S&P Lecture 7: Wound and Burn

What are the four wound types? (select all that apply)

1. Incision 2. Laceration 3. Puncture 4. Avulsion

Which wound type has clean, sharp edges with minimal collateral tissue damage?

Incision

Which wound type involves tearing of tissue with irregular margins and crushing?

Laceration

Which wound type is deep, narrow penetration with high anaerobic infection risk?

Puncture - don't close (infection risk)

Which wound type involves tearing away of tissue with a significant remaining defect?

Avulsion

What are the four phases of wound healing, in order?

1. Hemostasis 2. Inflammation 3. Proliferation 4. Maturation (remodeling)

Hemostasis phase: timing and key events?

Minutes - platelet aggregation and fibrin clot formation

Inflammation phase: timing and key cells?

Days 1-4 - neutrophil and macrophage infiltration

Proliferation phase: timing and key events?

Days 4-21 - fibroblast activity, angiogenesis, granulation tissue

Maturation phase: timing and key events?

Up to 2 years - collagen cross-linking, tensile strength increases

Which wounds require updated tetanus prophylaxis? (select all that apply)

1. All contaminated wounds 2. All burns

When should tetanus be updated for a contaminated wound or burn?

If not up to date in the last 5 years - update today

What are the characteristics of a CLEAN (Class I) wound? (select all that apply)

1. Not infected 2. No inflammation 3. No foreign body 4. Surgical incision 5. Does NOT enter respiratory, urinary, alimentary, or genital tract

How is a Class I (clean) wound typically closed? Give an example.

At initial presentation with suture/staple/glue/steri-strips - ex: thyroidectomy

What defines a CLEAN-CONTAMINATED (Class II) wound?

Surgical entrance into the respiratory, urinary, alimentary, or genital tract - only under a controlled environment

How is a Class II (clean-contaminated) wound closed?

Primary intention

What defines a CONTAMINATED (Class III) wound? (select all that apply)

1. Grossly contaminated with debris, dirt, gravel (traumatic wounds) 2. Breach of sterile technique 3. Leakage from the GI tract

Does a Class III (contaminated) wound always need systemic antibiotics?

No - only if other clinical signs of infection, or for bites, water injuries, high-risk patients

How is a Class III (contaminated) wound managed and closed?

Extensive cleansing/monitoring; likely closure by secondary intention or delayed primary closure (some properly cleaned traumatic wounds can close primarily)

What defines an INFECTED (Class IV) wound? (select all that apply)

1. Generally older wounds 2. Inadequate treatment/cleansing of traumatic wounds 3. Gross purulence 4. Obvious signs of infection 5. Surgery with perforated organs

How is a Class IV (infected) wound managed?

Antibiotics; often left open - perhaps wound vac depending on size/location

What is a CHRONIC wound, and what class is it if taken to the OR?

A wound that failed to progress through normal healing (wound- or patient-related, e.g., DM) - Class IV if taken to the OR

Do chronic wounds need antibiotics?

Generally no - unless acute infection has developed

How are chronic wounds managed? (select all that apply)

1. Debridement 2. Wound vac 3. Specialized dressing 4. Surgery - goal is clean edges with good granulation tissue

What bacteria predominate in CHRONIC vs ACUTE wound cultures?

Chronic - more gram negative; acute - mostly gram positive/skin flora

What are the methods to assist in wound healing? (select all that apply)

1. Irrigation 2. Debridement 3. Dressing 4. Moisture 5. Infection control 6. Offloading (pressure/movement) 7. Advanced adjuncts

For wound irrigation, does tap water vs saline matter?

No - doesn't matter

What are the key elements of wound irrigation? (select all that apply)

1. Tap water or saline 2. Pressure 3. Soaking (sometimes)

What are the methods of debridement? (select all that apply)

1. Sharp or chemical 2. Gauze - wet to dry (starred)

How is a moist wound environment maintained, and what if exudate is heavy?

Dressings, ointments, alginates - with heavy exudate, absorb some to prevent maceration

What are the elements of wound infection control? (select all that apply)

1. Irrigate (repeatedly) 2. Appropriate closure times 3. Remove foreign body 4. Maintain appropriate dressing 5. Full and deep exploration of wound bed/ROM 6. Maybe antibiotics

What are the advanced adjuncts for wound healing? (select all that apply)

1. Wound vac 2. Special dressing 3. Bioengineered tissue 4. Hyperbaric oxygen

Which wounds require surgical debridement? (select all that apply)

1. Devitalized tissue 2. Accumulated debris 3. Foreign material 4. Biofilm 5. Eschar 6. Slough

What is a flap?

