Wound Management

Dr Sumer Yadav
• “the primary goal of wound care is not the
technical repair of the wound; it is providing
optimal conditions for the natural reparative
processes of the wound to proceed”
• – Richard L. Lammers (Roberts and Hedges)
 plastic surgeon consultation (a) the
acute wound where the final
appearance may be the principal
concern, (b) the wound in a patient
whose medical status and/or mode of
injury predisposes her to wound
healing difficulties and the threat of a
problem wound, or (c) the established
chronic wound refractory to past
interventions.
 GOALS of wound care
• Facilitate hemostasis
• Decrease tissue loss
• Promote wound healing
• Minimize scar formation
 TYPES of Wound Healing
1.) Healing by first intention (aka. primary wound healing or primary
closure)
• wound closed by approximation of wound margins or by placement
of a graft or flap, or wounds created and closed in the operating
room.
• Best choice for wounds in well-vascularized areas
• Indications -recent (<24h old)
-clean
-viable tissue
-tension-free
• treated within 24 h, prior to development of granulation tissue.
• epithelialize within 24 to 48 h. Water barrier function restored 
can shower or wash.
2.) Healing by second intention (aka. secondary wound
healing or spontaneous healing)
• wound left open and allowed to close by epithelialization and
contraction.
• Commonly : management of contaminated or infected
wounds.
• without surgical intervention.
• Unlike primary wounds, approximation of wound margins
occurs via reepithelialization and wound contraction by
myofibroblasts.
• Presence of granulation tissue.
• Complications -late wound contracture
-hypertrophic scarring
• 3.) Healing by third intention (aka. tertiary wound
healing or delayed primary closure)
• wounds that are too heavily contaminated for primary closure but
appear clean and well vascularized after 4-5 days of open
observation.
• Inflammation reduced bacterial concentration (“debribe”)
allow safe closure.
• Indications :- infected or unhealthy wounds with high
bacterial content,
-wounds with a long time lapse since injury, or
-wounds with a severe crush component with
significant tissue devitalization.
• Wound edges are approximated within 3-4 days
• tensile strength develops as with primary closure.
 Factors that affect wound healing

• In general, remember “DIDN'T HEAL”

• D = Diabetes: -diminishing sensation and arterial
inflow ++ acute loss of diabetic control  diminished
cardiac output, poor peripheral perfusion, and
impaired polymorphonuclear leukocyte
phagocytosis.
• I = Infection: -potentiates collagen lysis. Bacterial
contamination + susceptible host + wound
environment = wound infection. Foreign bodies
(including sutures) potentiate wound infection.
 DIDN’T HEAL
• D = Drugs: Steroids and antimetabolites impede
proliferation of fibroblasts and collagen synthesis.
• N = Nutritional problems: Protein-calorie malnutrition
and deficiencies of vitamins A (collagen synthesis,
antioxidant), C (collagen synthesis), and zinc (fibroblast
proliferation ).
• Malnutrition- Impaired organ function, Impaired
collagen synthesis, Impaired immune function,
Reduced antioxidant activity
• T = Tissue necrosis, from local or systemic ischemia or
radiation injury. Blood supply is important.
 DIDN’T HEAL
• H = Hypoxia: -esp the distal extent of the
extremities. Blood volume deficit, unrelieved
pain, or hypothermia  sympathetic
overactivity  local vasoconstriction 
Inadequate tissue oxygenation.
• E = Excessive tension on wound edges local
tissue ischemia and necrosis.
 DIDN’T HEAL
• A = Another wound: Competition for the
substrates required for wound healing.

