Wounds Part 2: Wound management

Approach to Traumatic Wound

Initial patient assessment (ABCs!!), Wound assessment, wound cleansing & debridement, +/- Surgical intervention, Wound management plan

Wound Assessment includes

- type of wound- location, proximity to vital structures- degree of contamination^- assess for trauma to deeper tissues (ie. fracture) +/- Culture & susceptibility of wound (consider macerated tissue culture)

Wound Assessment Golden Period

first 6-8 hours between contamination at injury and bacterial infection (>105 bacteria per gram of tissue)

Wound Cleansing Goal 

To reduce bacterial contamination and remove gross contaminants & necrotic debris from within the wound

How to perform Wound Cleansing

Wide clip of hair around wound → use sterile lubricant or oiled clipper blades

Aseptically prepare area around wound

Lavage or irrigate wound with copious amounts of warmed solution

Wound Cleaning- Lavage and irrigating solutions 

Saline (NaCl 0.9%), LRS (isotonic)

tap water (hypotonic)

dilute antiseptic solutions [CHX, P-I]

use only early in wound management & contraindicated in clean wounds

Antiseptics Used in Wound Management include 

Chlorhexidine 0.05%, Povidone- iodine 0.1-1% solution, Hydrogen Peroxide 

Chlorohexidine 0.05% solution characteristics

Synergistic antimicrobial effect when combined with TrisEDTA

residual activity (up to 48 hrs)

Some Pseudomonas spp. have developed resistance to chlorhexidine

Povidone- iodine 0.1-1% solution characteristics

broad spectrum of activity, free iodine is inactivated by organic debris, no significant residual activity

Hydrogen Peroxide Characteristics

effective sporocide → use in instances of possible exposure to Clostridium spores

no significant antiseptic activity 

effervescent action dislodges bacteria & debris

cytotoxic (esp. to new capillaries)

Types of Wound Debridement includes

Surgical, mechanical, hypodynamic, bio surgical, enzymatic, autolytic

What are the Types of Wound Healing

1st,2nd, 3rd intention

1st intention Wound healing

Wound closed with sutures

* clean (surgical) or fresh traumatic wounds (after being rendered surgically clean)

Type of wound closure = 1° CLOSURE

2nd intention Wound healing

Wound left open to heal by contraction & epithelialization (healing from the inside → out)

Type of wound closure* = 2° CLOSURE

*if wound does get closed (sometimes just left to heal on its own)

3rd intention Wound Healing

Wound sutured closed before granulation tissue has begun to form

Type of wound closure = DELAYED 1° CLOSURE

Primary closure + 1st intention wound healing

Wound sutured within <24 hours of injury

Indicated for clean surgical wound or contaminated traumatic wounds that have been rendered surgically clean

Examples. surgical incision, graft or flap, some wounds

Delayed primary closure + 3rd intention wound healing

Indicated for mild to moderately infected wounds… goal is to control infection before suturing wound closed

Wound should be closed within 3-5 days

Repair before granulation tissue forms

2nd Intention Wound Healing +/- secondary closure indications

Managing an open wound - Indicated in cases where: patient is a poor surgical candidate, heavily infected wound, wound too large to close surgically

Many of these wounds will eventually be closed surgically (by secondary closure)

Risk of contracture formation, proud flesh (horses)

Secondary Closure

Wound closure after development of granulation tissue (typically greater than 5 days post-injury)

Indicated for heavily infected wounds or very large wounds

Secondary Closure Procedure

1. Manage wound medically until granulation tissue forms (>5 days)

2. Surgically close wound when appropriate: - undermine skin first in order to be able to pull skin over granulation tissue- consider tension relieving patterns & techniques- place drain

Wound Management Plan can include

1. Drug therapy- antibiotics → topical, systemic- topical wound enhancers- analgesics (lidocaine/bupivacaine, NSAIDs, opioids, gabapentin)

2. Bandages- provide warm, moist environment to promote healing

3. Tetanus prevention (+/-)- species susceptibility: Equine, man>ruminants, swine>cat, dog

4. Drains (+/-)

Topical Antimicrobials uses 

Contaminated or mildly infected wounds: topical antibiotic (abx) only

Moderate-heavily infected and/or high risk of bacteremia: topical + systemic abx

Exuberant Granulation Tissue (Proud Flesh)

Horses → slower rate of wound repair

Can occur when wound healing process is delayed: movement, infection, foreign body, poor blood supply, malnutrition

Need to address the underlying cause of delayed healing and then debulk with sharp dissection

Wound Contracture

abnormal healing of tissue= functional impairment, typically around joints

Can occur with wounds over the flexion surface of a joint. If collagen fibers bond while joint is flexed, the contracture will impair the affected joint’s ability to extend