Podcast
Questions and Answers
Which factor can significantly affect wound healing by compromising blood supply?
Which factor can significantly affect wound healing by compromising blood supply?
What is a possible consequence of improper treatment of infected wounds?
What is a possible consequence of improper treatment of infected wounds?
Which of the following is NOT a factor that can lead to disrupted wounds?
Which of the following is NOT a factor that can lead to disrupted wounds?
In which scenario might surgical drainage be most beneficial?
In which scenario might surgical drainage be most beneficial?
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What does Halsted’s principle regarding 'meticulous haemostasis' emphasize in surgical practice?
What does Halsted’s principle regarding 'meticulous haemostasis' emphasize in surgical practice?
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What is the primary cause of decubital ulcers?
What is the primary cause of decubital ulcers?
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Which of the following is NOT an effective method in preventing decubital ulcers?
Which of the following is NOT an effective method in preventing decubital ulcers?
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What is a common underlying cause of infected wounds?
What is a common underlying cause of infected wounds?
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Which factor can inhibit wound healing in tissue?
Which factor can inhibit wound healing in tissue?
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How can one relieve pressure and prevent injury over bony prominences?
How can one relieve pressure and prevent injury over bony prominences?
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What is the purpose of tension relieving sutures in wound management?
What is the purpose of tension relieving sutures in wound management?
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What is one of the first steps in managing a draining tract due to foreign bodies?
What is one of the first steps in managing a draining tract due to foreign bodies?
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Which of the following is a characteristic of dead space in wound healing?
Which of the following is a characteristic of dead space in wound healing?
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Which wound management technique is generally discouraged for wound closure over joints?
Which wound management technique is generally discouraged for wound closure over joints?
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What can be a result of shearing movement with ambulation?
What can be a result of shearing movement with ambulation?
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Which of the following entries is NOT a common point for foreign bodies to enter?
Which of the following entries is NOT a common point for foreign bodies to enter?
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In cases of cat bite abscess, what is the most common clinical presentation?
In cases of cat bite abscess, what is the most common clinical presentation?
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What should be carefully monitored to prevent bandage sores?
What should be carefully monitored to prevent bandage sores?
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What is one method to approach the healing of a chronic draining sinus?
What is one method to approach the healing of a chronic draining sinus?
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What is the primary role of surgical drains in wound management?
What is the primary role of surgical drains in wound management?
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Which type of wound is characterized by recurrent cervical swelling and discharging sinuses that is difficult to treat?
Which type of wound is characterized by recurrent cervical swelling and discharging sinuses that is difficult to treat?
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What is the main disadvantage of using a Penrose drain?
What is the main disadvantage of using a Penrose drain?
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What type of drainage system is considered more effective in fluid removal and has reduced risk of ascending infection?
What type of drainage system is considered more effective in fluid removal and has reduced risk of ascending infection?
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Which clinical signs might indicate acute oropharyngeal injury from stick trauma within 7 days of presentation?
Which clinical signs might indicate acute oropharyngeal injury from stick trauma within 7 days of presentation?
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What should be done when antibiotics do not penetrate pus during the treatment of an abscess?
What should be done when antibiotics do not penetrate pus during the treatment of an abscess?
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What is essential to do when placing a closed suction drain?
What is essential to do when placing a closed suction drain?
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What should you monitor daily when maintaining an active suction drain?
What should you monitor daily when maintaining an active suction drain?
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Which of the following breeds is commonly affected by oropharyngeal penetrating injuries from sticks?
Which of the following breeds is commonly affected by oropharyngeal penetrating injuries from sticks?
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What is a key consideration during the placement of a Penrose drain?
What is a key consideration during the placement of a Penrose drain?
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What complication should be monitored for if using a closed suction drain?
What complication should be monitored for if using a closed suction drain?
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Which type of pharyngeal wound is most common in stick injuries?
Which type of pharyngeal wound is most common in stick injuries?
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What aids in the effectiveness of open passive drains?
What aids in the effectiveness of open passive drains?
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Which is a common disadvantage of employing closed suction drains?
Which is a common disadvantage of employing closed suction drains?
