Classification and management of

wound, principle of wound healing,

haemorrhage and bleeding control
1

GYÖRGYI SZABÓ
ASSISTANT PROFESSOR

DEPARTMENT OF SURGICAL
RESEARCH AND TECHNIQUES

Basic Surgical Techniques, Faculty of Medicine, 3rd year

2021/13 Academic Year, Second Semester
 2

WOUND
 What is a wound?
3

 It is a circumscribed injury which is caused by an external

force and it can involve any tissue or organ.
surgical, traumatic
It can be mild, severe, or even lethal.

Simple wound
Compound wound

Acute
Chronic
 Parts of the wound
4
Wound edge Wound
corner
Surface of
the wound

Base of the wound

Cross section of a simple wound

Wound edge
Wound Skin surface
cavity
Surface of Subcutaneus tissue
the wound
Superficial fascia
Muscle layer
Base of the wound
 The ABCDE in the injured assessment
5

The mnemonic ABCDE is used to remember the order

of assessment with the purpose to treat first that kills
first.

 A: Airway and C-spine stabilization

 B: Breathing
 C: Circulation
 D: Disability
 E: Environment and Exposure
 Wound management - anamnesis
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When and where was the wound occured?

Alcohol and drug consumption
What did caused the wound?
The circumstances of the injury
Other diseases eg. diabetes mellitus, tumour,
atherosclesosis, allergy
The state of patient’s vaccination against Tetanus
Prevention of rabies
The applied first-aid
Classification of the accidental wounds
1. Based on the origine
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 Mechanical wounds
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1.) Abraded wound 2.) Punctured wound

(v. abrasum) (v. punctum)
 Superficial part of the epidermal  Sharp-pointed object
layer  Seems negligible
 Good wound healing
BUT
 Anaerobic infection
 Injury of big vessels and nerves
 Mechanical wounds
9

3.) Incised wound

4.) Cut wound (v. caesum)
(v. scissum)

 Sharp object  Sharp object + blunt additional

 Best healing force
 Edges - uneven
 Mechanical wounds
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5.) Crush wound 6.) Torn wound

(v. contusum) (v. lacerum)

 Blunt force  Great tearing or pulling

 Pressure injury  Incomplete amputation
 Edges – uneven and torn
 Bleeding

(v. lacerocontusum)
 Mechanical wound
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7.) Shot wound (v. scolperatium)

 Close - burn injury

 Foreign materials

aperture output

slot tunel unijured tissue

necrobiotic zone
necrotic zone
foreign bodies
 Mechanical wounds
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8.) Bite wound (v. morsum)

 Ragged wound
 Crushed tissue
 Torn
 Infection
 Bone fracture

 Prevention of rabies
 Tetanus profilaxis
 The direction of the flap
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Distal Proximal

The wound healing is good

 Chemical wounds
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1.) Acid 2.) Base

 in small concentration – irritate  colliquative necrosis

 in large concentration –
coagulation necrosis
Wounds caused by radiation
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Symptoms and severity

depend on:
 Amount of radiation
 Length of exposure
 Body part that was exposed

Symptoms may occur immediately,

after a few days, or even as long
as months.

What part of the body is

most sensitive during
radiation sickness?

bone marrow
gastrointestinal tract
 Wounds caused by thermal forces
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1.) Burning
2.) Freezing
Metabolic change! - toxemia  mild, moderate, severe (redness,

 a – normal skin
bullas, necrosis)
 rewarm – not only the frozen area
 1 - 1st degree – superficial injury
(epidermis) but the whole body
 2 – 2nd degree –partial or deep partial
thickness (epidermis+superficial or deep
dermis)
 3 – 3rd degree – full thickness (epidermis
+ entire dermis)
 4 – 4th degree – (skin + subcutaneous
tissue + muscle and bone)

 Treatment:

 Cooling – cold water and clean covering

 Special wounds
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Exotic, poisonous animals

 Toxins, venom - toxicologist

 Skin necrosis
 Classification of the wounds
2. According to the bacterial contamination
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Clean wound
Clean-contaminated wound
Contaminated wound
Heavily contaminated wound
 Classification of the wounds
2. Depending on the depth of injury
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Superficial
Partial thickness
Full thickness
Deep wound

+ bone, opened cavities, organs…etc.

