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MANAGEMENT OF
WOUNDS
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OUTLINES

*local care
*Antibiotics
*Dressing
*Mechanical Device
*Skin replacement
*skin substitution
*Growth factor therapy
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Wound Class Examples of Cases Expected Infection Rates

Clean (class I) Hernia repair, breast 2%

biopsy

Clean/contaminated Cholecystectomy, elective 2-5%

GI surgery (not colon)
(class II)
Clean/contaminated (class Colorectal surgery 10-15%
II)

Penetrating abdominal
trauma, large tissue
Contaminated injury, enterotomy during
(class III) bowel obstruction

Perforated diverticulitis,
necrotizing soft tissue 30-40%
Dirty (class IV) infections
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CONT…
• management of acute wounds begins with obtaining a careful
history of the events surrounding the injury.
• The history is followed by a meticulous examination of the wound
*should asses
.Depth and configuration of the wound
.Extent of nonviable tissue
.Presence of foreign bodies and other contaminants
• may require irrigation & debridement of the edges of the wound,
and is facilitated by use of L.A
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• Antibiotic administration and tetanus prophylaxis

may be needed
• planning the type and timing of wound repair should take place
• After hx, exm and admn of tetanus prophylaxis, the wound should
be anesthetized:
--Lidocaine(0.5-1%) or
--Bupivacaine(0.25-0.5%)
combined with a1:100,000 to 1:200,000 dilution of Epinephrine
provides Anesthesia and hemostasis
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• N.B Epinephrine should not be used in wounds of the fingers, toes,

ears ,nose or penis
=> risk of tissue necrosis secondary to terminal arteriole
vasospasm in these structures
• Injection of the anesthetics can result in significant initial patient
discomfort
=> can be minimized by
*slow injection
*infiltration of the subcutaneous tissue
*buffering the solution with sodium bicarbonate
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• Irrigation to visualize all areas of wound and remove foreign

material is best accomplished with normal saline
• High pressure wound irrigation is more effective in achieving
complete debridement of foreign materials and nonviable tissues
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• All hematomas present within wounds should be evacuated

• Any remaining bleeding sources should be controlled with ligature
or cautery
• Injury → formation of a marginally viable flap of skin or
tissue
→resected or revascularized prior to further
wound repair and closure

*After all the above things are done ,the area

surrounding the wound should be cleaned
,inspected and the surrounding hair clipped
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• Having insured hemostasis and adequate debridement of nonviable

tissue and removal of any remaining foreign bodies,
• irregular,macerated,or bevealed wound edges should be debrided
=> to provide a fresh edge of
reapproximation
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• In general, the smallest suture required to hold z various layers of

the wound in approximation should be selected

=>minimize suture – related inflammation

=>nonabsorbable /slowly absorbing monofilament

sutures – deep fascial layers, particularly in
abdominal wall

=>Braided absorbable sutures

-subcutaneous tissues with care to avoid
placement of sutures in fat
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• In areas of significant tissue loss

- rotation of adjacent musculocutaneous flaps may
be required to provide sufficient tissue mass for closure
• May be based upon intrinsic blood supply, or
may be moved from distal sites as free flaps & anastomosed into
the local vascular bed
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In areas with significant superficial tissue loss, split thickness skin
grafting may be required
 Will speed formation of an intact epithelial barrier to fluid loss &
infection

NB: It is essential to ensure hemostasis of the underlying tissue

bed prior to placement of split thickness skin grafts
 Prevent the graft from taking, resulting in, sloughing of the graft
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• After closing deep tissues and replacing significant

tissue deficit, skin edges should be reapproximated
*Cosmoses
*Aid in rapid wound healing

*Stainless steel staples or nonabsorbable monofilament

sutures can be used

*prior to epithelization the suture must be removed

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• Failure to remove the suture or staples prior to 7 to 10days after

repair will result in a cosmetically inferior wound

• Where wound cosmoses is important ,buried dermal suture like

absorbable braided sutures can be used
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ROLE OF ANTIBIOTICS IN WOUND

MANAGEMENT
• Should be used only when there is an obvious
wound infection Signs of infection to look for
include:
• Erythema
• Swelling and
• Purulent discharge
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ANTIBIOTICS…
• Indiscriminate use of antibiotics should be avoided to prevent
emergence of multidrug resistant bacteria

• Antibiotic treatment of acute wound must be based upon

organisms suspected to be found within the infected wound and the
patient’s overall immune status
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III. DRESSINGS
• The main purpose of dressing is to provide the ideal
environment for wound healing
Desired characteristics of wound dressings
*promote wound healing (maintain moist
environment)
*Conformability
*Pain control
*Odor control
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CONT……
• Non allergenic and nonirritating
• Permeability to gas
• Safety
• Non traumatic removal
• Cost effectiveness
• Convenience
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CONT…..
• Covering a wound with a dressing
• Mimics the barrier role of epithelium and prevents further damage
• Provides hemostasis and limits edema
• Controls the levels of hydration and oxygen tension within the wound
• Allows transfer of gases and water vapor from the wound surface to the
atmosphere
• Helps in dermal collagen synthesis & epithelial cell migration and limits
tissue desiccation
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• =>Exposed wounds are more inflamed and develop more necrosis

than covered wounds

• Contraindications
• in infected and highly exudative wounds
• may enhance bacterial growth
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TYPES OF DRESSINGS

*are designed to achieve certain clinically desired end points

A/ Absorbent dressings
-Accumulation of wound fluid can lead to maceration and bacterial
overgrowth
-Should absorb with out getting soaked through , as this wound
permit bacteria from outside to enter the wound
-Include cotton, wool & sponge
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B/ NON ADHERENT DRESSINGS

• Impregnated with
• Paraffin
• Petroleum jelly or
• Water soluble jelly for use as noadherent coverage
=> A secondary dressing must be placed on top to seal the edges and prevent
desiccation and infection
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C/ OCCLUSIVE AND SEMI OCCLUSIVE

DRESSINGS

• Provide a good environment for clean, minimally exudative wounds

• Waterproof and impervious to microbes

• Permeable to water vapour and oxygen

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D/ HYDROPHILIC AND
HYDROPHOBIC DRESSINGS

• Components of a composite dressing

• Hydrophilic
• Aids in absorption

• Hydrophobic
• Water proof and prevents absorption
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E/ HYDROCOLLOID AND
HYDROGEL DRESSINGS
• Attempt to combine the benefits of occlusion and absorbency
• Form complex structures with water, and fluid absorption occurs with
particle swelling
• Aids in atraumatic removal of the dressing
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F/ ALGINATES
• are derived from brown algae
• Contain long chains of polysaccharides containing
mannuronic and glucuronic acid
• Turn into soluble sodium alginate through ion
exchange in the presence of wound exudates
• The polymers gel, swell and absorb a great deal of
fluid as they come in contact with the wound exudates
• Used in
• Skin loss
• Open surgical wounds with medium exudation
• Full thickness chronic wounds
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G/ ABSORBABLE MATERIALS
• Mainly used within wound as hemostats
• Include
• Collagen
• Gelatin
• Oxidized cellulose
• Oxidized regenerated cellulose

H/ Medicated dressings
-Used as a drug delivery system
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IV. MECHANICAL DEVICES

• Mechanical therapy augments and improves on certain functions of

dressings
• Absorption of exudates and
• Control of odor