classification and management of wound principle of wound healing haemorrhage and bleeding control
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Classification and management of wound , principle of wound healing , haemorrhage and bleeding control. Györgyi Szabó Assistant Professor Department of Surgical research and Techniques. Basic Surgical Techniques , Faculty of Medicine , 3rd year

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classification and management of wound principle of wound healing haemorrhage and bleeding control

Classification and management of wound, principleofwoundhealing, haemorrhage and bleedingcontrol

Györgyi Szabó

Assistant Professor

Department of Surgicalresearch and Techniques

Basic SurgicalTechniques, Faculty of Medicine, 3rd year

2021/13 Academic Year, SecondSemester

what is a wound
What is a wound?
  • It is a circumscribed injury which is caused by an external force and it can involve any tissue or organ.

surgical, traumatic

It can be mild, severe, or even lethal.

Simple wound

Compound wound

Acute

Chronic

parts of the wound
Wound edge

Wound

corner

Surface of

the wound

Base of the wound

Cross section of a simple wound

Wound edge

Skin surface

Wound

cavity

Subcutaneus tissue

Surface of

the wound

Superficial fascia

Muscle layer

Base of the wound

Parts of the wound
the abcde in the injured assessment
The ABCDE in the injured assessment

The mnemonic ABCDE is used to remember the order of assessment with the purpose to treat first that kills first.

  • A:Airway and C-spine stabilization
  • B:Breathing
  • C:Circulation
  • D:Disability
  • E:Environment and Exposure
wound management anamnesis
Wound management - anamnesis
  • When and where was the wound occured?
  • Alcohol and drug consumption
  • What did caused the wound?
  • The circumstances of the injury
  • Other diseases eg. diabetes mellitus, tumour, atherosclesosis, allergy
  • The state of patient’s vaccination against Tetanus
  • Prevention of rabies
  • The applied first-aid
classification of the accidental wounds 1 based on the origine
Classification of theaccidentalwounds1. Basedontheorigine
  • I. Mechanical:
    • 1. Abradedwound (vulnusabrasum)
    • 2. Puncuredwound (v. punctum)
    • 3. Incisedwound (v. scissum)
    • 4. Cutwound (v. caesum)
    • 5. Crushwound (v. contusum)
    • 6. Tornwound (v. lacerum)
    • 7. Bitewound (v. morsum)
    • 8. Shotwound (v. sclopetarium)
  • II. Chemical:
    • 1. Acid
    • 2. Base
  • III. Woundscausedbyradiation
  • IV. Woundscausedbythermalforces:
    • 1. Burning
    • 2. Freezing
  • V. Special
mechanical wounds
Mechanical wounds

1.) Abraded wound

(v. abrasum)

2.) Punctured wound

(v. punctum)

  • Superficial part of theepidermallayer
  • Good woundhealing
  • Sharp-pointedobject
  • Seemsnegligible

BUT

  • Anaerobicinfection
  • Injury of bigvessels and nerves
mechanical wounds1
Mechanical wounds

3.) Incised wound

(v. scissum)

4.) Cut wound (v. caesum)

  • Sharp object
  • Best healing
  • Sharp object + blunt additional force
  • Edges - uneven
mechanical wounds2
Mechanical wounds

5.) Crush wound

(v. contusum)

6.) Torn wound

(v. lacerum)

  • Bluntforce
  • Pressureinjury
  • Edges – uneven and torn
  • Bleeding
  • Great tearing or pulling
  • Incomplete amputation

(v. lacerocontusum)

mechanical wound
Mechanical wound

7.) Shot wound (v. scolperatium)

  • Close - burn injury
  • Foreign materials

aperture

output

slot tunel

unijured tissue

necrobiotic zone

necrotic zone

foreign bodies

mechanical wounds3
Mechanical wounds

8.) Bite wound (v. morsum)

  • Ragged wound
  • Crushed tissue
  • Torn
  • Infection
  • Bone fracture
  • Prevention of rabies
  • Tetanus profilaxis
the direction of the flap
The direction of the flap

