Characterized: inflammatory response vasodilatation and pouring out of fluid migration of inflammatory cells and

leukocytes rapid epithelial growth

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3- Proliferative Phase

• phase of fibroplasia• starts around the 3rd day of injury• stays for about 3 weeks• is characterized -fibroblast, epithelial and endothelial

proliferation -Collagen synthesis & ground substance -blood vessel production

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4- Maturation phase

• phase of remodeling• takes the longest period - up to 1 yr• Equilibrium between protein synthesis

and degradation occurs • with cross linking of collagen bundles

leading to slow and continuous increase in tissue strength

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Stages of Wound Healing

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Stages of wound healing

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Cells in Wound Healing

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Clinical types of healing• Healing by first intention - clean wound closed primarily - healing by epithelialization - minimal scar - <6 hours, longer with facial• Healing by Second intention- in wide, contaminated wounds- not primarily closed- healing by granulation tissue formation- tissue contraction and epithelialization- inferior cosmetic result

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Healing by third intention:-left open initially -closed later-delayed primary closure-In contaminated -long time lapse since initial injury-severe crush wound

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Factors affecting healing Local factors-Ischemia -decreased oxygen

tension-foreign bodies-tension-Infection-Irradiation

Systemic factors-Systemic diseases-

DM, cirrhosis, renal failure, malignancy

-malnutrition-immunosupression-Drug- steroids,

cytotoxic agents

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WOUND ASSESSMENT AND CLASSIFICATION

Assessment History• Mechanism of injury• Time• Place and circumstance• past and current medical• immunization history

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physical examination

• Extent of skin loss• Degree of circulation• soft tissue injury• The degree of contamination• foreign body • tissue necrosis

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Classification of wounds• Closed wound- an intact epithelial

surface- skin cover not

completely breeched

e.g Contusion Bruise Hematoma

• Open wounds- complete break of

the epithelial protective surface

E.g Abrasion Laceration Puncture Bites

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Open woundsTidy• Incised• Clean• Healthy tissue• Seldom tissue

loss

Untidy• crushed• Contaminated• Devitalised

tissue• Often tissue loss

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Classification of Wounds

ClassificationCriteriaRisk (%)

Clean Elective, not emergency, non traumatic, primarily closed; no acute inflammation; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered

< 2

Clean-contaminated

Urgent or emergency case that is otherwise clean; elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g., appendectomy) not encountering infected urine or bile; minor technique break

< 10

Contaminated Non purulent inflammation; gross spillage from gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique; penetrating trauma < 4 hours old; chronic open wounds to be grafted or covered

~ 20

Dirty Purulent inflammation (e.g., abscess); preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract; penetrating trauma > 4 hours old

~ 40

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Classification of Surgical Wounds

• Clean(no viscus opened)• Clean-contaminated(viscus opened

minimal spillage)• Contaminated(open viscus with

gross spillage or inflammatory ds)• Dirty(pus or perforation or incision

via abscess)

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WOUND MANAGEMENT-Priority: ABC-Stabilize-correct life threatening conditions• history & P/E -associated injuries• Assess wound• treatment• Follow up

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Proper wound care:• stop bleeding• irrigation• debridement• decision -to close -leave the wound open• antibiotics• tetanus prophylaxis • correcting systemic disease

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primary wound closure

• Clean wounds• Clean-contaminated wounds -if they

can be converted into clean wounds• all missile wounds, animal & human

bites should never be primarily closed • in wounds within 6-8 hours

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Delayed primary closure

• for traumatic or contaminated wounds• within 3 days

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Secondary closure

• wound left open to heal spontaneously

• contraction (myofibroblasts) and granulation

• requires dressing change• inferior cosmetic result• indication: when 1° closure not

possible or indicated

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Specific management

• Bruises -Superficial-no specific

management -local compress-analgesics

• Hematoma • collection of

extravasated blood• Management:- absorbed spontaneously - Local compress to

alleviate pain- aspiration-very large/

over a cosmetic area

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Abrasion• is rubbing or scraping of skin or mucous

membrane -variable depth• affect only a part or full layer of skin• Management- Cleanse using scrubbing brushes- Use antiseptic or clean tap water and soap- Analgesic

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Punctures• involve deeper structures• opening relatively small as compared with

depth (e.g. needle)• Management:- Evaluate the depth- Remove- Excise damaged tissue- Cover with antibiotics- Tetanus prophylaxis

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Lacerations- open wounds - knife, or glass- cut or torn tissue• Management:- cleansing- Closure- wound debridement - antibiotic - Tetanus Prophylaxis- Analgesics

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Laceration

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Crush and avulsion wounds

complicated wounds have more extensive damage caused by compression Management:- life threatening conditions- debridement- Early skin cover- late graft- wound left open if contaminated- antibiotics- Tetanus Prophylaxis- Analgesics

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Crush & avulsion

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Debridement

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Missile injuries• compound , complicated• excessive tissue damage• high degree of contamination• severe life threatening• Management- stabilize - debridement- Antibiotics- Tetanus Prophylaxis - analgesics - avoid primary closure

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Human bites• heavily contaminated • due to polymicrobial-Staph> a-hemolytic Strep

> Eikenella corrodens >Bacteroides• Management- culture - Scrubbing- irrigation with saline - debridement- Leave wound open- Broad-spectrum antibiotic-augmentin- Tetanus Prophylaxis

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Dog bites• can transmit the rabies virus• animal observation for 10 days Local- irrigation and repeated swabbing - flushing -soap & water/ antiseptics- anti-rabies serum infiltration- leave wound open Systemic- Post exposure anti rabies prophylaxis (1ml, IM) on the

1st, 3rd, 7th, 14th and 28th day- Tetanus prophylaxis- Antibiotics

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Dog bite

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Snake Bites• First aid :- irrigation- pressure bandage proximally- Immobilize- Transport to hospital

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Hospital Measures- Identify species- lab- hemoglobin, renal function- Anti-venom injection- Supportive care- Rest- IV-infusions to combat shock- Antibiotics- Blood transfusion- Tetanus Prophylaxis- Wound excision- Fasciotomy for compartment syndrome

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WOUND COMPLICATIONS• Local- Hematoma- Seroma- Infection- Dehiscence- Granuloma- Scar - Contracture

• systemic - shock -massive

bleeding- bacteremia & sepsis- death

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Hypertrophic Scar

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Hypertrophic Scars

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Keloid

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Keloids

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Questions?