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I Ketut Wiargitha,SpB(K)Trauma
Divisi Bedah Trauma & Bedah Akut
LUKA : TERPUTUSNYA KONTINUITAS JARINGAN
 Traumatic Wound Classification
Lacerations Contusions Abrasions Combination

• Lacerations are • Contusions are • Abrasions are • Combination are

caused when caused by more superficial epithelial usually severe
trauma exceeds extensive tissue woundscaused by trauma that have life
intrinsic tissue trauma after severe frictional scraping threatening problem
strength blunt or blast trauma forces
• Tissue damage may • The overlying skin • When extensive,
not be extensive, may seem to be they may be
and primary suturing intact but later associated with fluid
may be possible become non-viable loss. Such wounds
• Ex : skin torn by should be cleansed
blunt injury over a to minimise the risk
bony prominence of infection, and
such as the scalp. superficial foreign
bodies should be
removed

Enoch, Stuart & Grey, Joseph & Harding, Keith. (2006). ABC of wound healing: Recent advances and emerging treatments. BMJ (Cl inical research ed.). 332. 962-5. 10.1136/bmj.332.7547.962.
wound healing
▪ Inflammation
▪ Fibroplasia
▪ Epithelialisation
▪ Wound contraction
Factors that affect wound healing and the
potential for infection
Patient:
- Age
- Underlying illnesses or disease: consider anemia, diabetes or immunocompromised
- Effect of the injury on healing (e.g. devascularization)
Wound:
- Organ or tissue injured
- Extent of injury
- Nature of injury (for example, a laceration will be a less complicated wound than a crush injury)
- Contamination or infection
- Time between injury and treatment (sooner is better)
Local factors:
-Haemostasis and debridement
- Timing of closure
PROBLEMS IN WOUND MANAGEMENT
The most common reasons for failure of a wound to heal are:
▪ Foreign body/material in the wound
▪ Necrotic tissue present in the wound
▪ Dead space
▪ Infection
▪ Denervation
▪ Failure to create the right local wound environment (choice of dressing
material)
▪ Host factors/disease
▪ Lack of available skin/tension on wound edges
TREATMENT PRINCIPLES
▪ Remove any barrier to healing
▪ Create an environment that supports and
encourages wound healing
▪ Repair any underlying deficiency (nutrition,
vascular or nerve supply)
STEPS IN MANAGING EMERGENCY WOUNDS--
DEBRIDEMENT, CLEANING, COVERING
▪ Thorough wound exploration--may require substantial but
gentle dissection to expose deep lacerations
▪ Remove dead, damaged and contaminated tissue
▪ Remove foreign bodies
▪ Arrest haemorrhage
▪ Restore structural normality where possible
▪ Provide drainage of dead space
Goals of Wound Care

▪ Facilitate hemostasis
▪ Decrease tissue loss
▪ Promote wound healing
▪ Minimize scar formation
Evaluation of Wounds

• ABC’s first  Always!

• Ensure hemostasis
– Saline gauze dressing
– Compression
• Remove obstructions
– Rings, clothing, other jewelry
• History
History

• Symptoms • Tetanus status

• Type of Force • Allergies
• Contamination • Medications
• Event • Comorbidities
• Potential for
foreign body • Previous scar
formation
• Function
• Non-accidental
trauma
Wound Examination

• Location • Vascular function

• Size • Tendon function
• Shape • Underlying
• Margins structures
• Depth • Wound
• Alignment with contamination
skin lines • Foreign bodies
• Neuro function
 Debridemen Luka

▪ Luka Mulai dengan “Bersihkan”, “dicuci”,dan

”debridemen”  dengan menggunakan NaCL 0,9
% (saja), sebanyak mungkin, dan membersihkan
adanya “Corpus Alienium” dan jaringan nekrosis.
Dilakukan secara sistematis dari permukaan.
▪ Selama “debridement” , luka harus tetap dibasahi
(“Moisturizing”) jaringan “Telanjang”.
 Debridemen Luka

▪ Hemostasis harus “sempurna”  dokter harus bisa

bekerja baik dan bersih.
▪ “Corpus alenum” dan “jaringan nekrotik” dibuang secara
sistematis  tanda-tanda jaringan yang masih viable?
▪ Jika diputuskan untuk “suturing”  memilih “bahan
jahit” yang digunakan  teknik jahit ?  “Cellular
response/immune response” bahan atau benang jahit.
▪ Luka di approximasi dengan baik,”tidak ada
tension”,”kerapatan jahitan”(Mengganggu Vaskularisasi)
 Debridemen Luka

▪ Pilihan untuk “delayed primary suture”?

