Wounds-Wound

Healing And Care,

Surgical Infections
&SSIs
By Dr.Samuel(MD)
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presentation outline
 introduction
 classification of wounds
 methods of wound healing
 factors affecting wound healing
 wound management
 surgical infections
 SSIs

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Introduction.
 Wound. Wound is defined as a break

in the normal continuity of a tissue.

 It is caused by a transfer of any

form of energy into the body which

can be either to an externally visible
structure like the skin or deeper
structures like muscles, tendons or
internal organs.

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int.cont.
Wound classification.
1.Closed wounds.
-Have intact epithelial surface and skin
cover not completely breeched.
e.gs contusion,abrasion,hematoma.
2.Open wounds.
-Complete break of the epithelial
protective surface.
e.gs,laceration ,puncture,
penetrating,incised.degloved wound,
bites.

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 Classification of Wounds
1) Clean Wound:
Operative incisional wounds
2) Clean/Contaminated Wound:
uninfected wounds in which no inflammation is
encountered but the respiratory, gastrointestinal,
genital, and/or urinary tract have been entered.
3) Contaminated Wound:
open, traumatic wounds or surgical wounds
involving a major break in sterile technique that
show evidence of inflammation.
4) Infected Wound:
old, traumatic wounds containing dead tissue and
wounds with evidence of a clinical infection (e.g.,
purulent drainage).
 Classification depending on the time since the
trauma
 Acute wounds (mechanical and other injuries):
-Fresh wound: treatment within 8hrs.
-Old wound: ≥8hrs after trauma/discontinuity of
the skin.
 Chronic wounds (venous, arterial, diabetic
foot, Pressure ulcers and other ulcers, and
skin or soft tissue defects):
-They do not heal within 4 weeks after the
beginning of wound management.
- The majority of wounds that have not healed in
3 months are considered chronic.

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Methods of wound healing
 Healing by primary intention
 This is a type of healing of clean wound closed
primarily to approximate the ends. Healing takes
place by epithelialization and leaves minimal scar.
 Indication : recent wounds(<6hr,longer with
facial wounds),clean wounds
Contraindications:war injury, inflammation,
contamination, foreign body, animal/human
bites,shot, deep punctured wound, long
hour

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Healing by secondary intention
 This occurs in wide,
contaminated wounds, which are
not primarily closed.
 Healing takesplace by granulation

tissue formation, tissue

contraction and epithelialization.

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Healing by tertiary intention
 also referred to as delayed primary
closure
. Wounds are left open and closed
secondarily by 4 to 10 days
. Prolongation of inflammatory
phase
decreases bacterial count
Indication: contaminated
wound ,long time lapse , significant
tissue devitalisation 9
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 Wound healing is defined as the
repair or reconstruction of a defect
in an organ or tissue, commonly the
skin
◦ Physiological response – cellular
and biochemical
 but lack tissue regeneration
 Normal wound healing follows a

predictable pattern

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 The three phases of wound healing
are
A.Hemostasis and inflammation.
B.Proliferation.
C.Maturation and remodeling

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A.Hemostasis and Inflammation
• The immediate response
to injury is the
inflammatory (also called
reactive) phase which lasts
0-3 days.

• The aim is to limit damage

by
• stopping the bleeding,
• sealing the surface of the
wound,
• removing any necrotic tissue,
foreign debris, or bacteria
present.

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Roles of inflammatory mediators
 Neutrophils:

-Phagocytosis of bacteria and tissue

debris.
-Major source of cytokines early during
inflammation(TNF-; angiogenesis &
collagene synthesis).
-Release of proteases such as
collagenases.
(matrix and ground substance
degradation)

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Roles cont.
 Macrophages:

-Essential to successful healing.

-Phagocytosis
-Activation and recruitment of
other cells
-Regulate angiogenesis and
matrix deposition and remodeling.

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 Roles cont.
 Lymphocytes:

-Role in wound healing is not fully

defined.
-Bridge the transition from the
inflammatory to
the proliferative phase of healing.
-Participate in remodeling the wound
environment

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B.Proliferation.
 The second phase of wound healing and
roughly spans days 4 through 12.
 Tissue continuity is re-established.
 Fibroblasts and endothelial cells play a

role
 Characterized by angiogenesis and

matrix synthesis

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Prolif.cont.
 This is a phase during which important
events occur for healing of the
wound.
 It is characterized by fibroblast,

epithelial and endothelial proliferation,

Collagen
 synthesis, and ground substance and

blood vessel productions

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Re-epithelialization
 Begins within 1 day of injury
 primarily by proliferation and migration of

epithelial cells adjacent to the wound

 Re-epithelialization is complete in less than

48 hours in the case of approximated

incised wounds.

