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GYÖRGYI SZABÓASSISTANT PROFESSOR
DEPARTMENT OF SURGICAL RESEARCH AND TECHNIQUES
Classification and management of wound,
principle of wound healing, haemorrhage and bleeding
control
Basic Surgical Techniques, Faculty of Medicine, 3rd year 2021/13 Academic Year, Second Semester
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WOUND
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What is a wound?
It is a circumscribed injury which is caused by an external force and it can involve any tissue or organ. surgical, traumaticIt can be mild, severe, or even lethal.
Simple wound Compound wound
AcuteChronic
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Parts of the wound
Wound edge Woundcorner
Surface of the wound
Base of the wound
Cross section of a simple wound
Skin surface
Subcutaneus tissue
Superficial fascia
Muscle layerBase of the wound
Wound edge
Surface ofthe wound
Woundcavity
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The ABCDE in the injured assessment
The mnemonic ABCDE is used to remember the order of assessment with the purpose to treat first that kills first.
A: Airway and C-spine stabilizationB: BreathingC: CirculationD: DisabilityE: Environment and Exposure
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Wound management - anamnesis
When and where was the wound occured?Alcohol and drug consumptionWhat did caused the wound?The circumstances of the injuryOther diseases eg. diabetes mellitus, tumour,
atherosclesosis, allergyThe state of patient’s vaccination against TetanusPrevention of rabiesThe applied first-aid
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Classification of the accidental wounds1. Based on the origine
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1.) Abraded wound (v. abrasum)
2.) Punctured wound(v. punctum)
Superficial part of the epidermal layer
Good wound healing
Sharp-pointed object Seems negligibleBUT Anaerobic infection Injury of big vessels and
nerves
Mechanical wounds8
3.) Incised wound(v. scissum)
4.) Cut wound (v. caesum)
Sharp object Best healing
Sharp object + blunt additional force
Edges - uneven
Mechanical wounds9
5.) Crush wound(v. contusum)
6.) Torn wound (v. lacerum)
Blunt force Pressure injury Edges – uneven and torn Bleeding
Great tearing or pulling Incomplete amputation
Mechanical wounds10
(v. lacerocontusum)
7.) Shot wound (v. scolperatium)
Close - burn injury Foreign materials
Mechanical wound11
unijured tissuenecrobiotic zonenecrotic zoneforeign bodies
aperture
slot tunel
output
8.) Bite wound (v. morsum)
Ragged wound Crushed tissue Torn Infection Bone fracture
Prevention of rabies Tetanus profilaxis
Mechanical wounds12
Distal Proximal
The wound healing is good
The direction of the flap13
1.) Acid 2.) Base
in small concentration – irritate in large concentration –
coagulation necrosis
colliquative necrosis
Chemical wounds14
Symptoms and severity depend on: Amount of radiation Length of exposure Body part that was
exposed
Symptoms may occur immediately, after a few days, or even as long as months.
What part of the body is most sensitive during radiation sickness?
bone marrowgastrointestinal tract
Wounds caused by radiation15
1.) Burning 2.) Freezing
a – normal skin 1 - 1st degree – superficial injury
(epidermis) 2 – 2nd degree –partial or deep partial
thickness (epidermis+superficial or deep dermis)
3 – 3rd degree – full thickness (epidermis + entire dermis)
4 – 4th degree – (skin + subcutaneous tissue + muscle and bone)
Treatment: Cooling – cold water and clean covering
Wounds caused by thermal forces16
Metabolic change! - toxemia mild, moderate, severe (redness, bullas, necrosis)
rewarm – not only the frozen area but the whole body
Exotic, poisonous animals
Toxins, venom - toxicologist Skin necrosis
Special wounds17
Classification of the wounds2. According to the bacterial
contamination
Clean woundClean-contaminated woundContaminated woundHeavily contaminated wound
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SuperficialPartial thicknessFull thicknessDeep wound
Classification of the wounds2. Depending on the depth of injury
+ bone, opened cavities, organs…etc.
