Sx Skills- Wound Management

untimely's version from 2015-05-06 18:48

Wound management- steps about managing

Question Answer
what are the 6 steps in a approach to a traumatic wound?inital pt assessment--> wound assessment--> prelim exam--> detailed exam--> wounds tx plan--> medical and 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 (ie. fracture) and +/- culture and 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" ??first 6-8 hours btwn contamination at injury and bacterial infection (>10^5 bacteria per gram of tissue)
bacterial infection is how many bacteria per gram of tissue?more than 10^5
what are the three 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 with copious amounts of warmed solution
CQ: which of the following is least appropriate for wound lavage?--- sterile water, LRS, NaCl 0.9 with 0.05% chlorhex, dilute povodine-iodine.WATER is the least appropriate, because you want an ISOTONIC solution and 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 and 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 within cuff pressurized to 300 mmHg. 35-or 60-mL syringe + 18 guage needle
Chlorhexidine 0.05% solution--> what is its spectrum? how can its spectrum be improved?broad spectrum antimicrobial, antimicrobial effect increases by 1,000x if combined with 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 povodone ) (probably why you can clean shitty cages with chlorhex spray)
***which antiseptic can pseudomonas develop a resistance to??CHLORHEX!! (so if pseudo, choose povodone)
Povidone iodine solution (0.1~1%)--> what is the spectrum?broad spectrum
does povodone iodine have residual acvitiy?no
is povodone 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 with 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
CQ: with 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, autolytic, enzymatic, mechanical, hydrodynamic, biosurgical
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?maggott therapy
*what is 1st intention wound healing?Wound closed with 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 and then sew before granulation)
for clean or clean-contaminated wounds, you can use what type of closure?primary closure-- which is 1st intention wound healing
to minimize tension on a primary closure, consider... (2)(1) stay sutures (2) splint/bandage to restrict movement
1st intention wound healing---> when are antibiotics not indicated?Antibiotics (pre-& post-operative); not indicated for clean surgical wound
delayed primary 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 primary closure.
why do you wait a few days, but then close a wound before granulation tissue forms with delayed primary/3rd intention healing?goal is to control infection before suturing wound closed! Tx infxn for 3-5 days and then repair BEFORE granulation tissue forms
explain what you'd do for delayed primary closureThoroughly clean +/-debride. Bandage until surgery +/-topical Rx. After 3-5 days --> surgical debridement (if required), wound repair +/-drain. Parenteral abx.
secondary closure is done on...WOUNDS WHICH HAVE GRANULATION TISSUE!!
how long do you wait with delayed primary closure?3-5 days
how long do you wait with secondary closure?5-10 days (it takes at least 5 days for granulation tissue to form)
when would you want to do a secondary wound closure?(close after granulation tissue forms) indicated for heavily infected wounds or very large wounds
explain what you'd do for a secondary closureManage wound as an open wound until granulation tissue forms (>5 days)--> Will need to undermine skin & pull over granulation tissue. +/- tension sutures, and +/- drain
CQ: 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- primary closure vs delayed primary closure vs secondary closure (which one 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?first intention
delayed primary 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 Rx, pain management) (3) +/- bandages (4) +/- tetanus
CQ: 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.. patient 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 and THEN close it up (before granulation tissue forms)
medical management of a wound (2nd intention wound healing)--> when are abx indicated?Antibiotics 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 antibiotics in a 2nd intention wound healing?can potentially decrease 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 infection. poor efficacy against Pseudomonas
SIVER SULFADIAZINE--> spectrum?gram +ve & gram –ve (Pseudomonas!!!!), fungi (silver will get you far-- and pseudomonas wants to stay green not silver so it killsitself)
pros of silver sulfadiazine? cons?PRO: enhances epitheliazation, hydrophilic, penetrates necrotic tissue. CON: impairs fibroblasts (so slow down granulation tissue) (this effect decreased when used with aloe vera)
which antimicrobial might impair fibroblasts, thus impairing granulation tissue formation? (and how can you minimize this)silversulfadiazine, you can add aloe vera to dec 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 antibiotic concentration in wound fluid
which antimicrobial provides high antibiotic concentration in wound fluid?cefazolin (it's fazulous 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 and 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 Rx)--> 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 decreases skin ischemia (3) stimulates fibroblast replication (4) components of aloe vera extract used to promote wound healing (ie. 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 bupivicaine)--> 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 functions of bandages?protect wound, absorb exudate, decrease dead space, control hemorrhage, reduce edema, immobilize, promote epithelialization & contraction, creates warm environment= promotes healing, creates acidic environment= increases 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 (Vaccine) for tetanus--> who is this usually given to? how effective is it? what will happen if it's admin with the antitoxin as well?typically given to equine & humans only (the most susceptible), provides very good immunity, can be administered with antitoxin for immediate & long- term protection
CQ: is degloving a laceration wound?no
what is KEY to helping a degloving injury?Debridement and 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 and then granulation tissue mushroomed out of those holes (promotes the formation of granulation tissue) )
if a degloving injury is involving both orthopedic and soft tissue injury, which do you need to address first?Orthopedic injuries should only be repaired once infection is controlled and 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) increases 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 and insert into wound to promote healing/growth (accelerates healing)

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