07: Wound Mngmt

Things to tell an owner when they are on the phone and coming in with a large wound

• Caution: if they are in pain they may bite

• Cover: use a non-linting towel

• Compress: minimize hemorrhage and stabilization

Once a patient with a wound is in your clinic, how should you confirm stability

• Obtain quick history

• Evaluate patient for the XABCs: exsanguination, airway, breathing, circulation

• Assess for shock and life threatening conditions

If the wound patient is stable, what is appropriate to cover the wound

A light, temporary wrap

If the wound patient is unstable, what is appropriate to cover the wound

Make the first wrap count, something more long term

Goals when covering a wound

• Stop hemorrhage

• Prevent further contamination or infection

• Absorb fluid

Types of wound classification

• Clean

• Clean-contaminated

• Contaminated

• Dirty/infected

Definition of a clean wound

Incision created under aseptic conditions (sx incision) with no invasion in to an organ that communicates with the outside world

How are clean wounds typically closed

Primary closure

Definition of a clean-contaminated wound

• Surgical or aseptic incision into organs that communicate with the outside world with no fluid leakage

• Clean wounds with a drain

What is the “golden period” for a clean-contaminated wound

6-8 hours before significant contamination occurs to a clean-contaminated wound

Definition of a contaminated wound

• Open, fresh, accidental wounds

• Operative wound with a major break in asepsis

• Overt spillage from a luminal structure

Definition of a dirty/infected wound

A wound with >10⁵ bacteria/gram of tissue

What can bump a wound classification from clean-contaminated/contaminated to dirty/infected

Overt contamination or lack of treatment

Why is it important to remove foreign bodies and contaminants from a wound

They prolong the inflammatory period

Why is it important to ensure a wound has adequate drainage

To prevent abscess formation

Steps to prepare a wound for treatment/closure

• Lubricate the wound liberally with sterile lube

• Clip hair around the wound (WIDE)

• Dirty scrub of the skin around the wound

Why do we lubricate wound before we clip

Keeps hair from getting into the wound

What do we lavage a wound with

LOTS of sterile saline or dilute antiseptic (chlorhex, betadine)

Goal of wound lavage

Remove debris without causing tissue damage

Optimum psi when lavaging a wound

7-9 psi

When do you stop lavaging a wound

When there is no more evidence of gross contamination or there are tissue signs of over hydration (pale and bubbling)

What type of debridement should you do to a wound

Sharp debridement only please!

Instruments used for wound debridement

Scalpel > scissors

When you are debriding a wound, what should you do with tissue that is questionable

Leave it and reassess in 1-2 days

Features of healthy tissue

• Color: pink/red and moist

• Moist

• Intact blood supply

• Tissue attachment

• ± Warm

Purpose of clean probing a wound

To evaluate the depth of the wound

Indications for culturing a wound

• Chronic wounds (>6-8 hours)

• Purulent material/overt infection

• Devitalized wounds

• Deep wound: muscle/fascia involved

• Immunocompromised patient

Number one source of infection with a clean surgery

The patient’s own skin flora

How do you choose your preliminary antibiotic for a wound (or if not doing a culture)

Based on the expected native flora and the estimation of contamination

Indications for a drain

• Draining abscesses or fluid

• Foreign material or questionably viable tissue

• Massive contamination is inevitable

• Obliteration of dead space

• Prevent accumulation of serum, blood, air

Primary wound closure

Wound closed soon (same day) after damage

Delayed primary wound closure

Wound was too contaminated to close initially, but can be closed 2-5 days after the wound happened but before granulation tissue formation

Secondary wound closure

Wound closure >5 days after the insult and when healthy granulation tissue is present

Second intention wound closure

Letting the wound close on its own

T/F: you should close puncture wounds from a dog bite

False; those small surface wounds cause a lot of underlying damage and contamination