What is occuring?

-Vessel undergoes intense reflex vasoconstriction for up to 10 minutes

-platelets aggregate in lumen

-clotting cascade activated; initial plug formed

-upon becoming secure:  dilation of uninjured capillaries & initiation of wound exudation occurs

1. Promote wound healing

2. Restore funtion

3. Cosmetic appearance of wound

What is occuring with:

-redness

-heat

-swelling

-pain

1. Phagocytosis & ingestion of wound

2. Stimulate fibroblast reproduction & 

     neovascularization

3. Release chemotactic factor attracting more of its kind

      to the wound

What type of cell are responsible for:

-phagocytosis & ingestion of wound debris

-stimulate firbroblast reproduction & neovascularization

-release chemotatic factor attracting more of its kind to

  the wound

                                 T/F

Mature clot is formed as fibrinogen is enzymatically split to form a wound

-Epithelial layer develops under the surface of the scab

-Increase fibroblast activity inlaying down collagen

-Wound maximizing strength

-Remodeling occuring

-Granulation tissue replace by acellular fibrous mass

after the first 6 hours

12 hours & beyond for scalp, d/t ample blood supply present.

                                  T/F

The longer the injury is not treated, leads to a decrease of infection?

False.

Increased risk with longer injury is not treated.

-Wound etiolgy

-Location

-Degree of contamination

-Host risk factors

-Importance of cosmetic appearance

Possible contaminants-pus. feces, saliva, soil

Occupational / Non-occupational

Assualt/Self inflicted

Anatomical location

(Head & Trunk 1%,  UE 4 %,  LE 7%)

Mechanism of Injury

Crush

Shear

Bite

Puncture

What are the components of PMH?

Chronic medical conditions that increase risk of infection

Chronic medical conditions that increase poor wound healing.

Previous scar formation (keloids), common in Blacks & Asians

Anesthetucs

Antibiotics

Analgesics

Latex

T/F

Medication assesment is not needed for wound management?

What method achieves hemostatis by:

direct pressure

elevation

vasconstriction: epinephrine containing solutions

What method achieves hemostatis by:

direct clamping

electrocautry

chemical cautry

tourniquet

Epinephrine

vasoconstrictor, limited blood flow at these sites

T/F

It is better to shave the hair and this will limit infections.

False

Do not shave, causes hair follicle damage, allowing bacteria invasion

Hair should be clipped 1-2mm above skin with scissors

T/F

It is acceptable to remove eyebrow hair, as it will grow back.

False

Eyebrow hair does not always grow back, It should never be removed.

Restore skin integrity to reduce:

Risk of infection

Scarring

Impaired function

How is primary wound closure done?

What are the advantages?

Method:  Wound is immediatly closed by approximating edges.

Advantage:  Reduces healing time in comparison with secondary & tertiary.

Method of Secondary Wound Cloure?

What does this method reduce?

Method:  Wound is left OPEN & allowed to close on its own, well suited for highly contaminated/infected wounds with pt who are at high risk of infection.

Reduces:  Risk of infection

However it is slow & uncomfortable & leaves a larger scar than primary

Method of Delayed Primary Wound closure  "Tertiary Closure"

Combination of Primary & Secondary.

Wound is left open for 4-5 days & after it may be closed if no infection prevails.

Contraindications of Wound Closure?

5

1.  Prolong interval >6 hr, unless injury in highly vascular area (scalp, face)-24 hrs for closure.

2.  Heavily contaminated wounds.

3.  Active wound infection at time of intial eval.

4.  Wound cannot be closed without excessive tension.

5.  Retained FBs.

Gram (+)

Staphylococcus aurues

Followed by Staphylcococcal& Streptococcol

Wounds:

more than 6 hrs after injury

contaminated with debris

occuring outdoors

go through footwear

occur from longer objects with deeper penetration

Host factors inhibiting wound healing

What direction are wound perfusion assessed from?

proximal to the wound

or

distal to the wound

What has happened with these symptoms?

