1. Department of Surgical research and Techniques
Classification and management of wound, principle of wound healing, haemorrhage and bleeding control
Györgyi Szabó
Assistant Professor
Department of Surgical research and Techniques
Basic Surgical Techniques, Faculty of Medicine, 3rd year
2021/13 Academic Year, Second Semester

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. Cross section of a simple wound
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
cavity

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 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

8. Mechanical wounds 1.) Abraded wound (v. abrasum) 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

9. Mechanical wounds 3.) Incised wound 4.) Cut wound (v. caesum)
(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)
Great tearing or pulling
Incomplete amputation
Blunt force
Pressure injury
Edges – uneven and torn
Bleeding
(v. lacerocontusum)

11. Mechanical wound 7.) Shot wound (v. scolperatium) Close - burn injury
Foreign materials
aperture
output
A kialakult lőcsatorna első rétegében elhalt szövetek és idegen anyagok helyezkednek el (pl.: ruhadarabok). Körülötte kialakul az elsődleges necroticus zóna, amelyben a lökéshullám és a hőhatás miatt elhalt szöveteket észlelünk. E körül a necrobioticus zóna helyezkedik el, amelyben vérzést, érkárosodást, trombusokat észlelünk, majd körkőrösen a molekuláris rázkódtatás zónája, amely éles határ nélkül megy át az ép szövetekbe. A lőcsatornát mindig fel kell tárni!
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 wound healing is good

14. Chemical wounds 1.) Acid 2.) Base colliquative necrosis
in small concentration – irritate
in large concentration – coagulation 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
ulcers on people’s backs, chests, mouth, etc. are common when one is exposed to a vast amount of radiation

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, poisonous animals Toxins, venom - toxicologist
Skin necrosis

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

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

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

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

23. Applied wound management exudate continuum
Viscosity
volume
high - 5
medium - 3
low - 1
medium -3
Wound exudate
» View large image.
If a wound produces a large amount of fluid (exudate)1, the healing process can be slowed down. Increased exudate levels can be a symptom of infection and increased oedema. And the more a wound exudes, the higher the risk of maceration of the surrounding skin2 – and exudate leakage. Exudate leakage is not only clinically challenging to treat – it also prevents some patients from participating in social activities, or from going out altogether. Problems often associated with exuding wounds are [1-2] :
a negative impact on the patient’s quality of life
very time consuming treatment
complications such as infection, wound pain and maceration that slows the healing process
The composition and amount of wound exudate1 varies depending on the stage of the healing process. In the inflammatory phase of wound healing, exudate levels are usually high, which may be a sign of wound infection. Unlike acute wound exudate, chronic wound exudate contains enzymes (proteases) that break down proteins and newly formed cells. To break the vicious cycle in a non-healing wound, the exudate must be led away from the wound with an absorbent dressing. Controlling wound exudate Control of exudate, removal of unhealthy tissue by debridement and management of bacterial load are all part of good wound bed preparation. A good wound dressing keeps the wound moist and absorbs exudate, locking it inside the dressing to prevent maceration. Offering excellent absorption and retention, Biatain foam dressings are proven to deliver superior exudate management.[3-4] With longer wear time (up to seven days), minimal risk of leakage and maceration, your patients’ wounds will heal faster.[1,5-7]
source: Applied wound management supplement –

24. 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

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:
The wound edges
Handling the scalpel

27. 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

28. The wound healing Hemostasis-inflammation Granulation-proliferation
Remodelling
capillaries
fibroblasts
lymphocytes
macrophages
neutrophyl gr.
thrombocytes 1 2 3 4 5 6 7 8 9 10 11 13 14 15

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 
infection
Defect in wound healing
Wound healing needs energy
foreign bodies
ischemia
edema/ elevated tissue pressure
Impaired healing
Glucose and oxigen supply 
ATP production 
Elongation of inflammatory phase
Endotoxin  collagenase stimulation 
Collagen degration

31. Factors effecting on wound healing SYSTEMIC
inflammatory and proliferative phase!
slower reepithelization
Age and gender
Diseases
Obesity
Medication
diabetes
Alcoholism and smoking
Sepsis
Nutrition
Neutrophyl 
Phagocyte function 
Sorbitol  vascular complication,
Granulation, collagen level 
Infection, dehiscence, hematoma, seroma
Hemostasis, hemorheology 
Corticosteroid, citostatics, NSAIDs, radiation
Glucose, glutamin, vitamins, trace elements

