1. Wound Care and Dressing
Presented By
Dr. Osama Kentab, MD, FAAP, FACEP
Assistant Professor of Pediatrics and emergency Medicine
King Saud Bin Abdulaziz University for Health sinces
Riyadh

2. THE SKIN

3. FUNCTIONS OF THE SKIN Regulates body temperature.
Prevents loss of essential body fluids, and penetration of toxic substances.
Protection of the body from harmful effects of the sun and radiation.
Excretes toxic substances with sweat ( waste removal).
Mechanical support.
Immunological function mediated by Langerhans cells.
Sensory organ for touch, heat, cold, socio-sexual and emotional sensations.
Vitamin D synthesis from its precursors under the effect of sunlight and introversion of steroids.

4. Wound-definitions (Manley, Bellman, 2000)
A loss of continuity of the skin or mucous membrane which may involve soft tissues, muscles, bone and other anatomical structure.
Any disruption to layers of the skin and underlying tissues due to multiple causes including trauma, surgery, or a specific disease state.

5. WOUND HEALING Classification of wound healing
(According to the amount of tissue loss)
Primary intention healing
Secondary intention healing
Tertiary intention healing

6. PHASES OF WOUND HEALING
Healing is a quality of living tissue; it is also referred to as regeneration (renewal) of tissue.
The inflammatory phase (3-6 days)
The regenerative (Proliferative) phase (day 4-day21)
The maturation (Remodeling) phase (day or 2 yrs)
(Manley, Bellman, 2000)

7. The inflammatory phase (Initiated immediately after injury and last 3-6 days
Injury /damage Cells
Histamine
Blood Clot
Dry
Vasodilation
Permeability
Uniting the
wound edges
Neutrophils&
Monocytes
-Dilated blood vessels
Microcirculation slow down
Oedema& Engorgement
0-3 days

8. The Regenerative (Proliferative) phase
Blood vessels near the edge of the wound become porous
Begins 2-3 days of injury
Lasting up to 2-3 weeks
Allowing excess moisture to escape
- Resultant tissue filling is referred
To as granulation tissue
- process of wound contraction begins
Macrophage activity
Traps other blood cells &
damaged blood vessels
Begin to regenerate within
the wound margins
Stimulates
Formation& multiplication
of fibroblasts
This fibrous network
Which
- Laying down of a ground substance
- Beginning the synthesis of collagen fibers (granulation tissue )
migrate along fibrin threads
Resulting

9. The Maturative phase
Begins about day 21 and can extend up to 6 months up to one or two years after the injury.
Fibroblasts continue to synthesize collagen
The collagen fibers recognized into a more orderly structure
The scar become a thin ,less elastic, white line

10. Factors affecting wound healing
Developmental consideration/Age
Nutrition
Life-style
Medication
Infection
Wound perfusion

11. Description and Characteristics
Types of Wound
Description and Characteristics
Cause
Type
Open wound; painful
Sharp instrument eg. Knife
Incision
Close wound, skin appears ecchymotic (bruised) because of damaged blood vessels
Blow from a blunt instrument
Contusion
Open wound; involving the skin ; painful
Surface scrape, either unintentional (eg, scraped knee from fall) or intentional (eg, dermal abrasion to remove pockmarks)
Abrasion
Open wound; can be intentional or unintentional
Penetration of the skin and, often the underlying tissues from a sharp instrument
Puncture
Open wound; edges are often jagged
Tissues torn apart, often from accidents (eg, machinery)
Laceration
Open wound; usually accidental ( bullet or metal fragments)
Penetration of the skin and the underlying tissues
Penetrating wound

12. Classification of surgical wounds according to the degree of contamination
Clean wounds: Operations in which a viscus is not opened. This category includes non- traumatic, uninfected wounds where is no inflammation encountered and no break in technique has occurred. Clean-contaminated: A viscus is entered but without spillage of contents. This category included non- traumatic wounds where a minor break in technique has occurred.

13. Classification of surgical wounds cont’d (Altmeire 1997, Ayliffe & Lowbury 1992, NAS 1996)
Contaminated: Gross spillage has occurred or a fresh traumatic wound from a relatively clean source. Acute non-purulent inflammation may also be encountered. Dirty or infected : Old traumatic wounds from a dirty source, with delayed treatment, devitalised tissue, clinical infection, faecal contamination or a foreign body.