Full-thickness portion of skin including subcutaneous fat, transferred from donor to recipient site WITH its own blood supply

What is the key difference between a skin GRAFT and a FLAP?

A flap has its own blood supply; a graft does not

Graft vs flap - which has the reduced chance of failure, and which is good for areas of reduced blood supply?

Flap (for both)

What is an AXIAL flap?

Relies on larger, named vessels running longitudinally under the flap

What is a RANDOM flap?

Relies on the subdermal plexus - unnamed, smaller vessels

What is a PEDICLED flap?

Uses a deeper vessel and can be rotated or transposed while maintaining its vascular pedicle

What does a SPLIT-thickness skin graft contain?

Epidermis but not the entire dermis

What does a FULL-thickness skin graft contain?

Epidermis and the whole dermis (and hair follicles)

What must the recipient site have for a skin graft to survive, and how does a graft heal?

Good blood supply (or graft fails) - heals by developing its own blood supply

Which has an increased risk of failure: graft or flap?

Graft

What are the key characteristics of an ideal dressing? (select all that apply)

1. Absorbs excess fluid while maintaining a moist environment 2. Protects from damage 3. Prevents bacterial invasion 4. Conforms to wound/eliminates dead space 5. Debrides necrotic tissue 6. Does not macerate viable tissue 7. Minimizes pain and dressing changes

Should a wound be kept dry or moist?

Moist - but not wet (old idea was to let it dry out)

Why does keeping a fresh wound moist improve healing?

Natural drainage contains platelet-derived growth factor

What is the difference between a primary and secondary dressing?

Primary goes on the wound; secondary goes on top

What are the indications for wound dressings? (select all that apply)

1. Protect a new wound/surgical incision 2. Manage exudate 3. Protection over a joint 4. Deliver topical therapy

What are the functions of a wound dressing? (select all that apply)

1. Provide moist environment 2. Protect wound from trauma 3. Absorb excess exudate 4. Promote autolytic debridement 5. Reduce pain

What are the contraindications to wound dressings? (select all that apply)

1. Allergy 2. Completely occlusive dressing if infected 3. Heavily absorptive dressing if dry wound 4. Dressings the caregiver cannot manage

Which dressing is a transparent sheet that is gas/water VAPOR permeable but water/bacteria impermeable?

Film

Which dressing rehydrates the wound and requires a secondary dressing?

Hydrogel

Which dressing absorbs water to form a gel, provides cushion, and stimulates debridement?

Hydrocolloid

Which dressing is absorptive, provides cushion, and may need a second layer?

Foam

Which highly absorbent gel-forming dressing usually contains Ca2+ and is good for pressure or exudative wounds?

Alginate

Which dressing is made of carboxymethylcellulose, causes autolytic debridement, and is more absorbent than alginate?

Hydrofiber

What are examples of antimicrobial dressings? (select all that apply)

1. Silver 2. Honey (medical grade) 3. Iodine

What is negative pressure wound therapy (NPWT)?

Wound vac - a negative pressure dressing system, incisional or over the entire wound; pt can go home with it

What wounds is a wound vac good for?

Chronic open wounds; also acute/traumatic wounds, flaps/grafts, subacute wounds

How does a wound vac promote healing? (select all that apply)

1. Maintains moist warm environment 2. Fluid transport from wound bed/interstitium 3. Foam contracts and draws wound edges together 4. Reduced inflammation and bacterial burden 5. Release of growth factors → increased granulation

What are the contraindications to wound vac therapy? (select all that apply)

1. Untreated osteomyelitis 2. Malignancy in the wound 3. Necrotic tissue 4. Exposed blood vessel/organ

When should a wound vac be used with caution?

Unexplored fistulae or sinus tracts and high bleeding risk

What are the common complications of wound dressings? (select all that apply)

1. MARSI (medical adhesive-related skin injury) 2. Maceration of peri-wound tissue 3. Infection (impermeable, non-absorbing dressing) 4. Allergic dermatitis 5. Skin tear 6. Pain 7. Adherence to wound bed 8. Delayed healing (too wet/too dry, inadequate debridement)

What are the indications for wound closure? (select all that apply)

1. Facial wounds 2. Clean wounds 3. Fresh wounds (< 24 hr) 4. Select open fx after washout 5. Wounds with viable tissue 6. Wounds over tendons/nerves (protection)

What are the contraindications to wound closure? (select all that apply)

1. Heavily contaminated 2. Bites (except face) 3. Old 4. Dirty 5. Puncture wounds 6. Significant tissue loss requiring closure under tension

Which bites CAN be closed?

Facial bites (big bites - partial closure)

What closure method is used when primary closure is contraindicated?