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Study Notes
Learning Objectives
- Understand strategies for dealing with infected wounds
- Understand and describe the consequences of improper treatment of infected wounds
- Describe the management of foreign bodies and internally penetrating wounds
- Describe the distinction between active and passive drains
- Identify means of producing active or passive drainage
- Describe scenarios that may benefit from surgical drainage
- Describe drainage of the chest and abdomen
Factors Affecting Wound Healing
-
Patient factors:
- Poor nutrition/malnourishment (low protein levels)
- Concurrent disease (hyperadrenocorticism, hypothyroidism, cancer)
- Immunosuppressive drugs/chemotherapy
- Cat vs. dog wound interference
-
Wound factors:
- Blood supply
- Perfusion
- Infection/Contamination
- Tissue viability/fluid accumulation
- Movement/pressure/skin tension
- Neoplasia
Problem Wounds
- Disrupted wounds
- Pressure wounds
- Wounds in areas of movement and pressure
Factors Leading to Disrupted Wounds
- Wound tension
- Infection
- Haematoma or Seroma
- Suturing nonviable tissue
- Wound molestation
Dehiscence
- A topic likely covering wound separation
Halsted's Principles
- Gentle tissue handling
- Meticulous haemostasis
- Preservation of blood supply
- Strict aseptic technique
- Tension-free closure
- Accurate apposition of tissues
- Eliminate dead space
Pressure Wounds
- Decubital ulcers
- Bony prominences
- Greater trochanter
- Tuber coxae
- Acromion of scapulae
- Ischial tuberosity
- Lateral humeral epicondyle
- Lateral tibial condyle
- Lateral malleolus
- Sides of digit 5
- Olecranon
- Calcaneal tuberosity
- Sternum
- Repeated trauma (sitting/lying, tissue compression)
- Prolonged recumbency (neurological/spinal patients/multi orthopaedic patients)
- Bandage induced pressure sores
Prevention of Decubital Ulcers
- Turn recumbent dogs every 1-4 hours
- Meticulous nursing/skin care-clean and dry-well-padded bed
- Treat underlying condition to prevent recumbency
- Relieve pressure (donut dressing, splints)
Prevention of Bandage Sores
- Proper bandage placement and monitoring
- Prevent slipping, not overtight
- Careful padding over bony prominences
- Less is more with padding
- Care with rigid fixation (casting, splints)
- Place on opposite side of limb from healing wound
- Be aware of swelling
- Casting too early
- Use bivalve casts and check regularly
Movement and Pressure
- Wounds over joints (tension, compression, shearing forces)
- Meticulous attention to closure
- Casting/splinting
- Paw pad wounds (compression, weight-bearing)
- Suture pull through
- Spread with weight-bearing
- Bandaging/splinting (Palmar/plantar - prevent weight bearing on pad for 2 weeks)
- Tension relieving sutures
- Far-near-near-far, large diameter monofilament suture
- Eventually heal by granulation or owner will tolerate sock/bandage/clean walks
Chronic Wounds - Movement and Pressure
- Axillary and inguinal wounds
- Collar wounds
- Shearing movement with ambulation
- Meticulous closure
- Debride and close
- Resect and close
- Reconstructive flaps
Infected Wounds
- Inhibits wound healing
- Chronic/recurrent wounds
- Causes dehiscence of closed wounds
- Surface contaminants do not often reflect infective agent
- Deep tissue culture
- Nature of wounding
- Puncture from a bite
- Underlying causes
- Foreign bodies
- Grass seeds, sx implants, bone sequestra, debris/contaminants
Nature of Wounding
- More energy applied to tissues
- More vascular damage
- Less blood supply (less O2), fewer plasma proteins
- Slower inflammatory response, prolonged inflammation
- Contaminated bacteria more likely to cause infection
- Shearing creates dead space
- Penetrating FBs create dead space
- FBs create avascular surface for bacteria
Trauma, Contamination, and Infection
- Layers of skin (skin, subcutaneous tissue, muscle)
- Dead space (warm, moist, low O2, proteins, immune response cannot penetrate)
Trauma, Contamination, and Infection
- Immune response can only reach edges
- Walled off area
- Abscess
Trauma, Contamination, and Infection
- Heals by granulation
- Abscess bursts
- Drains
Foreign Bodies and Penetrating Wounds
- Wood splinters, grass awns, straw, broken teeth or nail of an attacker
- Common entry points
- Interdigital
- Ear canal
- Conjunctiva
- Oropharynx
- Draining tract/sinus
- FBs
- Surgical implants, sutures, cotton swab strands bone sequestra
Approach to a Draining Tract
- Diagnostics
- Radiographs
- Impression smear
- Bacteriology
- CT/MRI
- Surgical exploration
- Identify and remove causes
- Leave to heal by 2nd intention or excise tract en bloc
- Tissue sample
- Thoroughly lavage
- Empirical antibiotics
- Change based on culture results
Penetrating Wounds – Cat Bite Abscess
- Cat bite abscess (punchure wounds with some crush injury)
- Clinical infection
- Presentation
- Rapid, occurring swelling
- Brave/timid cat
- Ruptured/burst with no visible swelling
- Systemically unwell (pyrexic, lethargic, painful)
- Should be differential in cats with PUO (possible fever)
- Lameness/ not using limb/tail
- May occur where drainage is difficult
Cat Bite Abscess – Treatments
- Presented before abscessation:
- No need to explore (low FB?)
