1. Principles of Wound Care
Ehsan Modirian MD., MPH.
Assistant professor of
Emergency Department

2. What is a Wound? Any break in the continuity of body tissue Examples:
grazes, burns, surgical incisions, stabs, leg ulcers, decubitus ulcers (pressure sores)

3. Stages of Wound Healing
Stage 1 - traumatic inflammation ( 0-3 days)- redness, heat, swelling
Stage 2 -destructive phase ( 2-5 days)- polymorphs and macrophages clear the wound of debris and stimulate new growth
Stage 3- the proliferative phase( 3-24 days increased collagen formation
Stage 4- maturation phase ( 24 days-1 year) scar tissue decreases granulating tissue gets stronger and changes from reddish to pale

4. Closure of Surgical Wounds
Primary closure - first intention
( direct suture- if no tissue loss
Delayed primary closure- usually when a drain is left in situ.
Secondary intention - wound closes by a process of contraction and epithelialisation e.g ulcers and pressure sores

5. Factors Influencing Wound Healing
Good blood supply: ( oxygen, nutrients)
Good nutrition:
Rest: skin cells multiply more rapidly during sleep
Lack of stress: increased levels of adrenaline and steriods delay healing
Lack of infection:
Age : children heal more rapidly than older people
Site of wound: face and neck heal more rapidly

6. Factors Delaying Wound Healing
General factors
poor diet
anaemia
pulmonary disease
cardiac insufficiency
arteriosclerosis
diabetes mellitus
smoking
Jaundice
malignant disease
high blood urea
stress
lack of sleep
drug therapy e.g. steroids and cytotoxic
radiotherapy

7. Factors Delaying Wound Healing
Local to patient/wound
skin edges not lined up
dead tissue in wound
foreign bodies in wound
tension on wound
infection
irritant material for suturing
too tight suturing

8. Complications of wounds
Haemorrhage ( surgical wounds)
Infection
non union
rupture ( dehiscence)
pressure and strain ( coughing vomiting)
over granulation of scar tissue
contractures

9. Pathophysiology of Soft-Tissue Injury (1 of 12)
Closed Wounds
Contusions
Erythema
Ecchymosis
Hematomas
Crush injuries
Open Wounds
Abrasions
Lacerations
Incisions
Punctures
Impaled objects
Avulsions
Amputations

10. Pathophysiology of Soft-Tissue Injury (2 of 12) Soft-Tissue Wounds

11. Pathophysiology of Soft-Tissue Injury (3 of 12)
Hemorrhage
Arterial
Capillary
Venous

12. Pathophysiology of Soft-Tissue Injury (4 of 12)
Wound Healing
Hemostasis
Body’s natural ability to stop bleeding and the ability to clot blood
Begins immediately after injury
Inflammation
Local biochemical process that attracts WBCs
Epithelialization
Migration of epithelial cells over wound surface

13. Pathophysiology of Soft-Tissue Injury (5 of 12)
Neovascularization
New growth of capillaries in response to healing
Collagen Synthesis
Fibroblasts: Cells that form collagen
Collagen: Tough, strong protein that comprises connective tissue

14. Pathophysiology of Soft-Tissue Injury (6 of 12)
The Wound Healing Process

15. Pathophysiology of Soft-Tissue Injury (7 of 12)
Infection
Most common and most serious complication of open wounds
1:15 wounds seen in ED result in infection
Delay healing
Spread to adjacent tissues
Systemic infection: sepsis
Presentation
Pus: WBCs, cellular debris, and dead bacteria
Lymphangitis: visible red streaks
Fever and malaise
Localized fever

16. Pathophysiology of Soft-Tissue Injury (8 of 12)
Infection
Risk factors
Host’s health and pre-existing illnesses
Medications (NSAIDs)
Wound type and location
Associated contamination
Treatment provided
Infection management
Antibiotics and keep wound clean
Gangrene
Deep space infection of anaerobic bacteria
Bacterial gas and odor
Tetanus
Lockjaw
Uncommon with the exception of third-world country immigrants

