Györgyi Szabó Assistant Professor Department of Surgical research and Techniques

1. Classification and management of wound, principleofwoundhealing, haemorrhage and bleedingcontrol Györgyi Szabó Assistant Professor Department of Surgicalresearch and Techniques Basic SurgicalTechniques, Faculty of Medicine, 3rd year 2021/13 Academic Year, SecondSemester

2. WOUND

3. 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

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

5. 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

6. 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

7. Classification of theaccidentalwounds1. Basedontheorigine • I. Mechanical: • 1. Abradedwound (vulnusabrasum) • 2. Puncuredwound (v. punctum) • 3. Incisedwound (v. scissum) • 4. Cutwound (v. caesum) • 5. Crushwound (v. contusum) • 6. Tornwound (v. lacerum) • 7. Bitewound (v. morsum) • 8. Shotwound (v. sclopetarium) • II. Chemical: • 1. Acid • 2. Base • III. Woundscausedbyradiation • IV. Woundscausedbythermalforces: • 1. Burning • 2. Freezing • V. Special

8. Mechanical wounds 1.) Abraded wound (v. abrasum) 2.) Punctured wound (v. punctum) • Superficial part of theepidermallayer • Good woundhealing • Sharp-pointedobject • Seemsnegligible BUT • Anaerobicinfection • Injury of bigvessels and nerves

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

10. Mechanical wounds 5.) Crush wound (v. contusum) 6.) Torn wound (v. lacerum) • Bluntforce • Pressureinjury • Edges – uneven and torn • Bleeding • Great tearing or pulling • Incomplete amputation (v. lacerocontusum)

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

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

13. The direction of the flap Distal Proximal The woundhealing is good

14. Chemical wounds 1.) Acid 2.) Base • insmallconcentration – irritate • inlargeconcentration – coagulationnecrosis • colliquative necrosis

15. Wounds caused by radiation 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

16. Wounds caused by thermal forces 1.) Burning 2.) Freezing Metabolic change! - toxemia • mild, moderate, severe (redness, bullas, necrosis) • rewarm – not only the frozen area but the whole body • 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

17. Special wounds Exotic, poisonousanimals • Toxins, venom - toxicologist • Skin necrosis

18. Classification of thewounds2. Accordingtothebacterialcontamination • Clean wound • Clean-contaminated wound • Contaminated wound • Heavily contaminated wound

19. Classification of thewounds2. Dependingonthedepth of injury • Superficial • Partial thickness • Full thickness • Deep wound + bone, opened cavities, organs…etc. source: http://www.funscrape.com/Search/1/skin+layers.html

20. 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

21. Appliedwound management - colourcontinuum black black-yellow yellow yellow-red red red-pink pink source: Applied wound management supplement – www.wounds-uk.com

22. Appliedwound managementinfectioncontinuum the quantity and diversity of microbes contamination critical colonisation sterility colonisation infection source: Applied wound management supplement – www.wounds-uk.com

23. Appliedwound managementexudatecontinuum Viscosity source: Applied wound management supplement – www.wounds-uk.com

24. The wound managemanet • Temporarywound management (firstaid) • clean, hemostasis, covering • Finalprimarywound management • clean, anaesthesis, excision, sutures • ALWAYS:thoraciccavity, abdominalwallordura mater injury • NEVER:warinjury, inflammation, contamination, foreign body, specialjobs, bite, shot, deeppuncturedwound • Primarydelayedsuture (3-8 days) • clean, wash – saline, cover • excision of woundedges, sutures

25. The wound managemanet • 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

26. The surgical wound • 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

27. Tissue unifying and dressing the wound Skin: • Stiches • Clips • Steri-Strips • Tissueglues Fascia and subcutaneouslayers: • Interrupted stiches Fat – fatnecrosis! Dressing:sterile, moist, antibiotic-containing, non-allergic, non-adhesive

28. The wound healing • Hemostasis-inflammation • Granulation-proliferation • Remodelling http://www.worldwidewounds.com/2004/august/Enoch/images/enochfig1.jpg

29. 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 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%

