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Presented By

Dr. Osama Kentab, MD, FAAP, FACEPAssistant Professor of Pediatrics and emergency Medicine

King Saud Bin Abdulaziz University for Health sinces

Riyadh

WOUND CARE AND DRESSING

THE SKIN

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FUNCTIONS OF THE SKIN

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• Regulates body temperature.

• Prevents loss of essential body fluids, and penetration of toxic substances.

• Protection of the body from harmful effects of the sun and radiation.

• Excretes toxic substances with sweat ( waste removal).

• Mechanical support.

• Immunological function mediated by Langerhans cells.

• Sensory organ for touch, heat, cold, socio-sexual and emotional sensations.

• Vitamin D synthesis from its precursors under the effect of sunlight and introversion of steroids.

WOUND-DEFINITIONS(MANLEY, BELLMAN, 2000)

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- A loss of continuity of the skin or mucous membrane which may involve soft tissues, muscles, bone and other anatomical structure.

- Any disruption to layers of the skin and underlying tissues due to multiple causes including trauma, surgery, or a specific disease state.

WOUND HEALING

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Classification of wound healing(According to the amount of tissue loss)

Primary intention healing

Secondary intention healing

Tertiary intention healing

PHASES OF WOUND HEALING

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Healing is a quality of living tissue; it is also referred to as regeneration (renewal) of tissue.

A. The inflammatory phase (3-6 days)

B. The regenerative (Proliferative) phase (day 4-day21)

C. The maturation (Remodeling) phase (day 21- 1 or 2 yrs)

(Manley, Bellman, 2000)

THE INFLAMMATORY PHASE (INITIATED IMMEDIATELY AFTER INJURY AND LAST 3-6 DAYS

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Injury /damage Cells

Blood Clot

Uniting the wound edges

Histamine

Vasodilation Permeability

Neutrophils &Monocytes

Oedema& Engorgement

0-3 days

Dry

-Dilated blood vessels-Microcirculation slow down

THE REGENERATIVE (PROLIFERATIVE) PHASE

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Blood vessels near the edge of the wound become porous

- Resultant tissue filling is referredTo as granulation tissue- process of wound contraction begins

Traps other blood cells & damaged blood vesselsBegin to regenerate within the wound margins

Allowing excess moisture to escape

Macrophage activity

Formation& multiplication of fibroblasts

migrate along fibrin threads

- Laying down of a ground substance- Beginning the synthesis of collagen fibers (granulation tissue )

Stimulates

Which

This fibrous networkR

esultin

g

Begins 2-3 days of injuryLasting up to 2-3 weeks

THE MATURATIVE PHASE

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• Begins about day 21 and can extend up to 6 months up to one or two years after the injury.

• Fibroblasts continue to synthesize collagen

• The collagen fibers recognized into a more orderly structure

• The scar become a thin ,less elastic, white line

FACTORS AFFECTING WOUND HEALING

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Developmental consideration/Age Nutrition Life-style Medication Infection Wound perfusion

TYPES OF WOUND

Type Cause Description and Characteristics

Incision Sharp instrument eg. Knife Open wound; painful

Contusion Blow from a blunt instrument Close wound, skin appears ecchymotic (bruised) because of damaged blood vessels

Abrasion Surface scrape, either unintentional (eg, scraped knee from fall) or intentional (eg, dermal abrasion to remove pockmarks)

Open wound; involving the skin ; painful

Puncture Penetration of the skin and, often the underlying tissues from a sharp instrument

Open wound; can be intentional or unintentional

Laceration Tissues torn apart, often from accidents (eg, machinery)

Open wound; edges are often jagged

Penetrating wound

Penetration of the skin and the underlying tissues

Open wound; usually accidental ( bullet or metal fragments)

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CLASSIFICATION OF SURGICAL WOUNDS ACCORDING TO THE DEGREE OF CONTAMINATION

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Clean wounds: Operations in which a viscus is not opened. This category includes non- traumatic, uninfected wounds where is no inflammation encountered and no break in technique has occurred.

Clean-contaminated: A viscus is entered but without spillage of contents. This category included non- traumatic wounds where a minor break in technique has occurred.

CLASSIFICATION OF SURGICAL WOUNDS CONT’D (ALTMEIRE 1997, AYLIFFE & LOWBURY 1992, NAS 1996)

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Contaminated: Gross spillage has occurred or a fresh traumatic wound from a relatively clean source. Acute non-purulent inflammation may also be encountered.

Dirty or infected : Old traumatic wounds from a dirty source, with delayed treatment, devitalised tissue, clinical infection, faecal contamination or a foreign body.

CLASSIFICATION OF WOUNDS BY DEPTH

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I. Partial-thickness: Confined to the skin, the dermis and epidermis.