▪ Hindari “dead space”  Jika ada approximasi
atau “drain”
▪ Kekuatan luka pada kulit terletak pada  dermis
dan fascia  kedua struktur jaringan ini harus
dijahit. Sebaliknya lemak tidak mempunyai
“”kekuatan” dan mempunyai “Vaskularisasi” yang
buruk  perlu dijahit ?
PRINCIPLES OF WOUND CLOSURE
• Minimize bacterial contamination

• Remove foreign bodies & devitalized tissue

• Achieve hemostasis

• Handle tissue gently

• Approximate; do not strangulate

TIME Principles
TIME
PRINCIPLES
Decide appropriate treatment

▪ Defective tissues, slough, exudate,

debris  delay healing, infection
build-up
 DEBRIDEMENT
 AUTOLYTIC

OUTCOME:
Viable/vascularized wound bed
 Decide appropriate treatment

▪ Increased exudate, surface

discoloration, increased odor
 DRAINAGE
 ANTIMICROBIALS
 ANTIBIOTICS?

OUTCOME:
Viable wound bed
Decide appropriate treatment

▪ Maceration (heavy exudate)

▪ Dessication (dry wound bed)
 RESTORE MOISTURE BALANCE
 EXUDATE MANAGEMENT
 PROPER DRESSING

OUTCOME:
Optimal moisture balance
 Decide appropriate treatment

▪ Chronic wound
▪ Prolonged inflammation
 T-I-M ISSUES
 WOUND CLOSURE
 NPWT

OUTCOME:
Epithelialized wound
TIME Clinical Decision Support Tool
Wound Closure

• 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 4-5 days)
Suture Material

• Absorbable
– Chromic gut
– Vicryl
– PDS II
• Non-Absorbable
– Silk
– Prolene
– Dermalon
• Monofilament vs. braided
Staples, Adhesives & Tape

• Staples
– Quick, poor aesthetic result
• Adhesives
– Dermabond- painless, petroleum dissolves
• Tape
– Steri-strips
Pembalutan luka

Fungsinya :
• Proteksi, dari invasi bakteri (24 jam)
• Menekan, mencegah perdarahan.
• Absorbsi ( darah, transudat, exudat)
• Rasa aman , tidak takut melihat luka/ benang
jahit
• Membatasi gerak
• Memonitor perdarahan , exudasi, pus
 Teknik membalut pasca bedah

▪ Semua tepi tertutup oleh plester perekat

▪ “Bandage” harus cukup tebal
▪ Alat perekat harus sesuai dengan axis sendi
terdekat , atau tegak lurus dengan garis tarikan
kulit
▪ Teknik pembalut dibuka minimal setelah 24 jam
(Luka mengalami “Sealed Off”)
 Teknik membalut pasca bedah

▪ Pada luka dengan resiko infeksi yang besar

diganti sesering mungkin.
▪ Pada luka dengan resiko infeksi sangat kecil
dapat diganti > 24 jam
▪ Pada pergantian balutan ,perhatikanluka operasi
(merah, bengkak, keluar cairan?)
▪ Perhatikan kain pembalut untuk (darah, cairan
kekuningan, pus dsb)
 Perawatan luka

▪ Luka dapat dibersihkan dengan NaCl 0,9%, H202

1%, Alkohol 95%, betadine dsb
▪ Luka dapat ditutup dengan : kering, tulle,
betadine, antibiotika ointment dsb
▪ Luka basah rawat dengan basah (kompres), luka
kering rawat dengan ointment
 Perawatan luka

▪ Luka operasi dapat dirawat terbuka :

▪ Pada operasi leher kepala :luka operasi dirawat
terbuka setelah 24 jam
▪ Pada luka operasi ditempat lain : setelah 48 jam
▪ Tergantung dokter sendiri
 Luka pasca bedah

▪ Amati adanya perdarahan pada “kain pembalut”