Distal

Proximal

The woundhealing is good

chemical wounds
Chemical wounds

1.) Acid

2.) Base

  • insmallconcentration – irritate
  • inlargeconcentration – coagulationnecrosis
  • colliquative necrosis
wounds caused by radiation
Wounds caused by radiation

Symptoms and severity depend on:

  • Amount of radiation
  • Length of exposure
  • Body part that was exposed

Symptoms may occur immediately, after a few days, or even as long as months. What part of the body is most sensitive during radiation sickness?

bone marrow

gastrointestinal tract

wounds caused by thermal forces
Wounds caused by thermal forces

1.) Burning

2.) Freezing

Metabolic change! - toxemia

  • mild, moderate, severe (redness, bullas, necrosis)
  • rewarm – not only the frozen area but the whole body
  • a – normal skin
  • 1 - 1st degree – superficial injury (epidermis)
  • 2 – 2nd degree –partial or deep partial thickness (epidermis+superficial or deep dermis)
  • 3 – 3rd degree – full thickness (epidermis + entire dermis)
  • 4 – 4th degree – (skin + subcutaneous tissue + muscle and bone)
  • Treatment:
  • Cooling – cold water and clean covering
special wounds
Special wounds

Exotic, poisonousanimals

  • Toxins, venom - toxicologist
  • Skin necrosis
classification of the wounds 2 according to the bacterial contamination
Classification of thewounds2. Accordingtothebacterialcontamination
  • Clean wound
  • Clean-contaminated wound
  • Contaminated wound
  • Heavily contaminated wound
classification of the wounds 2 depending on the depth of injury
Classification of thewounds2. Dependingonthedepth of injury
  • Superficial
  • Partial thickness
  • Full thickness
  • Deep wound

+ bone, opened cavities, organs…etc.

source: http://www.funscrape.com/Search/1/skin+layers.html

wound management history
Wound management - history
  • Ancient Egypt – lint (fibrous base-wound site closure), animal grease (barrier) and honey (antibiotic)

„closing the wound preserved the soul”

  • Greeks – acute wound= „fresh” wound; chronic wound = „non-healing” wound

maintaining wound-site moisture

  • Ambroise Paré – hot oil  oil of roses and turpentine, ligature of arteries instead of cauterization
  • Lister pretreated surgical gauze – Robert Wood Johnson 1870s; gauze and wound dressings treated with iodide
applied wound management colour continuum
Appliedwound management - colourcontinuum

black black-yellow yellow yellow-red red red-pink pink

source: Applied wound management supplement – www.wounds-uk.com

applied wound management infection continuum
Appliedwound managementinfectioncontinuum

the quantity and diversity of microbes

contamination

critical colonisation

sterility

colonisation

infection

source: Applied wound management supplement – www.wounds-uk.com

applied wound management exudate continuum
Appliedwound managementexudatecontinuum

Viscosity

source: Applied wound management supplement – www.wounds-uk.com

the wound managemanet
The wound managemanet
  • Temporarywound management (firstaid)
    • clean, hemostasis, covering
  • Finalprimarywound management
    • clean, anaesthesis, excision, sutures
    • ALWAYS:thoraciccavity, abdominalwallordura mater injury
    • NEVER:warinjury, inflammation, contamination, foreign body, specialjobs,

bite, shot, deeppuncturedwound

  • Primarydelayedsuture (3-8 days)
    • clean, wash – saline, cover
    • excision of woundedges, sutures
the wound managemanet1
The wound managemanet
  • Early secondary wound closure (2 weeks)
    • after inflammation, necrosis – proliferation
    • anesthesia, refresh wound edges, suturing and draining
  • Late secondary wound closure (4-6 weeks)
    • anesthesis, scar excision, suturing, draining
    • greater defect – plastic surgery
the surgical wound
The surgical wound
  • Surgical incision
  • Stretch and fix
  • Handling the scalpel
  • Langer lines
  • Skin edges
  • Vessels and nerves
  • Hemostasis

Langer lines

source: http://www.med-ars.it/galleries/langer.htm

The wound edges

Handling the scalpel

tissue unifying and dressing the wound
Tissue unifying and dressing the wound

Skin:

  • Stiches
  • Clips
  • Steri-Strips
  • Tissueglues

Fascia and subcutaneouslayers:

  • Interrupted stiches

Fat – fatnecrosis!

