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138 Cards in this Set

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  • Back
Wound definition
Disruption in normal body anatomic relations as a result of injury, trauma, infection or pathalogical process.
What is the goal of wound healing?
Complete functional and cosmetic restoration
What is the importance of wound healing following a time line with an overlapping series of events?
Limits damage and restores function and integrity of healing.
How long does it take for acute wounds to heal approx?
2 weeks to 6 months
How long does it take for chronic wounds to heal?
> 6 months
How were wounds treated in ancient egypt and greece in 1500 B.C.
Ebers Papyrus: mentioned use of animal grease, lint, honey as topicl tx. First crude making of modern dressing: lint as base, grease as barrier and honey as abx.

Greeks: first to diff btwn acute (fresh) and chronic (non-healing) wounds.
Ignaz Philpp Sammelweis in 1840s, contribution to wound care?
Hungarian OB - discovered relationship btwn hand washing and declines of death from puerperal fever (childbed fever).
Joseph Lister 1860s, contribution to wound care?
Treated surgical gauze w/ carbolic acid (phenol)
Surgical mort rate decreased by almost half.
Robert Wood Johnson (as in Johnson and Johnson) 1870s, contribution to wound care?
Started production of iodine impreg gauze and dressings.
Ernst von Bergmann 1886, contribution to wound care?
Heat sterilization
Paul Leopold Friedrich 1898, contribution to wound care?
Wound excision
Henry Drysdale Dakin 1916 contribution to wound care?
Dakin's solution: highly diluted antiseptic of boric acid and 0.4-0.5% sodium hypochlorite - used to wash out traumatic wounds of British soldiers.
1950s contribution to wound care?
Synthetic materials: nylon, polyethylene, etc to protect wounds
George Winter and Howard Maibach 1960s contribution to wound care?
Moist dressings - superior clinical outcomes.
Wound healing 1990s to today?
Improved materials.
Grafting and biotechnology - living skin equivalents.
Manipulation and/or use of inflam cytokines and GF.
Advances for non-healing wounds: Intermittent pneumatic compression, hyperbaric ther, maggots, laser ther, hydrother, electrother, psoralen w/ UVA, radiant heat dressing, infared ther and US ther.
How do negative pressure wound therapies help wound healing? (4)
Manages exudates,
removes ECF,
Promotes wound contraction,
Reverses lymph flow.
What is the most basic and common process to all wounds?
Inflammation
What are the cardinal signs of wound healing? (5)
Rubor (redness),
Calor (heat),
Tumor (swelling),
Dolor (pain),
Loss of function.

However, these are also seen w/ wound infections!
How is TRAUMA a biochem aspect of wound healing?
It activates a whole cascade of chemo-attractants produced by degrading blood at site of injury.
- Platelet Derived Growth Factors (PGDFs),
- Complements.

Plts enter wound first and locate damaged collagen, de-gran and release growth factors.
What do the inflammatory cells and growth factors do in wound healing?
Inflam cells: attracted to wound and release variety of other growth factors and cytokines.

Growth factors: bind to cells, stim cell prolif and repair while cytokines "cell signal" which influences activities of other cells. (directors)
Result of all these growth factors and cytokines?
Synth of extra-cellular matrix and new capillary formation.

Arachadonic acid in cell walls - released when cell injured, degrading to thromboxanes and substances to prostaglandins --> vasodilation, swelling, pain.
What are the 4 main PHASES of wound healing?
Hemostasis: immed.

Inflammatory (substrate phase): 0-4 days.

Proliferative: 4-21 days.

Maturation (remodeling): up to 2 years.
3 key processes of the hemostatic phase?
Vasoconstriction

Platelet activation

Coagulation
What is the function of the Platelet Plug in the hemostatic phase?
Cellular bridge that cells migrate across and secrete factors, eventually dissolving the clot and replacing it w/ new granulation tissue and eventually collagen.
What two things characterize the inflammatory phase?
Hemostasis,

Inflammation
What serves as the scaffolding to wound repair?
Fibrin clot
3 key processes of the inflammatory phase?
Vasodilation --> increased blood flow to damaged area.