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C.Maturation and remodeling.
• It is characterized by a reorganization
of previously synthesized collagen.
• the net wound collagen content is the
result of a balance between
collagenolysis and collagen synthesis.
• By several weeks postinjury the
amount of collagen in the wound
reaches a plateau.

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Mat. & Rem. Cont.

 Scar remodeling
continues for many (6
to 12) months
postinjury, gradually
resulting in a mature,
avascular, and acellular
scar.

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 Factors Affecting Healing
Local :
 Ischemia and decreased O2 tension
 FB
 Infection
 Irritation by urine or fecal matter
 Mov’t
 Irradiation
 Siteof wound
 Mechanism of injury
 Loss of tissue

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Factors.cont.
Systemic:
 Age
 Malnutrition
 Ds like DM,cirrhosis,renal failure,

malignancies
 Medications:steroids,cytotoxic

agent
 Imminodef(HIV/AIDS)

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Abnormal wound healing

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NON HEALING WOUNDS
. Deficient scaring like ulcer and dehiscence
. chronic wounds(fails to close in 3 month)
. Marjolin ulcer
. Causes: DM, connective tissue disorder,
. ABNORMAL OVER HEALING
. Keloid formation-are scars that over grow the
original wound edges.
-occur mainly in dark pigmented individuals.
. Hypertrophic Scars-are scars that have not over
grown the original wound boundaries but are
instead raised.
-most common in wounds across joint surfaces on
extremities, but also commonly occur in
sternum & neck
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WOUND MANAGEMENT
GENERAL
The following priority has to be set and followed.
 •Stabilize the patient and correct all life

threatening conditions.
 Take quick general history.
 Do gross physical examination.
 Assess the wound.
 •Plan and institute treatment.
 •Follow up.

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Goal
 In all cases is to establish a good

environment to assist wound healing and

prevent infection.
Principles of wound care:
 Adequate hemostasis.
 Adequate irrigation.
 Careful debridement.
 wound closure.
 Antibiotics and TAT- prophylaxis .

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 1. Local wound care
 Assessment of wounds.
- determination of the mechanism of injury.
-age of injury.
-identification of possible contamination &
Forign b.
-extent of wound & configuration of the
wound.
-ass neurovascular or tendon injury.
-need of tetanus px.

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Wound preparation .

irrigation helps in:

-

-to visualize areas of the wound.

- to remove Fb. normal sine
-foreign body removal.
- necrotic tissue debridement.
- evacuation of hematoma.
-haemostasis
-wound closure.
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 2.Antibiotic
Must be based on-organisms suspected
-patients immune status.
-location of the wound.
-quality of tissue perfusion.
• Antibiotics should be used only when there is
an obvious wound infection.
• Indiscriminate use of antibiotics should be

avoided to prevent emergence of multidrug-

resistant bacter

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 3.Dressing.
 Purposes:

-maintaining a moist clean

environment.
-prevent pressure and mechanical
trauma.
- reduce edema
-stimulates repair.
- comfort and aesthetic appearance

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 SPECIFIC WOUND MANAGEMENT
Bruises
 - compress and analgesics if pain is severe.

Hematoma is a collection of
extravasated blood in the soft tissues
- Local compress to alleviate pain.
- Aseptic evacuation or aspiration only if
very large (expanding) or over a cosmetic area
or leading to compression of vital structures.

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 Abrasion-is rubbing or scraping of skin or
mucous membrane.
 - Cleanse using scrubbing brushes
 - Use antiseptic or lean tap water and soap
 - Analgesic
 Punctures
 These may be compound wounds which

involve deeper structures.

 -Evaluate the depth of damage
 -Remove pricking or other foreign bodies
 -Excise damaged tissue
 -Cover with antibiotics
 -Tetanus prophylaxis
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 Lacerations
 These are open wounds caused by an object moving
across the skin, commonly by sharp
 and thin objects which slice with minimal energy, like
a knife, or glass, but can also be due to
 high-energy impact.
 Management:
 - Careful inspection
 - Adequate cleansing
 - Closure, if feasible, under appropriate anesthesia
 - Proper wound debridement if needed
 - Appropriate antibiotic prophylaxis
 - Tetanus Prophylaxis
 - Analgesics as needed
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 Crush and avulsion wounds
 These are compound complicated wounds. They
are usually associated with systemic
 involvement and have more extensive damage

than may appear.

 Management:
 - Correct associated life threatening conditions
 - Proper wound debridement
 - Early skin cover if possible or late graft,

wound left open if contaminated

 - Appropriate antibiotics
 - Tetanus Prophylaxis
 - Analgesics as needed

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 BITES
Human bites
- Take culture from wound site
 Thorough scrubbing and liberal irrigation with

saline or plain water.

