Learning points of this lecture are about

:

wound 
Management of wounds; Everybody of us are responsible to get a
wound.
The wound either be

Wound, ulcer, fistula, cyst

happens by accidents

traumatic

surgical

made by surgeons

-we divided the Traumatic wounds to : -Sharp, penetrating: by knife, sharp thin wire. -Blunt: stone -Bullet:

Types of wound:
҉ We have a division of wounds due to the cause of it, and if the cause settles inside the body, or stroke the body without settling inside: ╝Cut wounds: during shaving, cutting meat.

▒▒ most of our talk will be about traumatic wounds which cause by Car accidents, by Falling from high places,,, etc.

╝Lacerated wounds: when someone strikes u by a stone or stick and u get a wound, and u can describe that wound that its Broken and irregular. ╝Crushed wounds: when a stone fall into someone or car hit him. ╝Wounds with skin loss : by a drill, piece from skin loss in place of accident. ҉ Examination of Wounds: it’s a very important step, u must care of it.

Examination -By examine the wound I can know :-the extension of the wounds, of Wounds It's as -how its deep, -if there is any associated injures. important as history if the Associated injuries: patient was unconscious. In emergency room there is a lot of cases about people come with a horrible look, their heads covers with blood, but when u put them on the table and remove the blood, cut the covering hair, may found that’s a very small wound, anyway, u must examine the wound carefully, maybe inside that a small wound there is a stone, glass, breakage of bone, so the examination of the wound is very important, to know the extent of the wounds, and to know if we have associated injures,

Always the people concern about the superficial wound, but often
there are things inside are more serious, so we must care about the muscles, vessels, tendons, and bones that there location in, or near the injured site. Eg; A patient with an injured wrist by a knife, we have underneath that area artery and tendons that moven the fingers, there is a nerve that moven the muscle, and the nerves that get us the

sensations, and any one of them may get associated injure, so we have to examine carefully. Abdominal cavity: Eg; patient have an injury in the abdomen by a thin sharp wire as example,,, so we must be aware about everything in the place of injury, to impose the injury was near the spleen, we must think about the stomach, the colon, the kidney, even if it looks superficially not deep, but in deep may there is a server bleeding. Chest cavity: we must be aware about the lung the heart, maybe there is a collection of air or blood in plural space. cranial cavity: Eg; someone striking with stone, he come to hospital walking as normal, the wound was small, the Dr suture it, but after six hours the patient come back in a coma, after a new examination, the Dr found that the patient has a broken cranial bone, there is sub- cranial bleeding, that compress the brain associated injury.
so u have to ensure there is no associated injuries

▒Types of Suturing:
- Primary suturing :if the wound was in the skin and clean we suture it. -Excision and primary suturing: we cutting from the wound and then do suturing. -Delayed primary suturing: I want to delay the suturing to next day or like that. -Secondary suturing: suturing after a week, I can't suture it today or tomorrow.

-Skin grafting.

How do we think to choice the type of suturing????!!
♣ when the wound is clean "there edges very regular and there is no debris on it" we do primary suturing-after antiseptic for sure♣ when the wound is polluted with debris like soil and glass, and there edges not regular, so we need first of all to regulate the edges and clean the wound then suture it so we do excision and primary suturing, ♣If the wound was" a crashed wound"; we have hematoma, swelling, broken bone underneath it, obstructing vessels >>> we can't do suturing to it, how we deal with it: we clean it, and wait to second day third day until the inflammation gone and the suturing become possible so we do delay primary suturing. ♣ if the suture delay more than that time- like a week- we name the suturing a secondary suturing.

The big question: if we don’t suture the wound ,,,
what will happen??
-The wound will heal ,,, as simple as this  >> the explanation is: ≥Our Great Creator gives us all the mechanism of healing, so we as Doctors, we just accelerate this mechanism, because if we don’t do suturing the process of healing will delayed and inflammation will occurs, and the final result will be a large scar.

But when we do suturing; we lower the distance between edges
of the skin, so the space that must filled with granulation tissue will be very minimum, and that of course mean that the process of healing become easier for the body, and the scar that forming will be very minimum.

