Wounds & Wound Management PDF

WOUNDS “A cut or break in the continuity of any tissue, caused by WOUNDS & WOUND MANAGEMENT injury or operation which may be associated with...

WOUNDS “A cut or break in the continuity of any tissue, caused by WOUNDS & WOUND MANAGEMENT injury or operation which may be associated with disruption of the structure and function.” By AHMED Elshora Wound healing Haemostasis & inflammation phase ◼ Day 0 – 5 ◼ All wounds heal following a specific sequence of phases which ◼ Starts at the moment of injury – the clotting cascade is initiated may overlap ◼ Platelets aggregate, release cytokines & growth factors that stimulate: ◼ These phases are: 1. Chemotaxis of macrophages which help phagocytosis & wound debridement ◼ Inflammatory phase 2. Activation of fibroblasts & endothelial cells. ◼ Proliferative phase ◼ Remodelling or maturation phase Haemostasis & inflammation phase Proliferation phase Characterized by proliferation of : The inflammatory phase is characterised by heat, swelling, redness, Fibroblasts: Derived from surrounding tissues and secrete collagen pain and loss of function at the wound site fibers. This phase is short lived in the absence of infection or contamination Endothelial cells: Derived from intact venules and form new capillary buds which together with fibroblasts form the granulation tissue. Epithelial cells: Derived from wound edges and migrate to close the epithelial defect.  Maturation and remodeling phase Wound contraction Deposition of collagen in the wound: Helps to diminish the size of the wound. Collagen III 1st then over the next weeks it decreases while collagen I Starts immediately and continues for the next 2-3 weeks. increases. Special myofibroblasts. Collagen fibers become thicker, arranged along lines of stress and increase the tensile strength of the wound. Remodeling continues for about 1 year. Wound never attains its full original tensile strength. Factors affecting wound healing General factors Factors affecting wound healing Age: Slow in elderly due to decreased protein turnover. Debilitating diseases: as ureamia, jaundice, cirrhosis, diabetes and malignancy. Irradiation: inhibit wound contraction and granulation tissue formation. Prior irradiation causes ischemia due to end arteritis obliterans. General factors Local factors Factors affecting wound healing Factors affecting wound healing General factors Local factors ◼ Nutrition: ◼ Vascularity: good blood supply in face & scalp helps rapid healing while ❖ Proteins: essential for synthesis of collagen. poor blood supply below knee causes delayed healing: (time of suture ❖ Vit. C: essential for maturation of protocollagen. removal). ❖ Vit. A: essential for epithelialization. ◼ Immobilization: wounds over joints or weight bearing areas. ❖ Calcium, Zinc, Copper and Manganese. ◼ Tension: sutures under tension, haematoma increase wound tension causing ischemia & delayed healing. ◼ Drug intake: ❖ Steroids: inhibit the inflammatory response and the formation of fibroblasts.  Factors affecting wound healing Local factors CLASSIFICATION OF WOUNDS ◼ Infection: bacteria compete with fibroblasts for oxygen and nutrition & (Rank and Wakefield) classification. secrete collagenolytic enzymes that destroy collagen. a. Tidy Wounds ◼ Foreign bodies and necrotic tissue: impair wound healing. ❖ like surgical incisions and wounds caused by sharp ◼ Adhesion to a bony surface: prevents wound contraction as over the shin objects. of the tibia & chronic venous ulcers. ❖ Usually primary suturing is done. Healing is by primary intention. Types of wounds b. Untidy Wounds ❖ They are due to: Crushing, Tearing , Avulsion , Devitalised injury , Vascular injury, multiple irregular wounds and Burns. ❖ Fracture of the underlying bone may be present. Closed Open wounds wounds ❖ Wound dehiscence, infection, delayed healing are common. Haema Incised Lacerated Missile Contusions toma Abrasions wounds wounds Penetrating wounds wounds Bites Contusion Haematoma Image:Hematoma Feb 07.jpg Blow with blunt object. Excessive bleeding. Extravasation of blood from injured 1st cystic then clot within hours and capillaries. later liquefies. Painful & swollen. TTT: Bluish, brownish then green. Absorption TTT:Elevation & anti-infl. Oint. Organization by fibrosis Abscess Liquifaction and cyst formation Calcification (myositis ossificans) False aneurysm  Incised Abrasions wounds Scraping of the superficial layers of ◼ Sharp cutting instruments as razors, the skin due to friction with a hard glass pieces or knives. rough surface. ◼ Longer than deep, edges are clean Very painful due to exposure of cut & usually extensive hge. sensitive nerve endings. ◼ Tendons & nerves are liable to be TTT: Cleaning with antiseptic & non cut. adherent dressing. Lacerated Lacerated wounds wounds ◼ Severe violence with blunt Degloving injury objects, (RTA or falling from ◼ Lacerated wound are Commonly height). accompanied by degloving injury of ◼ Irregular in shape, severely skin & s.c. tissue from deep fascia. traumatized, devascularized & ◼ Skin devascularization become contaminated. apparent in few days. Penetrating Bites wounds ◼ Penetration by a pointed object as a knife. Either animal or human bites ◼ More deep than long, so may Lacerated wounds with involvement of bones, joints, tendons, injure deep important structures vessels, nerves. that can be missed. Puncture wounds (difficult to irrigate and decontaminate) with high ◼ Small external opening & poor risk of infection. drainage encouraging infection.  