GYÖRGYI SZABÓ ASSISTANT PROFESSOR DEPARTMENT OF SURGICAL RESEARCH AND TECHNIQUES Classification and management of wound, principle of wound healing, haemorrhage and bleeding control Basic Surgical Techniques, Faculty of Medicine, 3rd year 2021/13 Academic Year, Second Semester 1

WOUND 2

What is a wound? 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 3

Parts of the wound Wound edge Wound corner Surface of the wound Base of the wound Cross section of a simple wound Skin surface Subcutaneus tissue Superficial fascia Muscle layer Base of the wound Wound edge Surface of the wound Wound cavity 4

The ABCDE in the injured assessment 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 5

Wound management - anamnesis 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 6

Classification of the accidental wounds 1. Based on the origine I. Mechanical:  1. Abraded wound (vulnus abrasum)  2. Puncured wound (v. punctum)  3. Incised wound (v. scissum)  4. Cut wound (v. caesum)  5. Crush wound (v. contusum)  6. Torn wound (v. lacerum)  7. Bite wound (v. morsum)  8. Shot wound (v. sclopetarium) II. Chemical:  1. Acid  2. Base III. Wounds caused by radiation IV. Wounds caused by thermal forces:  1. Burning  2. Freezing V. Special 7

1.) Abraded wound (v. abrasum) 1.) Abraded wound (v. abrasum) 2.) Punctured wound (v. punctum) 2.) Punctured wound (v. punctum) Superficial part of the epidermal layer Good wound healing Sharp-pointed object Seems negligible BUT Anaerobic infection Injury of big vessels and nerves Mechanical wounds 8

3.) Incised wound (v. scissum) 3.) Incised wound (v. scissum) 4.) Cut wound (v. caesum) Sharp object Best healing Sharp object + blunt additional force Edges - uneven Mechanical wounds 9

5.) Crush wound (v. contusum) 5.) Crush wound (v. contusum) 6.) Torn wound (v. lacerum) 6.) Torn wound (v. lacerum) Blunt force Pressure injury Edges – uneven and torn Bleeding Great tearing or pulling Incomplete amputation Mechanical wounds 10 (v. lacerocontusum)

7.) Shot wound (v. scolperatium) Close - burn injury Foreign materials Mechanical wound 11 unijured tissue necrobiotic zone necrotic zone foreign bodies aperture slot tunel output

8.) Bite wound (v. morsum) Ragged wound Crushed tissue Torn Infection Bone fracture Prevention of rabies Tetanus profilaxis Mechanical wounds 12

Distal Proximal The wound healing is good The direction of the flap 13

1.) Acid 2.) Base in small concentration – irritate in large concentration – coagulation necrosis colliquative necrosis Chemical wounds 14

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 radiation 15

1.) Burning 2.) Freezing a – normal skin st degree – superficial injury (epidermis) 2 – 2 nd degree –partial or deep partial thickness (epidermis+superficial or deep dermis) 3 – 3 rd degree – full thickness (epidermis + entire dermis) 4 – 4 th degree – (skin + subcutaneous tissue + muscle and bone) Treatment: Cooling – cold water and clean covering Wounds caused by thermal forces 16 Metabolic change! - toxemia mild, moderate, severe (redness, bullas, necrosis) rewarm – not only the frozen area but the whole body

Exotic, poisonous animals Toxins, venom - toxicologist Skin necrosis Special wounds 17

Classification of the wounds 2. According to the bacterial contamination Clean wound Clean-contaminated wound Contaminated wound Heavily contaminated wound 18

Superficial Partial thickness Full thickness Deep wound Classification of the wounds 2. Depending on the depth of injury + bone, opened cavities, organs…etc. 19 source:

Wound management - history 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 20

Applied wound management - colour continuum black black-yellow yellow yellow-red red red-pink pink 21 source: Applied wound management supplement –

Applied wound management infection continuum contamination colonisationinfectionsterility critical colonisation 22 the quantity and diversity of microbes source: Applied wound management supplement –

Applied wound management exudate continuum volumehigh - 5medium - 3low - 1 high - 5 medium -3 low - 1 Viscosity 23 source: Applied wound management supplement –

The wound managemanet 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 24

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 Surgical incision Stretch and fix Handling the scalpel Langer lines Skin edges Vessels and nerves Hemostasis Langer lines The wound edges Handling the scalpel 26 source: ars.it/galleries/langer.htm

Tissue unifying and dressing the wound 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 27

The wound healing Hemostasis-inflammation Granulation-proliferation Remodelling capillaries fibroblasts lymphocytes macrophages neutrophyl gr. thrombocytes