-How the healing occurs??  ①the wound will contraction, ②the space between the walls of wound will filled with tissues that will forms from the edges of the wound, with blood supply will form granulation tissues, and after filled, it will convert to fibrous tissue③ the skin will growth and form epithelium "epithelization". Elements of
healing: ①contraction ②granulation Phases of healing: tissue③ the epithelization phase:, the phagocytes, neutrophil, and macrophages-that .

❶Lag

doing phagocytosis- will go to site of wound to remove the damaged tissue and any sign of inflammation.

❷Proliferation phase: the phase that the granulation tissue
will form.

❸Maturation (differentiation): when fibrous tissue form and
cover the skin(epithelization).

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₰The organ of repair: is the granulation tissue which is forms and
fills the cavity, and form a new cavity instead of tissue which was lost in the accident.

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wound strength: does after suturing and healing
occur the strength of the skin will back to original one? When I open the muscle and go to the abdomen and then suture them,, does the strength of the muscle come back as it was?? No,, it will never come back to normal, usually by six month it will have maximum strength which is less than the original one (come back to 60, 70 % of their original strength )

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Wound histology: if we take a biopsy from the wound, and
examine it in the lab, what are the cells that are proliferating there??? -at the first day "neutrophils" are there, by plenty amount, they go out of the capillary and get into the tissue, and engulf the foreign bodies by phagocytosis, -after 24 hrs.: we find monocyte, the monocyte have the same function as phagocytes, -after 5-6 days: fibroblast; which working in building unit, since the fibroblast is the cells that form the connective tissue, this fibroblast appears in the surrounding tissue, - the capillary will appear by the 5-6 day -the collagen after 4th day.
the collagen is the connective fibers which gives strength to the tissue

neutrophils represent the first line defense.

Once the wound in the 5-6 days it

starts building the

collagen that forms from fibroblast, , and in the same duration in the wound, the microbes release an enzymes that lysing the collagen "collagenase", but if the immunity of the person is good the collagen synthesis will overcome the collagen lysis ..

 Factor affecting healing

What are the factor delay healing?? Why we find people with fast healing and others are not??
-the age: healing in young and children is better than elderly. -the nutrition: if the person have protein, ascorbic acid or zinc deficiency, this will delay healing. -vascularity: if the tissues have good blood supply, the healing will be quick. - sepsis: if the wound infected the healing will delay. -oxygenation: its related to vascularity. -Wound dressing: if the wound contaminated we have to repeat dressing.

but if the wound is clean, we don’t repeat dressing,
because repeat dressing in a clean wound that will interrupt with the healing process, and this will delay the healing.

types of healing
❶first intention: if I suture the wound, the spaces between two edges become too minimum, so the healing is quick. ❷Second intention: if the wound is wide, and it remains open all the time, it will need to fill this cavity-in a month maybe-, at the end we get a scar which is very wide and thick.

bullet injures
- it has many types:❶ high velocity missile,❷ shock waves,❸ temporary cavitation.

♣high velocity missile: the bullet inter the abdomen -as example,and injures the liver or colon, then it may go out or remain inside. It can also pass just through the skin. ♣Even if it pass just through the skin, the shock waves that Generated by it, will damage the liver, even if it doesn’t pass through it. ♣the temporary cavitation: if the bullet pass the liver from point to another point, the damage will not only in the tract "that made by passing the bullet", the damage will extend to the surroundings of the tract, by the effect of cavitation.