• L = Low temperature: (relatively) distal aspects

of the upper and lower extremities (a
reduction of 1-1.5°C [2-3°F] from normal core
body temperature) is responsible for slower
healing of wounds at these sites.
 Basics
• Wound evaluation and history
• Wound preparation and closure
• Optimize systemic parameters
• Debride nonviable tissue
• Reduce wound bioburden
• Optimize blood flow
• Reduce edema
• Use dressings appropriately
• Use pharmacologic therapy
• Close wounds with suturing/grafts/flaps as indicated
 Wound Evaluation -HISTORY
• identify all extrinsic and intrinsic factors that
jeopardize healing and promote infection
– mechanism of injury
– time of injury (accelerated growth phase of
bacteria starts at 3 hours post wound)
– environment in which wound occurred
potential contaminants, foreign bodies
– species of animal if bite wound
– pt’s medical problems (allergies to
medication) / immune status
• tetanus immunization status
 Wound assessment
• Examine for:
– amount of tissue destruction
– degree of contamination
– damage to underlying structures
•Body Location
–Proximity to Other Structures
–Joints –Nerves –Tendons–Vasculature
–Test integrity of each structure

•Assess laxity/muscle and tendon function

•Assess 2-point discrimination
•Assess vascular supply
 Physical examination
• Wound Location
– importance in the risk of infection
– high endogenous bacterial counts in hairy
scalp, forehead, axilla, groin, foreskin of
penis, vagina, mouth, nails
– wounds in areas of high vascularity more
easily resist infection (scalp, face)
 Wound Preparation - Anesthesia
• Topical
– Solution or paste
– LET
– TAC
– EMLA
• Local
– Direct infiltration
– 1% lidocaine with or without epinephrine
– Bupivicaine or sensorcaine for longer acting anesthesia
• Regional Block
– Local infiltration proximally in order to avoid tissue disruption
– Smaller amount of anesthesia required
 Local anesthetic
Drug Max Dose Onset Duration

Cocaine 6.6 mg/kg Rapid 1 hour

Procaine 10-15 mg/kg Rapid 30min-1hr

Tetracaine 1.5 mg/kg Moderate 2 hours

Lidocaine 5 mg/kg 5-30 min 2 hours

(with Epi) 7 mg/kg 5-30 min 2-3 hours

Bupivacaine 2 mg/kg 7-30 min > 6 hours

 Epinephrine

• Vasoconstrictive
–Increases Duration of Action
–Promotes Hemostasis
–Avoid end-arterial blood supply areas
–May increase pain (low pH)
 Wound Preparation - Hemostasis
• Direct Pressure–Usually best choice
• Ligatures
– Use a tourniquet
• Chemicals
–Epinephrine
–Gelfoam
–Oxycel
–Actifoam
• Cautery
 Debridement & Reduction of Bioburden

• Surface irrigation with saline.

• Debridement: surgical, enzymatic (papain with urea,
collagenase), mechanical (pressurized water jet),
autolytic, maggots.
• Antibiotics: cellulitis, decreased rate of healing,
increased pain, straw colored oozing from skin,
contaminated wounds, mechanical implants.
• Removal of FB.
 Wound Preparation – Foreign Body
Removal
• Suspect with point tenderness
• Visual inspection (to the apex)
• Imaging
– Glass, metal, gravel fragments >1mm should be
visible on plain radiographs
– Organic substances and plastics are usually
radiolucent
• Always discuss and document possibility of
retained foreign body
 Wound preparation : CLEANING
• high pressure irrigation (Normal Saline)
• min 100-300 ml with continued irrigation
• at least 8 psi force to the wound  the irrigation
fluid dislodges foreign bodies, contaminants, and
bacteria.
• A simple device setup
30-60 ml syringe and an 14-gauge angiocatheter.
 Hair removal
• Shaving –Increases risk of infection X 10 !
• Clip Hair with Scissors
• Matt Hair with Ointment

• Never shave eyebrows ( may not regrow )

