Gyorgyi Szabo Classification and Management of Wound

8/12/2019 Gyorgyi Szabo Classification and Management of Wound

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GYRGYI SZABA S S I S T A N T P R O F E S S O R

DEPARTMENT OF SURGICALRESEARCH AND TECHNIQUES

Classification and management ofwound, principle of wound healing,haemorrhage and bleeding control

Basic Surgical Techniques, Faculty of Medicine, 3rd year2021/13 Academic Year, Second Semester

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WOUND

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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

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Parts of the wound

Wound edge Woundcorner

Surface of

the wound

Base of the wound

Cross section of a simple wound

Skin surface

Subcutaneus tissue

Superficial fascia

Muscle layer

Base of the wound

Wound edge

Surface of

the wound

Wound

cavity

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The ABCDE in the injured assessment

The mnemonic ABCDE is used to remember the orderof assessment with the purpose to treat first that killsfirst.

A:Airway and C-spine stabilization

B:Breathing

C:Circulation

D:Disability

E:Environment and Exposure

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Classification of the accidental wounds1. Based on the origine

I. Mechanical: 1. Abraded wound (vulnus abrasum) 2. Puncured wound (v. punctum) 3. Incised wound (v. scissum) 4. Cut wound (v. caesum) 5. Crush wound (v. contusum) 6. Torn wound (v. lacerum) 7. Bite wound (v. morsum) 8. Shot wound (v. sclopetarium)

II. Chemical: 1. Acid

2. Base III. Wounds caused by radiation IV. Wounds caused by thermal forces:

1. Burning 2. Freezing

V. Special

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1.) Abraded wound

(v. abrasum)

1.) Abraded wound

(v. abrasum)

2.) Punctured wound

(v. punctum)

2.) Punctured wound

(v. punctum)

Superficial part of the epidermallayer

Good wound healing

Sharp-pointed object

Seems negligible

BUT Anaerobic infection

Injury of big vessels and nerves

Mechanical wounds7


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3.) Incised wound

(v. scissum)

3.) Incised wound

(v. scissum)4.) Cut wound(v. caesum)4.) Cut wound(v. caesum)

Sharp object

Best healing

Sharp object + blunt additionalforce

Edges - uneven

Mechanical wounds8


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5.) Crush wound

(v. contusum)

5.) Crush wound

(v. contusum)

6.) Torn wound

(v. lacerum)

6.) Torn wound

(v. lacerum)

Blunt force Pressure injury

Edges uneven and torn Bleeding

Great tearing or pulling

Incomplete amputation

Mechanical wounds9

(v. lacerocontusum)


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7.) Shot wound(v. scolperatium)7.) Shot wound(v. scolperatium)

Close - burn injury

Foreign materials

Mechanical wound10

unijured tissuenecrobiotic zonenecrotic zoneforeign bodies

aperture

slot tunel

output


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8.) Bite wound(v. morsum)8.) Bite wound(v. morsum)

Ragged wound

Crushed tissue

Torn

Infection

Bone fracture

Prevention of rabies Tetanus profilaxis

Mechanical wounds11


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DistalDistal ProximalProximal

The wound healing is good

The direction of the flap12


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1.) Acid1.) Acid 2.) Base2.) Base

in small concentration irritate

in large concentration coagulation necrosis

colliquative necrosis

Chemical wounds13


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Symptoms and severitydepend on:Symptoms and severitydepend on:

Amount of radiation Length of exposure Body part that was exposed

Symptoms may occur immediately,after a few days, or even as longas months.

What part of the body is

most sensitive duringradiation sickness?

bone marrowgastrointestinal tract

Wounds caused by radiation14


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1.) Burning1.) Burning 2.) Freezing2.) Freezing

a normal skin

1 - 1stdegreesuperficial injury(epidermis)

2 2nddegreepartial or deep partialthickness (epidermis+superficial or deepdermis)

3 3rd degreefull thickness (epidermis

+ entire dermis)

4 4thdegree(skin + subcutaneoustissue + muscle and bone)

Wounds caused by thermal forces15

Metabolic change! - toxemia mild, moderate, severe orclassification in 4 degree

rewarm not only the frozen areabut the whole body


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Exotic, poisonous animalsExotic, poisonous animals

Toxins, venom - toxicologist

Skin necrosis

Special wounds16


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Classification of the wounds2. According to the bacterial contamination

Clean wound

Clean-contaminated wound

Contaminated wound

Heavily contaminated wound

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Superficial

Partial thickness

Full thickness

Deep wound

Classification of the wounds2. Depending on the depth of injury

+ bone, opened cavities, organsetc.

