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Classification and management of

wound, principle of wound healing,


haemorrhage and bleeding control
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GYRGYI SZAB
ASSISTANT PROFESSOR

DEPARTMENT OF SURGICAL
RESEARCH AND TECHNIQUES

Basic Surgical Techniques, Faculty of Medicine, 3rd year


2021/13 Academic Year, Second Semester

WOUND

What is a wound?
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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


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Wound edge

Wound
corner
Surface of
the wound
Base of the wound

Cross section of a simple wound


Wound edge
Wound
cavity
Surface of
the wound
Base of the wound

Skin surface
Subcutaneus tissue
Superficial fascia
Muscle layer

The ABCDE in the injured assessment


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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 patients 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


(v. abrasum)

2.) Punctured wound


(v. punctum)

Superficial part of the epidermal

Sharp-pointed object

layer
Good wound healing

Seems negligible

BUT
Anaerobic infection
Injury of big vessels and nerves

Mechanical wounds
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3.) Incised wound


(v. scissum)

4.) Cut wound (v. caesum)

Sharp object

Sharp object + blunt additional

Best healing

force
Edges - uneven

Mechanical wounds
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5.) Crush wound


(v. contusum)

Blunt force
Pressure injury
Edges uneven and torn
Bleeding

6.) Torn wound


(v. lacerum)
Great tearing or pulling
Incomplete amputation

(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

in small concentration irritate


in large concentration

coagulation necrosis

2.) Base
colliquative 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
Metabolic change! - toxemia
a normal skin
1 - 1st degree superficial injury

(epidermis)
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

2.) Freezing
mild, moderate, severe (redness,

bullas, necrosis)
rewarm not only the frozen area
but the whole body

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, organsetc.

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 Par 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

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

red

red-pink

pink

Applied wound management


infection continuum
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the quantity and diversity of microbes

contamination
sterility

critical colonisation

colonisation

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

infection

Applied wound management


exudate continuum
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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


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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

The wound edges


Handling the scalpel

source: http://www.medars.it/galleries/langer.htm

Tissue unifying and dressing the wound


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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
macropha
ges
neutrophyl gr.
thromboc
ytes
0
1
2
3
4 5

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10

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14

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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-regenerationand-repair-flash-cards/

Factors affecting wound healing


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Systemic

Local

Ischemia
Infection
Foreign body
Edema, elevated
tissue pressure

Hyperbaric oxygen
treatment

infectio
n
foreign
bodies

IMPAIRE
D
HEALING
edema/
elevated
tissue
pressure

ischem
ia

Age and gender


Sex hormones
Stress
Ischemia
Diseases
Obesity
Medication
Alcoholism and smoking
Immunocompromised
conditions
Nutrition

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
Fluctuation, swelling, redness,
tenderness, subfebrility

anticoagulant
Risk of infection
Swelling, fluctuation, pain,
redness

TREATMENT:
Sterile punture and
compression
Suction drain

TREATMENT
Sterile puncture
Surgical exploration

Early complications of wound healing


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3.) Wound disruption


Surgical error
Increased intraabdominal

pressure
Wound infection
Hypoproteinaemia
TREATMENT:
U-shaped sutures

A. partial dehiscenece
B. complete - disruption

Early complications of wound healing


Superficial wound infection
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1.) Diffuse

2.) Localized

Located below the skin

Anywhere

TREATMENT
Resting position
Antibiotic
Dermatological consultation

TREATMENT
Surgical exploration
Drainage
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
Surgical exploration
Open therapy
H2O2 and antibiotics

Inside the tissues or body cavities

e.g. anaerobic necrosis

TREATMENT
surgical exploration
drainage

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
Develop in areas of thick

chorium
Non-hyalinic collagen
fibres and fibroblasts
Confine to the incision
line

TREATMENT
Regress spontaneously
(1-2 yrs)

Keloid
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

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BLEEDING AND HEMOSTASIS

Bleeding
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Anatomical

Arterial bright red,


pulsate
Venous dark red,
continuous

Diffuse

Capillary can become


serious
Parenchymal

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
Hematoma, suffusion,

ecchymosis
Compression in the pleural
cavity, in pericardium, in the
skull
Functional disturbancies e.g.
hyperperistalsis

General
Pale skin, cyanosis, decreased

BP. and tachycardia, difficulty


in breeding, sweeting,
decreased body temperature,
unconsciousness, cardiac and
laboratory standstill, laboratory
disorders, signs of shock

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
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HemCon