 Adequate debridement
 Leave wound open except early face and head

wounds
 Do not suture severed tendons and nerves primarily
 Broad-spectrum antibiotics, later, specific

antibiotics- culture result

 - Tetanus Prophylaxis
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 Dog bites
 Local management:
 Vigorous irrigation and repeated swabbing and

flushing with soap and water or antiseptics

 Local anti-rabies serum infiltration under the

wound if available
- Leave wound open
 Systemic management:
 Post exposure anti rabies prophylaxis (1ml, IM) on

the 1st, 3rd, 7th, 14th and 28th day of bite.

 Tetanus prophylaxis
 - Antibiotics
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WOUND COMPLICATIONS
Local:
 Hematoma
 Seroma
 Infection
 Dehiscence
 Granuloma formation
 Scar formation
 Contracture

Systemic:
 Death may occur if un controlled sepsis or hemorrhage
 Systemic manifestations of hemorrhagic shock due to massive

bleeding
- Bacteremia and sepsis from a source of locally infected wound

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 Snake Bites
First aid measures:
 Local wound irrigation
 - Apply pressure bandage proximally to avoid or

reduce venom spread with caution on the blood

supply
 Immobilize the limb to minimize venom absorption
 Transport patient immediately to nearby hospital
 Hospital Measures:
 Identify the species
 Conduct necessary laboratory investigations like

hemoglobin, renal function...

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 Anti-venom injection, if available
 Supportive care for severe conditions
 Rest
 IV-infusions to combat shock Antibiotics
 Blood transfusion
 Tetanus Prophylaxis
 Surgery, if local complications
 Wound excision

- Fasciotomy for compartment syndrome

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SURGICAL INFECTIONS
Introduction
 Surgical infection defined broadly as an
infection related to or complicating a
surgical therapy and requiring surgical
management..
 Examples of infections, which definitely

need surgery, can be:

 - Gas gangrene
 - Abscess
 - Appendicitis...

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 Any infection that is related to surgical
therapy but that may not definitely
require surgery is also categorized as a
surgical infection.
 Examples:
 - Urinary tract infections after

catheterization for surgical purpose

 - Pulmonary complications following

intubation for surgery

 - Tracheotomy site infection
 All wounds that follow operative

procedure or incision are also grouped as

surgical 44
Factors contributing to surgical infections
Local factors:
 injury of skin or mucosa
 duct obstruction
 poor blood perfusion and oxygen supply
 skin or mucosa diseases
Systemic factors:
 Metabolic: malnutrition (including obesity),
diabetus, uremia, jaundice
 Disseminated disease: cancer, AIDS, severe
disease
 Iatrogenic: radiotherapy, chemotherapy,
steroides
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 Abscess
 An abscess is a localized collection of pus. It
contains necrotic tissue and suppuration
from damage by the bacteria, and white
blood cells. It is surrounded by area of
inflamed tissue due to the body’s response to
limit the infection.
 Etiology:
 Pyogenic organisms, predominantly

staphylococci are the leading causes. These

organisms lead to tissue necrosis and pus
formation.

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 Clinical features:
 Clinical features of inflammation
when superficial (Heat, pain, edema,
redness and loss of function)
 Local fluctuation if superficially

located.
 Spontaneous discharge and sinus

formation
 Systemic manifestations like fever,

sweating, tachycardia
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 Treatment of Abscesses
 Abscesses should be drained
 If the abscess has a lot of cellulitis around

it, an antibiotic is probably needed

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 Cellulitis
 Cellulitis is an inflammation of the subcutaneous
tissue characterized by invasion without
 definite localization. Thin exudate spreads through

the cleavage planes of tissue spaces. It

 usually involves the extremities and identifiable

portal of entry is detectable.

 Etiology: The most common etiologic organisms

are
 - Beta hemolytic streptococci
 - Staphylococci
 - Clostridium perfringens

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Clinical Features:
 There is usually an identifiable portal of entry which can

be a surgical wound, puncture site, skin ulcer or

dermatitis. Other features include:
 - Local signs of inflammation, which may be very intense
 - Poorly defined brown-red edema
 - Central necrosis and suppuration may occur late in

some complicated cases

 - Systemic signs of bacteremia and toxemia due to

spread and toxin release

 Management:
 - Rest to limit spread of infection and pain
 - Elevation of the involved limb
 - Hot, wet pack
 - High dose broad spectrum antibiotics IV

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 Management:
- Rest to limit spread of infection and pain
- Elevation of the involved limb
- Hot, wet pack
 High dose broad spectrum antibiotics IV

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 Pyomyositis is an acute bacterial infection
of skeletal muscles with accumulation of pus
in the intra-muscular area.
It usually occurs in the lower limbs ites include
the (thigh, calf and gluteal muscles) and trunk
spontaneously or following penetrating wounds,
vascular insufficiency, trauma or injection.
Predisposing factors  
 immunodeficiency, trauma, injection drug

use, concurrent infection, and malnutrition

 Etiology: The most common causative agent is

Staphylococcus aureus. Streptococci can

 also be detected in acute form.