Blast injures:
sometime we will have complex blast waves: no only the explosion will make a shock wave, but the shrapnels too, and even if we don’t hit directly by the blast, we may have injury by the" mass air movement" because the air in this area if it has an explosion the air will move to another side rapidly and can shattered.

high velocity missile: which is the automatic weapons like " Kalashnikov" and the velocity of them is very high, more than 16m/sec, and we have the low velocities, and blast waves

Surgical wounds
Made by surgeon in a regular way , under anesthesia, under complete aseptic condition, so there will be no contamination.

clean

clean contaminated

surgical wound

contaminated

dirty

patient: Dr u will do to me "a thyroid operation", what's the possibility that my wound will get inflamed?? Dr :very minimal,, because the operation is clean. Patient: Why clean?? Dr: the thyroid is sterile, it don’t have any microbe, the wound will be clean, the possibility of wound infection is very minimum. -petiant2: Dr u will remove my Gallbladder, what's the possibility that my wound will get inflamed?? Dr: HERE the possibility of wound infected is more, WHY?? Because while I cutting through the duct, I open the biliary system, and the biliary system which have bile which have microbes, those microbe which lives normally inside the body, can contaminate the wound, so this wound is clean contaminated. Petient3: Dr u will remove my appendix, what the possibility to wound infection?? Dr: according to the appendix, if it is inflamed so,, its fill of microorganism and pus cells, so whatever u do to isolate it going to contaminate, so the % from 15-20 %, BUT if the appendix was gangrenous or the colon have gangrene and it has a lot of stool, so this wound get infected in highly percent may reach to 40%, so this wound we can classified it " dirty".
In first case the possibility of wound infection b/w 0-2%, the second case like 10%

So if the operation was mastectomy >>> clean.
Hernia>>> clean Gallbladder and it acutely inflamed>>> contaminated.

Now, why we classifying this like that??? Because we want to inspect how much inflammation we get, to try to reduce this incidence, so; in clean operation we don’t give the patient antibiotics, like in thyroid operations, that considers a mistake if we give the patient of thyroid operation an antibiotic.
Prophylactic antibiotics gives in all cases of surgical wound except: the clean one

While, clean contamination, like gallbladder operation in case it is
not inflamed but have a stone, we give the patient one dose antibiotic which called prophylactic antibiotic- because while am removing gallbladder and during explosior of contaminations, we have high level of antibiotics in blood, so I reduce the possibility of infection, and sometime, we may give in the contaminated cases prophylactic and wait to three days, In dirty cases we wait till five days or week maybe. So this is to gauge how much the wound will affect by infections, and to decide which patient we should give an antibiotic at which time, and for how long.

Factors which affect healing:
-General: Malnutrition, ureamia, malignancy, radiothempy,
cytotoxic drugs, diabetes, "vit c" deficiency.

-Local Factors: - Blood supply, presence of necrotic tissue and FB,
presence of hematoma, excessive cauterization, rough manipulation, infection, Tension in wound" THE GOAL of suturing the wound is to approximate the edges but not to strangulate the wound, if the edges of wound don’t meet together I should not put intension, if I make intention in wound where will be no blood supplying and the healing will delay".

♥Now,, after we manage the wound, what's the problems that may happen??

①wound infection,, but,,, what's the sings of wound infections?? Redness, swelling, pain, fever, tachycardia..

When the wound get infected,,, what I should do?? -I don’t give the patient antibiotic but I open the wound or part of it,, so the collection of pus will go out, and give antibiotics if there is a surrounding cellulitis.

Ps: if we open the wound in first few days of suturing, it will be very
easy to open and maybe it opens by itself by the effect of collection and pus, but with passaging of time the wound become harder and harder. ②Wound dehiscence: while the surgeon work in abdomen, like bowel obstruction operation, in the end of it, he sutures the layers of abdominal wall, and the most important layers is the aponeurotic layer- muscular layer- and suture it by no absorbable suturing filament, in the end of 7th day after operation that there is a swelling in wound and fluid coming out, and when we examine we may found that the bowels coming out between the muscles and collecting below the skin directly which we call it" Wound dehiscence". and that may occur because of increase in the abdominal pressure, so after operation we should for many days avoid occurring the intraabdominal pressure which may occurs by intension, sever cough, sever constipation, -Hyper trophied scar, keloid: When the patient has thyroid swelling, asking for operation, after he considers in his mind the cosmetic appearance for sure, and we do a plastic cosmetic operation and after the 7th day we look at it , we find it very fine, very thin, difficulty to seen it, but after a month he come back, and his wound is thick and red in color" hyper trophied scar"