17. Pathophysiology of Soft-Tissue Injury (9 of 12)
Other Wound Complications
Impaired hemostasis
Medications
Anticoagulants
Aspirin
Warfarin (Coumadin)
Heparin
Antifibrinolytics
Re-bleeding
Delayed healing
Compartment syndrome
Abnormal scar formation
Pressure injuries

18. Pathophysiology of Soft-Tissue Injury (10 of 12)
Crush Injury
Body tissues subjected to severe compressive forces
Tamponading of distal tissue
Buildup of byproducts of metabolism
“Wood-like” distal tissue
Associated injury

19. Pathophysiology of Soft-Tissue Injury (11 of 12)
Crush Syndrome
Body is entrapped for >4 hours.
Crushed muscle tissue becomes necrotic.
Traumatic rhabdomyolysis
Skeletal muscle degradation
Release of toxins
Myoglobin
Phosphate
Potassium
Lactic acid
Uric acid
When tissue is released, toxins move RAPIDLY into systemic circulation.
Impacts cardiac function
Impacts kidney function

20. Pathophysiology of Soft-Tissue Injury (12 of 12)
Injection Injury
High-pressure line bursts
Injects fluid or other substance into skin and into subcutaneous tissue

21. Caring for Wounds Assess for: type of wound location of wound
size of wound
shape of wound
level of exudate
condition of wound bed
condition of surrounding skin

22. Caring for Wounds Recognising inflammation
redness over area and surrounding tissue
swelling
heat
pain/ tenderness
loss of function

23. Caring for Wounds cleansing wounds should it be done?
what should be used?
how should it be done/
types of dressing
who makes the decision

24. Cleansing wounds: an area where ritualistic practice predominates
Key questions:
1. Does the wound really need cleaning?
2. What is the safest method that causes no ill effects and maintains the wound temperature?
3. What is acceptable to the patient?
Wounds that are clean and healthy do not require cleaning and should be left alone

25. Cleansing wounds: Main reasons
Excess exudate and signs of infection
Foreign body contamination ( eg. grit in a graze)
Presence of devitalised tissue ( slough or necrotic tissue)
To assess the wound
psychological reasons

26. Types of Cleansing Fluids
Antiseptics: generally discouraged now- can be toxic to tissue healing
Saline solutions: normal saline sachets commonly used
Tap water: Why not!!
tip: cleansing fluids should be at body temperature

27. Methods of Cleansing
Swabbing: not particularly effective, mainly redistributes organisms
Bathing: useful for chronic wounds such as leg ulcers. Take care with equipment to avoid cross contamination
Irrigation: shower head, waterjug, syringes - don’t be overzealous

28. Choice of Dressing The concept of moist wound healing
Modern dressing technology is based on the principle that the wound /dressing interface should be moist rather than dry.

29. Common characteristics of wound dressings
Capable of maintaining high humidity at wound site
free of particles and contaminants]
non toxic / non allergenic
capable of protecting the wound from further trauma
Impermeable to bacteria
thermally insulating
capable of allowing gaseous exchange]
able to withstand infrequent changes
cost effective
long lasting

30. Patient Factors Influencing the choice of dressing:
Age
Lifestyle
Medical History
Care environment
Ability to maintain /change own dressing
Competence and willingness of potential carers

31. Types of Dressings Low adherent dressings-Tullegras,Tegapore
Semi permeable films- Opsite, Tegaderm
Hydrocolloids - Comfeel plus, Granuflex
Hydrogels- Intrasite, Sterigel
Alginates- Sorbisan, Kaltostat
Foam dressings- Cavicare, Lyofoam extra
Antimicrobial dressings- Actisorb plus, Inadine

32. Minimising Cross Infection
Dressing and cleansing wounds is at the very minimum a Clean Procedure and is often an Aseptic Procedures
Thorough hand-washing and use of gloves are the most effective methods of preventing contamination of the wound
If wounds are infected then care must be taken to prevent cross contamination