Slide 1: WOUND CLASSIFICATION AND ITS MANAGEMENT Presented by:
Dr. Dhiren B. Bhoi
E. Mail:-email@example.com DEFINITION : DEFINITION A wound is a break in the continuity of soft tissues
A wound is defined as a separation or discontinuity of the skin, mucous membrane or tissue caused by physical, chemical or biological insult CLASSIFICATION : CLASSIFICATION Open wound
There is discontinuity in the skin and other covering tissues to a varying depth Classification : Classification Incised wound
Caused by sharp cutting instruments.
Minimum loss to tissue tends to gap (the extent of gaping depends upon elasticity and tension).
Edges are regular.
Bleeds freely and painful.
Heals by primary intension healing. Slide 5: Lacerated wound
Caused by tearing of tissues,
Wounds have irregular jagged borders
Loss of tissue is limited to skin and s/c tissue.
eg: barbed wire.
Cause by sharp pointed objects like nails
Have relatively small opening.
May be very deep.
Infection/ foreign particles might have been carried deep in to wound
opening is inadequate for drainage.
eg: punctured wound on foot due to gathered nail. Slide 6: Perforating wound
Have two opening one of entrance and other of exit.
Deep wounds communicating with cavities like adbominal, throrax,joints etc.
eg: stab wounds
Abrasions wound Slide 7: Avulsion
Caused by bacteria or virus. leading to formation of pustules or vesicles.
eg: FMD, anthrax, TB organisms
Aseptic wound Closed wound/ internal wound : Closed wound/ internal wound In closed or internal wound only deeper tissues, barring the skin or mucous membrane are damaged. Classification : Classification Contusion or Bruises
Produced by blunt objects
Results in damage to subcutaneous tissue without breaking the continuity of the skin surface.
Classified into 1st, 2nd and 3rd damages according to the extent or severity of the injury.
. Slide 10: Mild degree of contusion characterized by rapture of capillaries in skin giving rise to a reddish blue or purplish condition of the skin (Echymosis).
First degree: There is rapture of capillaries of the skin and subcutaneous tissue to form echymosis.
Second degree: Larger vessels are raptured leading to the formation of haemetoma.
Third degree: Tissues are considerdly damaged and gangrene may set in. the internal organs which may also be impaired and there might be evidence of impending shock. Slide 11: 2. Haematoma:
Collection of blood beneath the skin
Caused by injury to a superficial vein.
Frequently seen s/c or submucosally.
Common sites of haematoma in various species
Cow: mammary vein(fall) vaginal mucous membrane (copulation)
Bull: haematoma involving penis (copulation)
Horse: spur vein / external thoracic vein
Dog: ear flap, vaginal mucous membrane (copulation) Symptoms : Symptoms Local
Remote Local Symptoms : Local Symptoms Hemorrhage
Gaping of the edges of wound
Phenomena of repair General Symptoms : General Symptoms Febrile disturbances Remote Symptoms : Remote Symptoms Observed away from the wound
Abscess formation in a dependent lymph node
Paralysis or a loss of function in a dependent portion
Neuritis extending along the course of the nerve involved in the wound. Management of wounds : Management of wounds Contusions: are treated with cold and astringent applications to minimize extravasation.
Haematomas: when small get absorbed ,other wise they may have to be opened and treated.
Open wound: surgical or aseptic wound/ contaminated and septic wound/ accidental traumatic wounds. Surgical or aseptic wounds : Surgical or aseptic wounds A surgical wound made with all aseptic precautions in a non infected tissue is an aseptic wound.
Surgeon should avoid drying of the tissue, excessive trauma and haemorrhage – lower the wound infection.
Prophylaxis against tetanus
Drainage should be provided if haemotoma or seroma formation is expected. Slide 18: Suture should be supported up to healing time 8 -14 days
Systemic use of specific antibiotics as a therapeutic or prophylactic measure.
Local application of Fly repellents – hot summer months.
The patient and the affected injured part should be kept at rest Contaminated and septic wounds : Contaminated and septic wounds A fresh wound gets contaminated when it is more than 4 -5 hours old.
Management is mainly directed towards overcoming factors like.
Type and number of invading micro organisms
Type and location of the wound
Poor blood flow at the wound site
Effective ness of the treatment
Presence of foreign material
Dead tissue at the wound site. General principle : General principle Control of haemorrhage: Bleeding is controlled and ligating large vessels if any
Wound and its periphery should be thoroughly cleaned with warm normal saline, water, soap or 2% H2O2 5% dettol, 0.5% potassium permanganate
Clipping and shaving of large area around wound Cleaning of wound/ irrigation of wound : Cleaning of wound/ irrigation of wound The wound and surrounding areas are irrigated with mild, non irritant, antiseptic lotions:
1:1000 Per chloride of mercury lotion.
1:500 acriflavin lotion
1:40 Eusol lotion (Eupad is 1:40 bleaching powder + boric acid)
5 – 10 % hyper tonic salines.
