GYÖRGYI SZABÓASSISTANT PROFESSOR

DEPARTMENT OF SURGICAL RESEARCH AND TECHNIQUES

Classification and management of wound,

principle of wound healing, haemorrhage and bleeding

control

Basic Surgical Techniques, Faculty of Medicine, 3rd year 2021/13 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 layerBase of the wound

Wound edge

Surface ofthe wound

Woundcavity

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The ABCDE in the injured assessment

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 stabilizationB: BreathingC: CirculationD: DisabilityE: Environment and Exposure

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Wound management - anamnesis

When and where was the wound occured?Alcohol and drug consumptionWhat did caused the wound?The circumstances of the injuryOther diseases eg. diabetes mellitus, tumour,

atherosclesosis, allergyThe state of patient’s vaccination against TetanusPrevention of rabiesThe applied first-aid

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Classification of the accidental wounds1. Based on the origine

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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 epidermal layer

Good wound healing

Sharp-pointed object Seems negligibleBUT Anaerobic infection Injury of big vessels and

nerves

Mechanical wounds8

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 additional force

Edges - uneven

Mechanical wounds9

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 wounds10

(v. lacerocontusum)

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

Close - burn injury Foreign materials

Mechanical wound11

unijured tissuenecrobiotic zonenecrotic zoneforeign bodies

aperture

slot tunel

output

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

Ragged wound Crushed tissue Torn Infection Bone fracture

Prevention of rabies Tetanus profilaxis

Mechanical wounds12

DistalDistal ProximalProximal

The wound healing is good

The direction of the flap13

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

in small concentration – irritate in large concentration –

coagulation necrosis

colliquative necrosis

Chemical wounds14

Symptoms and severity depend on: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 marrowgastrointestinal tract

Wounds caused by radiation15

1.) Burning1.) Burning2.) Freezing2.) Freezing

a – normal skin 1 - 1st degree – superficial injury

(epidermis) 2 – 2nd degree –partial or deep partial

thickness (epidermis+superficial or deep dermis)

3 – 3rd degree – full thickness (epidermis + entire dermis)

4 – 4th degree – (skin + subcutaneous tissue + muscle and bone)

Treatment:

Cooling – cold water and clean covering

Wounds caused by thermal forces16

Metabolic change! - toxemia mild, moderate, severe (redness, bullas, necrosis)

rewarm – not only the frozen area but the whole body

Exotic, poisonous animalsExotic, poisonous animals

Toxins, venom - toxicologist Skin necrosis

Special wounds17

Classification of the wounds2. According to the bacterial

contamination

Clean woundClean-contaminated woundContaminated woundHeavily contaminated wound

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SuperficialPartial thicknessFull thicknessDeep wound

Classification of the wounds2. Depending on the depth of injury

+ bone, opened cavities, organs…etc.

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source: http://www.funscrape.com/Search/1/skin+layers.html

Wound management - history

Ancient Egypt – lint (fibrous base-wound site closure), animal grease (barrier) and honey (antibiotic)„closing the wound preserved the soul”

Greeks – acute wound= „fresh” wound; chronic wound = „non-healing” woundmaintaining 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

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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

Applied wound managementinfection continuum

contamination

colonisation

infectionsterility

critical colonisation

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the quantity and diversity of microbes

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

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

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,

foreign body, 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 managemanet25

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

Surgical incisionStretch and fixHandling the scalpelLanger linesSkin edgesVessels and nervesHemostasis

Langer lines

The wound edges

Handling the scalpel

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source: http://www.med-ars.it/galleries/langer.htm

Tissue unifying and dressing the wound

Skin:StichesClipsSteri-StripsTissue gluesFascia and subcutaneous layers:Interrupted stichesFat – fat necrosis!

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

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The wound healing

Hemostasis-inflammationGranulation-proliferationRemodelling

capillariesfibroblasts

lymphocytesmacrophages

neutrophyl gr.thrombocytes0 1 2 3 4 5 6 7 8 9 10 11 10 13 14 15

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http://www.worldwidewounds.com/2004/august/Enoch/images/enochfig1.jpg

The main steps of the wound healing

1. Hemostasis-inflammation

vasoconstriction fibrin clot formation

proinflammatory citokines andgrowth factors releasing

vasodilatationinfiltration PMNs, macrophages

cytokines releasing→ angiogensis→ fibroblast activation→ B- and T-cells activation→ keratinocytes activation→ wound contraction

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2. Granulation-proliferation

fibroblast migrationcollagen depositionangiogensisgranulation tissue formationepithelisationcontraction

