WOUND MANAGEMENT

UNDERSTANDING WOUNDS & HEALING

 GOAL OF WOUND MANAGEMENT
✓UNDERSTANDING NATURE AND TYPES OF WOUNDS
✓PROVIDING PAINLESS, QUICK WOUND CLOSURE
✓EXCELLENT COSMETIC RESULT
✓ AVOIDING INFECTION
DEFINITION
A wound is a physical trauma where the skin is torn, cut or punctured. An
injury which breaks the skin or other tissues and which can allow blood to
escape from the body and germs to enter it .
a wound is considered as minor when it is:
• superficial;
• away from natural orifices;
• there is only a minor bleeding;
• it was not caused by a tool or an animal.
Any other wound should be considered as severe.
 TYPES OF WOUNDS
• TYPES OF WOUNDS

Wounds

Open Closed
 OPEN-WOUND
• ALLOWS BLOOD TO ESCAPE FROM THE BODY
• THERE IS DISRUPTION IN THE CONTINUITY OF THE SKIN THEREFORE SUSCEPTIBLE TO
EXTERNAL BLEEDING AND CONTAMINATION
TYPES OF OPEN WOUND :
❖ INCISION
❖LACERATION
❖ABRASION
❖PUNCTURE
❖ AVULSION
❖AMPUTATION
 OPEN-WOUND
• INCISION : CAUSED BY SHARP CUTTING INSTRUMENT MINIMUM
LOSS OF TISSUE EDGES ARE REGULAR HEALS BY PRIMARY
INTENTION HEALING.
• LACERATION: CAUSED BY TEARING OF SOFT TISSUE IRREGULAR
JAGGED EDGES LOSS OF TISSUE LIMITED TO SKIN AND
SUBCUTANEOUS TISSUE.
 OPEN-WOUND
ABRASION :
• SUPERFICIAL WOUND CAUSED BY RUBBING OR SCRAPPING
• RESULTS IN PARTIAL LOSS OF SKIN SURFACE

PUNCTURE
• IS A STAB FROM A POINTED OBJECT.
• EXAMPLE: NAILS, NEEDLES, FORK, KNIFE AND EVEN TEETH
• RISK OF INFECTION IS HIGH IF WOUND IS DEEP BECAUSE
GERMS AND DIRT MAY HAVE CARRIED INTO IT
• SPECIAL TREATMENT IS REQUIRED WHEN THE OBJECT
CAUSING THE INJURY REMAINS IMPALED IN THE WOUND
 OPEN-WOUND
AVULSION
• IS THE TEARING OF A PATCH OF SKIN OR OTHER
TISSUES
• NOT TOTALLY TORN FROM THE BODY BUT CREATES A
LOOSE, HANGING FLAP
• INVOLVES BODY PARTS SUCH AS EYEBALLS,
EARS,FINGERS, OR HANDS

AMPUTATION
• INVOLVES CUTTING OR TEARING OFF A BODY PART
• EXAMPLE: FINGERS, TOES, HANDS,FEET, ARMS OR
LEG.
 CLOSED / INTERNAL WOUND
ONLY DEEPER TISSUES BARRING THE SKIN OR
MUCOUS MEMBRANE ARE DAMAGED
CONTUSION/BRUISES:
• CAUSED BY BLUNT OBJECTS
• DAMAGE TO SUBCUTANEOUS TISSUE
WITHOUT BREAKING THE CONTINUITY OF
SKIN SURFACE
• CLASSIFIED ACCORDING TO SEVERITY OF
DAMAGE
 CLOSED / INTERNAL WOUND
CONTUSSION / BRUISES
CLASSIFICATION
• 1ST DEGREE: ECHYMOSIS – DAMAGE TO
CAPILLARIES TO SKIN AND SUBCUTANEOUS
TISSUE
• 2ND DEGREE: HEMATOMA- DAMAGE TO
LARGER VESSELS
• 3RD DEGREE :TISSUE/ORGAN DAMAGE,
MAY CAUSE GANGRENE AND SHOCK
 SURGICAL WOUND CLASSIFICATION
CLASS I: CLEAN
• NON TRAUMATIC, NO INFLAMMATION,
• INTACT TECHNIQUES, GU/GIT/RESP TRACTS NOT BREACHED
EG. : LUMP EXCISION
CLASS II: CLEAN CONTAMINATED
• NON TRAUMATIC
• MINOR BREAK IN TECHNIQUES
• TRACTS BREACHED WITHOUT SPILLAGE
EG. : APPENDICECTOMY
CLASS III: CONTAMINATED
• FRESH TRAUMATIC WOUND
• MAJOR BREAK IN TECHNIQUES
• TRACTS ENTERED WITH SPILLAGE
EG. : OPEN FRACTURE
 LEG ULCER CLASSIFICATION
ULCER:
• A LESION THAT IS ERODING AWAY THE SKIN OR
MUCOUS MEMBRANE USUALLY COMPLICATED BY
DELAYED HEALING OR RECURRENCE

