Any tissue (Skin, Muscle, Bone, etc. ) that has been

damaged torn or cut by either intentional (surgical)

or accidental (traumatic) means

DEPTH of the wound is more important than

AREA.

The skin remains intact, but underlying tissues

suffer damage

The integrity of the skin is destroyed.

Mechanism of Injury:

INCISED WOUND

LACERATED WOUND

PUNCTURED WOUND

GRAZE OR ABRASION

AVULSION AMPUTATION

GUN SHOT WOUND

– The integrity of the skin is destroyed, there is no

loss or destruction of tissue and there is no foreign body in the

wound.

– Tissue is lost or destroyed, or a foreign

body remains in the wound.

– Wound edges can be approximated and secured.

A clean wound is expected to heal by first intention.

– Contamination occurs when a dirty

object damages the integrity of the skin. Debridement of

necrosed tissue may be necessary.

INCISED

LACERATED

PUNCTURED

CONTUSED

BURNS

Primary closure.

Delayed primary closure.

Secondary closure.

Closure of partial thickness skin wound.

much under used method of wound care .

recommended technique for contaminated wounds.

reduced the infection rate by 50% in 104 extremity wounds.

1. War Wounds.

2. Agricultural Wound.

3. Infectious Wound.

4. Late Non Treated tell 6-12 Hour.

5. Best for all combat injuries, human bites.

Size and Shape

Location(s) - Entrance & Exit

Devitalized tissue

Associated injuries FracturesCompartment

syndromeBurnsNeurovascular

injuryBLEEDING!

Morgan et al

◦ Arm and hand: 4 hours

Baker and Lanuti

◦ Arm and hand: 6 hours

◦ Jamaica

◦ Face: no time limit

Never close an infected wound

If wound merely contaminated, clean it up and

then make a decision for primary, secondary or

tertiary (delayed primary closure)

contaminated wounds

*Pack wound with fine mesh saline soaked

gauze and cover with a sterile dressing

*Change every 12 hours for 4 days

*On the fourth day, remove dressing,

inspect wound, and if no infection, approximate wound

edges using primary closure technique.

Debride all dead or marginal tissue (if unsure

cut a little, does it bleed?)

Remove all foreign debris

When irrigation needed use either a

hydrostatic irrigator or a 10 cc syringe with an

18 ga angicath or Zerowet

DEFINITION:

Removal of any devitalized skin tags and

necrotic tissue along with foreign bodies

and debris

Removes foreign matter & devitalized tissue.

Creates sharp wound edge.

Excision with elliptical shape.

Respect skin lines.

Before debridement After debridement

Debridement of nonviable tissue a must!

Devitalized tissue doesn’t bleed when it is scrubbed and appears blue/black

Devitalized tissue acts as anaerobic medium and inhibits leukocyte phagocytosis (decreases wound’s resistance to infx)

Goal is to reestablish a margin of normal tissue and wound edges (elliptical area around wound)

4 C’s: used most commonly for soft

tissue

Color dusky vs. pink

Consistency “mushy” vs. firm

Contractility non-reactive vs.

fasciculation

(forceps pinch or Bovie)

Circulation no bleeding vs. punctate

bleeding.

Freshen skin edge Incise through fascia

Remove non-

viable tissue

Irrigate

Most do.

Exception: small fragment wounds.

Punctate

< 1 cm

No fascial defect

Irrigate, leave open, and dress

you should not use primary repair for a

wound that is more than 6 hours old.

Wounds with too much swelling or skin loss

Wounds with dead space under the skin closure.

Highly contaminated wounds.

High velocity gunshots may cause massive amounts

tissue damage requiring debridement.

Close range shotgun wounds also cause massive

tissue destruction.

Both may have large amounts of contamination

◦ Secondary to negative pressure of cavitation

◦ Thorough surgical debridement is

imperative

Low velocity gunshot wounds rarely need

debridement.

High velocity and close range shotgun wounds

always need debridement.

Most civilian gunshot wounds are low velocity

and low energy

In the limb the incision made in long axis In flexoin along the creases

Subcutaneous fat:

Has poor blood supply .

It is liable to be heavily contaminated .

It should excised generously.

Retraction and fasciotomy :

Deep fascia should incised parallel to long axis

of wound.

If necessary incise the fascia transversely .

The purpose is to make a good exposure of

depth of wound .

Deep to the fascia the gloved finger is the best

probe for estimation of extend of damage

Dead and damaged muscle:

It is absolutely vital that all dead muscle excised .

dead muscle is the ideal medium for clostridial

infection lead to gas gangrene.

All muscle which is not healthy and red , not contract

when pinched or bleed when cut must be excised until

healthy contractile bleeding muscle is found .

Technique :

Take the muscle (less the 2cm) pinch it if no contract cut it by scissor

No more than 2 cm of muscle piece should not take in forceps because it will cause inadvertent removal of healthy tissue and vital structure

Muscle will not contract when patient received paralyzing anesthetic agent

Bleeding control:

First by packing .

Suture ligate by fine absorbable suture.

Do not use electro cautery because it make other dead tissue .

If main artery damaged repair it.

All penetrating (high or low velocity missile)

abdominal wound should be explored

Stab wound should first excised if it’s penetrated to

abdomen and if necessary laparotomy is don.

Morbidity and mortality from

Negative laparotomy is

Very low

Un operated bullet abdominal

Wound always fatal

Fined entry and exit wound if present and position is noted.

Estimate which abdominal organ will damaged .

In low thoracic and perineal injury aware of intra abdominal damage.

Maybe blunt abdominal trauma without any external sign.

Sign of infection:

1. Offensive moist dressing .

2. Pyrexia .

Sever contaminated wound.

Thanks