- Antibiotics
- Pain relief (NSAIDs)
- Presented with abscessation:
- Antibiotics that penetrate pus
- Lance, drain, flush, place drain (dead space) antibiotics
- Pain relief (NSAIDs)
- Bacteria: Pasturella, Staph, Strep (aerobes + anaerobes)
- Broad spectrum antibiotics (amoxy-clav, clindamycin, cephalosporins)
Oropharyngeal Penetrating Trauma – Stick Injuries
- Med to large breed dogs (collies, Labradors, spaniels)
- Acute (within 7 days of presentation)
- Oral pain, dysphagia, dyspnea
- Submandibular/cervical swelling
- Abscesses, pain opening mouth
- Pyrexia
- Injury observed or knowledge of stick catching/carrying
- Chronic (>7 days before presentation)
- More common
- Systemically well
- Recurrent cervical or submandibular swelling or discharging sinus
- Rostral pharyngeal wounds
- Enters at acute angle
- Penetrates pharynx at tonsil
- Can lead to involvement of temporal, masseter or retrobulbar muscles
- Lateral pharyngeal wounds
- Most common
- Oblique entry damages para pharyngeal, cervical tissues, and intermandibular area to cranial thorax
- Dorsal pharyngeal injuries
- Enters in front of dog
- Damages soft palate and dorsal pharynx
- Can lacerate esophagus
Oropharyngeal Stick Injuries – Treatment
- Acute
- Examine oral cavity and pharynx
- Identify & remove foreign object
- Cervical and thoracic radiographs
- Soft tissue swelling (loss of detail, gas between tissue planes, subcutaneously, pneumomediastinum (if esophageal perforation)
- Prevent chronic fistulous tracts: surgically explore via ventral midline approach, inspect dorsal esophagus for tears.
- Chronic
- Recurrent cervical swellings and discharging sinuses
- Original injury often unknown and difficult to treat
- Meticulous exploration of tracts and debridement of all diseased tissue
Surgical Drains
- Tissue apposition and obliteration of dead space
- Remove fluid that provides media for bacterial growth
- Relieve pressure that can affect tissue perfusion
- Remove inflammatory mediators, bacteria, necrotic tissue, foreign material
- Drains incite inflammatory response
- Open drain (passive)
- Closed suction drain (active)
Comparison of Closed, Active Suction Drains vs Open, Passive Drains
- Path of drainage
- Fluid collection site
- Mechanism of action
- Exit site
- Monitoring fluid quantity
- Monitoring fluid character
- Relative risk for ascending infection
- Need fully closed wound
- Ability to collapse dead space
- Irritation of skin
Open Passive Drains
- Penrose drain
- Capillary action
- Gravity
- Drainage along outside of tube
- High surface area to volume ratio
- Fenestration contraindicated
Penrose Drains
- Advantages: inexpensive, soft/malleable, low tissue trauma
- Disadvantages: cannot quantify fluid production, not useful for large volume drainage, requires gravity, cannot use in thoracic cavity, more risk of ascending infection
Placing a Penrose Drain
- Proximal end deep in wound/dead space
- Exit via stab incision, dependent on wound
- Distal end secured to skin with single suture through drain
- Must not exit through incision
- Cover with dressing
- Do not use for flushing
- Secure proximal end with suture
- Care with neoplasia (place close to wound incision)
- Need to clean regularly and attempt to quantify drainage production
Closed Suction Drains (Active)
- Tubing and suction device/vacuum
- Fenestrations
- Airtight cavity
- Less risk of contamination
- More effective fluid removal
- Reduced risk of ascending infection
- Easily portable
- Doesn't require a lot of dressing
- Can collect and record fluid
- Constant suction decreases occlusion
- Loss of vacuum if not airtight
- Occlusion by clots
- Premature removal (BC often needed)