Why that happens??!! It's not caused by the surgery, its sometimes due to the patient, to the area. The story is the wound after it heal,, it continue growing, and become red in color with an itching state, and this case is more in pregnant woman, and in wound that in bony contours, so I try to overcome doing insegen in the shoulder, over the sternum, which is the areas of probability of trophied scar to occur. Anyway, we said to patient don’t worry, we will wait for six weeks, and it will reduce by itself and sometime we inject in it a corticosteroid and sometimes using laser to reduce it. The more big problem in thing called keloid: It's rare, I do the surgery, in appropriate manner, but after 2 to 3 month the wound gets growth, after 6 month it still growing, and invade the surrounding areas and it may reach areas we don’t wound it,,, this is keloid, and its due to the body itself, growing a lot of cells more than needed and even if we remove it , it will recur and need many operations.

IS THERE A POSSIPLITY OF LATENCY OF THE INFECTION TO INFECT THE WOUND?:?
USUALLY THE infection of the wound occurs in the end of the week, and if the wound completely healed after one or two weeks, it's unlikely to get wound infections after month or two, except in some cases, when there is a retained foreign bodied-stone, glasses-, deep

in the wound,, or there is non-absorbable Internal stitch, it may get infected.

the time rate of the injury to heal? The healing in the skin and the appearance of epithelization ends in the first week almost, However; the wound itself not mature enough, it will continue maturing till 6 month, and that include the bone, since when we have bone fracture, we use plaster to confirm the bone and prevent the patient from walking if the fracture was in his leg till 3 month,, until his fracture healing become more strength.

can we associate more than one type of wound with another, during surgery?? -if I was doing a hernia surgery and in the same time the patient was having a mass in his inguinal region and we removed it normally

BUT, IF I WANT

to remove perforated appendix, and I found a

hernia near of it, I can't do it in the same time, because the first one is contaminated, and will infect the other.

What is the Difference between clean contaminated and contaminated?? -clean contaminated means that there is a possibility of contamination but not always, for example, if I open the stomach, which have an acid, so usually the microorganisms in it very low, if I open the common bile duct usually it's not having microorganism, if I open the pelvis of the kidney, its unlikely to have microorganisms but,

if have some infection, it can contain, while if I open the colon, this is absolutely contaminated,

how can we differentiate between contaminated and dirty?? -this depends upon the degree of contaminations, like, sometimes I go and remove the appendix, pus is coming out from appendix-its contaminated- but sometimes I go to remove the appendix and I found that the abdominal cavity is full of pus and feces, and the smell of the theater is full of feces, so this is dirty, so when the contaminated is very massive its dirty.

Ulcers
Ulcer:

is a break in continuity of the skin, or its any

discontinuity in any epithelial surface, or it’s a microscopic discontinuity of normal epithelium, epithelium like skin and mucous membrane, the mucosa of the mouth, mucosa of the stomach, so ulcer may happen in skin, mouth, stomach, intestine, , , and if the discontinuity are microscopic we call it erosion. Ulcers are non-healing wounds that develop on the skin, mucous membranes or eye. Although they have many causes, they are marked by: 1-Loss of integrity of the area

2-Secondary infection of the site by bacteria, fungus or virus 3-Generalized weakness of the patient 4-Delayed healing

Locations:
-Lower limbs: most ulcers of the foot and leg are caused by underlying vascular insufficiency . The skin breaks down or fails to heal because of repeated insult or trauma. -Mouth ulcers: by fungal, or virus infections.

-Ulcers in sacrum: like diabetic patient which has ulcers in
their legs, and it's not healing, because he has delay in the healing mechanism.

-Peptic ulcers: this kind of ulcer occur by digestion of the
entire acids and enzymes to the mucosa of the stomach or duodenum, so it will ulcerate. This includes ulcers of the esophagus, stomach, large and small intestine. -Genitalia: May be penile, vulvar or labial. Most often are due to sexually-transmitted disease.