II. Full-thickness : Involve the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone

Partial Thickness Full Thickness

WOUND ASSESSMENT CONT’D(HAHN,OLSEN,TOMASELLI, GOLDBERG ,2004)

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What to assess?1. Location2. Dimensions/Size3. Tissue viability4. Exudate/Drainage5. Periwound condition6. Pain7. Stage or extent of tissue damage , dictates how often a

wound is reassessed8. Swelling

DIAGNOSES

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• Risk for Impaired Skin Integrity

• Impaired Skin Integrity • Impaired Tissue Integrity

• Risk for Infection

• Pain

RISK FACTORS WHICH INCREASE PATIENT SUSCEPTIBILITY TO INFECTION (MANLEY.K, BELLMAN. L,2000)

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A- Intrinsic risk factors:1. Extremes age: Defined as “ Children aged 1 year and under, and

people aged 65 years and over’.2. Underling Conditions/Disorders

A. DiabetesB. Respiratory disordersC. Blood disorders

3. Smoking

4. Nutrition and build

RISK FACTORS WHICH INCREASE PATIENT SUSCEPTIBILITY TO INFECTION CONT’D (MANLEY.K, BELLMAN. L,2000)

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B- Extrinsic risk factors:1. Drug therapy as a risk factor: e.g. Cytotoxic drugs

2. Break in the integrity of the skin

3. Items such as foreign bodies

4. Bypassing of defense mechanisms through devices e.g. Intubations

S&S OF PRESENCE OF INFECTION

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• Wound is swollen.

• Wound is deep red in color.

• Wound feels hot on palpation.

• Drainage is increased and possibly purulent.

• Foul odor may be noted.

• Wound edges may be separated with dehiscence present.

TYPES OF WOUND DRAINAGE

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Exudate is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and deposited in or on tissue surfaces. The Nature

and amount of exudate vary according to: Tissue involved, Intensity and duration of the inflammation, and the presence of microorganisms.

1. Serous Exudate Mostly serum

Watery, clear of cells

E.g., fluid in a blister

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2. A purulent Exudate Is thicker than serous exudate because of the presence of pus.

It consists of leukocytes, liquefied dead tissue debris, dead and living bacteria.

The Process of pus formation is referred to as suppuration, and the bacteria that produce pus are called pyogenic bacteria.

Purulent exudate vary in color, some acquiring tinges of blue, green, or yellow. The color may depend on the causative organism.

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3. A sanguineous (hemorrhagic) Exudate It consists of large amount or blood cells, indicating damage to capillaries that

is very severe enough to allow the escape of RBCs from plasma

This type of exudate is frequently seen in open wounds.

we often need to distinguish whether the exudate is dark or bright. Bright indicate fresh blood, whereas dark exudate denotes older bleeding.

COMPLICATIONS OF WOUNDS

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• Infection

• Hemorrhage

• Dehiscence and possible evisceration

• Fistula formation

THE RYB COLOR CODE(STOTTS,1999)

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• This concept is based on the color of the open wound rather than the depth or size of the wound.

On this scheme, the goal of wound care is to protect ( cover) red, cleanse yellow, and debride black.

The RYB code can be applied to any wound allowed to heal by secondary intention.

R=Red Y=Yellow B= Black

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Red woundsRed wounds• Usually in the late regeneration phase of tissue repair (ie,

developing granulation tissue) and are clean and uniformly pink in appearance

• They need to be protected to avoid disturbance to regenerating tissue. Examples are superficial wounds, skin donor sites, and partial- thickness or second – degree burns.

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• How to protect red wounds:

Gentle cleansing

Avoid the use of dry gauze or wet- to-dry saline dressings.

Applying a topical antimicrobial agent.

Appling a transparent film or hydrocolloid dressing.

Changing the dressing as infrequently as possible.

YELLOW WOUNDS

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• Characterized primarily by liquid to semiliquid ”slough” that is often accompanied by purulent drainage.

• clean yellow wounds to absorb drainage and remove nonviable tissue. Methods used may include .

• Applying wet-to-wet dressing; irrigating the wound; using absorbent dressing material such as impregnated nonadherent, hydrogel dressing, or other exudate absorbers; and a topical antimicrobial to minimize bacterial growth.

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Black WoundBlack Wound• Covered with thick necrotic tissue or Eschar.

• e.g.. third degree burns and gangrenous ulcer.

• Required debridement .

• When the eschar is removed, the wound is treated as yellow, then red.

PURPOSES OF WOUND DRESSING

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1. To protect the wound from mechanical injuries

2. To protect the wound from microbial contamination

3. To provide or maintain high humidity of the wound

4. To provide thermal insulation

5. To absorb drainage and /or debride a wound

PURPOSES OF WOUND DRESSING

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6. To prevent hemorrhage (when applied as a pressure dressing or with elastic bandages).

7. To splint or immobilize the wound site and thereby facilitate healing and prevent injury.

8. To provide psychological (aesthetic) comfort.

PRINCIPLES OF ASEPSIS

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The aim:• Guarantee the safety of the equipment used

(cleaning/disinfection/sterilisation).

• Reduce the level of microbial contamination of the site requiring manipulation (antisepsis).

• Ensure that no microorganisms are introduced (asepsis).

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Cleaning : Is the removal of dirt, debris and organic material.

Disinfection: Removes or destroys harmful microorganisms but not bacterial spores or slow viruses.