Wound Preparation – Debridement
• Removes devitalized tissue
• Creates sharp wound edge
• Excision with elliptical shape
• Respect skin lines
 Wound closure in relation to time
• Primary closure
– Suture, staple, adhesive, or tape
– Performed on recently sustained lacerations: <12 hours
generally and <24 hours on face
• Secondary closure
– Secondary intent
– Allowed to granulate
• Tertiary closure
– Delayed primary (observed for 3-4days)
 SUTURE TECHNIQUES
• Deep layer approximation
– Absorbable sutures
– Buried knot
– Serves two purposes
• Closes potential spaces
• Minimizes tension on the wound
margins
 Skin Closure
• Key – wound edge eversion
• “Approximate, don’t strangulate”
• Anticipate wound edema
• Choose appropriate size of suture for location
of laceration
 Other devices in wound closure
• Staples
– Quick, poor aesthetic result
– where scar is less of an issue (hairy scalp)
• Adhesives
– Dermabond
– clean, sharp edges, clean nonmobile areas, laceration
less than 5 cm in length
• Tape
– Steri-strips
– superficial, straight laceration under little tension
 After care
•Wound Dressings
• Maintain moist –24 –48 hours
–Augments reepithelialization
•“Water-Tight” after 48 hours
•Bandages
–Soft-splint
–Absorb exudates
–Protects Wound
–Protects knots
 Optimize systemic parameters
• Age: cannot be reversed, usage of growth
factors, aggressive optimization of systemic
parameters & supplementation.
• Avoidance of ischemia & malnutrition.
• Correction of diabetes, removal of FB.
• Avoidance of steroids, alcohol, smoking.
• Avoidance of reperfusion injury: total contact
casting, compression therapy.
 Optimize systemic parameters-
nutrition
• Glucose -give energy for angiogenesis and the
deposition of new tissue.
• Fatty acids-essential for cell structure and have
an important role in the inflammatory process.
• Protein deficiency-contribute to poor healing
rates with reduced collagen formation and
wound dehiscence.
• Vitamins- vitamins A (collagen synthesis,
antioxidant), C (collagen synthesis), and zinc
(fibroblast proliferation )..
 Optimize blood flow & oxygen supply
• Warmth
• Hydration
• Surgical revascularization
• Hyperbaric O2 therapy: limb salvage.
 Reduce edema
• Elevation
• Compression
• Negative pressure wound therapy: removes
pericellular transudate & wound exudate as
well as deleterious enzymes. Cannot be used
in ischemic, badly infected or inadequately
debrided wounds or in malignancy.
 Indications for systemic antibiotic
for traumatic wounds
• Injury 6 hours old on the extremities
• Injury 24 hours old on the face and scalp
• Tendon, joint, or bony involvement
• Cartilage involvement
• Mammalian bite
• Co-morbidity (diabetes mellitus, extremes of age,
steroid use, morbid obesity)
• Puncture wound
• Complex intraoral wound
 Wound preparation -Tetanus
prophylaxis
• Clean wounds
– Incompleted immunization toxoid
– >10 years, then give toxoid
• Tetanus prone wound
– Incompleted immunization Toxoid &
immunoglobulin
– > 5 years, give toxoid
 Dressings
• Absorption characteristics: none – films, low –
hydrogels, moderate - hydrocolloids, high – foams,
alginates, collagen.
• Hydrogels (eg. starch) rehydrate wounds (benefit in
small amounts of eschar, infected wounds).
• Hydrocolloids promote wound debridement by
autolysis.
• Antimicrobial dressings: silver, cadexomer iodine,
mupirocin, neomycin.
 Suture removal guidelines
• Anatomic location Days (average)
face 3-5
arm 7
anterior trunk 7
back 10-14
feet and hand 10-14
joint 10-14
scalp 10-14
 Skin Substitutes
• Autologous keratinocyte sheets.
• Biobrane
• Oasis
• Alloderm
• Integra (sites prone to contracture, coverage of
tendons, bone, surgical hardware)
• TransCyte
• Dermagraft
• Orcel
Collagen & chondroitin sulphate : Integra
Apligraftrade: skin substitute containing collagen and seeded cells
Alloderm: immunologically inert, nonliving, allogenic, acellular dermal matrix
with intact basement membrane prepares wound bed for grafting
 Tegaderm

Used for simple shallow wound dressing

Protects from water loss mechanical injury and drying
TransCyte (ECM matrix generated by
allogenic human dermal fibroblasts serves
as a matrix for neodermis generation

ORCEL: Composite cultured skin.

