2. Wound Management.pptx

Management of Acute Wound Prof. Dr. Aung Win Thein Department of Surgery Learning Outcomes By the end of this lecture, students will be able to: • Describe the types of wounds, and • Discuss the principles of management of the acute wounds. 20XX presentation title 2 TYPES OF WOUNDS – TIDY VER...

Management of Acute Wound Prof. Dr. Aung Win Thein Department of Surgery Learning Outcomes By the end of this lecture, students will be able to: • Describe the types of wounds, and • Discuss the principles of management of the acute wounds. 20XX presentation title 2 TYPES OF WOUNDS – TIDY VERSUS UNTIDY • The site injured, the structures involved in the injury and the mechanism of injury (e.g., incision or explosion) all influence healing and recovery of function. • Management of wounds based upon classification into tidy and untidy. • The aim is to convert untidy to tidy by removing all contaminated and devitalised tissue. • Primary repair of all structures (e.g., bone, tendon, vessel and nerve) may be possible in a tidy wound, 20XX presentation title 3 • A contaminated wound with dead tissue requires debridement on one or several occasions before definitive repair can be carried out. • e.g., injuries caused by explosions, bullets or other missiles. • Multiple debridement are often required after crushing injuries in road traffic accidents or in natural disasters such as earthquakes, where fallen masonry causes widespread muscle damage and compartment syndromes. 20XX presentation title 4 • Any explosion where there are multiple victims at the same site or where there has been a suicide related explosion will carry the risk of tissue and viral contamination. • Appropriate tests for hepatitis viruses and human immunodeficiency virus (HIV) are required. 20XX presentation title 5 (a) Tidy incised wound on the finger. (b) Untidy avulsed wound on the hand. 20XX presentation title 6 Wound Management – Types of Wounds # Tidy wounds • Tidy • Incised • Clean • Healthy tissues • Seldom tissue loss 20XX # Untidy wounds • Untidy • Crushed or avulsed • Contaminated • Devitalised tissues • Often tissue loss presentation title 7 20XX presentation title 8 Managing the Acute Wound • Examine the whole patient according to acute trauma life support (ATLS) principles. • The wound examined - the site and the possible structures damaged. • Assess movement and sensation. • Tetanus cover should be noted, and appropriate treatment carried out. • A bleeding wound should be elevated, and a pressure pad applied. • Clamps should not be put on vessels blindly because nerve damage is likely and vascular anastomosis is rendered impossible. 20XX presentation title 9 • Facial trauma – apparent tissue loss but none found after careful matching. 20XX presentation title 10 Managing the Acute Wound (Contd’) Exploration and diagnosis / Assessment • Adequate analgesia and/or anaesthesia (local, regional or general) are required (to facilitate examination). • General anaesthesia often needed in children. • A tourniquet should be used in order to facilitate visualisation of all structures (with limb injuries). • Avoid uneven pressure in tourniquet application and note the duration of tourniquet time. • After assessment, a thorough debridement is essential. 20XX presentation title 11 Debridement • Abrasions, ‘road rash’ and explosions all cause dirt tattooing and require the use of a scrubbing brush or even excision under magnification. • A wound should be explored and debrided to the limit of blood staining. • Devitalised tissue must be excised until bleeding occurs, with the obvious exceptions of nerves, vessels and tendons. • These may survive with adequate revascularisation subsequently or after being covered with viable tissue such as that brought in by skin or muscle flaps. 20XX presentation title 12 Cleansing  The use of copious saline irrigation or pulsed jet lavage can be less destructive than knife or scissors when debriding.  Pulsed jet lavage can implant dirt into a deeper plane and care should be taken to avoid this complication.  Muscle viability is judged by the colour, bleeding pattern and contractility. https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1742481X.2012.01062.x 20XX presentation title 13 Repair of structures • In a tidy wound, repair of all damaged structures may be attempted. • Repair of nerves under magnification (loupes or microscope) using 8/0 or 10/0 monofilament nylon is usual. • Vessels (radial or ulnar artery) may be repaired using similar techniques. • Tendon repairs, particularly those in the hand, benefit from early active mobilisation because this minimises adhesions between the tendon and the tendon sheath. 20XX presentation title 14 Replacement of loss tissues / Skin cover / skin closure without tension • Skin cover by flap or graft may be required as skin closure should always be without tension and should allow for the oedema typically associated with injury and the inflammatory phase of healing. • A flap brings in a new blood supply and can be used to cover tendon, nerve, bone and other structures that would not provide a suitable vascular base for a skin graft. • A skin graft has no inherent blood supply and is dependent on the recipient site for nutrition. 20XX presentation title 15 Summary – Managing the Acute Wound ●● Cleansing ●● Exploration and diagnosis ●● Debridement ●● Repair of structures ●● Replacement of lost tissues where indicated ●● Skin cover if required ●● Skin closure without tension ●● All of the above with careful tissue handling and meticulous Technique 20XX presentation title 16 • Tetanus prophylaxis is determined by previous immunization and classifying low versus high-risk wound(s): • Unimmunized (less than 3 doses or unknown) versus immunized (greater than 3 doses), • low risk (clean and minor) versus high risk (contaminated, puncture, avulsions, or resulting from missiles, crushing, burns, animal or human bites, or frostbite). • In an unimmunized individual with a low-risk wound, the tetanus vaccine is indicated; • if high risk, then both vaccine and human tetanus immune globulin (HTIG) are also indicated. • In immunized individuals with low-risk wounds, the tetanus vaccine is indicated only if the last dose was given more than 10 years ago. • If high risk, then the vaccine is indicated more if the last booster was more than 5 years ago. • Prophylaxis should be administered as soon as a possible following wound or traumatic injury and even upon delayed presentation due to the long and variable incubation period of tetanus. 20XX presentation title 17 References: 1. Bailey & Love’s Short Practice of Surgery, 27th ed 20XX presentation title 18