source: http://www.funscrape.com/Search/1/skin+layers.html
 Wound management - history
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 Ancient Egypt – lint (fibrous base-wound site closure), animal grease (barrier)
and honey (antibiotic)
„closing the wound preserved the soul”
 Greeks – acute wound= „fresh” wound; chronic wound = „non-healing” wound
maintaining wound-site moisture
 Ambroise Paré – hot oil  oil of roses and turpentine, ligature of arteries
instead of cauterization
 Lister pretreated surgical gauze – Robert Wood Johnson 1870s; gauze and
wound dressings treated with iodide
 Applied wound management -
colour continuum
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black black-yellow yellow yellow-red red red-pink pink

source: Applied wound management supplement – www.wounds-uk.com

 Applied wound management
infection continuum
22

the quantity and diversity of microbes

contamination critical colonisation

sterility colonisation infection

source: Applied wound management supplement – www.wounds-uk.com

 Applied wound management
exudate continuum
23

Viscosity
volume high - 5 medium - 3 low - 1
high - 5
medium -3
low - 1

source: Applied wound management supplement – www.wounds-uk.com

 The wound managemanet
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Temporary wound management (first aid)

 clean, hemostasis, covering
Final primary wound management
 clean, anaesthesis, excision, sutures
 ALWAYS: thoracic cavity, abdominal wall or dura mater injury
 NEVER: war injury, inflammation, contamination, foreign
body, special jobs,
bite, shot, deep punctured wound
Primary delayed suture (3-8 days)
 clean, wash – saline, cover
 excision of wound edges, sutures
 The wound managemanet
25

Early secondary wound closure (2 weeks)

 after inflammation, necrosis – proliferation
 anesthesia, refresh wound edges, suturing and draining
Late secondary wound closure (4-6 weeks)
 anesthesis, scar excision, suturing, draining
 greater defect – plastic surgery
 The surgical wound
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Surgical incision
Stretch and fix
Handling the scalpel
Langer lines
Skin edges
Vessels and nerves
Hemostasis
Langer lines source: http://www.med-
ars.it/galleries/langer.htm

The wound edges

Handling the scalpel

 Tissue unifying and dressing the wound
27

Skin:
Stiches
Clips
Steri-Strips
Tissue glues
Fascia and subcutaneous layers:
Interrupted stiches
Fat – fat necrosis!

Dressing: sterile, moist, antibiotic-containing, non-allergic,

non-adhesive
 The wound healing
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Hemostasis-inflammation
Granulation-proliferation
Remodelling

capillaries
fibroblasts
lymphocytes
macrophages
neutrophyl gr.
thrombocytes
0 1 2 3 4 5 6 7 8 9 10 11 10 13 14 15

http://www.worldwidewounds.com/2004/august/Enoch/images/enochfig1.jpg
 The main steps of the wound healing
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1. Hemostasis-inflammation
vasoconstriction
fibrin clot formation
proinflammatory citokines and
growth factors releasing
vasodilatation
infiltration PMNs, macrophages
cytokines releasing
→ angiogensis
→ fibroblast activation
→ B- and T-cells activation
→ keratinocytes activation
→ wound contraction
2. Granulation-proliferation
fibroblast migration
collagen deposition
angiogensis
granulation tissue formation
epithelisation
contraction
3. Remodelling
regression of many capillaries
physical contraction – myofibroblasts
collagen degeneration and synthetisation
new epithelium
tensile strength – max. 80%
 Types of wound healing
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 Healing by primary
intention

 Healing by secondary
intention

 Healing by tertiary
intention

source: http://quizlet.com/13665246/chapter-3-tissue-renewal-regeneration-
and-repair-flash-cards/
 Factors affecting wound healing
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 Local  Systemic
 Ischemia  Age and gender
 Infection  Sex hormones
 Foreign body  Stress
 Edema, elevated  Ischemia
tissue pressure  Diseases
 Obesity
Hyperbaric oxygen  Medication
treatment  Alcoholism and smoking
 Immunocompromised
conditions
infection  Nutrition

foreign IMPAIRED
ischemia
bodies HEALING
edema/
elevated
tissue
pressure
 Complications of wound healing
I. Early complications
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Seroma
Hematoma
Wound disruptin
Superficial wound infection
Deep wound infection
Mixed wound infection
 Early complications of wound healing
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1.) Seroma 2.) Hematoma

 Filled with serous fluid, lymph  Bleeding, short drainage time,

or blood anticoagulant
 Fluctuation, swelling, redness,  Risk of infection
tenderness, subfebrility  Swelling, fluctuation, pain,
redness
TREATMENT:
 Sterile punture and TREATMENT
compression  Sterile puncture
 Suction drain  Surgical exploration
 Early complications of wound healing
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3.) Wound disruption A. partial – dehiscenece