VENOUS STASIS ULCER

• ASSOCIATED WITH VARICOSE VEINS
• BELOW THE KNEE, INNER PART OF LEG JUST ABOVE
ANKLE
• BORDER: IRREGULAR, DISCOLORED SURROUNDING
SKIN, SWELLING
• BASE: RED COVERED BY YELLOWISH FIBROUS TISSUE
 CLOSED / INTERNAL WOUND
NEUROTROPHIC ULCER
ASSOCIATED WITH DIABETES MELLITUS
PRESSURE AREAS AT PLANTAR ASPECT OF
FOOT
BORDER: PUNCHED OUT, CALLOUSITY
BASE: VARIABLE: PINK/BROWN/BLACK
ARTERIAL ULCER
ON THE FEET: HEEL, TIP OF TOES, NAILBED
BORDER: PUNCHED OUT
BASE: GREY/ BROWN/ BLACK
PAINFUL ESPECIALLY AT NIGHT
 BURNS
1ST DEGREE: FIERY RED, VERY PAINFUL, NOT BLISTERED
2ND DEGREE : PARTIAL THICKNESS, EXTEND TRU EPIDERMIS AND
DERMIS, FULL HEALING EXPECTED
3RD DEGREE: FULL THICKNESS, EXTEND TRU DERMIS AND
SUBCUTANEOUS LAYER. HAIR FOLLICLES/ SWEAT AND SEBACEOUS
GLANDS DAMAGED. HEALING TRU SCAR FORMATION
4TH DEGREE: COMPLETE BURNS EXTEND TO SUBCUTANEOUS TISSUE,
MUSCLE, FASCIA OR BONE MAY CAUSE SYSTEMIC TOXICITY,
INFECTION/SEPSIS
 DIABETIC FOOT ULCER
GRADE 0 (PRE OR POST ULCERATIVE LESION)
GRADE 1 (PARTIAL/ FULL THICKNESS ULCER, I.E. SUPERFICIAL
ULCER)
GRADE 2 (PROBING TO TENDON OR CAPSULE, I.E. DEEP
ULCER)
GRADE 3 (PRESENCE OF OSTEOMYELITIS)
GRADE 4 (PARTIAL FOOT GANGRENE)
GRADE 5 (WHOLE FOOT GANGRENE)
 Diabetic foot ulcer

• GRADE 0 (PRE OR POST ULCERATIVE ULCER THAT HAS HEALED)

• GRADE 1 (SUPERFICIAL WOUNDS NOT INVOLVING TENDON, CAPSULE OR BONE)
• GRADE 2 (WOUND PENETRATING TO TENDON OR CAPSULE)
• GRADE 3 (WOUND PENETRATING BONE OR JOINT)

WITHIN EACH GRADE, THERE ARE 4 STAGES

• A (CLEAN WOUNDS)
• B (NON ISCHEMIC INFECTED WOUNDS)
• C (ISCHEMIC NON INFECTED WOUNDS)
• D (ISCHEMIC INFECTED WOUNDS)
 GOLDEN PERIOD FOR WOUND REPAIR
THE ACCEPTED INTERVAL FROM INJURY TO WOUND CLOSURE IS UP TO
6 HOURS FOR WOUNDS TO THE EXTREMITIES AND UP TO 24 HOURS
FOR FACE AND SCALP WOUNDS.
Tetanus-Prone Wounds
• Age of wound greater than 6 hours
• Stellate wound or avulsion
• Depth of wound greater than 1 cm, mechanism of injury is a missile,
crush, burn, or frostbite
• Signs of infection are present
• Devitalized tissue is present
• Presence of contaminants (dirt, feces, soil, or saliva)
• Presence of denervated or ischemic tissue
 FACTORS AFFECTING WOUND HEALING
HEALING IS INFLUENCED BY SYSTEMIC CONDITIONS OR BY LOCAL
CONDITIONS IN THE WOUND
Systemic In general,
Local remember
▪ Age and gender
▪ Ischemia “DIDN'T HEAL”
▪ hormones
▪ Infection D = Diabetes
▪ Stress I = Infection
▪ Foreign body D = Drugs:
Stages of wound healing
▪ Ischemia
▪ Edema, elevated tissue N = Nutritional
▪ Diseases problems
▪ pressure T = Tissue necrosis
▪ Obesity H = Hypoxia
▪ Medication E = Excessive tension
on wound edges
▪ Alcoholism and smoking A = Another wound
▪ Immuno-compromised L = Low temperature
▪ conditions
▪ Nutrition
 ideal wound dressing
Dressings are applied to wounds for the In addition an ideal dressing have the
following reasons; following features;
• To provide a protective cover • does not induce pain or itching
• To maintain moisture • easy to change
• Allows gaseous exchange
• To reduce pain • Cheap
• To absorb exudates • Freely available

Types of Wound Dressings

❑ Gauze dressings
❑ Tulle
❑ Hydrocolloid dressings
❑ Hydrogel dressings
❑ Alginate dressings
❑ Foam dressings
❑ Transparent film dressings
❑ Etc
 MATERIALS AVAILABLE
✓ STAPLES : for closure of linear lacerations of the scalp, trunk, or extremities.
more rapid wound repair and lower rate of reactivity and infection.

