Sx Skills - Wound Management

drraythe's version from 2016-05-05 11:32

Wound Management - Steps in Managing

Question Answer
What are the 6 steps in an approach to a traumatic wound?Initial PTx assessment
Wound assessment
Prelim exam
Detailed exam
Wounds Tx plan
Medical & or surgical Tx
What do you determine on the preliminary exam of a wound? (4, +/-1)Determine the...
(1) Type of wound
(2) Location, proximity to vital structures
(3) Degree of contamination
(4) Assess for trauma to deeper tissues (i.e. fracture) & +/-culture & sensitivity of wound
What 4 things do you do during a detailed exam? (The exam after the prelim exam)(1) Clean wound
(2) Explore wound
(3) +/- Debride wound
(4) Establish a wound management plan
What is the "Golden period" ??1st 6-8 hours btwn contamination at injury & bacterial infxn (>10^5 bacteria per gram of tissue)
Bacterial infxn is how many bacteria per gram of tissue?More than 10^5
What are the 3 steps for cleansing a wound?(1) Clip hair around wound (*use sterile lube or oiled clipper blades) (easier to wipe hair out if it's in the lube/oil)
(2) Aseptically prepare area around wound
(3) Lavage or irrigate w/ copious amounts of warmed solution
**Which of the following is least appropriate for wound lavage?
Sterile water
NaCl 0.9 w/ 0.05% chlorhex
Dilute povidone-iodine
WATER is the least appropriate, bc you want an ISOTONIC solution & water is hypotonic
What are appropriate lavage & irrigating solutions you can use? (2)Saline (isotonic)
Lactated Ringer’s (isotonic)
Should you use tap water to flush a wound?No, it's hypotonic & cytotoxic
Should you use antiseptics (examples?) as a lavage or irrigating solutions?Antiseptics [chlorhexidine, povidone-iodine] should only be used early in wound management; contraindicated in clean wounds
Explain high-pressure irrigation1 litre bag w/in cuff pressurized to 300 mmHg. 35-or 60-mL syringe + 18 gauge needle
Chlorhexidine 0.05% solution → what is its spectrum? How can its spectrum be improved?Broad spectrum antimicrobial, antimicrobial effect ↑ by 1,000x if combined w/ TrisEDTA
Does chlorhexidine have residual activity?Yes, up to 48 hrs
Is chlorhex sensitive to organic debris?NOT inactivated by organic debris (so if you have a exudative lesion, pick chlorhex over povidone) (probably why you can clean shitty cages w/ chlorhex spray)
***Which antiseptic can pseudomonas develop a resistance to??CHLORHEX!! (so if pseudo, choose povidone)
Povidone iodine solution (0.1~1%) → what is the spectrum?Broad spectrum
Does Povidone Iodine have residual activity?No
Is Povidone Iodine sensitive to organic debris?YES, it is inactivated by organic debris
*If Clostridium SPORES are suspected, which antiseptic is an effective Sporocide?Hydrogen peroxide
How is the antiseptic spectrum of hydrogen peroxide?TRICK QUESTION-H.P. has no significant antiseptic activity
What is a property of hydrogen peroxide that makes it useful for wound cleaning?Effervescent action (bubbles) dislodges bacteria & debris
Why would hydrogen peroxide be used w/ caution?It is CYTOTOXIC!!! (Esp. to new capillaries)
Which antiseptic solution is cytotoxic?Hydrogen peroxide (actually it has no significant antiseptic activity, lol)-HOWEVER, AT THE WRONG CONCENTRATION, ANY ANTISEPTIC IS CYTOTOXIC-DON''T "EYEBALL" IT
**W/ some traumatic wounds, it can take some time before the full extent of devitalized tissue can be assessed. Up to how long can it take for a wound to "prove itself"?48 hours
What are 6 different methods of wound debridement?Surgical
Biosurgical (maggots)
Explain what autolytic debridement entails?Hydrophilic, semi-or occlusive bandages
Explain what enzymatic debridement entails?Enzymes break down necrotic tissue & liquefies coagulum
Explain what mechanical debridement entails?Wet-dry, dry-dry dressings
Explain what hydrodynamic debridement entails?Pressure irrigation
Explain what biosurgical debridement entails?Maggot therapy
*What is 1st intention wound healing?Wound closed w/ sutures (1° closure) THIS IS FOR: *clean (surgical) or * Clean-contamination (contaminated traumatic wounds only after being rendered surgically clean)
*What is 2nd intention wound healing?Wound left open to heal by contracture & epithelialization (healing from the inside → out) (NO surgical closure!)