▪ Jika banyak dan aktif : perhatikan ada tidaknya
“drain”!
▪ Jika drain  perdarahan  lapor
▪ Lihat keadaan lapangan operasi ! :perdarahan,
bengkak,oedematous
▪ Perhatikan daerah operasi dileher 
pembengkakan  obstruksi nafas
 drain pasca bedah

▪ Drain terbuka : drain sarung tangan, drain

penrose  hanya boleh terpasang 24 jam
▪ Drain tertutup : Redon drain, boleh terpasang
sampai 14 hari, tergantung sterilitas, dan macam
drain yang terpasang
 Drain pasca bedah

Fungsinya:
▪ Drainage “Dead Space”
▪ Drainage pus,exudat infeksi/pembedahan dengan pus / infeksi
▪ Monitor adanya perdarahan yang aktif
▪ Monitor terhadap kemungkinan kebocoran anastomosis usus, dll
▪ Drainage agar terjadi “symphysis” kulit dan lapangan operasi
 Asal cairan drain

▪ Oozing lapangan operasi  jernih dan serous

▪ Jika > 12 jam darah segar  perdarahan aktif
▪ Jumlah sangat tergantung lapangan operasi dan
jenis pembedahan : rata-rata tidak lebih dari 100
cc
▪ Perhatikan produk yang tidak semestinya!
 perawatan drain pasca bedah

▪ Lubang keluar drain harus terus tertutup

▪ Drain harus dirawat setiap hari, crusta dan
benang drain harus terus dibersihkan setiap hari
▪ Drain harus diputar-putar agar tidak terjadi
perlekatan
 Produksi dari drain

▪ Perhatikan kualitas cairan yang keluar! Darah,

pus, empedu, urine  catat
▪ Perhatikan kwantitas yang keluar, dan
korelasikan dengan tempat posisi drain
▪ Perhatikan jika produk yang keluar tidaklah
seharusnya.
SUTURE REMOVAL TIME
Take-home messages

X
Take-home
messages
Take-home
messages
FACTORS AFFECTING WOUND HEALING
LOCAL FACTORS SYSTEMIC FACTORS
▪ Inadequate blood supply ▪ Age
▪ Wound dehiscence ▪ Obesity
▪ Infection ▪ Malnutrition
▪ Excess local mobility  joint ▪ Smoking; alcohol
▪ Poor surgical technique ▪ Diabetes mellitus
▪ Increased skin tension ▪ Malignancy; chemotherapy & radiation
▪ Foreign body; hematoma ▪ Immunosuppressant; anticoagulants
▪ Shock
DO NOT STRANGULATE
Remove foreign bodies & devitalized tissue
Achieve hemostasis
FOLLOW UP
 Tulle dressing
▪ Wound contact layer  paraffin
▪ Lacerations, abrations, skin loss, skin grafts, burns
▪ Chlorhexidine acetate  antiseptic
▪ Framycetin sulphate  antibiotic
Hydrogel
▪ Autolysis debridement & granulation
▪ Maintain a moist environment
▪ Diabetic ulcer, pressure sore; exudating or dry
necrotic wounds
CADEXOMER Iodine
▪ Necrotic tissue, slough
▪ Absorb fluids, removing exudate, pus and debris
▪ Iodine  slowly released; killing micro-organisms
and forming a protective gel over the wound
surface
ANTIMICROBIAL dressing
▪ Silver dressing
▪ Broad spectrum of non-selective antibacterial action
▪ Reduce wound bacterial colonization and infection 
improve healing process
Calcium alginate
▪ Effective barrier to microbial penetration for moderate to heavy LEVEL of
exudate  forms a soft, gel that absorbs when it comes into contact
▪ Moist wound management
▪ Pressure sores, arterial, venous and diabetic leg ulcers, fungating lesions
▪ Hemostasis for minor bleeding
 calcium ions
 gel serves as a matrix for aggregation
of platelets and erythrocytes
Foam absorbent dressing
▪ Absorb exudate  transpire
▪ Create a moist wound healing environment
▪ Chronic and acute exudative wounds, pressure
ulcers, diabetic foot ulcers, infected wounds,
oncological Wounds
Negative pressure wound therapy
▪ Stimulates development of granulation tissue formation and
angiogenesis
▪ Promotes moisture balance in the wound bed
▪ Removes exudate from the wound site
▪ Helps to increase vascular perfusion
▪ Edema reduction
THANK YOU