Download How to protect red wounds

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
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THE SKIN
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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.
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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 .
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WOUND HEALING
Classification of wound healing
(According to the amount of tissue loss)
 Primary intention healing
Secondary intention healing
Tertiary intention healing
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PHASES OF WOUND HEALING
Healing is a quality of living tissue; it is also referred to as regeneration (renewal) of tissue.
A.
The inflammatory phase (3-6 days)
B.
The regenerative (Proliferative) phase (day 4-day21)
C.
The maturation (Remodeling) phase (day 21- 1 or 2 yrs)
(Manley, Bellman, 2000)
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THE INFLAMMATORY PHASE
(INITIATED IMMEDIATELY AFTER INJURY AND LAST 3-6 DAYS
Injury /damage Cells
Histamine
Vasodilation
Permeability
Neutrophils&
Monocytes
Oedema&
Engorgement
0-3 days
Blood Clot
Dry
Uniting the
wound edges
-Dilated blood vessels
-Microcirculation slow
down
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THE REGENERATIVE (PROLIFERATIVE) PHASE
Blood vessels near the edge of the
wound become porous
Allowing excess moisture
to escape
Begins 2-3 days of injury
Lasting up to 2-3 weeks
- 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
Resulting
migrate along fibrin
threads
- Laying down of a ground
substance
- Beginning the synthesis of
collagen fibers (granulation
tissue )
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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
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FACTORS AFFECTING WOUND HEALING
Developmental consideration/Age
Nutrition
Life-style
Medication
Infection
Wound perfusion
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TYPES OF WOUND
Type
Cause
Description and
Characteristics
Incision
Sharp instrument eg. Knife
Open wound; painful
Contusion
Blow from a blunt instrument
Close wound, skin
appears ecchymotic
(bruised) because of
damaged blood vessels
Abrasion
Surface scrape, either unintentional
(eg, scraped knee from fall) or
intentional (eg, dermal abrasion to
remove pockmarks)
Open wound; involving
the skin ; painful
Puncture
Penetration of the skin and, often the
underlying tissues from a sharp
instrument
Open wound; can be
intentional or
unintentional
Laceration
Tissues torn apart, often from
accidents (eg, machinery)
Open wound; edges are
often jagged
Penetrating
wound
Penetration of the skin and the
underlying tissues
Open wound; usually
accidental ( bullet or
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metal fragments)
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.
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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.
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CLASSIFICATION OF WOUNDS BY DEPTH
I. Partial-thickness: Confined to the skin, the dermis and epidermis.
II. Full-thickness : Involve the dermis, epidermis, subcutaneous tissue,
and possibly muscle and bone
Partial Thickness
Full Thickness
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WOUND ASSESSMENT CONT’D
(HAHN,OLSEN,TOMASELLI, GOLDBERG ,2004)
What to assess?
1. Location
2. Dimensions/Size
3. Tissue viability
4. Exudate/Drainage
5. Periwound condition
6. Pain
7. Stage or extent of tissue damage , dictates how often a
wound is reassessed
8. Swelling
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DIAGNOSES
• Risk for Impaired Skin Integrity
• Impaired Skin Integrity
• Impaired Tissue Integrity
• Risk for Infection
• Pain
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RISK FACTORS WHICH INCREASE PATIENT
SUSCEPTIBILITY TO INFECTION
(MANLEY.K, BELLMAN. L,2000)
A- Intrinsic risk factors:
1.
Extremes age: Defined
as “ Children aged 1 year and under,
and people aged 65 years and over’.
2.
Underling Conditions/Disorders
A. Diabetes
B. Respiratory disorders
C. Blood disorders
3.
4.
Smoking
Nutrition and build
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RISK FACTORS WHICH INCREASE PATIENT
SUSCEPTIBILITY TO INFECTION CONT’D
(MANLEY.K, BELLMAN. L,2000)
B- Extrinsic risk factors:
1.
Drug therapy as a risk factor: e.g. Cytotoxic drugs
2.
Break in the integrity of the skin
3.
Items such as foreign bodies
4.
Bypassing of defense mechanisms through devices e.g. Intubations
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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.
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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
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2.
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.
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3.
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.
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COMPLICATIONS OF WOUNDS
• Infection
• Hemorrhage
• Dehiscence and possible evisceration
• Fistula formation
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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.
R=Red
Y=Yellow
B= Black
 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.
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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.
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• 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.
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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.
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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.
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PURPOSES OF WOUND DRESSING
1. To protect the wound from mechanical injuries
2. To protect the wound from microbial
contamination
3. To provide or maintain high humidity of the wound
4. To provide thermal insulation
5. To absorb drainage and /or debride a wound
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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.
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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).
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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
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EVALUATION OF WOUNDS
• ABC’s first  Always!
• Ensure hemostasis
• Saline gauze dressing
• Compression
• Remove obstructions
• Rings, clothing, other jewelry
• History
HISTORY
• Symptoms
• Type of Force
• Contamination
• Event
• Potential for foreign body
• Function
• Non-accidental trauma
• Tetanus status
• Allergies
• Medications
• Comorbidities
• Previous scar formation
WOUND EXAMINATION
• Location
• Vascular function
• Size
• Tendon function
• Shape
• Underlying structures
• Margins
• Wound contamination
• Depth
• Foreign bodies
• Alignment with skin lines
• Neuro function
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
WOUND PREPARATION - HEMOSTASIS
• Physical vs. chemical
• Direct pressure
• Epinephrine
• Gelfoam
• Cautery
• Refractory
• Use a tourniquet
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
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
WOUND PREPARATION – DEBRIDEMENT
• Removes foreign matter & devitalized
tissue
• Creates sharp wound edge
• Excision with elliptical shape
• Respect skin lines
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
WOUND PREPARATION – ANTIBIOTICS
• Dog & cat bites
• Cover pasteurella
• Augmentin
• Human bites
• Cover eikenella
• Augmentin
• Puncture wounds
• Cover pseudomonas
• Cipro, levaquin
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!
GUIDELINES FOR CLEANING WOUNDS
1.
Use physiologic solution, such as isotonic saline or lactated ringer
solution.
2.
When possible , warm the solution to body temperature before use.
3.
If the wound is grossly contaminated by foreign material , bacteria, slough,
or necrotic tissue clean the wound at every dressing change.
4.
If a wound is clean , has little exudate , and reveals healthy granulation
tissue , avoid repeated cleaning.
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5.
6.
Use gauze squares .
7.
To retain wound moisture , avoid drying a wound after
cleaning it.
Consider cleaning superficial noninfected wound by irrigating
them with normal saline rather than using mechanical means.
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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 .
BURNS: FIRST CONTACT
Assessment
• site
• depth
• surface area involved
• age of patient
• other influencing factors
SUPERFICIAL BURN CHARACTERISTICS
• epidermis only
• erythema (vasodilatation)
• tenderness (nerve irritability)
• oedema.
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.
BURN SURFACE AREA
• Wallace’s rule of nines
• Lund and Browder chart
• closed palmar hand of victim
= 1% of body surface area.
ANATOMICAL SITE CONSIDERATIONS
• hands
• feet
• face
• perineum
• genitalia
• joints
• circumferential burns
OTHER CONSIDERATIONS
• extremes of age: very young or very old will need special care
• co-morbidities
• medications.
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.