Wound is:

swollen

 severly painful

erythema

warm

fluctance

drainage

pain with motion of tendons & joints

Radiographs-visualize soft tissue

CT-method of choice with susptect FB (puncture wound)

MRI-provides excellent visualization of FB, but not for metallic objects

What type of wound tx is this for Complicated/Uncomp?

Superficial wound cleansing

Tetanus prophylaxis

Low pressure irrigation

Debridement/Coring

Prophylatic Antibiotics

Whis complication is this:

Localized infection of dermis surround puncture wound

Usually present 1st 4 days

Tx: Radiograph-FB, 7-10 1st generation Cephalosporin

What complication is this referring to:

Localized assoc. with FB

Incision & Drainage

Short course antibiotics

What complication is this referring to:

Pain

Swelling

Redness

Redness at remote site from puncture site

Requires parenternal antibiotics

Immediate referral to surgical specialist

Deep Tissue Infections

What complications is this referring to:

Bone & Joint infections

Presents later than other complications

Often a period of symptom improvement

Pain is present

Osteomyelitis

Definitive dx: Bone scan, can be detected 72 hrs of sx

Immediate surgical referral

Amoxicillin-clauvanate

Parenternal:

Ampicillin-sulbactam

Cefoxitin

Piperacillin-taxobactam

How is irrigation performed?

solution used

syringe size

gauge needle

amount of solution

solution used:  Normal Saline

syringe size:  35-65 ml

gauge needle:  19

amount of solution:  at least 200 ml of saline

Pasteurella mutocida

Anaerobes

Streptococcal

Staphylococcal

Prophylactic antibiotics for high risk uninfected wounds

5-7 day course antimicrobial, follow up wound care 24-48 hours

Amoxicillin-clavunate

PCN/ampicillin for Pasteurella multicida

Doxycycline/ Cefuroxime cat, allergic to PCN

Clindamycin plus fluroquinolone dog

Tx for Rabies

HRIG- Human Rabies Immune Globulin

Inital day- 1st done

day 3

day 7

day 14

day 28

If already immunized against rabies, series of 2 boosters on day zero & day 3

Wound protection

Elevation

Cleanliness

Analgesia

Dressing changes

Signs of wound infection

Follow-up visit, date, time

1. Superficial wound cleansing

2. Low pressure irrigation

3. Debridement/ Coring

4. Prophlaxis Tetanus

5. Prophylaxis Antibiotics

( Oral Fluroquinolone, Ciprofloxacin/Levofloxacin)

Tackycardia

&

Elevated Temperature

What are the following for Lidocaine  0.5%-1.0%application for a wound?

Onset of action

Duration of action

Maximum dose for adult & child

Onset of action:  3-5 minutes

Duration of action:  30-60 minutes

Maximum dose for: adult 300mg. & child 4 mg/kg

What are the following for Lidocaine application at

 1-2% for wound anasthesia?

Onset of action

Duration of action

Maximum dose for adult & child

Onset of action:  5-10 minutes

Duration of action:  30-60 minutes

Maximum dose for: adult 300 mg & child 4mg/kg

Selective debridement of grossly nonviable tissue

(cut away dead tissue)

Regarding Povidone iodine surgical scrub & solution,

what are the following:

Antibacterial activity

Tissue toxicity

Potential Uses

Antibacterial activity:  Strongly Bactericidal Gram (+), Gram (-)

Tissue toxicity:  Detergent, toxic to tissue

Potential Uses:  Hand cleanser

 & Wound Periphery cleanser

Regarding use of Hydrogen Peroxide for wound cleansing, what are:

Antibacterial activity

Tissue toxicity

Potential uses

Antibacterial activity:  Very weak

Tissue toxicity:  Toxic to Red cells

Potential uses:  Wound cleanser adjunct

Allows more easy & correct identification of:

Tendons

Joint Capsules

Nerve Vessel

&

Locates FB well

Ischemia of extremity

Compression damage of blood vessels & nerves

Elevate extremity

Inflate cuff, not to exceed 250 mmhg

Clamp cuff to prevent slow leakage

Discomfort for pt 30-40 minutes

Maximum time is 1 hour

Elevate digit

Stretch a Penrose drain around base

Secure with hemostat

Maximum time 20-30 minutes