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

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GYÖRGYI SZABÓ A S S I S T A N T P R O F E S S O R DEPARTMENT OF SURGICAL RESEARCH AND TECHNIQUES

Basic Surgical Techniques, Faculty of Medicine, 3rd year 2021/13 Academic Year, Second Semester

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WOUND

What is a wound?

3  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

4 Wound edge Wound corner Surface of the wound Base of the wound

Cross section of a simple wound

Wound edge Wound cavity Skin surface Surface of the wound Subcutaneus tissue Superficial fascia Muscle layer Base of the wound

The ABCDE in the injured assessment

5 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

6   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 7  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

Mechanical wounds

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1.) Abraded wound (v. abrasum)

  Superficial part of the epidermal layer Good wound healing

2.) Punctured wound (v. punctum)

 Sharp-pointed object  Seems negligible BUT   Anaerobic infection Injury of big vessels and nerves

Mechanical wounds

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

  Sharp object Best healing   Sharp object + blunt additional force Edges - uneven

5.) Crush wound (v. contusum)

Mechanical wounds

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6.) Torn wound (v. lacerum)

    Blunt force Pressure injury Edges – uneven and torn Bleeding   Great tearing or pulling Incomplete amputation (v. lacerocontusum)

Mechanical wound

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7.) Shot wound (v. scolperatium)

  Close - burn injury Foreign materials aperture output slot tunel unijured tissue necrobiotic zone necrotic zone foreign bodies

Mechanical wounds

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8.) Bite wound (v. morsum)

     Ragged wound Crushed tissue Torn Infection Bone fracture   Prevention of rabies Tetanus profilaxis

Distal

The direction of the flap

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Proximal

The wound healing is good

1.) Acid

Chemical wounds

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2.) Base

  in small concentration – irritate in large concentration – coagulation necrosis  colliquative necrosis

Wounds caused by radiation

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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

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1.) Burning 2.) Freezing

     Metabolic change! - toxemia a – normal skin 1 -

1 st degree

(epidermis) – superficial injury 2 –

2 nd

dermis)

degree

–partial or deep partial thickness (epidermis+superficial or deep 3 –

3 rd degree

+ entire dermis) – full thickness (epidermis 4 –

4 th degree

– (skin + subcutaneous tissue + muscle and bone)   mild, moderate, severe (redness, bullas, necrosis) rewarm – not only the frozen area but the whole body   Treatment: Cooling – cold water and clean covering

Special wounds

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Exotic, poisonous animals

  Toxins, venom - toxicologist Skin necrosis

Classification of the wounds 2. According to the bacterial contamination 18     Clean wound Clean-contaminated wound Contaminated wound Heavily contaminated wound

Classification of the wounds 2. Depending on the depth of injury 19     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

20     Ancient Egypt – lint (barrier) and honey (fibrous base-wound site closure), (antibiotic) animal grease „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 21 black black-yellow yellow yellow-red red red-pink pink source: Applied wound management supplement – www.wounds-uk.com

Applied wound management infection continuum 22 the quantity and diversity of microbes

sterility contamination critical colonisation colonisation infection

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

Applied wound management exudate continuum 23

Viscosity medium - 3 low - 1 volume

high - 5 medium -3 low - 1

high - 5

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

The wound managemanet

24    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, foreign body, special jobs, bite, shot, deep punctured wound Primary delayed suture (3-8 days)   clean, wash – saline, cover excision of wound edges, sutures

The wound managemanet

25   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

26        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

27 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

The wound healing

 Hemostasis-inflammation 28   Granulation-proliferation Remodelling

macrophages neutrophyl gr.

thrombocytes

0 1 2 3 4 5

fibroblasts lymphocytes

6 7 8 9

capillaries

10 11 10 13 14 15 http://www.worldwidewounds.com/2004/august/Enoch/images/enochfig1.jpg

The main steps of the wound healing

29 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

30  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

31  Local     Ischemia Infection Foreign body Edema, elevated tissue pressure infection Hyperbaric oxygen treatment  Systemic           Age and gender Sex hormones Stress Ischemia Diseases Obesity Medication Alcoholism and smoking Immunocompromised conditions Nutrition foreign bodies

I MPAIRED HEALING

edema/ elevated tissue pressure ischemia

Complications of wound healing I. Early complications 32    Seroma Hematoma Wound disruptin    Superficial wound infection Deep wound infection Mixed wound infection

Early complications of wound healing

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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 healing

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3.) Wound disruption 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 35

1.) Diffuse

 Located below the skin TREATMENT  Resting position  Antibiotic  Dermatological consultation e.g. erysipelas

2.) Localized

 Anywhere TREATMENT  Surgical exploration   Drainage X-ray examination e.g. abscess

Early complications of wound healing Deep wound infection 36

1.) Diffuse 2.) Localized

TREATMENT  Surgical exploration  Open therapy  H 2 O 2 and antibiotics  Inside the tissues or body cavities TREATMENT  surgical exploration  drainage e.g. anaerobic necrosis

Complications of wound healing I. Early complications 37

Mixed wound infection

e.g. gangrene  necrotic tissues   putrid and anaerobic infection a severe clinical picture TREATMENT  aggresive surgical debridement  effective and specified (antibiotic) therapy

Complications of wound healing II. Late complications 38       Hyperthrophic scar Keloid formation Necrosis Inflammatory infiltration Abscesses Foreign body containing abscesses

Late complications

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Hypertrophic scar

   Develop in areas of thick chorium Non-hyalinic collagen fibres and fibroblasts Confine to the incision line TREATMENT  Regress spontaneously (1-2 yrs)

Keloid

     Mostly African and Asian population 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

Anatomical

  Arterial – bright red, pulsate Venous – dark red, continuous

Bleeding

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Diffuse

  Capillary – can become serious Parenchymal

Bleeding

42 Severity of bleeding – the volume of the lost blood and time source: http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/

The direction of hemorrage

43   External Internal    In a luminar organ (hematuria, hemoptoe, melena) In body cavities (intracranial, hemothorax, hemascos, hemopericardium, hemarthros) Among the tissues (hematoma, suffusion)

Bleeding

44  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

Local

Signs of the bleeding

45    Hematoma, suffusion, ecchymosis Compression in the pleural cavity, in pericardium, in the skull Functional disturbancies – e.g. hyperperistalsis

General

 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

46 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 47  Digital pressure – direct pressure, e.g. Pringle maneuver    Tourniquet Ligation Suturing     Preventive hemostasis Clips Bone wax other

Thermal methods

48  Low temperature  Hypothermia – eg. stomach bleeding  Cryosurgery  dehidratation and denaturation of fatty tissue  decreases the cell metabolism  vasoconstriction

Thermal methods

49  High temperature  Electrosurgery – electrocauterization   Monopolar diathermy Bipolar diathermy  Laser surgery coagulation and vaporization for fine tissues

Thermal methods

50  High temperature  Electrocoagulation   Electrofulguration (A) Electrodessication  Electrosection

Hemostasis with chemical and biological methods 51 vasoconstriction coagulation hygroscopic effect O x i d i z e d c Absorbable collagen Absorbable gelatin Microfibrillar collagen e l l u l o z e Oxytocin Epinephrine Hemcon Thrombin QuikClot

Hemostasis with chemical and biological methods 52 HemCon