Increased vasc permeability --> plasma leaks from blood vessels into damaged area.

Emigration of leukocytes into damaged area.
Process of vasodilation as part of inflammatory phase?
Damaged vessels reflexively constrict to reduce blood flow and allow for coag. This lasts 5-10 min.

Shortly after, inflammatory mediators from damaged tissue and mast cells released --> vasodilation.
This peaks about 20 min post injury.
Process of vascular permeability as part of inflammatory phase?
Inflammatory factors released right after injury (i.e. histamine) --> vessels porous.
Tissue becomes edematous - proteins ooze from intravascular space into extravasc space.
Proteins - osmosis - pulls water into area.
Also facilitates leukocytes entering wound.
Predominant cell in wound for first 48 hrs? What do they do?
PMNs

Attracted immed by kinins and other GFs, phagocytize debris and bacteria and kill bacteria.
Once their job is doe, they die and get eaten by macrophages.
Function of macrophages in wound?
Replace PMNs after 48 hrs - become predominant.

Macrophages phagocytize and secrete factors that help mature wound into prolif phase.
What happens at the end of the inflammatory phase?
Reduced secretion of inflammatory factors.
PMNs and macros reduced.
Inflammation can be prolonged if debris or foreign body remains --> tissue damage and form chronic wound.
When does proliferative phase take place?
Overlaps w/ inflammatory phase.

Begins once wound is epithelialized.
What happens during proliferative phase?
Primary reconstructive phase. Repair and reconstruction.
Lasts 4 days - 3 weeks.

Characterized by production of collagen in wound.
Less swelling and inflammation and scar may be red, raised and firmer.
What is the primary cell that functions in the proliferative phase?
Fibroblast!!!
Work horse of wound repair.
4 sub-phases of proliferative phase?
Angiogenesis

Granulation

Epithelialization

Contraction
What occurs in the angiogenesis phase of prolif phase?
Formation of new vessels to provide O2 rich environment to fibroblasts and endothelial cells.
What occurs in the granulation phase of prolif phase?
Rudimentary tissue forms base for collagen matrix.
Wound has reddish, moist, granular appearance.
What occurs in epithelialization phase of prolif phase?
Continued resurfacing of entire wound.
Keratinocytes from stratum basale at base of dermis detach themselves and migrate into wound.
Eventually, whole wound is covered in mono-layer of these cells --> full layer of epidermal tissue formed.
What occurs in contraction phase of prolif phase?
Wound is closed - edges pulled together and size decreases.
No hair follicles or sweat glands.
Some increase in tensile strength, but continues to strengthen over remodeling phase.
What occurs during the maturation phase (remodeling phase)?
Maturation of collagen by cross-linking.
Scar flattens - less prominent.
Very metabolically active.
Collagen deposited and remodeled.
Tensile strength increases dramatically.

Can take 9-12 months.
What are acute wounds?
Usually heal primarily or w/ support.
Smooth, clean wound edges heal and close w/out complications.

Ex: incisions, bite wounds, burns, skin donor sites, abrasions, postop wounds, lacs, contusions.
What are chronic wounds?
No signs of healing after casual tx.
Most heal secondarily. Underlying dz may be responsible.

Ex: leg ulcers, postop wounds, decubs, diabetic foot syndrome.
4 classifications of healing wounds?
Primary intention/ primary closure.

Secondary intention/ closure.

Tertiary intention/ delayed primary closure.

Skin grafting.
What is Primary intention/ closure?
MC method to manage acute wounds.
Involves epidermis and dermis w/out total penetration of dermis healing by process of epithelialization.
Epidermal edges approximated (brought together) and closed simple suturing, staples, glue tape.
May also include flaps, grafts, tissue transfers.
Advantages of primary intention/ closure?
Easy, rapid return of function.

