Wound Management

The wound healing process involves 4 key phases

1 - Bleeding

2 - Inflammatory

3 - Proliferation

4 - Maturation/remodelling phases

Inflammatory phase - immediate phase - haemorrhage

• Allows healing process to begin

• Cleans the wound

• Flushes out any contaminates in the wound

Vasoconstriction and clotting cascade

• Haemostasis 

• Clot formed to stem haemorrhage 

Vasodilation 

• Increase blood flow 

• Transudates into the wound 

• Inflammation

• White blood cells proliferate 

• Neutrophils break down debris 

• Monocytes/macrophages 

• Removal of debris and promote factors to aid repair 

3 - 7 days - or lag/repair phase - post injury

• Capillaries grow into the wound from surrounding health tissue 

• Migration of fibroblasts 

• Lead to creation of collagen 

• Granulation tissue production

• Weak in the initial stages 

• Acts as a barrier to heal tissue beneath 

• Wound contraction 

• Looks smaller 

• If over a joint, may get loss of function 

5 - 7 days post injury

• Restoration of normal structure

• Weaker than normal dermis but gets stronger

• Phases overlap 

• Avoid infection as this will delay healing 

• Healthy granulation tissue 

Factors affecting wound healing

• Health status 

• Age 

• Body condition 

• Nutrition 

• Medication 

• Mechanical factors → bandaging 

Classifications of wound healing

• Primary intention 

• Secondary intention 

• Third intention 

Classification - Primary intention

2 opposing edges brought together

Classifications - Secondary intention

• Edges cannot be brought together 

• Heal by granulation 

Classifications - Third intentions

Debride wound and structure

Ideal conditions for wound healing

• A clean wound

• No interference 

• Good blood supply 

• Fresh wound edges 

• Moist environment 

• Good apposition of wound edges 

Wound healing - Surgical wounds

• Heal by primary intention

• Meaning that the dermis will knit back together and a thin line of new epithelial cells will grow

Post operator wound healing

• Wound edges seal after 6 hours

• Initially there will be some inflammation

• After a couple of days this should subside

• By 7 - 10 days healing of the skin should be complete

Classification - Closed wounds

• Contusion

• Haematoma 

Classification - Open wounds

• Incised 

• Laceration 

• Abrasion 

• Burn 

• Avulsion 

• De-gloving/shear 

• Puncture 

• Pressure sore 

Treatment - Contusion

• Cold compress 

• Analgesia 

Treatment - Haematoma

• Cold compress

• Pain relief 

• Pressure dressing 

• Surgical draining 

Incised

Image of incised wound

Laceration 

Image of laceration wound 

Abrasion

• A ‘graze’ 

• Not full-thickness - epidermis and/or dermis 

• Painful, and often contused 

Treatment - Abrasion

• Clip remaining hair 

• Clean skin surface 

• Flush with sterile saline 

Burn

Damaged tissue undergoes necrosis and may slough over a period of days

Treatment - Thermal Burns

Cold flowing water or 0.9% saline over the area for 15 minutes after injury

Treatment - Avulsion

• Flush with saline

• Analgesia 

• VS to attempt reconstruction 

• ABs - risk of infection 

Treatment - Degloving/shear injury 

• Clip hair 

• Flush with 0.9% saline

• Dress

• Antibiotics

• Surgical intervention

Clinical signs of a puncture wound

• Pain

• Inflammation 

• Infection

• Abscess 

• Discharge 

Treatment - Puncture wound

• Clip hair

• Clean and flush thoroughly 

• Explore radiographically or surgically if needed 

• Antibiotics 

• If progressed to abscess, drain and flush plus antibiotics 

Bite wounds

• Often more damage than can be seen 

• Need to explore surgically 

• Skin can become necrotic and slough 

Puncture wound - Snake bite

Snake venom has additional effects

• Anaphylaxis 

• Local toxic effect on tissue which may letter cause necrosis 

• Anti-venom may be used 

Pressure sores - Decubital ulcers

Trauma to the skin over bony prominences 

Treatment - Decubital ulcers

Successful removal of the underlying cause

Classification by contamination

• Clean 

• Clean-contaminated 

• Contaminated 

• Dirty 

Clean 

Wound made surgically under aseptic conditions 

Clean-contaminated

Created when a non-sterile organ (resp system/GI tract_ is entered with little or no pillage of its contents or minor break of asepsis in clean wounds, wounds less than 6 hours old 

Contaminated 

• Foreign matter present 

• GI spillage or a wound with grit/dirt within it 

• Length of time - longer than 6hrs old 

Dirty

• Old or infected 

• Active infection 

• Pathogens present 

• Older than 12hrs 

Initial aims of wound management 

• Prevent further blood loss 

• Prevent further contamination

• Dressing application is used to achieve this initially

Managing wounds

Wounds not suitable for immediate suturing must be manage as open wounds until secondary closure is possible 

Aim of managing wounds

• To reduce bacterial contamination

• To remove devitalised tissue

• Promote a moist healing environment