✓ TISSUE ADHESIVES Less painful and faster than closure with sutures.
Limited to linear lacerations less than 4 Cm in length in wounds devoid of
significant tension or repetitive movement

Stages of wound healing

 MATERIALS AVAILABLE
✓ ADHESIVE TAPES Less risk of infection than either staples or sutures.

✓ TISSUE ADHESIVES Less painful and faster

than closure with sutures. Limited to linear
lacerations less than 4 Cm in length in wounds
devoid of significant tension or repetitive
movement
✓ Sugical instruments
Stages of wound
Like : healing
Surgical scissors , Forceps ,
catheters , cutters , calipers,
Dressings
• Absorption characteristics: none – films, low –
needle holders etc 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.
 DRESSINGS - AVAILABLE OPTIONS
• Collagen & chondroitin sulphate : integra
• It was initially used to safely cover large areas of burned tissue where skin needed to be
regrown. However, integra is now used far more widely as part of skin grafts in
reconstructive surgery. Integra is sometimes referred to as a dermal matrix or dermal
scaffold

Stages of wound healing

Click on the documents to open it .

 SURGICAL DRESSINGS More prospects
• Alloderm: immunologically inert, non-living, allogenic, acellular dermal
matrix With intact basement membrane prepares wound bed for grafting

The Alloderm skin substitute is essentially formed from acellular matrix

derived from a cadaveric dermis. The allodermis is processed by salt to
remove the epidermis and then extracted with a solution to remove any
Stages of wound healing
cellular material. It is then freeze-dried to render it inert
immunologically, although its basement membrane remains intact. It
has no epidermal layer. However, the acellular matrix provides a good
natural medium for fibroblast and endothelial cells to regenerate from
the neodermis.

https://www.biohorizons.com/Products/BioPlugBioStrip
 SURGICAL DRESSINGS / SKIN SUBSTITUE
• Apligraf trade: skin substitute containing collagen and seeded cells

The bilayered bioengineered skin substitute (BBSS) [Apligraf] is used for

the treatment of venous leg ulcers and diabetic foot ulcers. It has an
epidermal layer formed from human keratinocytes and a dermal layer
composed of human fibroblasts in a bovine type I collagen matrix.

https://videos-apligraf-com-prod.s3.amazonaws.com/apligraf-moa_1024.mp4
SURGICAL DRESSINGS More prospects
Tegaderm Used for simple shallow wound dressing Protects from
water loss mechanical injury and drying

Stages of wound healing

SURGICAL DRESSINGS More prospects
Tegaderm Used for simple shallow wound dressing Protects from
water loss mechanical injury and drying

Stages of wound healing

SURGICAL DRESSINGS More prospects
Indications for use
– Large wounds – Cavities – Large amount of exudate

Stages of wound healing

 SURGICAL DRESSINGS Silver Dressings
Antimicrobial to reduce bio burden of wound through slow release of silver
ion into the wound

e.g. Acticoat, Biatin Ag, Atruman Ag

Stages of wound healing

 MATERIALS More prospects
✓TRANSCYTE (ECM matrix
generated by Allogenic human
dermal fibroblasts serves As a
matrix for neodermis
generation
Stages of wound healing

ORCEL: Composite cultured skin.

Fibroblasts, keratinocytes seeded
on opposite sides of bilayered
matrix of bovine collagen.
 MATERIALS - DERMAGRAFT
✓DERMAGRAFT living
allogenic dermal
fibroblasts grown on
a degradable
scaffold. Good
Stages of wound healing
resistance to tearing
MATERIALS - More prospects

Stages of wound healing

MATERIALS - More prospects
 MATERIALS - BIOLOGIC DRESSINGS
✓HONEYSOFT
Natural dressing honey-impregnated
dressing chronic unhealing wounds.
Impregnated into a compress of eva
(ethylenevinylacetate) mesh
Stages of wound healing

Honey cleans the wound without disturbing it Removing

the dressing causes no damage no known side effects
 WOUND HEALING PHYSIOLOGY
WOUND HEALING IS A PHYSIOLOGIC PROCESS IN WHICH THE SKIN OR ORGAN OR
TISSUE REPAIRS ITSELF AFTER INJURY.
Skin healing goes through 4 phases in order as follow:
MATERIALS - BIOLOGIC DRESSINGS

Stages of wound healing

 WOUND HEALING PHASES

Stages of wound healing

 WOUND HEALING

Stages of wound healing

WOUND APPEARANCE & treatment

Stages of wound healing

MARKET OF WOUND DRESSING

Stages of wound healing

MARKET OF WOUND DRESSING

Stages of wound healing

MARKET TOP 5 COMPETITORS:

Stages of wound healing

MARKET TOP 5 COMPETITORS:

Stages of wound healing

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