Superior cosmetic result, minimizes scarring.
Disadvantages of primary intention/ closure?
Risk of infection.
What is secondary intention/ closure?
Used in full-thickness wound.
Allows wound to granulate from base upward.
Packed w/ wet-to-dry dressing (pack w/ wet dressing, that dries and w/ removal it debrides wound. then repack).
Can also use drainage system.
Granulation --> broader scar.
Can be slow healing d/t drainage from infection.
Need to perform wound care daily!
Edges usually irregular and far apart.
Disadvantages of secondary intention?
Epithelialization and contraction take much longer.

Daily dressing changes,

Larger and more unsightly scar
Advantages of secondary intention?
Low infection rate.
What is delayed primary closure/ tertiary intention?
Wound initially cleaned, debrided and observed typically 4-5 days before closure and left open performing dressing changes.

Once granulation tissue appears, wound edges are loosely approximated.
Not sterile.
Achieves better cosmetics, quicker return to function and lower infection rate.
How long after injury would you want to close w/ delayed primary closure/ tertiary intention?
Ideally 8-12 hrs after injury.

If you wait longer, it will become colonized and get infected.
Examples of when you would use delayed primary closure/ tertiary intention?
Skin graft replacement,
Flap design,
After repeated debridement and abx,
Closure of abdominal wounds,
Fasciotomies.
Define closed injury?
Damage is beneath skin or mucous membrane.
Surface is in tact.

Caused by blunt forces.
Define burns?
Damage resulting from thermal heat, frictional heat, toxic chemicals, electricity or nuclear radiation.
Define crush injury?
Results from prolonged continuous pressure on large muscles like in legs and arms. --> muscle disintegration.

Extent of damage depends on amount of force and length of time force is applied.
Complications of closed soft tissue injuries?
Compartment syndrome,

Rhabdo
Define laceration?
Caused by sharp object or blunt force that tears the skin tissues and blood vessels --> jagged, torn cut.

High degree of contamination and devitalized tissue.

*Note: a surgical incision is not a laceration.
Define incision?
Sharp, smooth, straight cut w/ minimal contamination.
Define avulsion?
Injury from a shearing force that separates skin layers so they become completely detached or hang as a flap.

Often: significant bleeding.
NEVER remove avulsion skin flap! Clean and loosely bring together.
5 LOCAL factors that affect wound healing?
Bleeding.
Bacteria.
Devitalized tissue.
Hydration.
Radiation.
What can you do to maximize local factors that affect wound healing?
BE AGGRESSIVE!!!

Clean wound.
Debride devitalized tissue.
Appropriate closure.
What can happen if a wound is closed without hemostasis?
Poor healing!
Can form hematoma!
- provides medium for bacterial growth.
- can separate wound edges and --> poor cosmetics.
How to decontaminate wound?
All wounds have some contam - clean them to reduce this.

Usually gentle soap and water is enough.
Irrigation w/ warm isotonic saline should be used to decrease bacteria and remove loose material.
What should you NOT use to decontaminate a wound?
Dilute iodine,
Chlorhexidine,
Hydrogen peroxide.

May be cytotoxic!
What is a tool that can be used to irrigate a wound?
Pulsvac irrigator
What is KEY PROCESS in successful wound healing?
Debridement!!!
Different ways to debride a wound?
Surgical: Sharp debridement (fastest),
Mechanical (i.e. wet to dry dressing),
Chemical,
Autolytic (use of dressings - body debrides itself),
Maggot therapy
Advantage of hydrating wound?
How?
Hydration --> faster epithelialization than dry.

Occlusive dressings retain moist environment.
How does radiation adversely affect wound healing?
Causes injury by:
- causing vasculitis --> tissue hypoxia.
- decreasing tensile strength of wound.
- adversely affects fibroblasts.
MCC of wound infection?
Hypoxia.

Poor perfusion!
Why is oxygen so important in wound healing?
Fibroblasts are O2 sensitive: at low o2 levels, synth of collagen can't take place.

Prolif phase: increased metabolic demand and increased O2 requirements.