B. complete - disruption
 Surgical error
 Increased intraabdominal
pressure
 Wound infection
 Hypoproteinaemia

TREATMENT:
 U-shaped sutures
 Early complications of wound healing
Superficial wound infection
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1.) Diffuse 2.) Localized

 Located below the skin  Anywhere

TREATMENT TREATMENT
 Resting position
 Surgical exploration
 Antibiotic
 Drainage
 Dermatological consultation
 X-ray examination

e.g. erysipelas e.g. abscess

 Early complications of wound healing
Deep wound infection
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1.) Diffuse 2.) Localized

TREATMENT  Inside the tissues or body cavities

Surgical exploration TREATMENT

 surgical exploration
Open therapy  drainage

H2O2 and antibiotics

e.g. anaerobic necrosis

 Complications of wound healing
I. Early complications
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Mixed wound infection

e.g. gangrene
 necrotic tissues
 putrid and anaerobic
infection
 a severe clinical picture

TREATMENT
 aggresive surgical
debridement
 effective and specified
(antibiotic) therapy
 Complications of wound healing
II. Late complications
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Hyperthrophic scar
Keloid formation
Necrosis
Inflammatory infiltration
Abscesses
Foreign body containing abscesses
 Late complications
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Hypertrophic scar Keloid

 Mostly African and Asian
Develop in areas of thick population
chorium  Well-defined edge
Non-hyalinic collagen  Emerging, tough structure

fibres and fibroblasts  Overproliferation of collagen

fibers in the subcutaneous tissue
Confine to the incision  Subjective complains
line
TREATMENT
 Postoperative radiation
TREATMENT  Corticosteroid + local anaesthetic
Regress spontaneously injection
(1-2 yrs)
 40

BLEEDING AND HEMOSTASIS

 Bleeding
41

Anatomical Diffuse

 Arterial – bright red,  Capillary – can become

pulsate serious
 Venous – dark red,  Parenchymal
continuous
 Bleeding
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Severity of bleeding – the volume of the lost blood and

time

source: http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/
 The direction of hemorrage
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External
Internal
 In a luminar organ (hematuria, hemoptoe, melena)
 In body cavities (intracranial, hemothorax, hemascos,
hemopericardium, hemarthros)
 Among the tissues (hematoma, suffusion)
 Bleeding
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Preoperative hemorrhage
Prehospital care! – maintenance of the airways, ventillation and circulation
bandages, direct pressure, turniquets
Intraoperative hemorrhage
anatomical and/or diffuse
depending on the surgeon, the surgery, position,
the size of the vessel, pressure in the vessel
ANESTHESIA!
Postoperative bleeding
ineffective local hemostasis, undetected hemostatic defect,
consumptive coagulopathy or fibrinolysis
 Signs of the bleeding
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Local General
 Pale skin, cyanosis, decreased
 Hematoma, suffusion,
BP. and tachycardia, difficulty
ecchymosis in breeding, sweeting,
 Compression in the pleural decreased body temperature,
cavity, in pericardium, in the unconsciousness, cardiac and
skull laboratory standstill, laboratory
 Functional disturbancies – e.g. disorders, signs of shock
hyperperistalsis
 Surgical hemostasis
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Aim – to prevent the flow of blood from the incised or

transected vessels

Mechanical methods
Thermal methods
Chemical and biological methods
 Surgical hemostasis
Mechanical methods
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Digital pressure – direct pressure,

e.g. Pringle maneuver
Tourniquet
Ligation
Suturing
Preventive hemostasis
Clips
Bone wax
other
 Thermal methods
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Low temperature
 Hypothermia – eg. stomach bleeding
 Cryosurgery
 dehidratation and denaturation of fatty tissue
 decreases the cell metabolism
 vasoconstriction
 Thermal methods
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High temperature
 Electrosurgery – electrocauterization
 Monopolar diathermy
 Bipolar diathermy

 Laser surgery
coagulation and vaporization
for fine tissues
 Thermal methods
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High temperature
 Electrocoagulation
 Electrofulguration (A)
 Electrodessication
 Electrosection
 Hemostasis with chemical and biological
methods
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vasoconstriction coagulation hygroscopic effect

Absorbable collagen
Absorbable gelatin
Microfibrillar collagen
Oxidized celluloze
Oxytocin
Epinephrine
Thrombin
Hemcon
QuikClot
Hemostasis with chemical and biological
methods
52

HemCon