30. Factors effecting on wound healing LOCAL Chronic inflammation Inflammatory cells  Inflammatory cytokines and IL  Wound healing needs energy Defect in wound healing infection Impairedhealing foreign bodies ischemia Glucose and oxigensupply ATP production edema/ elevated tissue pressure Elongation of inflammatory phase Endotoxin  collagenase stimulation  Collagen degration

31. Factors effecting on wound healingSYSTEMIC inflammatory and proliferativephase! slowerreepithelization • Age and gender • Diseases • Obesity • Medication • Alcoholism and smoking • Sepsis • Nutrition Neutrophyl Phagocytefunction  Sorbitol vascularcomplication, Granulation, collagenlevel Infection, dehiscence, hematoma, seroma Hemostasis, hemorheology Corticosteroid, citostatics, NSAIDs, radiation Glucose, glutamin, vitamins, traceelements diabetes

32. Types of wound healing • 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/

33. Complications of woundhealingI. Earlycomplications • Seroma • Hematoma • Wound disruptin • Superficial wound infection • Deep wound infection • Mixed wound infection

34. Early complications of wound healing 1.) Seroma 2.) Hematoma • Filled with serous fluid, lymph or blood • Fluctuation, swelling, redness, tenderness, subfebrility TREATMENT: • Sterile punture and compression • Suction drain • Bleeding, short drainage time, anticoagulant • Risk of infection • Swelling, fluctuation, pain, redness TREATMENT • Sterile puncture • Surgical exploration

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

36. Earlycomplications of woundhealingSuperficialwoundinfection 1.) Diffuse 2.) Localized • Locatedbelowtheskin TREATMENT • Resting position • Antibiotic • Dermatologicalconsultation • Anywhere TREATMENT • Surgicalexploration • Drainage • X-rayexamination e.g. erysipelas e.g. abscess

37. Earlycomplications of woundhealingDeep woundinfection 1.) Diffuse 2.) Localized TREATMENT • Surgical exploration • Open therapy • H2O2 and antibiotics e.g. anaerobic necrosis • Inside the tissues or body cavities TREATMENT • surgical exploration • drainage

38. Complications of woundhealingI. Earlycomplications Mixed woundinfection e.g. gangrene • necrotictissues • putrid and anaerobicinfection • a severeclinicalpicture TREATMENT • aggresivesurgicaldebridement • effective and specified (antibiotic) therapy

39. Complications of woundhealingII. Latecomplications • Hyperthrophic scar • Keloid formation • Necrosis • Inflammatory infiltration • Abscesses • Foreign body containing abscesses

40. Late complications HypertrophicscarKeloid • Developinareas of thickchorium • Non-hyaliniccollagenfibres and fibroblasts • Confinetotheincision line TREATMENT • Regressspontaneously (1-2 yrs) • MostlyAfrican and Asianpopulation • Well-definededge • Emerging, toughstructure • Overproliferation of collagenfibersinthesubcutaneoustissue • Subjectivecomplains TREATMENT • Postoperativeradiation • Corticosteroid + local anaestheticinjection

41. BLEEDING AND HEMOSTASIS

42. Bleeding Anatomical Diffuse • Arterial – bright red, pulsate • Venous – dark red, continuous • Capillary – can become serious • Parenchymal

43. Bleeding Severity of bleeding – the volume of the lost blood and time source: http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/

44. 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)

45. Bleeding • Preoperativehemorrhage Prehospitalcare! – maintenance of theairways, ventillation and circulation bandages, directpressure, turniquets • Intraoperativehemorrhage anatomical and/ordiffuse dependingonthesurgeon, thesurgery, position, thesize of thevessel, pressureinthevessel ANESTHESIA! • Postoperativebleeding ineffective local hemostasis, undetectedhemostaticdefect, consumptivecoagulopathyorfibrinolysis

46. Signs of the bleeding 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

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

48. SurgicalhemostasisMechanicalmethods • Digital pressure – direct pressure, e.g. Pringle maneuver • Tourniquet • Ligation • Suturing • Preventive hemostasis • Clips • Bone wax • other

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

50. Thermal methods • High temperature • Electrosurgery – electrocauterization • Monopolar diathermy • Bipolar diathermy • Laser surgery coagulation and vaporization for fine tissues