Dressing:sterile, moist, antibiotic-containing, non-allergic, non-adhesive

the wound healing
The wound healing
  • Hemostasis-inflammation
  • Granulation-proliferation
  • Remodelling

http://www.worldwidewounds.com/2004/august/Enoch/images/enochfig1.jpg

the main steps of the wound healing
The main steps of the wound healing

1. Hemostasis-inflammation

vasoconstriction

fibrin clot formation

proinflammatory citokines and

growth factors releasing

vasodilatation

infiltration PMNs, macrophages

cytokines releasing

→ angiogensis

→ fibroblast activation

→ B- and T-cells activation

→ keratinocytes activation

→ wound contraction

2. Granulation-proliferation

fibroblast migration

collagen deposition

angiogensis

granulation tissue formation

epithelisation

contraction

3. Remodelling

regression of many capillaries

physical contraction – myofibroblasts

collagen degeneration and synthetisation

new epithelium

tensile strength – max. 80%

types of wound healing
Types of wound healing
  • Healing by primary

intention

  • Healing by secondary

intention

  • Healing by tertiary

intention

source: http://quizlet.com/13665246/chapter-3-tissue-renewal-regeneration-and-repair-flash-cards/

factors affecting wound healing
infection

Impairedhealing

foreign bodies

ischemia

edema/ elevated tissue pressure

Factors affecting wound healing
  • Local
    • Ischemia
    • Infection
    • Foreign body
    • Edema, elevatedtissuepressure
  • Systemic
    • Age and gender
    • Sex hormones
    • Stress
    • Ischemia
    • Diseases
    • Obesity
    • Medication
    • Alcoholism and smoking
    • Immunocompromisedconditions
    • Nutrition

Hyperbaric oxygen treatment

complications of wound healing i early complications
Complications of woundhealingI. Earlycomplications
  • Seroma
  • Hematoma
  • Wound disruptin
  • Superficial wound infection
  • Deep wound infection
  • Mixed wound infection
early complications of wound healing
Early complications of wound healing

1.) Seroma 2.) Hematoma

  • Filled with serous fluid, lymph or blood
  • Fluctuation, swelling, redness, tenderness, subfebrility

TREATMENT:

  • Sterile punture and compression
  • Suction drain
  • Bleeding, short drainage time, anticoagulant
  • Risk of infection
  • Swelling, fluctuation, pain, redness

TREATMENT

  • Sterile puncture
  • Surgical exploration
early complications of wound healing1
Early complications of wound healing

3.) Wounddisruption

A. partial – dehiscenece

B. complete - disruption

  • Surgical error
  • Increased intraabdominal pressure
  • Wound infection
  • Hypoproteinaemia

TREATMENT:

  • U-shaped sutures
early complications of wound healing superficial wound infection
Earlycomplications of woundhealingSuperficialwoundinfection

1.) Diffuse

2.) Localized

  • Locatedbelowtheskin

TREATMENT

  • Resting position
  • Antibiotic
  • Dermatologicalconsultation
  • Anywhere

TREATMENT

  • Surgicalexploration
  • Drainage
  • X-rayexamination

e.g. erysipelas

e.g. abscess

early complications of wound healing deep wound infection
Earlycomplications of woundhealingDeep woundinfection

1.) Diffuse

2.) Localized

TREATMENT

  • Surgical exploration
  • Open therapy
  • H2O2 and antibiotics

e.g. anaerobic necrosis

  • Inside the tissues or body cavities

TREATMENT

  • surgical exploration
  • drainage
complications of wound healing i early complications1
Complications of woundhealingI. Earlycomplications

