Wound Management and Classification PDF

WOUND MANAGEMENT AND CLASSIFICATION ALISON LIVESEY MRCVS LECTURER IN SMALLANIMAL SURGERY  L E A R N I N G OBJECTIVES By the end of this lecture you should be able to: demonstrate understanding of wound healing by primary or secondary intention describe...

WOUND MANAGEMENT AND CLASSIFICATION ALISON LIVESEY MRCVS LECTURER IN SMALLANIMAL SURGERY  L E A R N I N G OBJECTIVES By the end of this lecture you should be able to: demonstrate understanding of wound healing by primary or secondary intention describe the appropriate means of treating wounds to effect closure by primary or secondary intention classify wounds according to a scheme describe a classification of fracture type describe potential causes of wounds in each classification use that scheme to help describe a strategy for managing a particular type of wound Wound Classification and Management 2  WOUNDS Cuts, tears, burns, breaks, abrasions, degloving and shearing injuries, dehisced surgical wounds, punctures, pressure sores, crush Acute or chronic at presentation Open vs closed wounds Most clean wounds are created by us → elective surgery Wound Classification and Management 3  W O U N D DESCRIPTION Laceration/tear – skin is cut or torn open in irregular pattern (catching on a barbed wire fence/tooth/claw and pulled open) Incision – wound created by sharp tool with minimal trauma (knife/scalpel/glass) Burn/thermal – (scalding, fire, chemical, inappropriate patient warming) skin damage, superficial to full thickness Abrasion/scrape/graze - superficial skin removed (epidermis), being dragged across the road/rub against something Degloving and shearing injuries – extensive skin loss caused by significant force (HBC/RTA) Punctures/penetrating – caused by a sharp object(nail, tooth, splinter) leaving a small hole on the surface skin (minimal visible skin damage) can leave FB or just penetrate, higher risk of contamination to deep tissues Pressure sores – prolonged pressure to one area over time (immobile animals, pressure points) Crush – closed wound caused by extreme force over a period of time (bite wounds) Contusion – blunt force trauma, doesn’t break the skin but can cause underlying damage Wound Classification and Management 4  P R I N C I P L E S O F W O U N D MANAGEMENT S TA B I L I S E Y O U R PAT I E N T B E F O R E D E A L I N G W I T H T H E WOUND 1. Stabilise your patient Severe/multi-system trauma or shock ABCs/Triage Pressure haemostasis Basic bandaging to protect wound Rigid stabilisation if unstable Pain relief 2. Risk Assessment and planning Visible+/- invisible wounds Wound Classification and Management 5  T R I A G E A N D STABILISE 2. (cont) Triage Major Body Systems Neurological Respiratory Cardiovascular Abdominal palpation Rectal temperature Wounds Stabilise IV access Baseline bloods/minimum database O2 flow by Pain relief Keep stress low Gentle handling, hands off as much as possible First do no harm Wound Classification and Management 6  P R I N C I P L E S O F W O U N D MANAGEMENT 3. Clean and debride wound, repair vital structures Maintain sterility (clean, gloved hands & sterile instruments) GA (or sedation), often necessary Severed tendons, ligaments, nerves, exposed joints must be dealt with quickly Ruptured bowel, bladder, excessive haemorrhage Wound Classification and Management 7 P R I N C I P L E S O F W O U N D MANAGEMENT 4. Wound management options A. Early closure or partial closure if possible Reduction in wound size Covering vital structures Only if not infected B. Open wound management if full closure not possible Wound too large Tissues not viable/questionable viability Infection/contamination Only partial closure possible 5. Closure Primary, reconstructive technique or left to heal by granulation Wound Classification and Management 8 I N I T I A L W O U N D ASSESSMENT Type of wounding Amount, direction, and type of energy applied to the tissues Crushing, puncture, shearing, avulsion Wound location: likelihood of the involvement of deeper or adjacent structures (hazard awareness) potential consequences of missing something (risk analysis) practicalities of dressing Bacteriological factors General status of the patient Wound Classification and Management 9  B A S I C S O F W O U N D MANAGEMENT 1. Clip