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source: http://www.funscrape.com/Search/1/skin+layers.html
http://www.google.hu/url?sa=i&rct=j&q=layers+of+the+skin&source=images&cd=&cad=rja&docid=Cg_uivrO1fzKtM&tbnid=0K48hs2TB54nJM:&ved=0CAUQjRw&url=http://www.nonsurgicalskincare.com/laser-skin-treatments-new-weapons-in-the-fight-on-ageing/&ei=frETUYDdLcyFtQbHp4HYDw&bvm=bv.42080656,d.bGE&psig=AFQjCNFqm7U4f__CnozHxlTdArQRDBuJUw&ust=1360331469304752


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Applied wound management -colour continuum

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

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source: Applied wound management supplement

www.wounds-uk.com


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Applied wound managementinfection continuum

contaminationcolonisation infectionsterility

critical colonisation

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the quantity and diversity of microbes

source: Applied wound management supplement

www.wounds-uk.com


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Applied wound managementexudate continuum

volume high - 5 medium - 3 low - 1

high - 5

medium -3

low - 1

Viscosity

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


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The wound managemanet

Temporary wound management (first aid) clean, hemostasis, covering

Final primary wound management clean, anaesthesis, excision, sutures

ALWAYS:thoracic cavity, abdominal wall or dura mater injury

NEVER:war injury, inflammation, contamination, foreignbody, special jobs,

bite, shot, deep punctured wound

Primary delayed suture (3-8 days) clean, wash saline, cover

excision of wound edges, sutures

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The wound managemanet23

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


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The surgical wound

Surgical incision

Stretch and fix

Handling the scalpel

Langer lines

Skin edges

Vessels and nerves

HemostasisLanger lines

The wound edges

Handling the scalpel

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source: http://www.med-

ars.it/galleries/langer.htm
http://www.google.hu/url?sa=i&rct=j&q=langer+lines&source=images&cd=&cad=rja&docid=3GUNPeEPL60e-M&tbnid=gom5noe33-xiTM:&ved=0CAUQjRw&url=http://www.med-ars.it/galleries/langer.htm&ei=XLgTUeSEH4ndswbCwoGoCw&bvm=bv.42080656,d.bGE&psig=AFQjCNFt9WVJX9KUIsWzQuOON1hzAd_VtQ&ust=1360333133923041


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Tissue unifying and dressing the wound

Skin: Stiches

Clips

Steri-Strips

Tissue glues

Fascia and subcutaneous layers:

Interrupted stiches

Fat fat necrosis!

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

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The wound healing

Hemostasis-inflammation Granulation-proliferation

Remodelling

capillariesfibroblasts

lymphocytes

macrophages

neutrophyl gr.

thrombocytes

0 1 2 3 4 5 6 7 8 9 10 11 10 13 14 15

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source: internet


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The main steps of the wound healing

1. Hemostasis-inflammationvasoconstiction, fibrin clot formationproinflammatory citokines andgrowth factors releasingvasodilatation

infiltration PMNs, macrophagescytokines releasing

2. Granulation-proliferationfibroblasts and endothelial cellsangiogenesis, collagen formation,

granulation tissue formationECM

3. Remodellingregression of many capillaries,physical contraction

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http://www.pilonidal.org/aftercare/wound_healing_indepth.php


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Types of wound healing

Healing by primary

intention

Healing by secondary

intention

Healing by tertiary

intention

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source: http://quizlet.com/13665246/chapter-3-tissue-renewal-regeneration-and-repair-flash-cards/
http://www.google.hu/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=09ewcRTqZp0Q0M&tbnid=2tLkfIyPPDGPEM:&ved=0CAUQjRw&url=http://www.studyblue.com/notes/note/n/tissue-injury-and-repair/deck/1472496&ei=RMIUUZ6ZM9DktQbhyYGAAQ&psig=AFQjCNHxd5-Hlu2BczTkKmnniG3M70uLWw&ust=1360401260485413


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Factors affecting wound healing

Local Ischemia Infection Foreign body Edema, elevated

tissue pressure

Systemic Age and gender Sex hormones Stress Ischemia Diseases Obesity Medication Alcoholism and smoking Immunocompromised

conditions Nutrition

Hyperbaric oxygentreatment

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infection

ischemiaforeign

bodies

edema/

elevated

tissue

pressure

IMPAIREDHEALING

C li i f d h li


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Complications of wound healingI. Early complications

Seroma

Hematoma

Wound disruptin Superficial wound infection

Deep wound infection

Mixed wound infection

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1.) Seroma 2.) Hematoma1.) Seroma 2.) Hematoma

Filled with serous fluid, lymphor blood

Fluctuation, swelling, redness,tenderness, subfebrility

TREATMENT:

Sterile punture andcompression

Suction drain

Early complications of wound healing31

Bleeding, short drainage time,anticoagulant

Risk of infection

Swelling, fluctuation, pain,redness

TREATMENT Sterile puncture

Surgical exploration


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3.) Wound disruption3.) Wound disruption A. partial dehisceneceB. complete - disruptionA. partial dehisceneceB. complete - disruption

