Wound management

What are Halsted’s surgical principles?

1. Gentle tissue handling

2. Meticulous hemostasis

3. Preserve blood supply

4. Aseptic technique

5. Minimize tension

6. Avoid dead space

7. Meticulous apposition

What are the general steps in wound management?

• Prevent contamination

• Lavage

• Debridement

• Drainage (if needed)

• Closure method

• Bandaging

When is lavage important in wound treatment?

Immediately after stabilizing the patient to flush out contaminants using saline or tap water

What is the goal of debridement?

Remove necrotic and non-viable tissue to promote healing

What is en bloc debridement?

Wide excision of contaminated tissue followed by immediate closure, only if no vital structures are involved to minimize infection and promote healing

Why are surgical drains used?

To eliminate dead space, remove harmful fluid or gas, and enable flushing of a closed wound

What are the 3 main reasons to place a drain?

1. Obliterate dead space

2. Remove harmful material

3. Enable flushing after closure

What are the types of surgical drains?

1. Passive (e.g., Penrose)

2. Active (e.g., closed suction drains)

What are the pros and cons of passive drains?

Pros

• Cheap

• Simple

Cons

• Higher infection risk

• Can't measure output

What are the pros and cons of active drains?

Pros

• Sealed system

• Measurable output

Cons

• More expensive

• Can clog

When should passive drains be used?

In contaminated/infected wounds that can't be fully sealed

When should active drains be used?

In clean wounds or sealed cavities where accurate drainage measurement is needed

How should a Penrose drain be placed?

Exits ventrally through another site, not through sutured incision → never sutured deep into tissue

What is first intention healing?

Primary closure using sutures, glue, or staples

• Immediate

• Delayed

• Secondary closure

What is delayed primary closure?

Wound is closed 2–5 days post-injury before granulation tissue forms

What is secondary closure?

Closure after granulation tissue forms, often 5–10 days after injury

When is second intention healing used?

For dirty, large, or hard-to-close wounds where granulation and contraction are needed

What are disadvantages of second intention healing?

• Slower healing

• Thin epithelium

• Poor cosmesis

• Potential loss of function

What are examples of clean wounds?

Spay, castration, removal of skin mass under sterile technique

How are clean-contaminated wounds managed?

• Prophylactic antibiotics

• Primary closure

• Monitor for infection

What are contaminated wound examples?

GI spillage, cystotomy with active infection

How are dirty wounds managed?

• Delayed or secondary closure

• Drainage

• Antimicrobials

• Monitor closely

Why is wound classification important

• To guide closure decisions

• Antibiotic use

• Predict healing complications

What is the difference between dressing and bandage?

Dressing = contact layer on wound

Bandage = all layers including dressing

What are the three layers of a bandage?

1. Contact (primary)

2. Intermediate (secondary)

3. Outer (tertiary)

What are the purposes of wound bandaging?

• Maintain moisture

• Absorb exudate

• Protect

• Eliminate dead space

• Reduce motion

What do passive dressings do?

Protect the wound and may provide debridement (e.g., adherent gauze)

What is the function of wet-to-dry gauze?

Mechanical debridement of necrotic tissue as gauze dries and is removed

What are pros and cons of non-adherent dressings?

Pros

• Cheap and simple

Cons

• May dry wound

• Tear healing tissue with prolonged use

Why use absorbent dressings?

• To manage exudate

• Prevent bacterial overgrowth

• Protect surrounding skin

What is the benefit of Allevyn?

• Sterile

• Highly absorbent

• Non-adherent

• Can be left in place for days

What are active dressings?

Dressings that promote healing by maintaining a moist wound environment

Name 3 types of active dressing

1. Hydrocolloids (e.g. Granuflex)

2. Hydrogels (e.g. Intrasite)

3. Alginates (e.g. AlsiSite)

What do hydrocolloid dressings do?

Promote granulation and moist healing

Not suitable for infected wounds

What do hydrogels do?

• Rehydrate dry wounds

• Aid debridement

• May provide analgesia if cool

When are alginates used?

For exudative wounds:

• Absorb fluid

• Promote moist healing

• Provide hemostasis

Why can dressing choice change during healing?

Different phases (inflammatory, debridement, granulation) need different support