Mixed woundinfection

e.g. gangrene

  • necrotictissues
  • putrid and anaerobicinfection
  • a severeclinicalpicture

TREATMENT

  • aggresivesurgicaldebridement
  • effective and specified (antibiotic) therapy
complications of wound healing ii late complications
Complications of woundhealingII. Latecomplications
  • Hyperthrophic scar
  • Keloid formation
  • Necrosis
  • Inflammatory infiltration
  • Abscesses
  • Foreign body containing abscesses
late complications
Late complications

HypertrophicscarKeloid

  • Developinareas of thickchorium
  • Non-hyaliniccollagenfibres and fibroblasts
  • Confinetotheincision line

TREATMENT

  • Regressspontaneously

(1-2 yrs)

  • MostlyAfrican and Asianpopulation
  • Well-definededge
  • Emerging, toughstructure
  • Overproliferation of collagenfibersinthesubcutaneoustissue
  • Subjectivecomplains

TREATMENT

  • Postoperativeradiation
  • Corticosteroid + local anaestheticinjection
bleeding
Bleeding

Anatomical

Diffuse

  • Arterial – bright red, pulsate
  • Venous – dark red, continuous
  • Capillary – can become serious
  • Parenchymal
bleeding1
Bleeding

Severity of bleeding – the volume of the lost blood and time

source: http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/

the direction of hemorrage
The direction of hemorrage
  • External
  • Internal
    • In a luminar organ (hematuria, hemoptoe, melena)
    • In body cavities (intracranial, hemothorax, hemascos, hemopericardium, hemarthros)
    • Among the tissues (hematoma, suffusion)
bleeding2
Bleeding
  • Preoperativehemorrhage

Prehospitalcare! – maintenance of theairways, ventillation and circulation

bandages, directpressure, turniquets

  • Intraoperativehemorrhage

anatomical and/ordiffuse

dependingonthesurgeon, thesurgery, position,

thesize of thevessel, pressureinthevessel

ANESTHESIA!

  • Postoperativebleeding

ineffective local hemostasis, undetectedhemostaticdefect, consumptivecoagulopathyorfibrinolysis

signs of the bleeding
Signs of the bleeding

Local

General

  • Hematoma, suffusion, ecchymosis
  • Compression in the pleural cavity, in pericardium, in the skull
  • Functional disturbancies – e.g. hyperperistalsis
  • Pale skin, cyanosis, decreased BP. and tachycardia, difficulty in breeding, sweeting, decreased body temperature, unconsciousness, cardiac and laboratory standstill, laboratory disorders, signs of shock
surgical hemostasis
Surgical hemostasis

Aim – to prevent the flow of blood from the incised or transected vessels

  • Mechanical methods
  • Thermal methods
  • Chemical and biological methods
surgical hemostasis mechanical methods
SurgicalhemostasisMechanicalmethods
  • Digital pressure – direct pressure,

e.g. Pringle maneuver

  • Tourniquet
  • Ligation
  • Suturing
  • Preventive hemostasis
  • Clips
  • Bone wax
  • other
thermal methods
Thermal methods
  • Low temperature
    • Hypothermia – eg. stomach bleeding
    • Cryosurgery
      • dehidratation and denaturation of fatty tissue
      • decreases the cell metabolism
      • vasoconstriction
thermal methods1
Thermal methods
  • High temperature
    • Electrosurgery – electrocauterization
    • Monopolar diathermy
    • Bipolar diathermy
    • Laser surgery

coagulation and vaporization

for fine tissues

thermal methods2
Thermal methods
  • High temperature
    • Electrocoagulation
    • Electrofulguration (A)
    • Electrodessication
    • Electrosection
hemostasis with chemical and biological methods
Hemostasiswithchemical and biologicalmethods

vasoconstrictioncoagulationhygroscopiceffect

Absorbablecollagen

Absorbablegelatin

Microfibrillarcollagen

Oxidizedcelluloze

Oxytocin

Epinephrine

Thrombin

Hemcon

QuikClot

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