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Clinical Features: It usually has sub-acute
onset and can present with
 Localized muscle pain and swelling, late

tenderness
 Induration, erythema and heat
 Muscle necrosis due to pressure
 Fever and other systemic manifestations

later after some days

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 Pyomyositis can be divided into three
clinical stages
 Stage 1 is characterized by crampy local

muscle pain, swelling, and low-grade

fever. Mild leukocytosis and induration of
the affected muscle may be present.
 Stage 2 occurs 10 to 21 days after the

initial onset of symptoms and is

characterized by fever, exquisite muscle
tenderness, and edema.
 Marked leukocytosis is usually present.

More than 90%t of the pts present at this

stage. 54
 Stage 3 is characterized by systemic
toxicity.
 The affected muscle is fluctuant.
 Complications of S. aureus bacteremia

such as septic shock, endocarditis, septic

emboli, pneumonia, pericarditis, septic
arthritis, brain abscess, and acute renal
failure can occur
Treatment
 Immediate IV antibiotics before surgery
 Surgical drainage of all abscess
 Excision of all necrotic muscles
 Supportive 55
 Surgical Site Infections
 SSIs are infections of the tissues, organs, or
spaces exposed by surgeons during
performance of an invasive procedure
 The United States Centers for Disease

Control and Prevention (CDC) has

developed criteria for defining SSIs
 These criteria define SSIs as infections

related to the operative procedure that

occurs at or near the surgical incision
within 30 days of an operative procedure or
within one year if an implant is left in place.
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The clinical criteria used to define a SSI
include any of the following:
 A purulent exudate draining from a

surgical site
 A positive fluid culture obtained from

a surgical site that was closed

primarily
 The surgeon's diagnosis of infection
 A surgical site that requires reopening

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Classification cont…
 Major SSI: a wound that either

discharges significant quantities of

0
pus spontaneously or needs a 2
procedure to drain it.
 The patient may have systemic signs

such as tachycardia, pyrexia and a

raised white count [systemic
inflammatory response syndrome
(SIRS)]
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60
 Minor SSIs may discharge pus or
infected serous fluid but not
associated with excessive discomfort,
systemic signs or delay in return
home.

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 Surgical Wound Classification and Subsequent
Risk of Infection (If No Antibiotics Used)*

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 Pathogenesis
 The development of SSIs is related to
three factors:
(a) the degree of microbial
contamination of the wound during
surgery,
(b) the duration of the procedure,
and
(c) host factors

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Risk Factors for Development of SSIs
 Patient factors   

-Older age  
-Immunosuppresion  
  -Obesity   
-Diabetes mellitus   
-Malnutrition   
-Peripheral vascular disease   
-Anemia   
-Radiation   
-Recent operation
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 Local factors   
-Poor skin preparation  
- Contamination of instruments   
-Inadequate antibiotic prophylaxis
  
-Prolonged procedure  
-Local tissue necrosis   
-Hypoxia, hypothermia

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Microbial factors   
-Prolonged hospitalization
(leading to nosocomial
organisms)   
-Toxin secretion   
-Resistance to clearance
(e.g., capsule formation)

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Clinical manifestations and diagnosis
The diagnosis of wound infection is clinical.
 Symptoms include:

- localized erythema,
- induration,
- warmth, and
-pain at the incision site.
 Purulent wound drainage and separation of

the wound may occur.

 Some patients will have systemic evidence of

their infection such as fever and leukocytosis.

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Common pathogens in surgical patients

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Anaerobes Gram-positive
 Clostridium difficile
 Clostridium perfringens,
 C. tetani,
 C. septicum
 Peptostreptococcus spp.

Other bacteria
 Mycobacterium avium-intracellulare
 Mycobacterium tuberculosis

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70
 PRINCIPLES of TREATMENT
 Prevention
 Surgical Treatment

 Surgical drainage of localized collection of

pus and all dead and devitalized tissue
 Excision of infected organs and extremities
 Bypassing an area of infection
 Antibiotic therapy
 Immunotherapy
 Prophylactic antibiotic therapy

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Thank you!!

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