Vascular endothelium in hypoxia --> widespread vasodilation --> capillary leak --> induces deposition of fibrin and provokes TNF-a release.
How can edema adversely affect wound healing?
Causes increased pressure in tissue --> perfusion is adversley affected --> cell death, tissue necrosis, ulceration.
5 systemic factors that affect wound healing?
Nutrition.
DM.
Meds.
Smoking.
Syndromes.
Main importance of proper nutrition during wound healing?
Huge metabolic demand needed to support protein synth and collagen formation.
For proper healing to occur, adequate intake of what nutrients are needed? (11)
Protein,
Folic acid (collagen),
Fat (needed to absorb vit A,D, E, K),
Vit K,
Vit A (increases inflam response),
Mg (protein synth),
ZINC!!!!! (in MANY enzymes - influences B, T cell activity, influences epithelialization),
Vit C (cofactor in collagen synth),
Glutamine (enhances lymph, macro, pmn actions),
Glycine (affects leukocytes),
Vit E (needed, but lrg dose can inhibit healing)
How does uncontrolled DM affect wound healing?
Sorbitol accum --> increased vasc perm and impaired O2 and nutrient delivery.

Hyperglycemia alters phagocytosis, collagen formation. Inhibits fibroblast prolif in wound.
How can meds affect wound healing?
STEROIDS - BLUNT INFLAM RESPONSE!!

Vit A: can restore inflam response --> promotes wound epithelialization in early phase of injury.

Anticoags.
How can smoking affect wound healing?
Nicotine: vasoconstriction. 1 cigarette: constrict > 90 min.
Decreases O2 to tissue and promotes hypoxia.
3 syndromes that are associated w/ abnormal wound healing?
Cutis Laxa: CT disorder, congen - auto dom. Defective elastin fibers.

Ehlers-Danlos syndrome: CT disorder. Skin hyperextensibility, joint hypermobility, tissue fragility, poor wound healing.

Acquired: inflam skin disorders, drugs, neoplasms.
6 steps in wound management?
1) Sterile prep and draping.
2) Give local anesthetic.
3) Hemostasis
4) Irrigation, debridement.
5) Close in layers.
6) Dressings, bandage.
What should you consider in ASSESSMENT of wound??
Can I close this? Consider nerves, etc.

Pt allergies: anesthetics, abx, latex.

Tetanus status
If a pts tetanus status is unknown or they have had < 3 doses, what should you do for a clean/ minor wound? All other wounds?
Clean: Give tetanus vaccine, but not immune globulin.

Other: Give vaccine AND immune globulin.
If pt has had >/= 3 doses tetanus vaccine, what should you do for clean/ minor wound? All other?
Clean: Only give vaccine if dose given > 10 yrs ago. No need for tetanus Ig.

Other: Only give vaccine if last dose >5 yrs ago. No need for tetanus Ig.
What should you be looking for when assessing extent of wound?
Identify the base of the wound!

Is there injury to underlying structures: fracture, joint space invasion, tendon injury?
What should you be looking for when assessing neurovascular or tendon injury?
Assess circ and sensation on all wounds, espec hand wounds PRIOR to giving local anesthetic.

Assess tendon function for any wound overlying tendon.

More complex wounds may need OR for exploration.
What is the importance of age of injury when assessing wound?
Determines how you'll close wound.
Clean wound: < 12 hrs old w/ minimal contam. = golden period for repair.
If clean and uninfected in healthy pt, may be closed up to 18 hrs after injury.
Facial wounds up to 24 hrs if no infection.
How can you help to assure hemostais?
Direct pressure 10-15 min w/ gauze pad.
Larger wounds; Gelfoam, but DO NOT use in infected wound or at skin closure site.
Tourniquets.
Bleeding from small arterials may need clamping and ligation, but this can cause damage to nerves, tendons, etc. Get help!!
Should you remove hair for wound closure?
Not unless it really interferes!!
Bacitracin can help push hair away and can clip longer hairs.