Types of wound healing Types of wound healing Primary intension: ◼ Secondary intension: ❖clean wounds immediately closed ❖ Edges not approximated or gaping by sutures or clips. due to haematoma or infection. ❖Minimal scar ❖ Filling with granulation tissue & ugly scar. Types of wound healing Classifying wounds ◼ Tertiary intension: Wounds may be classified according to the ❖ Contaminated wounds may be left number of skin layers involved: open for about 5 days. ◼ Superficial ◼ Involves only the epidermis ❖ If there are no signs of infection ◼ Partial Thickness delayed primary sutures can be done. ◼ Involves the epidermis and the dermis ◼ Full Thickness ◼ Involves the epidermis, dermis, fat, fascia and exposes bone 3. Contaminated wound CLASSIFICATION OF SURGICAL WOUNDS Acute abdominal conditions. 1. Clean wound Open fresh accidental wounds. Herniorrhaphy. Infective rate is 15-30%. Excisions. 4. Dirty infected wound Surgeries of the brain, joints, heart, transplant. Abscess drainage. Infective rate is less than 2%. Pyocele. 2. Clean contaminated wound Empyema gallbladder. Appendicectomy. Faecal peritonitis. Bowel surgeries Infective rate is 40-70%. Gallbladder, biliary and pancreatic surgeries. Infective rate is 10%.  Management of open wounds Management of open wounds Bleeding: control by direct local compression (clean dressing & tight Arteries & veins either large (repaired) or small (ligated). bandage).No tourniquet except as a temporary measure. Nerves or tendons (repaired). Suspcted fracture: splint & arrange for X-ray Muscles are repaired by mattress sutures if cleanly incised, while ischaemic or Thorough cleaning of the wound: saline irrigation & removal of necrotic muscles should be completely excised (dark red or gray in colour, does not foreign bodies then antiseptics as povidine iodine. contract if pinched and does not bleed if incised). Inspection: of all structures within the wound and dealing with them: Bones : no internal fixation if there is possibility of infection, better external fixation. Deep fascia should be left open in contaminated wounds or extensive tissue destruction.  Medicine will never be a risk-free practice. From the beginning of Patient Safety training, doctors are taught that errors are unacceptable and that the philosophy of (first, do no harm) should permeate all aspects of treatment. Mohammad Samy Kharoub Assistant Professor of General Surgery Term Definition Patient safety: A science that promotes the use of evidence-based medicine and local wisdom to minimize the impact of human error on quality patient care. Patient Safety incidents A preventable events or circumstances that could have, or did, result in unnecessary (PSI): harm to the patient. This might be an adverse event, near miss and no-harm event Adverse event: An incident which results in harm to the patient (either due to the underlying condition or its treatment. Could be preventable or non-preventable. A near miss: An incident that could have resulted in unwanted consequences but did not, either by chance or through a timely intervention preventing the event from reaching the patient. A no-harm event: An incident that occurs and reaches the patient but results in no injury to the patient. Harm is avoided by chance or due to mitigating circumstances. Never Event: Adverse events that are serious and largely preventable. A kind of medical error that should never happened. Negligence: Care that falls below the recognized standard of care. Standard of care: The care that a reasonable physician of similar knowledge, training and experience would use in similar circumstances. Term Definition Competence: Knowledge, skills and attitudes required to be able to carry out one’s duties.. Credentialing: A way that is used to ensure that clinicians are adequately prepared to safely treat patients with particular problems or to undertake defined procedures.  WHO estimates that, even in advanced hospital settings, one in ten patients receiving healthcare will suffer preventable harm. The financial burden of unsafe care is due to prolonged hospitalization, loss of income, disability and litigation costing many billions of dollars every year. Factors Examples Inadequate patient assessment; delays or errors in diagnosis Failure to use or interpret appropriate tests Error in performance of an operation, treatment or test Inadequate monitoring or follow up of treatment Human factors: Deficiencies in training or experience Fatigue, overwork, time pressures Personal or psychological factors, e.g. depression or drug abuse Lack of recognition of the dangers of medical errors Poor communication between healthcare providers PSI = Patient Safety Incidents Inadequate staffing levels Disconnected reporting systems or overreliance