General Surgery PDF - Wounds

General SURGERY GENERAL SURGERY DEPARTMENT FACAULTY OF MEDICINE – DAMIETTA UNIVERSITY Faculty of medicine – Damietta university Page |0  CONTENT Wounds........

General SURGERY GENERAL SURGERY DEPARTMENT FACAULTY OF MEDICINE – DAMIETTA UNIVERSITY Faculty of medicine – Damietta university Page |0  CONTENT Wounds............................................................................................................. 2 Cause, Hernia = Burst Wounds Page |1 Wounds Page |2  Wounds causes : Mechanicalwounds Abrasion, cut, stab wound, insect bite Introduction: or shot wound Chemicalwound skin or mucous membrane has necrotized Burns burning or frostbite DEFINITION Electricitywounds integrity Disruption of the continuity of the skin, mucous membrane or soft tissue - caused by[ [ physical, chemical or biological insult. CLASSIFICATION OF WOUNDS They are classified into: ▪ Closed (blunt): e.g. motor car accident, falling from height. - ▪ Open (penetrating): I - Sharp/ (Non Surgical) o Accidental e.g. gunshot, cut wounds, stabbing, bites - - - - o Surgical trauma. > - Caused by sharp instruments. They are always tidy and cleanly cut. According to intention ↑ ex : surgery ▪ Intentional (Surgical) - results from planned treatment - & - - ▪ Unintentional wounds (Traumatic / accidental) result from unexpected - trauma as accident, burns, shooting. - - According to extent of tissue injury: - ▪ Superficial ▪ Deep It can be classified according to onset into: T open -Nons > closed - ▪ Acute wounds (goes through normal/timely healing process) - ▪ Chronic wounds (fails to go through normal stages of healing, no timely - progress in healing) Page |3  Onset : Acute wound: go through normal healing process ▪ Open wound o Surgical: Caused by sharp instruments. They are always tidy and cleanly cut. o Non-surgical. accidental ( gunshot, cut wounds, stabbing, bites I ▪ Closed Wounds: with an intact epithelial cover - motor car accident - falling from height A. Open wound: ▪ Abrasions: scraping away of the superficial layers of the skin. It is superficial injury (scratch/graze/pressure/ contact) and is due to - - - - shearing of the skin where the surface is rubbed off. -This tangential force causes loss of epidermis exposing dermal vessels - - and nerves leading into profuse painful oozing. - -Abrasion heals by epithelialization. Any dirt or foreign body on the abrasion should be removed to avoid formation of poor tattoo like scar. ▪ Friction burns: Forceful sheering a abrasion causing thermal injury ▪ Penetrating (puncture) Wounds: Pressure by sharp object (pointed - - instrument) like nail or needle. The wound is deeper than longer - - increasing the risk of injury of deep important structures. External opening is small and drainage is poor encourages infection. -Deeper vital structures or organs may be injured, so should be H Q assessed; foreign body or object may be present in the depth of the CT/US ! wound. Page |4  H -Wound should be explored under general or regional anaesthesia to - ② ⑤ assess the depth and severity of the injury and sutured layer by layer after through saline wash ⑮ - ▪ Stab wound: caused by sharp flat object such as a knife or screwdriver. These wounds are deep with possibility of deep organ injury. -Ultrasound and CT scan should be done to evaluate deeper organ ① injuries. -Under general anaesthesia wound should be explored properly. ② ▪ Bites: caused by the teeth of animal or human. They are lacerated & contaminated wounds with increased incidence of infectionC (tetanus and6 rabies). Snake bites are poisonous. ▪ Stings: Caused by insects, spiders and scorpions. They can be poisonous ▪ Cut wounds: caused by sharp object with minimal blunt force. b & ▪ Incised wound: A neat cut wound usually caused by scalpel in surgical - surgical operations - Road traffic ▪ Lacerations: Severe violence with blunt objects e.g RTA or falling from - - & - - accident a height. - Page |5  Note box! Characters of lacerated wound: O ▪ The wounds are severely traumatized and devascularized. 