Wound Management Quiz

Wound Management and Classification

• Wound healing can occur via primary or secondary intention. Primary intention involves treatment to close the wound edges, while secondary intention involves permitting the wound to heal from the inside out.
• Wounds can be classified based on a scheme that describes the appropriate means for treating and managing them.
• Wound types include; cuts, tears, burns, breaks, abrasions, degloving and shearing injuries, dehisced surgical wounds, punctures, pressure sores, and crush injuries.
• Wounds can be acute or chronic in presentation.
• Most clean wounds are created during elective surgery.
• Types of wounds (with descriptions) include:
  • Laceration/tear: Skin is cut or torn open in an irregular pattern.
  • Incision: Wound created by a sharp tool with minimal trauma (e.g., knife, scalpel).
  • Burn/thermal: Skin damage ranging from superficial to full-thickness (e.g., scalding, fire, chemical burns).
  • Abrasion/scrape/graze: Superficial skin removal caused by abrasion against a surface.
  • Degloving and shearing injuries: Extensive skin loss caused by significant force (e.g., high-impact collisions).
  • Puncture/penetrating: Small hole caused by a sharp object (e.g., nail, tooth, splinter).
  • Pressure sores: Prolonged pressure to one area over time.
  • Crush injury: Closed wound from extreme force over time (e.g., bite wounds).
  • Contusion: Blunt-force trauma that does not break the skin but causes underlying damage.

Principles of Wound Management

• Stabilize the patient before dealing with the wound (prioritize ABCs/Triage, severe/multi-system trauma).
• Risk assessment and planning are important aspects of patient management.
• Ensure a baseline minimum database of blood results or other similar diagnostics.
• Establish IV access.
• Administer O2 flow by.
• Administer pain relief.
• Keep the patient calm and avoid unnecessary stress or manipulation.

Principles of Wound Management - continued

• Clean and debride the wound while maintaining sterility (clean, gloved hands, sterile instruments). Sedation or general anesthesia (GA) may be necessary.
• Severed tendons, ligaments, nerves, and exposed joints need to be addressed promptly.
• Deal with ruptured bowels, bladders, and excessive hemorrhage.
• Wound management options include early closure or partial closure if possible and reduction in wound size, covering vital structures.
• Open wound management is an alternative if full closure is not possible.

Initial Wound Assessment

• Determine the type, amount, direction, and type of energy applied to the tissues (e.g. crushing, puncture, shearing, avulsion).
• Consider the likelihood of deeper or adjacent structures involvement and potential consequences of missing something or of dressing issues.
• Factors to consider are bacteriological and general status of the patient.

Basics of Wound Management

• For wound management clip away fur.
• Fill defects and cover exposed tissue with a sterile lubricant.
• Clean and irrigate the wound using a sterile solution (hydrodynamic debridement).
• This removes gross contamination and microscopic debris to reduce infection risk.
• Explore vital structures if necessary (e.g., artery, vein, nerve, joint, tendon/ligament). Identify foreign bodies and foreign material, including an assessment of deep tracts or penetrating wounds and entering the abdomen or thorax.
• Perform debridement (surgical) to remove unviable tissue and gross foreign material and reduce bacterial contamination.
• Antibiotic administration is based on likely contaminants from the type of wound. Take tissue samples for culture prior to administration.

Contamination vs Infection

• Contamination is the presence of an infectious agent on a body surface, such as soiling or introduction of microorganisms into a wound from sources like water, milk, food, or bandages.
• Infection is the invasion and multiplication of microorganisms in tissues, causing local cellular injury due to competitive metabolism, toxins, or antigen-antibody responses.

Lavage

• Large volume, isotonic fluids are necessary for lavage. Pressure should not be excessively high or low (6-8 psi is recommended).
• An 18-gauge needle with a 20ml syringe, or a 1-litre bag with a pressure cuff at 300mmHg may be used.