on automated systems System failure: Drug similarities Environment design, infrastructure Equipment failure, due to lack of parts or skilled operators Inadequate systems to report and review patient safety incidents Advanced and new technologies Medical complexity: Potent drugs, their side effects and interactions Working environments – intensive care, operating theatres The problem of error can be viewed in two ways Person approach System approach Human performance principles tell us that humans are Health systems add complex organisational fallible and that errors can occur through: structures to human fallibility thus substantially Errors of commission: doing the wrong thing. increasing the potential for errors. Errors of omission: failure to act. A systems approach to error recognises that adverse events rarely have a single isolated Errors of execution: doing the right thing incorrectly. cause and that they are best addressed by For most errors, the person approach on its own tends examining why the system failed rather than to blame the individual and restricts learning. who made the mistake. Even most of the individual potentially catastrophic events, eg.: retained instrument, wrong site surgeries, unchecked blood transfusion,…. Could be prevented by implementation of safer hospital system.  Open communications with the patient Heinrich’s pyramid Clinical risk management It is important to report all near misses or adverse events so that we can constantly Proper staff communications learn from mistakes. Healthy working environment Error models can help us understand the factors that cause near misses and adverse events and also direct us to where our defences against harm need to be improved. Surgical Check list Safe prescription Technical & operation errors Open communications with the patient Clinical risk management A patient-centred approach by medical staff, with involvement of patients and their It is a specific task, based upon reporting risk identification, analysis and control of carers as partners is now recognized as being of fundamental importance. events, carried out within a ‘blame-free’ environment. There are better treatment outcomes and fewer errors when there is good communication while poor communication is a common reason for patients taking legal actions. Proper staff communications Good team work, good communication and continuity of care reduce errors and improve patient care. Healthy working environment Stress, tiredness and mental fatigue in the workplace are significant occupational health and safety risks in healthcare. Information to be provided when seeking consent for surgery. Surgical Check list Accepted as standard safety protocol. ✓ The use of a surgical safety checklist in 8 hospitals around the world was associated with a reduction in major complications from 11.0 % before, to 7.0 % after. ✓ The main aims are to overcome: wrong patient in the operating room; wrong side or site surgery; wrong procedure performed; failure to communicate changes in the patient’s condition; disagreements about proceeding; retained instruments or swabs.  Safe prescription Technical & operation errors ✓ High surgical proficiency: ✓ Unfortunately, medication errors are common and their many causes include: It is a state of automatic unconscious processing, with the execution being effortless, intuitive and untiring. ✓ Nonproficient execution: Characterized by conscious control processing requiring constant attention and resulting in slow, deliberate execution and inducing fatigue. The transition from one state to the other is better known as the ‘learning curve’. ❖Failures in operative technique include: Cognitive errors of judgement: such as failure or late conversion of a difficult laparoscopic procedure into an open one. Procedural: when the steps of an operation are not followed, or omitted. Executional: for example, too much force is used which may result in damage. Misinterpretation: which is unique to minimal access surgery and is a function of the misreading of a two-dimensional image. Misuse of instrumentation: such as with energized dissection modalities, for example, diathermy. Missed iatrogenic injury: either at the time of surgery or diagnosed late. So, Saudi Patient Safety Center was established in 2017. ❖A lot of national important strategies should be developed to maintain the This is the 1st of its kind in the middle east. It is the patient safety and quality of health care, as: main custodian of the patient safety strategies. regulating and licensing of physicians and healthcare institutions; developing and adopting policies for patient safety and quality improvement; providing patient safety education programs; instituting national clinical audits; reporting (and learning from) adverse events; setting up agencies to resolve concerns about the practice of doctors by providing case and incident management services.  BRAIN STORMING A 33-year-old male patient underwent open repair of right sided oblique inguinal hernia. The surgeon by mistake incised over the left inguinal canal. How to describe this surgical error? a) A near miss. b) No harm event. c) Never event. d) Non-preventable adverse event. BRAIN STORMING At which step of the surgical check list, the nurse should check the count of sponge and instruments? a) Sign In. b) Time out. c) Sign out.  