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source: http://www.funscrape.com/Search/1/skin+layers.html
Wound management - history
Ancient Egypt – lint (fibrous base-wound site closure), animal grease (barrier) and honey (antibiotic)„closing the wound preserved the soul”
Greeks – acute wound= „fresh” wound; chronic wound = „non-healing” woundmaintaining wound-site moisture
Ambroise Paré – hot oil oil of roses and turpentine, ligature of arteries instead of cauterization
Lister pretreated surgical gauze – Robert Wood Johnson 1870s; gauze and wound dressings treated with iodide
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Applied wound management - colour continuum
black black-yellow yellow yellow-red red red-pink pink
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source: Applied wound management supplement – www.wounds-uk.com
Applied wound managementinfection continuum
contamination colonisatio
ninfectionsterility
critical colonisation
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the quantity and diversity of microbes
source: Applied wound management supplement – www.wounds-uk.com
Applied wound managementexudate continuum
volume high - 5 medium - 3
low - 1
high - 5medium -3 low - 1
Viscosity
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source: Applied wound management supplement – www.wounds-uk.com
The wound managemanet
Temporary wound management (first aid) clean, hemostasis, covering
Final primary wound management clean, anaesthesis, excision, sutures ALWAYS: thoracic cavity, abdominal wall or dura mater
injury NEVER: war injury, inflammation, contamination,
foreign body, special jobs, bite, shot, deep punctured wound
Primary delayed suture (3-8 days) clean, wash – saline, cover excision of wound edges, sutures
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The wound managemanet25
Early secondary wound closure (2 weeks) after inflammation, necrosis – proliferation anesthesia, refresh wound edges, suturing and
drainingLate secondary wound closure (4-6 weeks)
anesthesis, scar excision, suturing, draining greater defect – plastic surgery
The surgical wound
Surgical incisionStretch and fixHandling the scalpelLanger linesSkin edgesVessels and nervesHemostasis Langer lines
The wound edges
Handling the scalpel
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source: http://www.med-ars.it/galleries/langer.htm
Tissue unifying and dressing the wound
Skin:StichesClipsSteri-StripsTissue gluesFascia and subcutaneous layers:Interrupted stichesFat – fat necrosis!
Dressing: sterile, moist, antibiotic-containing, non-allergic, non-adhesive
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The wound healing
Hemostasis-inflammationGranulation-proliferationRemodelling
capillariesfibroblasts
lymphocytesmacrophages
neutrophyl gr.thrombocytes0 1 2 3 4 5 6 7 8 9 10 11 10 13 14 15
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http://www.worldwidewounds.com/2004/august/Enoch/images/enochfig1.jpg
The main steps of the wound healing
1. Hemostasis-inflammation
vasoconstriction fibrin clot formation
proinflammatory citokines andgrowth factors releasing
vasodilatationinfiltration PMNs, macrophages
cytokines releasing→ angiogensis→ fibroblast activation→ B- and T-cells activation→ keratinocytes activation→ wound contraction
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2. Granulation-proliferation
fibroblast migrationcollagen depositionangiogensisgranulation tissue formationepithelisationcontraction3. Remodellingregression of many capillariesphysical contraction – myofibroblastscollagen degeneration and synthetisationnew epitheliumtensile strength – max. 80%
Types of wound healing
Healing by primary intention
Healing by secondary intention
Healing by tertiary intention
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source: http://quizlet.com/13665246/chapter-3-tissue-renewal-regeneration-and-repair-flash-cards/
Factors affecting wound healing Local
Ischemia Infection Foreign body Edema, elevated
tissue pressure
Systemic Age and gender Sex hormones Stress Ischemia Diseases Obesity Medication Alcoholism and smoking Immunocompromised
conditions Nutrition
Hyperbaric oxygen treatment
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infection
ischemiaforeign bodies
edema/ elevated tissue pressure
IMPAIRED HEALING
Complications of wound healingI. Early complications
SeromaHematomaWound disruptinSuperficial wound infectionDeep wound infectionMixed wound infection
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1.) Seroma 2.) Hematoma
Filled with serous fluid, lymph or blood
Fluctuation, swelling, redness, tenderness, subfebrility
TREATMENT: Sterile punture and
compression Suction drain
Early complications of wound healing33
Bleeding, short drainage time, anticoagulant
Risk of infection Swelling, fluctuation, pain,