14. Classification of wounds by depth
Partial-thickness: Confined to the skin, the dermis and epidermis.
Full-thickness : Involve the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone
Partial Thickness
Full Thickness

15. Wound assessment cont’d (Hahn,Olsen,Tomaselli, Goldberg ,2004)
What to assess?
Location
Dimensions/Size
Tissue viability
Exudate/Drainage
Periwound condition
Pain
Stage or extent of tissue damage , dictates how often a wound is reassessed
Swelling

16. Risk for Impaired Skin Integrity Impaired Skin Integrity
Diagnoses
Risk for Impaired Skin Integrity
Impaired Skin Integrity
Impaired Tissue Integrity
Risk for Infection
Pain

17. A- Intrinsic risk factors:
Risk Factors Which Increase Patient Susceptibility to infection (Manley.K, Bellman. L,2000)
A- Intrinsic risk factors:
Extremes age: Defined as “ Children aged 1 year and under, and people aged 65 years and over’.
Underling Conditions/Disorders
Diabetes
Respiratory disorders
Blood disorders
Smoking
Nutrition and build

18. B- Extrinsic risk factors:
Risk Factors Which Increase Patient Susceptibility to infection cont’d (Manley.K, Bellman. L,2000)
B- Extrinsic risk factors:
Drug therapy as a risk factor: e.g. Cytotoxic drugs
Break in the integrity of the skin
Items such as foreign bodies
Bypassing of defense mechanisms through devices e.g. Intubations

19. S&S of Presence of Infection
Wound is swollen.
Wound is deep red in color.
Wound feels hot on palpation.
Drainage is increased and possibly purulent.
Foul odor may be noted.
Wound edges may be separated with dehiscence present.

20. Types of Wound Drainage
Exudate is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and deposited in or on tissue surfaces. The Nature and amount of exudate vary according to: Tissue involved, Intensity and duration of the inflammation, and the presence of microorganisms.
1. Serous Exudate
Mostly serum
Watery, clear of cells
E.g., fluid in a blister

21. A purulent Exudate
Is thicker than serous exudate because of the presence of pus.
It consists of leukocytes, liquefied dead tissue debris, dead and living bacteria.
The Process of pus formation is referred to as suppuration, and the bacteria that produce pus are called pyogenic bacteria.
Purulent exudate vary in color, some acquiring tinges of blue, green, or yellow. The color may depend on the causative organism.

22. A sanguineous (hemorrhagic) Exudate
It consists of large amount or blood cells, indicating damage to capillaries that is very severe enough to allow the escape of RBCs from plasma
This type of exudate is frequently seen in open wounds.
we often need to distinguish whether the exudate is dark or bright. Bright indicate fresh blood, whereas dark exudate denotes older bleeding.

23. Complications of Wounds
Infection
Hemorrhage
Dehiscence and possible evisceration
Fistula formation

24. The RYB color code (Stotts,1999)
This concept is based on the color of the open wound rather than the depth or size of the wound.
On this scheme, the goal of wound care is to protect ( cover) red, cleanse yellow, and debride black.
The RYB code can be applied to any wound allowed to heal by secondary intention.
R=Red Y=Yellow B= Black

25. Red wounds
Usually in the late regeneration phase of tissue repair (ie, developing granulation tissue) and are clean and uniformly pink in appearance
They need to be protected to avoid disturbance to regenerating tissue. Examples are superficial wounds, skin donor sites, and partial- thickness or second – degree burns.

26. How to protect red wounds:
Gentle cleansing
Avoid the use of dry gauze or wet- to-dry saline dressings.
Applying a topical antimicrobial agent.
Appling a transparent film or hydrocolloid dressing.
Changing the dressing as infrequently as possible.

27. Yellow wounds
Characterized primarily by liquid to semiliquid ”slough” that is often accompanied by purulent drainage.
clean yellow wounds to absorb drainage and remove nonviable tissue. Methods used may include .
Applying wet-to-wet dressing; irrigating the wound; using absorbent dressing material such as impregnated nonadherent, hydrogel dressing, or other exudate absorbers; and a topical antimicrobial to minimize bacterial growth.

28. Black Wound Covered with thick necrotic tissue or Eschar.
e.g.. third degree burns and gangrenous ulcer.
Required debridement .
When the eschar is removed, the wound is treated as yellow, then red.

29. Purposes of wound dressing
To protect the wound from mechanical injuries
To protect the wound from microbial contamination
To provide or maintain high humidity of the wound
To provide thermal insulation
To absorb drainage and /or debride a wound

30. Purposes of wound dressing
6. To prevent hemorrhage (when applied as a pressure dressing or with elastic bandages).
7. To splint or immobilize the wound site and thereby facilitate healing and prevent injury.
8. To provide psychological (aesthetic) comfort.

31. Principles of asepsis The aim:
Guarantee the safety of the equipment used (cleaning/disinfection/sterilisation).
Reduce the level of microbial contamination of the site requiring manipulation (antisepsis).
Ensure that no microorganisms are introduced (asepsis).

