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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
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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 Skin surface
cavity
Surface of Subcutaneus tissue
the wound
Superficial fascia
Muscle layer
Base of the wound
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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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
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
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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,


bullas, necrosis)
a normal skin
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, 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 red red-pink pink

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


Applied wound management
infection continuum
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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
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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 source: http://www.med-
ars.it/galleries/langer.htm

The wound edges

Handling the scalpel


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
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 2. Granulation-proliferation
vasoconstriction fibroblast migration
fibrin clot formation collagen deposition
angiogensis
proinflammatory citokines and granulation tissue formation
growth factors releasing epithelisation
contraction
vasodilatation 3. Remodelling
infiltration PMNs, macrophages regression of many capillaries
physical contraction myofibroblasts
collagen degeneration and synthetisation
cytokines releasing
new epithelium
angiogensis tensile strength max. 80%
fibroblast activation
B- and T-cells activation
keratinocytes activation
wound contraction
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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A. partial dehiscenece
3.) Wound disruption 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)
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BLEEDING AND HEMOSTASIS


Bleeding
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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
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HemCon