away fur Fill defects & cover exposed tissue with sterile lubricant Wound Classification and Management 10  B A S I C S O F W O U N D MANAGEMENT 2. Lavage (or irrigation) (hydrodynamic debridement) Dilution is the Irrigation with (sterile) solution solution to the Removes gross contamination and microscopic debris pollution Reduces infection risk Wound Classification and Management 11  B A S I C S O F W O U N D MANAGEMENT 3. Exploration Exposure of vital structures? (artery, vein, nerve, joint, tendon/ligament) Explore/probe any deep tracts/penetrating wounds Foreign body/foreign material Entered abdomen or thorax Wound Classification and Management 12 B A S I C S O F W O U N D MANAGEMENT 4. Debridement (surgical) Removes unviable tissue and gross foreign material Reduces bacterial contamination Take tissue sample/swab for culture Depends upon presentation (acute vs chronic) 5. Antibiotics Contaminated wounds Given IV Based on likely contaminants from type of wound Take culture samples prior to administration (no point in gross contamination really) Wound Classification and Management 13  CONTAMINATION V S INFECTION Contamination ‘presence of an infectious agent on a body surface’ ‘soiling or making inferior by contact or mixture, as by introduction of infectious organisms into a wound, water, milk, food or onto the external surface of the body or on bandages’ Infection ‘invasion and multiplication of microorganisms in body tissues, especially that causing local cellular injury due to competitive metabolism, toxins, intracellular replication, or antigen-antibody response.’ ‘invasion of the body by pathogenic microorganisms that reproduce and multiply, causing disease by local cellular injury, secretion of a toxin, or antigen-antibody reaction in the host.’ Bacteria count of 105 colony forming units per gram of tissue = infection Wound Classification and Management 14 LAVAGE Large volume Isotonic fluids Pressure Too high → drive bacteria deeper or damage tissue Too low → won’t remove debris 6-8 psi recommended 18g needle with 20 ml syringe 1-litre bag with pressure cuff at 300mmHg Aerosol saline sprays available Animalcare.couk Wound Classification and Management 15 LAVAGE SOLUTIONS Wound Classification and Management 16 LAVAGE SOLUTIONS Wound Classification and Management 17  EXPLORATION Radiographs/US/imaging Plan for multiple options Wide clip and prep Wide drape Think about approach (through the wound or open the abdomen) Blunt probe/finger Follow direction of wounding Remove gross/contaminants and FBs Wound Classification and Management 18  S U R G I C A L DEBRIDEMENT Sterile technique Aseptic prep of surrounding skin, not open wound Sharp dissection in layers Allows exploration Remove unviable tissues Lighter or darker Unattached with no blood supply No active bleeding on cut surface (but beware) Often followed by autolytic debridement (open wound management) Can remove smaller lesions ‘en bloc’ Loosely close wound and remove as if a ‘mass’ If enough healthy tissue and no vital structures Wound Classification and Management 19 DEBRIDEMENT Wound Classification and Management 20 Surgical Debridement Layered En bloc BSAVA Manual of Canine and Feline WoundWound Management Classification and Reconstruction and Management 21  S U R G I C A L DEBRIDEMENT SKIN Immediate assessment of viability may be misleading due to vasoconstriction Trim edges Staged debridement to preserve as much skin as possible where needed FAT Debride all exposed fatty tissue to a clean fascial plane MUSCLE Debride muscle that is dark or friable NERVES Preserve and protect from other damaged tissue JOINTS Lavage thoroughly. Repair and immobilise TENDONS Preserve as much as possible. Anastamosis will fail in the presence of infection Repair will take three to five days to start to develop strength – consider immobilise Wound Classification and Management 22 Types of debridement Selective Debridement Non Selective Debridement Autolytic Using dressing and topical Hydrodynamic Lavage and flushing applications (hydrogels, Mechanical Use of force, adherent honey, sugar) bandages (wet to dry) Biological agents Medical maggots or leeches Enzymatic/chemical Uses proteolytic enzymes Surgical Scalpel or scissors Wound Classification and Management 23 #universityofsurrey