Shaving can increase infection and leave particulate matter in wound.
NEVER SHAVE EYEBROWS!!
What things can affect the duration of action of local anesthetics?
Protein binding,
Solubility,
Vascularity,
pH
What do you base your calculation on of how much anesthetic to use?
Wound extent and pt wt.
What should you consider if the maximum allowable dose calculated is exceeded?
General anesthesia.
Why add vasoconstrictor (like epi) to anesthetic?

When should you NOT?
Helps w/ short lived hemostais while repairing wound.

NEVER use on tissues w/ end arteries: nose, digits, penis, ears. NEVER!!!
What are the two main pharm groups of local anesthesia?
Amides and
Esters.

Cocain used to be used for otolaryngologic procedures, but isn't anymore.
Commonly used amides for local anesthesia? (4)
Xylocaine,
Bupivicaine,
Mepivicaine,
Prilocaine
Commonly used esters for local anesthesia (3)
Procaine,
Chloroprocaine,
Tetracaine
How do local anesthetics work?
Reveersibly inhibit conduction of nerve impulses.

Can have toxic side effects so calculate dosages!
When irrigating, what should be used for uncomplicated wounds?

Contaminated wounds?
Uncomp: normal saline.

Contam (ex bites): 1:10 mixture saline and providone/ iodine solution (betadine). (**NOTE: NOT betadine surgical scrub solution. Cytotoxic).
What are absolute contraindications to wound closure?
Signs of inflammation or infection: redness, warmth, swelling, pain.
What are some examples of when you would utilize secondary wound closure?
Deep stab or puncture that can't be adequately irrigated.
Contamination.
Small noncosmetic animal bites.
Abscess cavities.
Presentation after significant delay.
When would you utilize tertiary wound closure?
Uncomp wounds present after safe period for primary closure.
Initially clean and debride, then wait to allow host defense to decrease bacteria. May admin abx as well. May need to do additional debridement before closure.
When should you close with sutures?
Deep wounds,

Wounds that excessive scarring will occur if wound edges not approximated.
When should you NOT close w/ sutures?
Grossly contaminated or infected.
Presenting beyond closure window.
Animal bites (unless in cosmetic area).
Deep puncture wounds.
Too much tension (edema or loss of tissue).
Active bleeding.
Supervficial - only involving dermis.
Pts w/ risk factors for proper wound healing.
Two types of suture material?
Monofilament

Polyfilament: can harbor bacteria.
How is suture size graded?
More zeros, smaller suture. (ex 0 > 6-0)
Sizes sutures used for different tissues?
11-0: nerves and vessels.
5-0 or 6-0: face or neck.
3-0 or 4-0: torso or extremities.
2-0 to 4-0: deeper tissue or scalp.
Define tensile strength?
Amt of wt required to break a suture divided by its cross sectional area.
Designated by number of zeros, smaller suture and less strength.
Define elasticity?
Suture's ability to hold original form and length after stretching.
Allows for expansion w/ wound edema and retraction to maintain wound closure.
Define plasticity?
Opposite of elasticity.
Suture, when stretched stays stretched and loses original length.
Define memory?
Ability of suture to recover its former shape after manipulation
Define knot strength?
Force required to cause knot to slip.
Proportional to coefficient of friction for given material.
What are absorbable sutures?
Lose most of its tensile strength w/in 60 days after being placed.
Low tissue reactivity, excellent tensile strength, relatively slow rate of absorption and reliable knot security.
Often used for deep sutures.
4 types of of absorbable sutures?
Vicryl

Dexon

Maxon

Catgut (doesn't come from cats, but does come from guts)
Benefits of non-absorbable sutures?
Excellent knot security,
Tensile strength,
Decreased tissue reactivity,
Ease in handling.
3 types of non-absorbable sutures and characteristics of each?
Silk: natural, easy to handle, not very strong.

Nylon (Dermalon, Ethilon): synthetic, strong, cheap and minimally reactive. Has lots of memory.