Fibroblasts, keratinocytes seeded on
opposite sides of bilayered matrix of
bovine collagen
 Dermagraft
living allogenic dermal fibroblasts grown on a degradable scaffold. Good resistance to
tearing
 Pharmacologic therapy
• Antimicrobials
• PDGF- becaplermin- US-FDA approved –
dibetic foot ulcers
• EGF- under trial
• VEGF- under trial
• Vit A: steroid use
• Absolutely of no use in normally healing
wounds
 Flaps & Grafts
• Radiation wounds require flaps.
• Chronic nonhealing ulcers.
• Extensive areas of ulceration.
• Major soft tissue loss.
• Other therapies: electrical stimulation for
recalcitrant ulcers.
beta-Glucan stimulates the macrophage activity
and promotes rapid wound healing.

Beta-Glucan Collagen mesh or

Glucan II (Beta-Glucan) mesh.

Rapid healing without dressing

changes
painless treatment.
BIOLOGIC DRESSINGS
 HONEYSOFT

Natural dressing
Honey-impregnated dressing Chronic
unhealing wounds.
Impregnated into a compress of EVA
(ethylenevinylacetate) mesh

Honey cleans the wound without disturbing

it
Removing the dressing causes no damage
no known side effects
 NPWT/VAC
• expeditiously prepare a wound bed for
surgical closure by tertiary intent.
• works through- relief of edema, improving
interstitial diffusion of oxygen to cells,
removes deleterious enzymes
• most wounds will heal optimally with a
pressure of 125 mm Hg, other wounds may
only tolerate a setting of 75 mm Hg before
capillary flow is occluded.
 NPWT/VAC
• Indications- lymphatic leaks, venous stasis ulcers,
diabetic wounds, and wounds with fistulae ,
sternal wounds, orthopedic wounds, and
abdominal wounds
• Some instances, it has enabled avoidance of free
flaps can also be used to assist the
neovascularization of skin grafts and tissue
engineered skin substitutes
• Contraindications- malignancy, ischemia,
inadequately debrided or badly infected wounds
 Hyperbaric Medicine
• (HBO) (typically, 100% O2saturation at 2 to 3 ATA)
raises the dissolved oxygen saturation in plasma from
0.3% to nearly 7%.
•
• Stimulates angiogenesis and fibroblast migration,
enhances neutrophil and antibiotic killing action, and
suppresses alpha toxin production in gas gangrene.

• if the periwound area/extremity demonstrates a rise in

tcPO2when the patient inspires supplemental oxygen,
the patient is likely to benefit from HBO.

• not benefit from HBO: those with a normal

environmental perfusion, and those with ischemic limbs
who need a bypass to restore blood flow to a limb
Patients with irradiated skin or steroid
users
• Patients who are on steroids should receive
vitamin A (25,000 IU daily by mouth or 200,000
IU topically t.i.d.).
• The progressive endarteritis obliterans and
microvascular damage, along with fibrotic
interstitial changes, results in a wound marked by
ischemia, hampered by cellular senescence, and
prone to infection.
• gingerly debrided, antimicrobial dressings,
growth factors and even hyperbaric oxygen
therapy, microvascular free flap.
 Pressure sore care
• Should be aggressively nourished and receive
vitamin supplementation.
• administration of growth hormone or anabolic
steroids.
• Debridements
• Dressings
• air-fluidized beds, air mattresses, air flotation
and water flotation devices, and low air-loss
beds.
Wound Care in Patients with Diabetes
• components of pressure necrosis, functional
microangiopathy, and true neuropathic
derangements.
• Selective debridement, control of glucose
levels, pressure offloading.
• Revascularization
• use of growth factors
 Wound Care in Patients with Venous
Stasis Ulcers
• Compression therapy is essential for venous
stasis ulcers.
• stockings, elastic wraps, and multilayer wraps,
Unna boot-paste dressings and low-stretch
bandages.
• contraindicated in patients with an ABI <0.7
• ideally the pressures exerted should be between
30 and 40 mm Hg
• continued for several weeks following successful
closure of the wound.
“ God heals, and the doctor
takes the fees ”

Benjamin Franklin(American Statesman, scientist, Philosopher)