WOUNDSDr Joel Arudchelvamconsultant vascular and transplant surgeon

Wound /Ulcer / abrasion

A full thickness breach in the continuity of the skin

Partial thickness - Abrasion

Skin Anatomy

Wound healing

4 stages Haematoma formation Inflammation/ debridment Proliferation Remodelling / maturation

Stages of Wound Healing Inflammatory Stage Characterized by redness, heat, pain and swelling

approximately 4 to 5 days

Within 24 hours of the initial injury, neutrophils, monocytes and macrophages migrate to wound

control bacterial growth and remove dead tissue

Proliferative Phase

Granulation •Fibroblasts - collagen •new capillaries

Contraction •Wound edges pull together to reduce defect Epithelialization •Crosses moist surface

Remodeling

Reorganization of collagen (type III to type I)

increase in tensile strength

Tensile strength reaches only about 80% of pre-injury strength

Phases overlap

“Overlapping terms”

Wound healing

Primary intention

Secondary intention

Tertiary intention Delayed closure

Primary IntentionPrimary intentionHealing of a clean linear wound /surgical incision with sligth damage of tissues

Healing by second intention

extensive loss of tissue that is filled with granulation tissue and replaced by scar.

Classification of Wounds

1) Clean Wound: Operative incisional wounds t.

2) Clean/Contaminated Wound: When respiratory, gastrointestinal, genital,

and/or urinary tract have been entered. 3) Contaminated Wound:

open, traumatic wounds or surgical wounds involving a major break in sterile technique that show evidence of inflammation.

4) Infected Wound: old, traumatic wounds containing dead tissue

and wounds with evidence of a clinical infection (e.g., purulent drainage).

Complications of wound healing Deficient scar formation

wound dehiscence Excessive scar formation

Hypertrophic scar keloid

Exuberant granulation (proud flesh)

Non healing ulcer / chronic ulcers

Ulcers not showing signs of healing by 6 weeks are called chronic ulcers.

Causes for non-healing ulcers.

1. Local causes-Repeated trauma-Presence of foreign body / slough-ongoing infection / osteomyelitis 

2. Regional causes

-Venous-Arterial-Neuropathic

3. Systemic causes -Diseases- diabetes mellitus, renal failure, etc.- Drugs- immunosuppressive drugs, cytotoxic-Nutritional deficiencies- hypo-albuminaemia, anaemia, vitamin and mineral

Differentiating Arterial, Venous and Neuropathic Ulcers

Differentiating Arterial, Venous and Neuropathic Ulcers

Treatment for chronic ulcers Local Regional Systemic

Treatment for chronic ulcersLocal Wound toilet

o Process of removal of slough, dead tissue, foreign bodies and draining pus.

o Following a wound toilet the wound base is made suitable for future granulation and epithelialisation.

Treatment for chronic ulcersRegional causes

Arterial- revascularization Venous - Strapping

(i.e. multilayer compression cotton wool

crape bandage

Cohesive - Coban

Adhesive - elasto-plaster.

Neuropathic- off loading

Treatment for chronic ulcers Systemic causes

Correct anaemia, vitamin deficiency and other nutritional deficiencies.

Optimization of underlying comorbidities.

Role of antibiotics in wound - indicated only in patients with evidence of local or systemic infection.

Wound dressings

The material which is applied to the surface of the wound to cover it is called a dressing. 1ry – dressing which touches the wound 2ry – dressing used to cover the primary

dressing

Ideal wound dressing

Dressings are applied to wounds for the following reasons; To provide a protective cover To maintain moisture To reduce pain To absorb exudates

In addition an ideal dressing have the following features; does not induce pain or itching easy to change Allows gaseous exchange Cheap Freely available

Types of Wound Dressings

Gauze dressings Tulle Hydrocolloid dressings Hydrogel dressings Alginate dressings Foam dressings Transparent film dressings Etc.

Gauze

Cheap Freely available

Dry Painful on removing Damages epithelium

Tulle

Cheap Freely available Easy removal

E.g : Vaseline

Hydrocolloid Dressings

Hydrocolloid Dressings

Made up of pectin based material Absorb exudate Occlusive – should not be used on

infected wounds Come in various shapes and sizes

Hydrogel Dressings

Hydrogel Dressings

Made up of primarily water in a polymer to maintain moist wound base

used in dry wounds Should not be used in exudating

wounds

Alginate Dressings

Alginate Dressings

Made up of seaweed

Absorb moderate amounts of drainage

becomes a gel when it comes into

contact with wound fluid through

Calcium/Sodium ion exchange

Foam Dressings

Foam Dressings

Made up of polyurethane foam Absorbs moderate to large amounts

of fluid Available in various sizes and shapes Some types my macerate peri wound

skin if it allows drainage laterally

Silver Dressings

Antimicrobial to reduce bio burden of wound through slow release of silver ion into the wound

e.g. Acticoat, Biatin Ag, Atruman Ag

Vacuum assisted closure VAC

Vacuum assisted closure VAC

Vacuum assisted closure VAC Macrostrain - visible stretch that occurs when negative

pressure contracts the foam.

Draws wound edges together Provides direct and complete wound bed contact Evenly distributes negative pressure Removes exudate and infectious materials

Microstrain - micro deformation at the cellular level

Reduces edema Promotes granulation tissue formation by facilitating cell

migration and proliferation

Vacuum assisted closure VAC Indications for use

Large wounds Cavities Large amount of exudate

Summary

Wound type Dressing

Dry Hydrocolloid, Hydrogel

Exudating wound Hydrocolloid, foam

Slough Hydrocolloid, hydrogels

Dead space / cavity Alginate, foam

When to change dressings

When there is an indication to change Soaking Pain Need to inspect

Discuss with doctor before changing

Avoid in chronic wounds

Iodine (Betadine) Hydrogen peroxide Other toxic agents

Avoid

• Do not tie gauze bandage tightly around limbs, digits – causes ischaemia

• Use – plaster , crepe instead

Thank You