*What is 3rd intention wound healing?Wound sutured closed before granulation tissue has begun to form (delayed 1° closure) (let it heal a bit & then sew before granulation)
For clean or clean-contaminated wounds, you can use what type of closure?1° closure-which is 1st intention wound healing
To minimize tension on a 1° closure, consider... (2)(1) Stay sutures
(2) Splint/bandage to restrict movement
1st intention wound healing → when are ABx not indicated?ABx (pre-& post-operative); not indicated for clean surgical wound
Delayed 1° closure is which intention wound healing?3rd
Which type of closure/intention is indicated for mild to moderately infected wounds?3rd intention wound healing, aka delayed 1° closure.
Why do you wait a few days, but then close a wound before granulation tissue forms w/ delayed primary/3rd intention healing?Goal is to control infxn before suturing wound closed! Tx infxn for 3-5 days & then repair BEFORE granulation tissue forms


Question Answer
How long do you wait w/ delayed 1° closure?3-5 days
How long do you wait w/ 2° closure?5-10 days (it takes at least 5 days for granulation tissue to form)
When would you want to do a 2° wound closure?(Close after granulation tissue forms) Indicated for heavily infected wounds or very large wounds
Explain what you'd do for a 2° closureManage wound as an open wound until granulation tissue forms (>5 days) → Will need to undermine skin & pull over granulation tissue. +/-tension sutures & +/-drain
TQ: Position of transfixing ligature using the three-clamp technique?Prox to the middle clamp (proximal clamp is the clamp CLOSEST TO THE BODY)
In summary - 1° closure vs delayed 1° closure vs 2° closure (which 1 is which intention healing)1°: 1st intention wound healing
Delayed 1°: 3rd intention wound healing
2°: Suture AFTER granulation forms
Primary closure is what kinda wound healing?1st intention
Delayed 1° closure is which kinda wound healing?3rd intention healing
What are the 4 things you can do to medically manage a wound?(1) Formulate Tx plan
(2) Drug therapy (ABx, topical rxn, pain management)
(3) +/- Bandages
(4) +/- Tetanus
*Which antimicrobial is efficacious against pseudomonas species?Silver sulfadiazine + aloe vera
What is 2nd Intention Wound Healing?* Managing an open wound *
When is 2nd intention wound healing indicated?(managing an open wound) indicated when... PTx is a poor surgical candidate or severely traumatized, wound is infected, wound too large to close surgically
When is 2nd intention wound healing inappropriate?Not appropriate for clean wounds (surgical wound)
1st intention vs 2nd intention vs 3rd intention wound healing1st: Sx closure! 2nd: let it heal by itself from inside out 3rd: leave it open a bit & THEN close it up (before granulation tissue forms)
Medical management of a wound (2nd intention wound healing) → when are ABx indicated?ABx are indicated for severely contaminated, crushed or infected wounds; wounds >6-8 hrs old (← past the golden period)
Medical management of a wound (2nd intention wound healing) → when would you use topical ABx?Topical only for mild-moderately contaminated wounds
Medical management of a wound (2nd intention wound healing) → when would you use topical+systemic ABx?Topical + systemic antibiotic indicated for heavily contaminated wounds
What is an upside to use of topical ABx in a 2nd intention wound healing?Can potentially ↓ healing time
Medical management of a wound (2nd intention wound healing) → when would you use systemic ABx?Indicated if high risk of bacteremia
Heavily infected wounds
TRIPLE ANTIBIOTIC → what is the spectrum? When is this usually used? Downsides?BROAD spectrum, best used to prevent rather than treat infxn. Poor efficacy against Pseudomonas
SIVER SULFADIAZINE → spectrum?Gram +ve & gram –ve (Pseudomonas!!!!), fungi (silver will get you far-& pseudomonas wants to stay green not silver so it kills itself)
Pros of silver sulfadiazine? Cons?PRO: Enhances epithelization, hydrophilic, penetrates necrotic tissue
CON: Impairs fibroblasts (so slow down granulation tissue) (this effect ↓ when used w/ aloe vera)
Which antimicrobial might impair fibroblasts, thus impairing granulation tissue formation? (& how can you minimize this)Silver sulfadiazine, you can add aloe vera to ↓ this effect tho (silver fibers don't grow)