32. Cleaning : Is the removal of dirt, debris and organic material
Cleaning : Is the removal of dirt, debris and organic material. Disinfection: Removes or destroys harmful microorganisms but not bacterial spores or slow viruses. Sterilization: is the complete destruction or removal of all living microorganisms including bacterial spores. Antisepsis: is the reduction of the number of microorganisms already present on the body site prior to a procedure. Asepsis: Procedure designed to prevent any introduction of microorganisms to the site achieved by a non-touching technique and use of sterile gloves

33. Evaluation of Wounds ABC’s first  Always! Ensure hemostasis
Saline gauze dressing
Compression
Remove obstructions
Rings, clothing, other jewelry
History

34. History Symptoms Tetanus status Type of Force Allergies Contamination
Event
Potential for foreign body
Function
Non-accidental trauma
Tetanus status
Allergies
Medications
Comorbidities
Previous scar formation

35. Wound Examination Location Vascular function Size Tendon function
Shape
Margins
Depth
Alignment with skin lines
Neuro function
Vascular function
Tendon function
Underlying structures
Wound contamination
Foreign bodies

36. Wound Consultation Tarsal plate or lacrimal duct
Open fracture or joint space
Extensive facial wounds
Associated with amputation
Associated with loss of function
Involves tendons, nerves, or vessels
Involves significant loss of epidermis
Any wound that you are uncertain about

37. Wound Preparation - Hemostasis
Physical vs. chemical
Direct pressure
Epinephrine
Gelfoam
Cautery
Refractory
Use a tourniquet

38. Wound Preparation – Foreign Body Removal
Visual inspection
Imaging
Glass, metal, gravel fragments >1mm should be visible on plain radiographs
Organic substances and plastics are usually radiolucent
Always discuss and document possibility of retained foreign body

39. Wound Preparation – Irrigation
Local anesthesia prior to irrigation
Do not soak the wound
Use normal saline
Large syringe (60mL) with Zerowet attachment
Do not use iodine, chlorhexidine, peroxide or detergents

40. Wound Preparation – Debridement
Removes foreign matter & devitalized tissue
Creates sharp wound edge
Excision with elliptical shape
Respect skin lines

41. Wound Preparation – Antibiotics
Infections occur in ~3-5% of traumatic wounds seen in the ED
Factors that increase risk
Heavily contaminated wound, especially with soil
Immunocompromised patients
Diabetics
Human bites > animal bites
Most important prevention  adequate irrigation & debridement

42. Wound Preparation – Antibiotics
Dog & cat bites
Cover pasteurella
Augmentin
Human bites
Cover eikenella
Puncture wounds
Cover pseudomonas
Cipro, levaquin

43. Wound Preparation – Tetanus Prophylaxis
Clean wounds
Incomplete immunization toxoid
>10 years, then give toxoid
Tetanus prone wound
Incomplete immunization
Toxoid & immune globulin
> 5 years, give toxoid
Remember to think about rabies!

44. Guidelines for cleaning wounds
Use physiologic solution, such as isotonic saline or lactated ringer solution.
When possible , warm the solution to body temperature before use.
If the wound is grossly contaminated by foreign material , bacteria, slough, or necrotic tissue clean the wound at every dressing change.
If a wound is clean , has little exudate , and reveals healthy granulation tissue , avoid repeated cleaning.

45. Use gauze squares .
Consider cleaning superficial noninfected wound by irrigating them with normal saline rather than using mechanical means.
To retain wound moisture , avoid drying a wound after cleaning it.

46. Ideal Dressing provide mechanical protection
protect against secondary infection
non adherent and easily removed without trauma
leave no foreign particles in the wound
remove excess exudates
cost effective
offer effective pain relief.

47. other influencing factors
Burns: First Contact
Assessment
site
depth
surface area involved
age of patient
other influencing factors

48. Superficial Burn Characteristics
epidermis only
erythema (vasodilatation)
tenderness (nerve irritability)
oedema.

49. Superficial Partial Burn Characteristics
epidermis and outer dermis
blisters (fluid shift)
shedding of skin
painful exposed (nerve endings to kinins)
bleeds when pricked with needle
hair present (hard to pull out)
full sensation
blanches on pressure.

50. Burn Surface Area Wallace’s rule of nines Lund and Browder chart
closed palmar hand of victim = 1% of body surface area.

51. Anatomical Site Considerations
hands
feet
face
perineum
genitalia
joints
circumferential burns
All these areas require special consideration to prevent cosmetic and functional problems secondary to hypertrophic scaring. 51

52. Other Considerations
extremes of age: very young or very old will need special care
co-morbidities
medications.

53. What to do about blisters?
controversial: removal causes pain
tense blisters can interfere with dermal circulation, restrict movement
beware of blisters with “red rings”
blisters can hide deep burns
popped blisters may need to be debrided.