Adapted from: Todaysveterinarynurse.com 23 T O C L O S E O R N O T T O CLOSE Wound Classification and Management 24  M E T H O D S O F C L O S U R E – F I R S T INTENTION Primary closure - less than 6 hours (Golden period) Minimal contamination, tissue loss or traumatised tissue Following lavage and debridement No dead space or tension Delayed primary closure – 2-5 days, before granulation tissue Minimal to moderate contamination, tissue loss, trauma Unable to appropriately or immediately debride or uncertain tissue viability Autolytic debridement until primary closure Secondary closure – 5-7 days, after granulation Severe contamination, tissue loss, trauma Large wounds unlikely to fully close by second intention or with undesirable outcome Incise between granulation and skin margins and close as primary wound Wound Classification and Management 25 M E T H O D S O F C L O S U R E – S E C O N D INTENTION Heal by granulation Closure by granulation, wound contraction and re-epitheliasation If severe contamination or tissue loss Disfigurement, incomplete healing and fragile scars can occur with large defects Not suitable for some areas Aided by moist wound management Wound Classification and Management 26 Methods of Closure Primary Closure/ Delayed Primary Closure Second Intention Wound Classification and Management 27 When to close traumatic wounds If there is any doubt then don’t Wound Classification and Management 28 W O U N D C L A S S I F I C A T I O N ( L E V E L O F CONTAMINATION) Wound Classification and Management 29  Classification of traumatic wounds (duration) Based on time since occurrence Correlates with time to establish infection Bacteria count of 105 colony forming units per gram of tissue = infection takes 6 hours to establish  Golden period Try to close ? Might close Don’t close Wound Classification and Management 30  Wound closure decision making – wound factors Closure Duration Classification Treatment option Primary 0-6 hours Clean wounds or clean-contaminated Lavage, debride, explore and close without tension or dead space closure May need flap/graft Delayed 2-5 days Clean-contaminated or contaminated Lavage, debride and explore primary Excess tension with primary closure Treat as open wound with repeated dressings and debridement closure Questionable tissue viability Close after 2-3 days; before granulation May need flap/graft Needs antibiotics Secondary More than Contaminated or dirty Lavage, debride and explore closure 5 days Treat as open wound with repeated dressings and debridement Close after 5 days once granulation tissue formed/excise granulation tissue for closure May need flap/graft Needs antibiotics Second Unsuitable for closure Lavage, debride and explore intention Severe contamination and devitalisation Treat as open wound with appropriate dressing and repeated and tissue loss debridement Wound Classification Heal by granulation and contraction and Management 31 #universityofsurrey Antibiotics until granulation tissue 31 When to close a traumatic wound? Location of Exposure of Blood wound vital supply structures Tissue Patient trauma/loss condition Degree of contamination Cost Time since Wound occurrence (golden closure Breed period) Wound Classification and Management 32 #universityofsurrey 32 OPEN WOUND MANAGEMENT Hydrogels – Intrasite Minimally exudative wounds Apply moisture to dry wounds Covered by semi-occlusive dressing (Allevyn ) Vapour permeable adhesive films – Opsite /Tegaderm Maintains moist environment Polyurethane foam – Allevyn Mild to moderately exudative wounds Hydrocolloids - Tegasorb Moderately exudative wounds Enhance autolytic debridement Promote granulation Alginate dressings – Algisite , Kaltostat® Heavily exudative wounds Potent hydrophilic Derived from seaweed Wound Classification and Management 33  OPEN WOUND MANAGEMENT; MOIST WOUND HEALING – A U T O L Y T I C DEBRIDEMENT Moderate to high exudate ➔foams or alginates Moderate to low exudate ➔ hydrocolloids Dry wounds ➔ hydrogels to rehydrate Because of the large number available, it is recommended to be familiar with 1 or 2 products Will allow appropriate treatment of most common wounds Dressings changed every 2–3 days, sometimes longer, later in the healing To avoid maceration of healthy skin, dressings can be cut to fit the shape