Which antimicrobial can penetrate necrotic tissue?Silver sulfadiazine (silver arrows penetrate)
CEFAZOLIN → spectrum?Gram +ve & Gram –ve (some)
What is the benefit of cefazolin?Provides high ABx concentration in wound fluid
Which antimicrobial provides high antibiotic concentration in wound fluid?Cefazolin (it's fabulous how high it can get)
NITROFURAZONE → spectrum?Broad spectrum (poor efficacy against Pseudomonas) (it's FURaous that it doesnt work against pseudo)
What are the pros & cons of nitrofurazone?PRO: Hydrophilic
CON: Delays epithelialization (also wear gloves when you apply-carcinogenic)
GENTAMICIN SULFATE → spectrum?Gram –ve activity (incl. Pseudomonas, E. coli & Proteus spp.) (Gentlemen are so negative)
MAFENIDE (topical sulfa rxn) → spectrum?Many gram +ve & gram –ve (incl. Pseudomonas), anaerobes (incl. Clostridium) (MAFendine-Mad as F*** so kills just about anything)
Which antimicrobial is effective against anaerobes like Clostridium?Mafenide
Why would you want to use ALOE VERA on a wound? (4)(1) Antibacterial effect on Pseudomonas aeruginosa
(2) Helps to maintain vascular patency which ↓ skin ischemia
(3) Stimulates fibroblast replication
(4) Components of aloe vera extract used to promote wound healing (i.e. Acemannan, allantoin)
Wound healing enhancers → PREPARATION H → what is this? How does this help wounds?This is a water-soluble yeast extract which can be used on granulating wounds to promote angiogenesis, epithelialization & collagen synthesis
Wound healing enhancers → SOLCOSERYL → what is this? How does it help wound healing?It is a protein-free calf blood ultrafiltrate which stimulates fibroblast proliferation & migration...however it is hella expensive (use the sol/spirit of the cow to heal your wounds)
TOPICAL ANESTHESTICS (Lidocaine or Bupivacaine) → when are these used for wound healing?Reduces traumatic & post-operative pain
Wound healing → STEROIDS → are these a good or a bad thing to use in wound healing?Use contraindicated except in case of exuberant granulation tissue (1 or 2 applications only)
What are some of the fxns of bandages?Protect wound, absorb exudate, ↓ dead space, control hemorrhage, reduce edema, immobilize, promote epithelialization & contraction, creates warm environment= promotes healing, creates acidic environment= ↑ oxygen availability at wound
You would change bandages every 2-3x per day if... (When?)Infected, ↑ exudate, ↑tissue trauma
You would change bandages every 2-4 days if… (When?)Wound granulated or bandage providing support only
When should you change a bandage IMMEDIATELY?Bandage is wet or soiled
List who is most to who is least susceptible to tetanusEquine, man > ruminants, swine > cat, dog
What are the uses for tetanus antitoxin?Provides immediate protection. Can also be given at time of castration & tail docking
Toxoid (Vx) for tetanus → who is this usually given to? How effective is it? What will happen if it's admin w/ the antitoxin as well?Typically given to equine & humans only (the most susceptible), provides very good immunity, can be administered w/ antitoxin for immediate & long-term protection
*Is degloving a laceration wound?No
What is KEY to helping a degloving injury?Debridement & lavage!
In a degloving injury, what are some ways you can help promote a granulation bed of tissue?“Sugaring”, honey, metaphyseal puncture (exposed bone) (bore holes into metaphysis of bone & then granulation tissue mushroomed out of those holes (promotes the formation of granulation tissue) )
If a degloving injury is involving both orthopedic & soft tissue injury, which do you need to address 1st?Orthopedic injuries should only be repaired once infxn is controlled & soft tissues are healing
What are the beneficial effects of honey on wound healing? (5)(1) Wound debridement
(2) Reduces edema & inflammation
(3) Promotes granulation & epithelialization
(4) ↑ wound collagen content & collagen cross-linking
(5) Antibacterial
*At what point in the healing timeline would you want to use honey to aid in healing?Use in early wound healing until granulation bed formed
What is punch grafting, why do you do it?Take cored samples of healthy skin & insert into wound to promote healing/growth (accelerates healing)