Sterilization: is the complete destruction or removal of all living microorganisms including bacterial spores.

Antisepsis: is the reduction of the number of microorganisms already present on the body site prior to a procedure.

Asepsis: Procedure designed to prevent any introduction of microorganisms to the site achieved by a non-touching technique and use of sterile gloves

EVALUATION OF WOUNDS

• ABC’s first Always!

• Ensure hemostasis

• Saline gauze dressing

• Compression

• Remove obstructions

• Rings, clothing, other jewelry

• History

HISTORY

• Symptoms• Type of Force• Contamination• Event• Potential for foreign body• Function• Non-accidental trauma

• Tetanus status

• Allergies

• Medications

• Comorbidities

• Previous scar formation

WOUND EXAMINATION

• Location

• Size

• Shape

• Margins

• Depth

• Alignment with skin lines

• Neuro function

• Vascular function

• Tendon function

• Underlying structures

• Wound contamination

• Foreign bodies

WOUND CONSULTATION

• Tarsal plate or lacrimal duct

• Open fracture or joint space

• Extensive facial wounds

• Associated with amputation

• Associated with loss of function

• Involves tendons, nerves, or vessels

• Involves significant loss of epidermis

• Any wound that you are uncertain about

WOUND PREPARATION - HEMOSTASIS

• Physical vs. chemical

• Direct pressure

• Epinephrine

• Gelfoam

• Cautery

• Refractory

• Use a tourniquet

WOUND PREPARATION – FOREIGN BODY REMOVAL

• Visual inspection

• Imaging

• Glass, metal, gravel fragments >1mm should be visible on plain radiographs

• Organic substances and plastics are usually radiolucent

• Always discuss and document possibility of retained foreign body

WOUND PREPARATION – IRRIGATION

• Local anesthesia prior to irrigation

• Do not soak the wound

• Use normal saline

• Large syringe (60mL) with Zerowet attachment

• Do not use iodine, chlorhexidine, peroxide or detergents

WOUND PREPARATION – DEBRIDEMENT

• Removes foreign matter & devitalized tissue

• Creates sharp wound edge

• Excision with elliptical shape

• Respect skin lines

WOUND PREPARATION – ANTIBIOTICS• Infections occur in ~3-5% of traumatic wounds seen in

the ED• Factors that increase risk

• Heavily contaminated wound, especially with soil• Immunocompromised patients• Diabetics • Human bites > animal bites

• Most important prevention adequate irrigation & debridement

WOUND PREPARATION – ANTIBIOTICS• Dog & cat bites

• Cover pasteurella• Augmentin

• Human bites• Cover eikenella• Augmentin

• Puncture wounds• Cover pseudomonas• Cipro, levaquin

WOUND PREPARATION – TETANUS PROPHYLAXIS

• Clean wounds• Incomplete immunization toxoid• >10 years, then give toxoid

• Tetanus prone wound• Incomplete immunization

• Toxoid & immune globulin• > 5 years, give toxoid

• Remember to think about rabies!

GUIDELINES FOR CLEANING WOUNDS

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1. Use physiologic solution, such as isotonic saline or lactated ringer solution.

2. When possible , warm the solution to body temperature before use.

3. If the wound is grossly contaminated by foreign material , bacteria, slough, or necrotic tissue clean the wound at every dressing change.

4. If a wound is clean , has little exudate , and reveals healthy granulation tissue , avoid repeated cleaning.

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5. Use gauze squares .

6. Consider cleaning superficial noninfected wound by irrigating them with normal saline rather than using mechanical means.

7. To retain wound moisture , avoid drying a wound after cleaning it.

IDEAL DRESSING

• provide mechanical protection

• protect against secondary infection

• non adherent and easily removed without trauma

• leave no foreign particles in the wound

• remove excess exudates

• cost effective

• offer effective pain relief.

BURNS: FIRST CONTACT

Assessment

• site

• depth

• surface area involved

• age of patient

• other influencing factors

SUPERFICIAL BURN CHARACTERISTICS

• epidermis only

• erythema (vasodilatation)

• tenderness (nerve irritability)

• oedema.

SUPERFICIAL PARTIAL BURN CHARACTERISTICS

• epidermis and outer dermis

• blisters (fluid shift)

• shedding of skin

• painful exposed (nerve endings to kinins)

• bleeds when pricked with needle

• hair present (hard to pull out)

• full sensation

• blanches on pressure.

BURN SURFACE AREA

• Wallace’s rule of nines

• Lund and Browder chart

• closed palmar hand of victim = 1% of body surface area.

ANATOMICAL SITE CONSIDERATIONS

• hands

• feet

• face

• perineum

• genitalia

• joints

• circumferential burns

OTHER CONSIDERATIONS

• extremes of age: very young or very old will need special care

• co-morbidities

• medications.

WHAT TO DO ABOUT BLISTERS?

• controversial: removal causes pain

• tense blisters can interfere with dermal circulation, restrict movement

• beware of blisters with “red rings”

• blisters can hide deep burns

• popped blisters may need to be debrided.