and size of the wound bed Wound Classification and Management 34  WET TO DRY You may see this in practice Apply saline soaked sterile swabs directly to wound (contact layer) Apply padding layer, conforming and support layer 24 hours later – swabs have dried onto wound Remove swabs and attached debris NON SELECTIVE DEBRIDEMENT Painful to remove – requires sedation/GA Labour intensive Must change daily - £££ Fibres can remain - nidus Wound Classification and Management 35  DRESSINGS (CONT) Allevyn Intrasite gel Thick layer of intrasite directly onto wound Allevyn absorbs exudate Provides good autolytic debridement Keep wound moist (hydrogel) Can change conscious Comfortable, non painful More expensive than swabs but can change less frequently Wound Classification and Management 36  N O N - S U R G I C A L DEBRIDEMENT Manuka Honey Autolytic debridement Antibacterial (osmotic cell death/dessication) Small amount of Hydrogen peroxide (H2O2) production Heavily contaminated/infected and exudative wounds (cover w dressing) Not appropriate for dry wounds Sugar Paste Similar to honey but not H2O 2 Wound Classification and Management 37  N O N - S U R G I C A L DEBRIDEMENT Larvae –medicinal maggots/leeches Enzymatic agents – non selective /££ Vacuum assisted/negative pressure wound therapy Fish skin - tilapia Wound Classification and Management 38 BANDAGING Simple – 3 layers with non absorbant dressing Tie over dressings For difficult to bandage areas Secured with large loose skin sutures around the wound Umbilical tape used to hold dressing in place Wound Classification and Management 39  VACUUM-A S S I S T E D C L O S U R E / N E G A T I V E P R E S S U R E WOUND T H E R A P Y (NPWT) Increases wound perfusion Decreases oedema Increases granulation tissue Decreases bacteria Removes exudate constantly via neg pressure Helpful for hard to dress areas £££ Wound Classification and Management 40  A C T I V E W O U N D MANAGEMENT Frequent bandage changes Not necessarily cheaper than surgical options Time-consuming and intensive Communication is key ACTIVE wound management, assessing at each change: Degree of inflammation Presence and quality of granulation tissue Degree of exudate Skin edges Degree of epithelialisation Very easy to photograph I measure wounds to help myself and owner feel better that contracture and healing is happening4 1 Wound Classification and Management 41  G R A N U L AT I O N T I S S U E Protects the wound No active dressing needed Barrier to infection No further antibiotics needed No nerve endings Will bleed if traumatised, then heal again Can remove all dressings, open to the air if possible or cover with protective dressing only Wound Classification and Management 42  T O P T I P S F O R W O U N D MANAGEMENT Lavage is determined by amount of solution, not type Lavage pressure should remove bacteria, not damage tissue Explore deep lacerations or punctures If unsure of tissue viability, reassess in a few days If unsure whether to close a wound, then don’t Topical agents at the right time aid healing; incorrect agents at the wrong time are detrimental Cover topical agents Tie-over bandages are helpful for difficult-to-bandage areas Change the plan as the wound changes Communication is key to success Wound Classification and Management 43  Approach to wound management Traumatic Debride wound Lavage Dress Clean/Debride Assess Delayed primary Granulation closure Contraction Primary Closure Second Intention Secondary Healed Wound closure Wound Classification and Management 44 W ednesday, 07 #universityofsurrey 44  F R A C T U R E C L A S S I F I C A T I O N A N D DESCRIPTION Open/closed Complete/incomplete Displaced/non-displaced Are fragments still close together or far apart Orientation of fracture lines Spiral Transverse Oblique Number of fractures/fragments Multiple/comminuted Reducible/non-reducible Fracture location Wound Classification and Management 45  Fracture Classification: Location Location of fracture Articular /PHYSIS Epiphyseal Physeal Metaphyseal Diaphyseal Special : Condylar Trochanteric Wound Classification and Management 52 Physeal Fracture Classification (Salter-Harris) Wound Classification and Management 53 S A LT E R H A R R I S C L A S S I F I C AT I O N First level Wound Classification and Management 48