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Wound management

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Lecture on wound management for medical students. Encompasses basic sciences, classifications and principles of management.

Publicado en: Salud y medicina
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Wound management

  1. 1. Wound management Chea Chan Hooi Surgeon Department of Surgery Sibu Hospital
  2. 2. Content • Introduction • Wound healing – Process – Factors • Surgical wound classification • Principles of management • Reconstructive ladder • Hyperbaric oxygen therapy
  3. 3. Introduction • Wound – A break in epithelium with structural & functional disruption • Healing – Ability of the body to replace destroyed tissue with viable tissue • Repair – Replacement of destroyed tissue with granulation tissue & later scar tissue
  4. 4. Wound healing process Stage Cellular events Clinical features Haemostasis Vasoconstriction Platelet aggregation & thrombus formation Blood clot to stanch bleeding Inflammation Neutrophil infiltration Monocyte infiltration then differentiate to macrophages Lymphocyte infiltration Surrounding tissue exhibit cardinal features of acute inflammation Removal and neutralising of infective and foreign agents Proliferation Re-epithelialisation Angiogenesis Collagen synthesis Granulation tissue scaffolding initially (within 48 hours), then converted to scar tissue Remodelling Collagen remodelling Vascular regression & maturation Wound contraction Scar relatively avascular Maximal tensile strength only 80% of normal skin, plateaus after 3 months
  5. 5. Factors affecting wound healing Patient Surgeon Systemic Local Non-modifiable Age Gender Modifiable Hypoxaemia Nutrition Anaemia Jaundice Ureamia Obesity Alcoholism Smoking Immunocompromised (diabetes, cancer, AIDS) Medications (steroids, chemotherapy) Oxygenation Infection Foreign body Arterial & venous sufficiency Radiotherapy Malignancy Repeat surgery Experience  Suture technique  Suture material  Knotting  Optimal tension  Anatomical continuity
  6. 6. Surgical wound classification Class Definition Examples Risk of SSI Clean Non-traumatic wounds Elective surgery Does not involve entering hollow viscus lumen Excision biopsy Mastectomy Hernia surgery Vascular surgery 2% Clean- contaminated Hollow viscus entered with minimal, controlled spillage of content Gastrectomy Pneumonectomy Hysterectomy ≤10% Contaminated Fresh traumatic wounds Hollow viscus entered with major, uncontrolled spillage of content Minor break in sterile technique Emergen 20 – 30% Dirty Prolonged exposed traumatic wounds Frank pus or faeces within operative field 40 – 55%
  7. 7. Principles of management • Irrigation • Medical – Antibiotics – Glycaemic control • Dressings • Surgical • Adjunctive therapies – Hyperbaric oxygen
  8. 8. Reconstructive ladder • A grading system • Describes the levels of increasingly complex surgical management of wounds
  9. 9. Flap – tissue transferred from its bed to another site while retaining its vascular attachment • Free – Tissue transferred to a distant recipient site after its vascular supply has been detached and then restored by microvascular anastomosis at recipient site • Pedicled – Tissue transferred to adjacent recipient site while still retaining its original, designated vascular supply • Random patterned – Tissue transferred to adjacent recipient site but lacks a significant pattern in its vascular design
  10. 10. Tissue expansion • By expanding local skin surrounding the defect to cover the wound/defect • Similar colour and texture without compromising the donor area • Tissue expander required with multiple sessions of surgery
  11. 11. – Graft – tissue transferred from its bed to another site (or between two individuals) without its own vascular supply
  12. 12. – Closure • Delayed – Wound closure is initially delayed to allow drainage of infective and necrotic material to minimise risk of surgical site infection – Wound closed with suture later on once deemed adequately clean • Primary – Wound edges are approximated, trimmed if necessary, and closed with suture – Allows healing by primary intention – Dressings • Wound edges are left gaping with resulting defect allowed to granulate from the floor and edges • Allows healing by secondary intention for relatively dirty wound but results in larger and more unsightly scar
  13. 13. Hyperbaric oxygen therapy • Breathing 100% oxygen while under increased atmospheric pressure • Blood hyperoxygenated by dissolving oxygen within the plasma • Indications – Enhancement of wound, flap and radiation injury wounds – CO poisoning – Decompression sickness – CRAO, idiopathic sudden SNHL • Absolute contraindication – Untreated pneumothorax – Drugs – bleomycin, cisplatin, disulfiram, doxorubicin
  14. 14. TQ! Q&A?