redness
TREATMENT Sterile puncture Surgical exploration
3.) Wound disruption A. partial – dehisceneceB. complete - disruption
Surgical error Increased intraabdominal
pressure Wound infection Hypoproteinaemia
TREATMENT: U-shaped sutures
Early complications of wound healing34
1.) Diffuse 2.) Localized Located below the skin
TREATMENT Resting position Antibiotic Dermatological consultation
Anywhere
TREATMENT Surgical exploration Drainage X-ray examination
Early complications of wound healingSuperficial wound infection
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e.g. erysipelas
e.g. abscess
1.) Diffuse 2.) Localized
TREATMENTSurgical explorationOpen therapyH2O2 and antibiotics
e.g. anaerobic necrosis
Inside the tissues or body cavities
TREATMENT surgical exploration drainage
Early complications of wound healingDeep wound infection
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Mixed wound infection
e.g. gangrenenecrotic tissues putrid and anaerobic
infection a severe clinical picture
TREATMENTaggresive surgical
debridement effective and specified
(antibiotic) therapy
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Complications of wound healingI. Early complications
Complications of wound healingII. Late complications
Hyperthrophic scarKeloid formationNecrosisInflammatory infiltrationAbscessesForeign body containing abscesses
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Hypertrophic scar Keloid
Develop in areas of thick chorium
Non-hyalinic collagen fibres and fibroblasts
Confine to the incision line
TREATMENTRegress
spontaneously(1-2 yrs)
Late complications39
Mostly African and Asian population
Well-defined edge Emerging, tough structure Overproliferation of collagen
fibers in the subcutaneous tissue
Subjective complains
TREATMENT Postoperative radiation Corticosteroid + local
anaesthetic injection
BLEEDING AND HEMOSTASIS
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Anatomical Diffuse
Arterial – bright red, pulsate
Venous – dark red, continuous
Capillary – can become serious
Parenchymal
Bleeding41
Bleeding
Severity of bleeding – the volume of the lost blood and time
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source: http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/
The direction of hemorrage
ExternalInternal
In a luminar organ (hematuria, hemoptoe, melena) In body cavities (intracranial, hemothorax, hemascos,
hemopericardium, hemarthros) Among the tissues (hematoma, suffusion)
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Bleeding
Preoperative hemorrhagePrehospital care! – maintenance of the airways, ventillation and circulationbandages, direct pressure, turniquets
Intraoperative hemorrhageanatomical and/or diffusedepending on the surgeon, the surgery, position,the size of the vessel, pressure in the vesselANESTHESIA!
Postoperative bleedingineffective local hemostasis, undetected hemostatic defect, consumptive coagulopathy or fibrinolysis
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Local General
Hematoma, suffusion, ecchymosis
Compression in the pleural cavity, in pericardium, in the skull
Functional disturbancies – e.g. hyperperistalsis
Pale skin, cyanosis, decreased BP. and tachycardia, difficulty in breeding, sweeting, decreased body temperature, unconsciousness, cardiac and laboratory standstill, laboratory disorders, signs of shock
Signs of the bleeding45
Surgical hemostasis
Aim – to prevent the flow of blood from the incised or transected vessels
Mechanical methodsThermal methodsChemical and biological methods
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Surgical hemostasisMechanical methods
Digital pressure – direct pressure, e.g. Pringle maneuverTourniquetLigationSuturingPreventive hemostasisClipsBone waxother
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Thermal methods
Low temperature Hypothermia – eg. stomach bleeding Cryosurgery
dehidratation and denaturation of fatty tissue decreases the cell metabolism vasoconstriction
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Thermal methods
High temperature Electrosurgery – electrocauterization Monopolar diathermy Bipolar diathermy
Laser surgerycoagulation and vaporizationfor fine tissues
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Thermal methods
High temperature Electrocoagulation Electrofulguration (A) Electrodessication Electrosection
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Hemostasis with chemical and biological methods
vasoconstriction coagulation hygroscopic effect
Absorbable collagen
Absorbable gelatin
Microfibrillar collagen Oxidized celluloze Oxytocin Epinephrine
Thrombin Hemcon
QuikClot
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Hemostasis with chemical and biological methods
HemCon
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