Secondary intention or delayed primary closure

What are the complications of wound closure? (select all that apply)

1. SSI 2. Hematoma 3. Seroma 4. Dehiscence 5. Strangulation 6. Nerve injury 7. Pain 8. Compartment syndrome 9. Bleeding

What are the risk factors for poor wound healing? (select all that apply)

1. Tobacco 2. DM 3. Immunosuppression 4. Active infection 5. Foreign body 6. Inappropriate dressing 7. Fecal contamination 8. Vascular disease 9. Malnutrition 10. Age 11. Immobilization 12. Steroids

How do steroids impair wound healing?

Suppress inflammation, preventing the wound from progressing to the next healing stage

What post-procedure wound care instructions are given? (select all that apply)

1. Keep covered and moist 2. Wash with gentle soap and water 3. Don't scrub 4. Ointment 5. No submerging/swimming 6. Wash hands 7. No smoking 8. Control sugars 9. Avoid excessive movement (joints)

Which agents should NOT be used for post-op wound care? (select all that apply)

1. Hydrogen peroxide 2. Betadine

What signs of infection/poor healing should patients watch for after wound closure? (select all that apply)

1. Red 2. Warm 3. Draining 4. Streaks 5. Pus 6. Smelly 7. Fever

What else should patient education after wound closure include? (select all that apply)

1. When to return 2. Suture removal times 3. Care of absorbable sutures

What are the four causes of burns? (select all that apply)

1. Heat 2. Electricity 3. Chemical 4. Radiation

What is the most common type of burn?

Radiation - sunburn (also radiation therapy)

Superficial (epidermal) burn: appearance, sensation, healing time?

Dry, red, blanches with pressure; painful; heals in 3-6 days

Superficial partial-thickness burn: appearance, sensation, healing time?

Blisters, moist, red, weeping, blanches with pressure; painful to temperature, air, and touch; heals in 7-21 days

Deep partial-thickness burn: appearance, sensation, healing time?

Blisters (easily unroofed), wet or waxy dry, patchy to cheesy white to red, sluggish blanching; painful to pressure only; > 21 days, usually requires surgery

Full-thickness burn: appearance, sensation, healing time?

Waxy white to leathery gray to charred and black, dry and inelastic, no blanching; deep pressure only; rare healing unless surgically treated

Deeper (fourth degree) burn: depth, sensation, healing?

Extends into fascia and/or muscle; deep pressure; never heals unless surgically treated

Which burn depth involves the epidermis ONLY, peels around day 4, and has no scarring?

Superficial

How is a superficial burn treated?

Topical agents, NSAID

Which burn depth involves the epidermis + superficial dermis and usually has no scarring (may have pigment changes)?

Superficial partial thickness

Which burn depth involves the epidermis + deep dermis including hair follicles and ALWAYS scars?

Deep partial thickness

How are superficial partial and deep partial thickness burns treated?

Debridement, topical antimicrobial, dressings

Which burn depth is anesthetic/hypoesthetic and destroys all layers + subcutaneous tissue?

Full thickness

How is a full-thickness burn treated?

Excision, skin grafting; escharotomy - watch for compartment syndrome

What chart is used to estimate TBSA burned in CHILDREN?

Lund-Browder chart

Rule of 9s (adults): head and each arm?

Head = 9%; each arm = 9%

Rule of 9s (adults): each leg, front trunk, back trunk?

Each leg = 18%; front trunk = 18%; back trunk = 18%

Rule of 9s (adults): perineum?

1%

What % TBSA is the patient's palm WITH fingers vs WITHOUT fingers?

With fingers = 1%; without fingers = 0.5%

Which burns are EXCLUDED from TBSA calculations?

Superficial burns

Which THERMAL burns need immediate burn center consultation/transfer? (select all that apply)

1. Full thickness burns 2. Partial thickness ≥ 10% TBSA 3. Deep partial/full thickness of face, hands, genitalia, feet, perineum, or over joints 4. Burns + comorbidities 5. Burns + concomitant trauma 6. Poorly controlled pain

Which thermal burns get a burn center CONSULTATION recommendation (not transfer)? (select all that apply)

1. Partial thickness < 10% TBSA 2. All potentially deep burns of any size

Which inhalation injuries need immediate burn center consultation/transfer?

All patients with suspected inhalation injury

Which chemical and electrical injuries need immediate burn center consultation/transfer? (select all that apply)

1. All chemical injuries 2. All high-voltage (≥ 1000 V) electrical injuries 3. Lightning injury

Why should low-voltage (< 1000 V) electrical injuries get burn center consultation?

To screen for delayed symptom onset and vision problems

What age/weight defines a pediatric burn patient for burn center referral?

≤ 14 years or < 30 kg