Placing a Closed Suction Drain
- From inside to outside
- Choose drain exit site (easy to cover, comfortable, manageable)
- Tunnel to site with forceps
- Incise skin over forceps
- Hole no larger than tubing (consider trocar)
- Handle tubing
- Fenestrated portion dependent
- Ensure fenestration in wound, allow suction
- Purse string suture and secure with finger trap
- Attach grenade
Activating Suction
- Best to wait 4-6 hours
- Compress grenade with evacuation port open
- Close the port/cap/clamp tubing
- Release compression to create negative pressure
- Cover exit site with adhesive dressing
- Use shirt/stockinette/bandage to protect tubing/grenade
- Use a buster collar if needed
Maintaining an Active Suction Drain
- Monitor and record fluid amount quality
- Empty drain daily or when half full
- Strength of suction dec as grenade fills
Drain Removal
- Passive drains: when fluid production slows
- ~2-5 days
- Cut one end prior to pulling
- If anchoring suture, cut and remove in smooth motion
- Active drains
- When fluid production <2-4mls/kg/24hrs
- Usually 2-5 days
- Gentle finger trap removal
- Measure drain to ensure complete removal
- Leave exit hole to heal by second intent
Ingress/Egress Drain Placement and Removal
- Useful in inguinal or axillary region
- To prevent suction drawing bacteria into the drain
- Pull one end, cut the ‘dirty’ end, put back in wound
- Pull the full drain out from stuck end
Top Tips for Drains
- Passive drains must be dependent
- Drains should not exit through incision
- Exit incision should be same width or slightly wider than active drains
- Place the drains from the inside out.
- Do not fenestrate Penrose drains!
- Flush Penrose drains (not advised)
- Remove drain as soon as possible
- Drains cause fluid production – unlikely to be zero fluid
- Measure the drain to ensure complete removal
- Leave exit holes to heal by second intention
Comparison of Active and Passive Drains
- How it works (active vs passive)
- Exit site
- Path of fluid
- Can you measure amount of fluid
- Ability to close dead space
- Requires airtight cavity
- Risk of contamination
Complications of Drains
- Increased risk of wound contamination and infection (ascending infections)
- Act as foreign bodies
- Increases with duration of drainage
- Increased with use for flushing the wound
- Converts a clean wound to a clean-contaminated one
- Patient interference: premature removal, breakage with drain in wound
- Drainage failure: improper placement/positioning, inadequate diameter, overfilling, suction system detachment, drain obstruction
- Local structures
- Erosion/seeding if neoplasia
- Breakage at removal (requires surgical retrieval)
Chest Drains
- Intermittent or continuous drains
- Remove when fluid production slows
- IV antibiotics if infection
- Precautions for sterility (nosocomial infection)
- Precautions to prevent patient interference
Chest Drainage – Thoracentesis
- Intermittent (every 4-6 hours)
- Easy to quantify amounts
- Works well for small volumes
- Can tell if volume decreasing
Chest Tube Placement
- Neurovascular bundle at caudal aspect
- Skin incision
- Subcutaneous tunnel
- J wire placement
- Small bore wire
Abdominal Drainage
- Palliative drainage of ascites (intermittent abdominocentesis)
- If septic peritonitis
- Open drainage
- Closed suction drain (Jackson-Pratt)
- Often get blocked or walled off
Small Bore Chest Tube
- Small bore chest tubes – video
- Mila Pneumothorax Catheter Placement https://vetgirlontherun.com/...
Step-by-Step Chest Tube Placement
- https://www.cliniciansbrief.com/article/chest-tube-placement
- Chest tube placement
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