8 ▪ Irregular in shape. ▪ Usually contaminated, so the risk of infection is high. ⑤ ▪ Inflammatory edema will develop after a few hours and will raise tension inside the wound to a high level leading to 2ry ischemia of the tissues. ④ ▪ Crushed: Extreme pressure smashing the skin and underlying tissues with marked soft tissue damage. -It is due to major wounds, war wounds, natural disaster like earthquake injuries, tourniquet injury. -It leads into compartment syndrome; muscle ischemia; loss of tissues; Lmsg gangrene; sepsis. S - Muscle will lose its viability which is identified by its colour (dark - coloured with loss of shining); loss of contractility; turgid and will not - bleed on cutting. -- ▪ Degloving: o Etiology: & ▪ Open degloving: e.g. ring avulsion injury with loss of finger = skin - e ▪ Closed degloving: e.g. rollover injury caused by passage of e motor vehicle over a limb. Page |6  Note box! Character: ▪ Skin and subcutaneous fat are stripped by avulsion from its underlying e fascia, leaving underlying structures exposed. - ▪ Traction and avulsion: o Wounds caused by traction force, usually big machines which is open with marked tissue damage. o The resulting wound is like a lacerated wound with additional loss of soft tissue. Open traction injury occurs on the surface. o6 & - oG Closed traction injury can occur in deeper plane like brachial plexus -- injury or traction bowel injury. o After initial resuscitation, definitive treatment like skin graft or nerve --- repair should be done. ▪ Missile wounds o Very serious, as the bullet transmits its high kinetic energy to the - & = tissues. M29 o Kinetic energy of the missile is determined mainly by: ▪ Its velocity (V). - ▪ Its weight (M) 🡲 Kinetic energy = MV2 / 2g. (g = gravity). - - o May be high velocity missile injuries (rifles) or low velocity ones - (pistols). - o Since velocity is included in the formula it proves that high velocity missiles are more dangerous than low velocity missiles. rifies pistols Page |7  Missiles Note box! I Characters: ▪ The edge of the inlet wound is&burnt. ▪ There may be also an& exit wound. ↓ & ▪ The tunnel between the inlet and exit contains foreign materials and ⑳ e necrotic tissue. ▪ There is usually associated deep organ injury - The damage is due to: ▪ Direct damage by the missile in its& track. => ▪ Shock waves: damage occurs in areas- far away from the missile track. ▪ Temporary cavitation effect. ▪ If the missile strikes a bone, the fragments of shattered bone act as & 2ry missiles producing more damage. ▪ In high velocity injuries, there’s extensive tissue damage & injury to the major blood vessels & nerves situated some distance from the tract of the missile B. Closed wound. ▪ Contusion: Bruises o Etiology: Blunt objects cause intradermal bleeding from minor capillaries with interstitial tracking. o Character: Skin discoloration and tenderness (therefore is called Bruises or Ecchymosis). o Fate: It takes variable time for the discoloration to clear off (needs no specific treatment). ▪ Hematoma: Collection of blood in a potential space under the skin or - - in deep tissues after blunt trauma. At 1st it is cystic, but it will clot within hours. Later the hematoma will liquefy. Page |8 ▪ Hematoma can occur spontaneously in coagulation disorders (haemophilia) or in individuals who are on anticoagulant drug therapy. o Clinical picture: & visible ▪ A tender cystic swelling. ▪ In deep parts may be invisible (e.g. in thigh and gluteal region) o Complications: ▪ Infection →& - abscess. c ▪ Fibrosis → firm mass. - e ▪ Calcification → hard mass. - o Treatment: Q ▪ Conservative treatment as hematoma gets absorbed unless it gets complicated. ② ③ ▪ Aspiration using a large bore needle or open surgical evacuation. - Abrasions Puncture wound Stab wound Page |9  fail to go through normal Chronic wound: healing process These are wounds that failed to undergo the usual sequence of acute healing (haemostasias, inflammation, proliferation, and remodeling or maturation). within a reasonable time (4-6 weeks). Chronic wounds are arrested at the inflammatory & proliferative phases of T wound healing, with overgrowth of granulation tissue with minimal wound b contraction & collagen formation. Cause: one or a combination of factors affecting wound healing. Hypoxia initially is a potent stimulus for fibroblast activity and angiogenesis; -m D persisting hypoxia impedes fibroblast and collagen activity and also allows bacterial invasion to make wounds chronic. # Managements of chronic wounds is composed of: ▪ Management of general factors. - ▪ Local wound management. = Examples of chronic wounds are: ▪X Leg Ulcers ▪ & Pressure Sores bedsores > - ▪ Diabetic foot Note box! Chronic wounds -requires biopsy, culture study, definitive treatment like wound debridement (Vacuum Assisted Closure) therapy, skin grafting or flap. P a g e | 11 -Specific conditions like tuberculosis if present should be treated. -Malignancy if confirmed is treated by wide local excision and skin graft. -Chronic wounds are chronically infected with biofilms which interfere mainly with the inflammatory phase of healing, contributing to the non-healing. - A biofilm is a complex structure of microorganisms contained in an extracellular matrix of proteins and polysaccharides that adhere to a surface, creating a protected environment for the organisms. Chronic leg ulcer Vacuum Vacuum Assisted closure (VC) # P a g e | 12