Causes:
╝Usually the ulcers when it forms, it starts in form of wound, and it does not heal, so it calculates the bacteria, and other microbes which inflame the wound and delay the heal.

╝And some time there is no infection, there is a cancer, like patient comes to Dr and said he has a mass in his face and then it ulcerated, from 6 month and it does not heal,, so this not ulcer this is cancer. ╝another patient came with Venous stasis, in her lower limps, for the last five years, but recently, her leg gets ulcerated "that does not heal", this is venous ulcer. Arterial insufficiency: patient with ischemia in lower limps, the blood supply to his lower limps is occluded, the wound is very painful. -Diabetes: the diabetic patient with wound for 6 month or more and not heal, if the diabetic patient has wound infection, and ulcer in his leg it's like to be as a fire in the forest, the ulcer will spread, why??,,,, because all the factor that needed in the healing process is defective. And the blood supply in diabetic patient; he has arteries sclerosis, the sensation is absent" neuropathy", he does not feeling in any kind of pain" loss of sensation", he has retinopathy, he has impaired immunity, so the wound don’t heal quickly, in contrast it spread quickly. -Loss of mobility: in Patient which is incapable of movement, large ages, which need someone to change his position, he will get ulcer, as a result of pressure with no blood supply.

Description:
you have to describe the features of the ulcer; Site, Size, shape, base, edges, tenderness, discharge and surrounding tissue and lymphatic's.
Those should be describe because it will give us impression if the ulcer will heal or not

Practices: I If the patient has ulcer in the upper half of the face, and its shape is circular, the edges is rolled, so I said these is : basal cell carcinoma" If the ulcer found in the foot and its very painful to patient, so I said this is "ischemic ulcer" If the ulcer in the foot and their smell awful, and it give out a pus, and the patient don’t feel anything,, so I said this patient is "diabetic".

ischemic ulceration:
- those patient with lower limp arteries sclerosis are more acceptable to get ulcer, because there is no blood supply, - In elderly , who also have symptoms of coronary vascular disease.

this patient has problem in the blood supply and has ulcer in the dorsum of the index.

-

this is an ulcer in the tip of pecto, and this ulcer may is ischemic ulcer, or diabetic patient.

-When we see this picture, we can notice that the base of ulcer is red, and that’s a good sign of healing, because when we find the floor black, and have pus, this is infected ulcer. -Look to the edges we call it sloped edges, and also is a sign of healing.

Neuropathic ulcer; loss of sensation, occur in patients have
diabetic, paraplegia. Causes: -peripheral nerve lesions “diabetes ,nerve injuries” -Spinal cord lesions This is pic of ulcer in diabetic patient, the ulcer occurs in the pressure areas.

The venous ulcers: occurs usually in females,
:

 This is a venous ulcer, you will see
varicosities,_" varicosities is venous veins which is congested and dilated". It's found everywhere, and we found pigmentation on it, in the

middle aspect of the lower third of the leg, this area called:" gatal area".,,,,,,,,,,,,,,,,,,,,,,,,,, MAY ALLAH PROTECT US .

what's the cause of gastric ulcer?? -the stomach HCL main function is to digest the protein, BUT, sometimes due to excessive production of IT, it will digest the mucosa of the gastric, new thing is explorer recently that there The is a bacteria called " helocapterpylori " may exist in the medications stomach and react with the HCl and cause ulceration, so we given; can stop this bacteria by reducing HCL production. lansoprazole
, and antibiotics.

Festulas 
Definition: Fistulas is an abnormal communication between tow epithelial -or endothelial- surfaces.

In pic: we see the anal canal which in it the feces collected, then it will go out by auns canal, that’s the normal scenario. But,,, there is some people have another opening for feces, this opening is end of a canal, which having another opening inside to anus canal, so its abnormal communication between the skin and the lining of anal canal, so the feces and secretion will discharge to go out from the extra abnormal canal.

Why that happens?? -before the canal form, an abscess form with pain sensation, this abscess is open in and out, but the patient don’t aware only to the out one, and at the way of the abscess we found a track, which is not closed and this is the fistula. This is acquired fistula.