If wound is fresh suturing may be attempted
Infected and deep penetrating wounds are not sutured
Wounds that are not sutured should be irrigated daily or on alternate days
Wounds of feet: warm antisepic foot baths may be given with 10% formalin Wound debridement : Wound debridement Debridement for removal of devitalized or necrosed tissue is either done by excising the unhealthy tissue or by use of topical mendicaments
2.5% sodium chloride solution.
Magnesium sulphate and glycerin paste. Control of infection : Control of infection After irrigation and debridement wound may cover with
Moist antiseptic pad / antiseptic powder / ointment.
Antiseptic powders, boric acid, eupad BIPP
Ointments: Boric ointment, penicillin ointment, streptomycin, chloromycin ointment, terramycin ointment.
Application of very strong antiseptics should be avoided as it will destroy granulation tissue. Providing drainage : Providing drainage If there is exudation and discharge the wound should not be sutured.
Deep wounds – fenestrated tube is advisable for drainage
Deep wounds with narrow external opening – may be enlarged for efficient drainage.
Counter opening may be made in a dependent part seton may be passed through it. Immobilization of wounded area : Immobilization of wounded area If proper immobilization is not provided healing is delayed, formation of excessive granulation tissue (Exubeenrt granulation / pround flush)
Application of caustics – copper sulphate, potassium permanganate Accidental traumatic wounds : Accidental traumatic wounds Check hemorrhage
Avoid development of shock
Prophylaxis against tetanus
Cleaning, excision, debridement
Systemic antibiotic treatment Slide 27: THANK YOU DETAILS OF WOUND HEALING : DETAILS OF WOUND HEALING Slide 29: A wound is defined as a separation or discontinuity of the skin, mucous membrane or tissue caused by physical, chemical or biological insult.
Wound healing is restoration of the tissue continuity Slide 30: Wound healing, is the foundation of surgery and complex process.
Always associated with process of inflammation.
Inflammation is a local reaction of living tissues to an injury of microcirculaion and its associated tissues. Wound Healing : Wound Healing First intension
Healing under scab Healing by First intension : Healing by First intension Occurs in incised or surgical wounds, with minimal tissue damage and bleeding
Repair begins in 12 hours by proliferation angioblast and fibroblast
Healing is complited in about 14 days
Scar formed is very little Slide 33: Wound should be clean and fresh
Free form infection and bleeding
Free from foreign bodies
Edges should have good blood supply
Edges should have proper alignment and apposition Healing by Sesond intension : Healing by Sesond intension By replacement of tissue
Wounds having extensive loss of tissue and edges widely separated
Granulating tissue consist of budding capillaries and fibroblast, grows from edges and bottom to fill up gap Slide 35: Granulating tissue is velvety in appearance, soft, moist and pink in colour
Granulation tissue is called so due to granular appearance presented by budding capillaries
Healing takes 14-21 days, in large wound with excessive loss of tissue it may take 42 days Healing by Mixed intension : Healing by Mixed intension Wound healing is partly by first intension and partly by second intension
Happens when sutured wound has partially disrupted Healing by Third intension : Healing by Third intension (Healing by secondary suture)
Granulating tissue are united by sutures for quicker healing Healing under scab : Healing under scab In superficial wounds like abrasions
Exudate present in the wound dries and froms scab
Granulation takes place under this scab
When granulation is complete the scab automatically separates and is cast off Phases of wound healing : Phases of wound healing [A] Inflammatory phase: -
Immediate response to injury is acute inflammation
Vasoconstriction of small vessels in the area
Response last for 5-10 minutes and followed by active vasodilation Slide 40: Vasodilatation causes accumulation of exudate in the area
Dilatation is due to release of histamine, serotonin and bradykinin
This causes swelling of vascular endothelial cells, creating gap between these cells Slide 41: Exudate provides fibrinogen and other clotting elements, which form fribin clots
These clots plugs the damaged lymphatics, preventing further damage from injured area
Inflammatory reaction is thus localized to a specific area surrounding the injury
Redness, swelling and heat are seen during inflammatory reaction in the area Slide 42: [B] Fibroblastic or Collagen phase: -
Begins at about 5th day
Fibroblast are actively engaged in production of connective tissue matrix
Fibrinogen in exudate is converted to fibrin by enzymes from blood and tissue cells Slide 43: Fibrin is laid down in the wound and provides a good frame work for repair besides haemostasis
Collagen is synthesized by the fibroblasts
Few collagen fibers are present at the beginning but by 15th day wound gets good tensile strength
Sutures are therefore removed about 2 weeks of surgery Slide 44: [C] Maturation phase: -
It starts after collagen bed is laid
Collagen fibers become thicker, denser and number of fibroblast decreases
Pale scar is formed, full maturation of scar may take months or year Slide 45: [D] Contraction phase: -
It involves movement of existing tissue at the wound edges resulting decrease in size of open wound
Absence of attachment of the skin to the underlying structures allow maximal contraction
Contraction has been reported to be a cell mediated phenomenon
Contractions near joints may result in the formation of tight band of scar tissue Factors affecting wound healing : Factors affecting wound healing LOCAL FACTORS: -
Extent of wound surface
Oedema and Dehydration
Suture material and techniques
Wound infection Slide 47: SYSTEMIC FACTORS: -
Anaemia and hypoxia
Temperature THANK YOU : THANK YOU