Polypropylene (Surgilene, Prolene): synthetic, strong, minimally reactive, great plasticity, but difficult to handle.
What are "swaged" sutures?
Needle and suture are connected.
Two parts of suture needle?
Eye: where suture and needle connect.
Body: part to grasp.
Point: extends from tip to maximum cross section of body.
4 types of points?
Choice depends on type of tissue
Cutting,
Taper-point (round),
Beveled,
Blunt-point
What type of suturing technique is most often used to close simple wounds?
Simple interrupted.
Goals in suturing techniques?
Wound edges must be everted.
TENSION FREE!! - Tension --> necrosis.
Knots tight, fixated, but not strangulate.
Use enough sutures to close wound w/out gap.
Be gentle, work quickly.
What are staples used for?
Good for linear lacs on scalp, arms, legs, torsos.

NEVER ON FACE!!
When can skin adhesives be used?
Benefits?
Small lacs or surgical incisions.

Clean, low risk of infection.
Quick application.

Avoid high tension areas and avoid getting adhesive directly in wound.
What are steri-strips used for?
Reinforced adhesive tape used to provide support to sutured wound.
NOT a replacement for suturing!!!!!!!!
Lot tension wounds. Can be used after suture or staple removal.
What should be especially considered in lip wounds?
Approximate vermilion border first! First suture at border.

Misalignment as small as 1mm can be noticed.
What should be especially noted about eybrow wounds?
NEVER SHAVE!!!
What should be especially noted about eyelid wounds?
Eyelids can hid complicated injuries. Evaluate the eye! Look for injury to tear drainage system. Have a low threshold for referral!
What should be especially considered in cheek (zygoma) wounds?
Consider possible involvement of parotid gland or facial nerve.
What should be especially considered in ear wounds?
Avoid suturing cartilage.
Notes about dog bites?
MC animal is known to victim.
MC areas: head, neck, extremities.
MC in males and children.
Can be complicated and potentially lethal.
Notes about cat bites?
Wounds from teeth or claws.
MC females and adults.
89% provoked.
MC upper extremities.
Deep wounds --> innoculation type injuries.
Notes about human bites?
Semicircular or oval area of erythemia or bruising usually visible.

Skin may or may not be intact.
MC pathogens of dog/ cat bites?
Pasteurella spp, Staph, Strep, Anaerobics.
Capnocytophaga canimorsus: asplenic pts.
Cat bites: Bartonella henselae,
Humans: Eikenella corrodens, Aerobic gram pos cocci, anaerobes.
What should you do for an infected bite wound?
Remove sutures if previously repaired,
Get cultures, blood culture.
Empiric abx.
Surg consult for exploration, drainage.
If systemic infection or complex wound mgmt, admit.
Consult w/ surgeon in these 7 circumstances:
Concerns about cosmetics.
Wounds w/ lrg defects/ missing tissue.
Gross contam.
Concomitant injuries: injury to vessels, nerves, tendons, fxs, joints, amputations.
Lacs: located over fracture site - considered open fracture!! Don't miss this!!!
Crush injuries.
High pressure spray gun injuries: deceptive and dangerous.
Follow up wound care?
Cover and leave dressing in place for 24 hrs.
Avoid immersion.
Gentle cleaning w/ mild soap or half strength hydrogen peroxide w/ non-absorbable sutures ok.
Abx ointment (bacitracin) ok 2x/ day until suture rmoved. But avoid buildup.
When should abx be considered?
Animal/ human bites, intraoral lacs, open fx, wounds into cartilage joints tendons, excessive contam, immunocompromised or w/ vasc dz,
Puncture wounds,
Mod-sever crush injury,
Wounds to hand, genitalia, face, close proximity to bone/ joint.
When should sutures be removed for eyelids, neck, face, scalp, trunk/ upper extremities, lower extremities?
Eyelids: 3 days.
Neck: 3-4 days.
Face: 5 days.
Scalp: 7-14 days.
Trunk/ upper extrem: 7 days.
Lower extrem: 8-10 days.
When is a wound considered infected?
*** When contam is >10 to the 5th