32. Types of wound healing Healing by primary intention
Healing by secondary
Healing by tertiary
Tertiary Intention
When a wound is intentionally kept open to allow edema or infection to resolve or to permit removal of exudate, the wound heals by tertiary intention, or delayed primary intention. These wounds result in more scarring than wounds that heal by primary intention but less than wounds that heal by secondary intention. (Johnstone, Farley,& Hendry, 2005)
source:

33. Complications of wound healing I. Early complications
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.) Wound disruption
A. partial – dehiscenece
B. complete - disruption
Surgical error
Increased intraabdominal pressure
Wound infection
Hypoproteinaemia
TREATMENT:
U-shaped sutures
Breast reduction – dehiscence – 2weeks

36. Early complications of wound healing Superficial wound infection
1.) Diffuse
2.) Localized
Located below the skin
TREATMENT
Resting position
Antibiotic
Dermatological consultation
Anywhere
TREATMENT
Surgical exploration
Drainage
X-ray examination
e.g. erysipelas
Diffuse – erysipelas – caused by hemolytic streptococci
Localized – joint abscess
This patient developed an abscess over the metacarpophalangeal joint of the thumb after an accidental cut with a kitchen knife.
See Also
Scar location related to patient and parent satisfaction with ...
A 15-year-old Hispanic girl with “bump”
12-year-old boy admitted for febrile illness
What is your diagnosis?
Source: Jeray KJ
Answer
The answer is methicillin-resistant Staphylococcus aureus.
Surgeons at one hospital system found that MRSA may become a more common bacteriologic flora of hand infections, and if so, surgeons must adjust their choices for empiric antibiotics.
After noticing a marked increase in the number of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) cases, surgeons at the Greenville Hospital System in South Carolina conducted a retrospective chart review of all orthopedic consultations done for hand infections from November 2003 to October 2005.
e.g. abscess

37. Early complications of wound healing Deep wound infection
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
Localised – massive empyema (see the article)

38. Complications of wound healing I. Early complications
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

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

40. Late complications Develop in areas of thick chorium
Hypertrophic scar 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
Develop in areas of thick chorium
Non-hyalinic collagen fibres and fibroblasts
Confine to the incision line
TREATMENT
Regress spontaneously
(1-2 yrs)

41. BLEEDING AND HEMOSTASIS

42. Bleeding Anatomical Diffuse Arterial – bright red, pulsate
Venous – dark red, continuous
Capillary – can become serious
Parenchymal
Figure 1: Diffuse terminal ileal ulceration and angiomal formtion with oozing hemorrhage from these ulcers.
Mentions: In the absence of a primary ulcer, Dieulafoy's lesion was seen in the terminal ileum with oozing hemorrhage from this lesion 10 cm away from the ileocecal valve (Figure 1). The bleeding could not be controlled by endoscopic hemostasis using thermal coagulation or any other endoscopic intervention. A decision was made accordingly for urgent explorative laparotomy to save her life. An ileocolectomy (emergency limited segmental resection for a known bleeding source) was also done on our patient (Figure 2). Histology revealed this to be of the Dieulafoy type of lesion in the distal ileum (Figure 3).

43. Severity of bleeding – the volume of the lost blood and time
source:

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)
Conjunctival suffusion with subconjunctival hemorrhage (ou), which was suggestive of leptospirosis, developed on the second hospitalization day.

45. 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

46. Signs of the bleeding Local 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
Hematoma, suffusion, ecchymosis
Compression in the pleural cavity, in pericardium, in the skull
Functional disturbancies – e.g. hyperperistalsis

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. Surgical hemostasis Mechanical methods
Digital pressure – direct pressure,
e.g. Pringle maneuver
Tourniquet
Ligation
Suturing
Preventive hemostasis
Clips
Bone wax
other
The Pringle maneuver. The portal triad is occluded by guiding the posterior blade of the clamp through the foramen of Winslow with the aid of the left index finger.
-6. kép: amennyiben vérnyomásmérő áll rendelkezésre, úgy pneumatikus vértelenség felhelyezése. 280 Hgmm-re felfújjuk a vérnyomásmérő mandzsettát, így a sebalapot megtekinthetjük. Betadines vagy Octeniseptes fedőkötés, steril pólya, korrekt nyomókötés
7-8.kép: a nyomókötés felhelyezése után a vértelenség felengedése. Amennyiben erős vérzést észlelünk, ismételten felfújjuk a mandzsettát és revideáljuk a kötést. (az erős vérzés forrása csak technikai hiba lehet az elsősegélynyújtó részéről).