Types of fistula:

Congenital Acquired Arteriovenous fistulas

external

Congenital and acquired(traumatic or iatrogenic)

Internal abdominal fistulas External abdominal fistulas

-҉ May all of us hear about new baby born with difficulty in breathing, when his family fed it the food go to the lung,

because of abnormal communication between the trachea and the esophagus, this is a congenital fistula, -Sometimes the fistula may happen between vain and artery" Arteriovenous fistulas". -A patient with mammal fistula," abscess in the breast", happen in pregnant woman or after delivery, after the abscess opened, at the site of drainage of the abscess the milk eject," the milk come out not from the nipple but from nearby" this is a fistula between the ducts of milk and the skin.

-A patient get operation, he remove the gallbladder, the biliary canal-common bile duct- tied, but after a while I found that the bile come out of the wound,,, this is a biliary fistula "bile is coming from the wound", there is abnormal communication between the biliary tree and skin. -A patient with bullet inside his body, the bullet get inside the pancreas "the pancreas produced pancreatic juice", The pancreatic juice will go to the bowel but since the wound reach the pancreas, so the pancreatic juices coming out through the wounds, and after 2-3 month the pancreatic juice will coming on skin by the wound,,,,, this is the pancreatic fistula" a communication between the skin and the pancreas". Gastrocutaneous fistula: a patient get a hit with knife, the knife go inside the stomach , in operation the stab wound in the stomach closed, but it was a big stab, in the next day he have a wound infection, in the 7ht-8th day when he start eating, the food go out from the wound, the stomach opens in the skin this is Gastrocutaneous fistula.

-Gastrojejunocolic fistula: between stomach and jejunum. -Small bowel fistula: a patient we do operation to him, we cut part of his bowel that is gangrenous as example then we suture the bowel with each other -that called" anastomosis" After week -10 days the wound secret pus and intestinal contents. Because there is opening between small bowel and stomach.

-External colonic fistula: a patient had operation in his colon, suture the colon after trauma and suture the skin overlaying, after few days the feces go out from the wound, and have a complications between the colon and skin. Colovesical and colovaginal fistulas: that happens with ladies, in cases of obstructed labor, so the head of the baby get necrotic in the neck of uterus, and it will open on the bladder, and the urea go up from the bladder to the uterus and the anus, That called" vesicovaginal fistula". . PS: The colon can also open in the vagina and the feces go out from the vagina.

Cyst :
any closed epithelium-lined cavity or sac, normal or abnormal, usually containing liquid or semisolid material.

cysts in the neck :
❶Branchial

cleft cysts: In imperiology phase there is arches, and it will disappear and some of it may remain, so may a baby born with a cyst in his neck, and that because one of this clefts did not obliterated, this is a brainchial cyst.

❷Thyroglossal

duct cysts: When the thyroid gland formed, its formed by Thyroglossal duct, this duct will extend from the posterior of the tongue to the neck region, once the thyroid gland form and the duct disappear, sometimes some of the remnants' form a cyst " Thyroglossal cyst".

❸Dermoid

cysts: after 1-2years of born of baby, we notice a swelling in the outer border of the eyebrow, its congenital because there is a part of skin cells implanted under the skin and make the dermoid cyst,, we remove it by excision.

❹Sebaceous

cysts: it’s a small cyst in the scalp, highly prevalence, and its mobile attach to skin, contain sebaceous materials.

in pic: a child with a swelling in the midline under the chin directly, when he swallow saliva it moves and when he rise his tongue it will go up. That’s it… All extra info in slides are not included.

‫والحــــــــــــــمد ل ّلـــــــــــه ربــــــــــــــــــــِّــ العـــــــالمـــــين‬
Malaysian brothers and sisters,,, for u, I did best what I can do


D:‫براءة,,, شكرا ألنك قلتيلي صعب تقدري تعملي تفريغ ساعة ونص لحالك‬ For my wonderful batch:
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 ‫وتذكروا الشام بدعوة‬

DONE BY: Asmaa Almawas