Surgical error

Increased intraabdominal

pressure

Wound infection

Hypoproteinaemia

TREATMENT: U-shaped sutures

Early complications of wound healing32


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1.) Diffuse1.) Diffuse 2.) Localized2.) Localized

Located below the skin

TREATMENT Resting position Antibiotic Dermatological consultation

Anywhere

TREATMENT Surgical exploration

Drainage

X-ray examination

Early complications of wound healingSuperficial wound infection

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e.g. erysipelas e.g. abscess

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1.) Diffuse1.) Diffuse 2.) Localized2.) Localized

TREATMENT

Surgical exploration Open therapy

H2O2and antibiotics

e.g. anaerobic necrosis

Inside the tissues or body cavities

TREATMENT surgical exploration drainage

Early complications of wound healingDeep wound infection

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C li i f d h li


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Mixed wound infectionMixed wound infection

e.g. gangrene necrotic tissues putrid and anaerobic

infection a severe clinical picture

TREATMENT aggresive surgical

debridement effective and specified

(antibiotic) therapy

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Complications of wound healingI. Early complications

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Complications of wound healingII. Late complications

Hyperthrophic scar

Keloid formation

Necrosis

Inflammatory infiltration

Abscesses

Foreign body containing abscesses

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Hypertrophic scar KeloidHypertrophic scar Keloid

Develop in areas of thickchorium

Non-hyalinic collagenfibres and fibroblasts

Confine to the incisionline

TREATMENT Regress spontaneously(1-2 yrs)

Late complications37

Mostly African and Asianpopulation

Well-defined edge

Emerging, tough structure Overproliferation of collagen

fibers in the subcutaneous tissue Subjective complains

TREATMENT Postoperative radiation Corticosteroid + local anaesthetic

injection


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BLEEDING AND HEMOSTASIS

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AnatomicalAnatomical DiffuseDiffuse

Arterial bright red,pulsate

Venous dark red,continuous

Capillary can becomeserious

Parenchymal

Bleeding39


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Bleeding

Severity of bleeding the volume of the lost blood andtime

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source: http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/
http://www.google.hu/url?sa=i&rct=j&q=classification+of+bleeding+Advanced+Trauma+Life+Support&source=images&cd=&cad=rja&docid=73ovbbTxf7EKVM&tbnid=2Znri-IvQJqRpM:&ved=0CAUQjRw&url=http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/&ei=qPclUf2GHcrTsgar_YCQCA&psig=AFQjCNEw0_7aGQ2V_mBGkWtIIzwpwaiujQ&ust=1361529116588371


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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)

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Bleeding

Preoperative hemorrhage

Prehospital care! maintenance of the airways, ventillation and circulation

bandages, direct pressure, turniquets

Intraoperative hemorrhage

anatomical and/or diffuse

depending on the surgeon, the surgery, position,

the size of the vessel, pressure in the vessel

ANESTHESIA!

Postoperative bleeding

ineffective local hemostasis, undetected hemostatic defect, consumptive

coagulopathy or fibrinolysis

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LocalLocal GeneralGeneral

Hematoma, suffusion,ecchymosis

Compression in the pleuralcavity, in pericardium, in theskull

Functional disturbancies e.g.hyperperistalsis

Pale skin, cyanosis, decreasedBP. and tachycardia, difficultyin breeding, sweeting,decreased body temperature,unconsciousness, cardiac andlaboratory standstill, laboratorydisorders, signs of shock

Signs of the bleeding43


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Surgical hemostasis

Aim to prevent the flow of blood from the incised ortransected vessels

Mechanical methods

Thermal methods

Chemical and biological methods

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Thermal methods

Low temperature Hypothermia eg. stomach bleeding

Cryosurgery

dehidratation and denaturation of fatty tissue

decreases the cell metabolism

vasoconstriction

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Thermal methods

High temperature Electrosurgery electrocauterization

Monopolar diathermy

Bipolar diathermy

Laser surgery

coagulation and vaporization

for fine tissues

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Thermal methods

High temperature Electrocoagulation

Electrofulguration (A)

Electrodessication

Electrosection

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source: internet

Hemostasis with chemical and biological


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Hemostasis with chemical and biologicalmethods

vasoconstriction coagulation hygroscopic effect

Absorbable collagenAbsorbable gelatin

Microfibrillar collagenOxidizedcelluloze

OxytocinEpinephrine

ThrombinHemconQuikClot

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Hemostasis with chemical and biological


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Hemostasis with chemical and biologicalmethods

HemCon

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http://www.google.hu/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=uY5PlM_6vFCEsM&tbnid=f_64i7L9n8brTM:&ved=0CAUQjRw&url=http://www.recothrom.com/reconstitution-and-flexibility-of-use.html&ei=0JMsUfrpGYbctAaqpYDYDA&psig=AFQjCNEAmYpAQpVPQG2esJZKhcPKp6sOsw&ust=1361962265699082

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Gyorgyi Szabo Classification and Management of Wound