49. Thermal methods Low temperature Hypothermia – eg. stomach bleeding
Cryosurgery
dehidratation and denaturation of fatty tissue
decreases the cell metabolism
vasoconstriction
Timed spot freeze technique used to treat a malignancy (possibly a small basal cell cancer), demonstrating freeze ball formation and the 5-mm treatment margins necessary to achieve a temperature of −50ºC (−58 ºF) and, thus, the required depth of 4 to 5 mm.
Cryosurgery is a method of superfreezing tissue in order to destroy it. The technique is used to treat tumors, control pain, and control bleeding.
Information
The cold is introduced through a probe which has liquid nitrogen circulating through it. To destroy diseased tissue, the tissue is cooled to below -20 degrees Celsius. Other procedures that control pain or bleeding are cooled to a lesser degree to prevent tissue damage.

50. Thermal methods High temperature Electrosurgery – electrocauterization
Monopolar diathermy
Bipolar diathermy
Laser surgery
coagulation and vaporization
for fine tissues
Electrocoagulation: A fine wire probe or other delivery mechanism is used to transmit radio waves to tissues near the probe. Molecules within the tissue are caused to vibrate which lead to a rapid increase of the temperature, causing coagulation of the proteins within the tissue, effectively killing the tissue. At higher powered applications, full desiccation of tissue is possible.
Two forms of electrosurgery: (A) Electrodesiccation with an active electrode tip touching the skin and showing penetration of planned tissue damage. (B) Fulguration with sparking from electrode to tissue. Treatment area is more superficial than in desiccation.Added by BiomedGuy
AboutEdit
Fulguration, also called electrofulguration, is the destruction of tissue by means of a high-frequency electric current applied with a needlelike electrode. In fulguration, the electrode is held away from the skin to produce a sparking at the skin surface and more shallow tissue destruction Fulguration is especially useful in treating superficial epidermal lesions, such as a superficial basal cell carcinoma of the trunk.[1]
LinksEdit
ReferenceEdit
↑ | Electrosurgery for the Skin | BARRY L. HAINER, M.D.,RICHARD B. USATINE, M.D., | Am Fam

51. Thermal methods High temperature Electrocoagulation
Electrofulguration (A)
Electrodessication
Electrosection

52. Hemostasis with chemical and biological methods
vasoconstriction coagulation hygroscopic effect Absorbable collagen Absorbable gelatin Microfibrillar collagen Oxidized celluloze Oxytocin Epinephrine Thrombin Hemcon QuikClot
HemCon Medical Technologies, Inc. began with funding from the United States Army and access to research by Dr. Kenton Gregory, Dr. Bill Wiesmann, the Oregon Medical Laser Center, and Providence Health Systems. The result was the HemCon® Bandage, which was designed to control life threatening bleeding.
Related Links: History & Mission Management Team Board of Directors Products Educational Resources Distribution and Sales Product Training Success Stories Media Room Customer Feedback Careers
The bandage was ushered through the FDA clearance process in a near-record 48 hours, and was soon deployed on the battlefield. Since then, the bandage has been used extensively and is credited with helping save over 100 lives with no adverse events reported. In 2005, the Army Surgeon General mandated that any soldier serving in Iraq or Afghanistan will carry at least one HemCon Bandage. This commitment by the U.S. Army is a testament to the efficacy and value of the HemCon Bandage. HemCon is rapidly changing from a military provider to a broad-based supplier of medical technology. With new products, strong partnerships in distribution, and a world class development team, we will continue to be unwavering in our commitment to innovate in all that we strive to achieve.

53. Hemostasis with chemical and biological methods
HemCon