3. Remodellingregression of many capillariesphysical contraction – myofibroblastscollagen degeneration and synthetisationnew epitheliumtensile strength – max. 80%

Factors effecting on wound healing LOCAL

Chronic inflammationInflammatory cells Inflammatory cytokines and

IL

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infection

ischemiaforeign bodies

edema/ elevated tissue pressure

IMPAIRED HEALING

Wound healing needs energy

Glucose and

oxigen supply

ATP productio

n

Defect in wound healing

Elongation of inflammatory phase

Endotoxin collagenase stimulation

Collagen degration

31 Age and gender

Diseases

Obesity

Medication

diabetes

Factors effecting on wound healingSYSTEMIC

inflammatory and proliferative phase!

slower reepithelization

Sorbitol vascular complication,Granulation,

collagen level

Corticosteroid, citostatics, NSAIDs,

radiation

Infection, dehiscence,

hematoma, seroma

Alcoholism and smoking

Sepsis

Nutrition

Neutrophyl Phagocyte function

Glucose, glutamin, vitamins, trace

elements

Hemostasis, hemorheology

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/

Complications of wound healingI. Early complications

SeromaHematomaWound disruptinSuperficial wound infectionDeep wound infectionMixed wound infection

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

Filled with serous fluid, lymph or blood

Fluctuation, swelling, redness, tenderness, subfebrility

TREATMENT: Sterile punture and

compression Suction drain

Early complications of wound healing34

Bleeding, short drainage time, anticoagulant

Risk of infection Swelling, fluctuation, pain,

redness

TREATMENT Sterile puncture Surgical exploration

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

A. partial – dehisceneceB. complete - disruption

Surgical error Increased intraabdominal

pressure Wound infection Hypoproteinaemia

TREATMENT: U-shaped sutures

Early complications of wound healing35

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

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

TREATMENTSurgical explorationOpen therapyH2O2 and 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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Mixed wound infectionMixed wound infection

e.g. gangrenenecrotic tissues putrid and anaerobic

infection a severe clinical picture

TREATMENTaggresive surgical

debridement effective and specified

(antibiotic) therapy

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Complications of wound healingI. Early complications

Complications of wound healingII. Late complications

Hyperthrophic scarKeloid formationNecrosisInflammatory infiltrationAbscessesForeign body containing abscesses

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Hypertrophic scar KeloidHypertrophic scar Keloid

Develop in areas of thick chorium

Non-hyalinic collagen fibres and fibroblasts

Confine to the incision line

TREATMENTRegress

spontaneously(1-2 yrs)

Late complications40

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

BLEEDING AND HEMOSTASIS

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AnatomicalAnatomical DiffuseDiffuse

Arterial – bright red, pulsate

Venous – dark red, continuous

Capillary – can become serious

Parenchymal

Bleeding42

Bleeding

Severity of bleeding – the volume of the lost blood and time

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source: http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/

The direction of hemorrage

ExternalInternal

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 hemorrhagePrehospital care! – maintenance of the airways, ventillation and circulationbandages, direct pressure, turniquets

Intraoperative hemorrhageanatomical and/or diffuse

depending on the surgeon, the surgery, position,the size of the vessel, pressure in the vesselANESTHESIA!

Postoperative bleedingineffective local hemostasis, undetected hemostatic defect, consumptive coagulopathy or fibrinolysis

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LocalLocal GeneralGeneral

Hematoma, suffusion, ecchymosis

Compression in the pleural cavity, in pericardium, in the skull

Functional disturbancies – e.g. hyperperistalsis

Pale skin, cyanosis, decreased BP. and tachycardia, difficulty in breeding, sweeting, decreased body temperature, unconsciousness, cardiac and laboratory standstill, laboratory disorders, signs of shock

Signs of the bleeding46

Surgical hemostasis

Aim – to prevent the flow of blood from the incised or transected vessels

Mechanical methodsThermal methodsChemical and biological methods

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Surgical hemostasisMechanical methods

Digital pressure – direct pressure, e.g. Pringle maneuverTourniquetLigationSuturingPreventive hemostasisClipsBone waxother

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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 surgerycoagulation and vaporizationfor fine tissues

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Thermal methods

High temperature Electrocoagulation Electrofulguration (A) Electrodessication Electrosection

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Hemostasis with chemical and biological methods

vasoconstriction coagulation hygroscopic effect

Absorbable collagen

Absorbable gelatin

Microfibrillar collagen Oxidized celluloze Oxytocin Epinephrine

Thrombin Hemcon

QuikClot

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Hemostasis with chemical and biological methods

HemCon

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