Fracture Classification and Description

• Open/closed: A bone fracture is open if the skin is broken, and closed if the skin remains intact.
• Complete/incomplete: Fracture lines that completely divide the bone are complete and incomplete if they do not divide the bone.
• Displaced/non-displaced: Fragments are still close together in non-displaced fractures, while they are not in displaced fractures.
• Orientation of fracture lines include spiral, transverse, and oblique types.
• Number of fractures/fracture fragments includes multiple and comminuted (small pieces).
• Fracture location describes the part of the bone involved.

Fracture Classification: Location

• Different areas of the fracture, such as articular, epiphyseal, physeal, metaphyseal, and diaphyseal locations, have special considerations for management.
• Special types of fractures, such as condylar or trochanteric fractures, involve unique locations and may present different treatment strategies.

Salter-Harris Classification

• Salter-Harris classification is used to describe fracture types involving the growth plate (physis) in children.
  • Type I: Fracture straight across the growth plate.
  • Type II: Fracture through the physis and a portion of the metaphysis.
  • Type III: Fracture through the physis and articular surface.
  • Type IV: Fracture through the physis, metaphysis, and joint.
  • Type V: Crushing of the physis.

Wound Closure Methods

• Primary closure (first intention): Minimal contamination, tissue loss, or traumatized tissue, following lavage, and debridement are key for primary closure (within 6 hours).

• Delayed primary closure: Minimal to moderate contamination, tissue loss, or trauma. Autolytic debridement may be necessary until primary closure can occur.

• Secondary closure (second intention): Severe contamination, tissue loss, or trauma, including large wounds. Closure occurs gradually with granulation tissue formation, with possible unsightly scaring. Includes incisions between granulation tissue and skin margins or primary closure.

• For traumatic wounds, if there is doubt about closing the wound, it is always better to avoid closing or delay closure.

Open Wound Management

• Choosing different dressings depends on the type of wound (minimal, moderate or heavily exudative).
• Dressings can involve hydrocolloids, hydrogels, alginates, films, foams, etc. They can be used for autolytic debridement.
• If the wound is dry, using hydrogels can be recommended to rehydrate it.

Wet-to-Dry Debridement

• Application of saline-soaked sterile swabs directly to the wound (contact layer).
• Apply padding layer, conforming and supporting layer.
• Remove swabs and attached debris.
• This method of debridement is often painful and requires sedation or general anesthesia.

Dressings

• Specific dressings can be important, depending on wound type.

Non-Surgical Debridement

• Uses include Manuka honey, sugar paste, larvae-medicinal maggots, enzymatic agents, and vacuum-assisted negative-pressure wound therapy.
• These methods provide autolytic debridement and promote healing.

Bandaging

• Bandaging may involve simple, non-absorbant layers or a combination of layers for difficult-to-bandage areas.
• Bandages are secured with sutures or tape to keep them in place.

Vacuum Assisted Closure Wound Therapy (NPWT)

• This therapy potentially increases wound perfusion, reduces edema, and promotes granulation tissue development. Also, it aids in reducing bacteria and improving exudate removal.

Active Wound Management

• Frequent bandage changes are important.
• Carefully assess the wound daily and take measurements.

Granulation Tissue

• Granulation tissue protects the wound, minimizing infection risk, and enabling healing.
• No active dressings may be needed and frequent antibiotics are not necessary.
• Autolytic debridement, which involves the natural breakdown of dead tissue, aids in promoting healing.

Top Tips for Wound Management

• Lavage is determined by the amount, not type, of solution.
• Explore deep lacerations or punctures; if unsure about tissue viability, reassess the wound in a few days.
• Incorrect topical agents to the wound at the wrong time can slow wound healing, therefore care is needed to select the correct agent at the correct time.

Approach to Wound Management

• A systematic approach involves a methodical assessment that considers various factors, including cleaning, debriding, and managing the wound for optimal healing.

Test your knowledge about wound management techniques, including lavage, debridement, and bacterial contamination. This quiz focuses on key concepts that are crucial for effective wound care practices. Evaluate your understanding of the significance of these actions in promoting healing.