Definition Classification Physiological response to hemorrhage HAEmorrhage Clinical Picture Treatment FLUID THERAPY By AHMED ABDELFATTAH Hemorrhage = bleeding means Escape of blood outside the circulatory 2. Internal (concealed): system. More serious and must be suspected, actively investigated and controlled. , Classifications: examples; I. According to site of bleeding: Hemoperitoneum 1. External (revealed): Retroperitoneal hemorrhage Bleeding is visible through the skin as in wounds, Hemothorax. From a body orifice as in epistaxis or hematemesis, hematuria. II. Type of disrupted vessel: 1. Arterial: 3. Capillary: Bleeding occurs as diffuse ooze The blood is bright red in colour Bright red blood. Comes in pulsatile jets. Sudden cessation of oozing during a surgical operation means cardiac arrest. Bleeding is more from the proximal than the distal end. 2. Venous: Blood is dark red in colour Comes as a steady flow. More from the distal than the proximal end. Can be terrifying if a large vein is injured.  III. According to Timing in relation to the onset of trauma: 1. Primary hemorrhage: 3. Secondary hemorrhage: Occurs at the time of trauma Occurs 1 - 2 weeks after trauma and is precipitated by factors such as infection 2. Reactionary hemorrhage: eroding vessel walls, e.g. after hemorrhoidectomy or tonsillectomy. , pressure necrosis (such as from a drain) or malignancy. Occurs within 24 hours after trauma. It can be fatal if a large vessel is involved, e.g. the carotid after sloughing of the As the blood pressure rises due to correction of Hypovolemia, or secondary skin flaps of a radical neck dissection to postoperative pain An insecure ligature is going to slip or a clot is going to dislodge IV. According to etiology: 3. Spontaneous: 1. Traumatic: Bleeding diathesis e.g. hemophilia, can: Accidental Increase the amount of traumatic and pathological bleeding Surgical Cause bleeding with little or no trauma. Interventional procedures, e.g. biopsy. It cannot be stopped by surgical means (except packing) but requires 2. Pathological: correction of the coagulation abnormalities. Atherosclerotic (ruptured aortic aneurysm). Inflammatory (bleeding peptic ulcer). Neoplastic (hematuria in renal cancer). Physiological response to heamorrhage In summary, a number of integrated mechanisms operate to stop hemorrhage and (1) Stopping the bleeding by: VC of injured blood vessel with subsequent clotting maintain perfusion for critical organs. (2) Maintaining effective circulating volume These mechanisms allow survival without therapy for losses up to 15% of blood for critical tissue ( heart & brain) at the expense on less critical (skin, skeletal muscle), and is achieved by: volume.  Greater losses or poor cardiovascular reserve eg.(CAD, severe anemia) lowers Clinical Picture: patients tolerance to hemorrhage and leads to progressive hypovolemia, shock I. Symptoms: and death unless appropriate therapy is instituted. 1. Weakness and fainting especially when standing. 2. The patient feels cold and thirsty. II. Signs: In patient with haemorraghe, it is important to have rough estimate of blood 1. The patient looks tired, pale. 2. Anxious or drowsy. loss from clinical data 3. Tachycardia & then progressive hypotension. Blood volume is estimated as 70 ml/kg in adults, and 80 ml/ kg in children. 4. Tachypnea 5. Hypothermia coagulopathy. Four classes of haemorrhage are recognized based on clinical changes in 6. Skin; pale, cold & clammy. haemodynamic parameters and indices of tissue perfusion. 7. Oliguria. Haemorrhage must be recognized and managed aggressively to reduce the severity and duration of shock and avoid death and/or multiple organ failure. Haemorrhage is treated by arresting the bleeding, and not by fluid resuscitation or blood transfusion.  Management: Although necessary as supportive measures to maintain organ perfusion, I. Stop the hemorrhage: attempting to resuscitate patients who have on-going haemorrhage will Packing, pressure, lead to physiological exhaustion (coagulopathy, acidosis and Position e.g. limb elevation hypothermia) and subsequently death. Pressure on the feeding artery e.g. the brachial artery in distal upper limb bleeding Definitive management ??Cause of bleeding. II. IV line: two short peripheral canulas; III. Blood Sample 1. Blood group 2. Cross matching 3. CBC 4. Hematocrite 5. Coagulation profile IV. Give IV fluids or blood according to the severity of bleeding; V. Oxygen mask VI. Keep the patient warm VII. Insert a Urinary Catheter and check urine output. VIII. General care: Analgesics, bed rest, elevate the legs IX. Monitoring of treatment: 1. Frequency of monitoring: i. every 15 minutes until the patient is resuscitated, ii. then half-hourly for 2 hours iii. then four hourly What to monitor: Pulse & blood pressure Respiratory rate Urine output (0.5-1 ml/kg/hour) Skin & temperature Mental state (level of consciousness) Central Venous Pressure