The main steps of the wound healing 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 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 Healing by primary intention Healing by secondary intention Healing by tertiary intention 30 source: and-repair-flash-cards/

Factors affecting wound healing Local  Ischemia  Infection  Foreign body  Edema, elevated tissue pressure Systemic  Age and gender  Sex hormones  Stress  Ischemia  Diseases  Obesity  Medication  Alcoholism and smoking  Immunocompromised conditions  Nutrition Hyperbaric oxygen treatment 31 infection ischemia foreign bodies edema/ elevated tissue pressure I MPAIRED HEALING

Complications of wound healing I. Early complications Seroma Hematoma Wound disruptin Superficial wound infection Deep wound infection Mixed wound infection 32

1.) Seroma2.) Hematoma Filled with serous fluid, lymph or blood Fluctuation, swelling, redness, tenderness, subfebrility TREATMENT: Sterile punture and compression Suction drain Early complications of wound healing 33 Bleeding, short drainage time, anticoagulant Risk of infection Swelling, fluctuation, pain, redness TREATMENT Sterile puncture Surgical exploration

3.) Wound disruption A. partial – dehiscenece B. complete - disruption A. partial – dehiscenece B. complete - disruption Surgical error Increased intraabdominal pressure Wound infection Hypoproteinaemia TREATMENT: U-shaped sutures Early complications of wound healing 34

1.) Diffuse 2.) Localized Located below the skin TREATMENT Resting position Antibiotic Dermatological consultation Anywhere TREATMENT Surgical exploration Drainage X-ray examination Early complications of wound healing Superficial wound infection 35 e.g. erysipelas e.g. abscess

1.) Diffuse 2.) Localized TREATMENT Surgical exploration Open therapy H 2 O 2 and antibiotics e.g. anaerobic necrosis Inside the tissues or body cavities TREATMENT surgical exploration drainage Early complications of wound healing Deep wound infection 36

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 37 Complications of wound healing I. Early complications

Complications of wound healing II. Late complications Hyperthrophic scar Keloid formation Necrosis Inflammatory infiltration Abscesses Foreign body containing abscesses 38

Hypertrophic scarKeloid Develop in areas of thick chorium Non-hyalinic collagen fibres and fibroblasts Confine to the incision line TREATMENT Regress spontaneously (1-2 yrs) Late complications 39 Mostly African and Asian population Well-defined edge Emerging, tough structure Overproliferation of collagen fibers in the subcutaneous tissue Subjective complains TREATMENT Postoperative radiation Corticosteroid + local anaesthetic injection

BLEEDING AND HEMOSTASIS 40

Anatomical Diffuse  Arterial – bright red, pulsate  Venous – dark red, continuous  Capillary – can become serious  Parenchymal Bleeding 41

Bleeding Severity of bleeding – the volume of the lost blood and time 42 source:

The direction of hemorrage External Internal  In a luminar organ (hematuria, hemoptoe, melena)  In body cavities (intracranial, hemothorax, hemascos, hemopericardium, hemarthros)  Among the tissues (hematoma, suffusion) 43

Bleeding 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 44

Local General Hematoma, suffusion, ecchymosis Compression in the pleural cavity, in pericardium, in the skull Functional disturbancies – e.g. hyperperistalsis Pale skin, cyanosis, decreased BP. and tachycardia, difficulty in breeding, sweeting, decreased body temperature, unconsciousness, cardiac and laboratory standstill, laboratory disorders, signs of shock Signs of the bleeding 45

Surgical hemostasis Aim – to prevent the flow of blood from the incised or transected vessels Mechanical methods Thermal methods Chemical and biological methods 46

Surgical hemostasis Mechanical methods Digital pressure – direct pressure, e.g. Pringle maneuver Tourniquet Ligation Suturing Preventive hemostasis Clips Bone wax other 47

Thermal methods Low temperature  Hypothermia – eg. stomach bleeding  Cryosurgery  dehidratation and denaturation of fatty tissue  decreases the cell metabolism  vasoconstriction 48

Thermal methods High temperature  Electrosurgery – electrocauterization  Monopolar diathermy  Bipolar diathermy  Laser surgery coagulation and vaporization for fine tissues 49

Thermal methods High temperature  Electrocoagulation  Electrofulguration (A)  Electrodessication  Electrosection 50

Hemostasis with chemical and biological methods vasoconstriction coagulation hygroscopic effect Absorbable collagen Absorbable gelatin Microfibrillar collagen Oxidized celluloze Oxytocin Epinephrine Thrombin Hemcon QuikClot 51

Hemostasis with chemical and biological methods HemCon 52