Inflammatory

Debridement

Repair

Maturation

1. Hemorrhage - flushes contaminants

2. Clot formation - minimal tensile strength

      - fibrin matrix - scaffolding for fibroblasts

3. Inflammation

      - /\ vascular permeability

           *plasma out (dilute bad stuff)

           *macrophages out - debridement

      - chemotaxis - needed for debridement

Corticosteroids (counterproductive) - \/ inflammatory process = \/ macrophages

Cleans it out

1. WBC infiltration

     - neutrophils (sloppy eaters = /\ inflammation = macrophage magnet)

     - monocytes - promote repair, produce growth factors (chemoattractants for fibroblasts)

         *epithelilization, angiogenesis, fibroplasia

2. Exudation (@ peak debridement) - /\ contamination & damage = /\ exudate

- Dermis

    *Fibroblast infiltration (5 days)

    *collagen deposition & remodeling by fibroblasts (shorter and bulkier/stronger)

    *angiogenesis

    *granulation tissue

    * wound contraction

- Epidermis

    *mitosis (basal cell layer)

    *epithelial proliferation ~48 hours in surgical wound (wound meets in middle)

    *collagenase - dissolves fibrin

    *pruritis @48 hours - nerve endings being simulated

- Once it's scared over (60-360 days post-wound)

- fibroblasts - (a few) reorganize/remodel collagen, contract scar

Keloid formation now

- progressively enlarging scar (abnormal wound maturation)

- Scar placed under physical stress/tension

- tells fibroblasts to lay down more collagen

- happens afeter the 60 day mark

- Exuberant (accelerated) granulation tissue - like a keloid but not covered by flesh

- Prevention: immediate closure

-Help: light pressure (\/ blood flow), nonadherent dressing

@ 24-48 hours

0-4 days: weak (just fibrin) - apply sutures/staples

5-7 days: minimal - poorly organized collagen

10 days: can remove sutures, parallel collagen, bulking up

15 days: optimal strength

Best @ 10-14 days

Longer if on corticosteriods or has corticosteroid problems

1st intention - clean lascerations or surgical closure

2nd intention - open wound

3rd intention - mixture of 1+2 (delayed surgical closure)

Primary closure

- clean-contaminated wounds

- contaminated wounds

Dirty wounds

If heavily contaminated, may stick drain in or wait

Golden period: <4-6 hours (ok to close - factor in cleanliness)

Optimal healing, minimal scarring

Suture material: remove 10-14 days or absorbed

surgical incisions w/ potential contamination
or

open wound with healthy granulation bed

- let heal by 1st intention

- acute traumatic wounds (some fresh wounds can be made "clean" for primary closure)

- major break in surgical asepsis

- hollow organ opened with gross spillage (stomach spill)

- acute inflammation

- Heal by 1st intention

- traumatic wound over 4-6 hours old (past the golden period)

- perforated hollow organ

- pus present

- if heavily contaminated, you might not close or insert drain

- open wound

- granulation - creates huge scar, non-flexible

- not usually closed b/c of contamination (theres a LOT to debride)

- very little bleeding (bc of thromboplastin release & exposed collagen)

- requires intensive open-wound management to optamize healing

1st + 2nd intention healing

- delayed surgical closure (allow granulation to close just far enought tha tyou can surgical close or skin graft)

- requires intensive open-wound management to optimize healing

- contamination

- debridement

- moisture (exudation, friable?)

- temperature

- pressure (none on skin grafts)

- pain (w/ bandage changes; corticosteroid release=bad)

Bandage Considerations:

Contamination

- microbes - ALWAYS be STERILE

- promote drainage away from wound

- no strike through

Bandage Considerations:

Debridement stage

- adherent vs nonadherent

- wicking contact layer, colleting 2nd layer

- lavage every bandage change for first 2 days

- periwound skin - protect from masceration

Moist gauze (saline gauze)

 - decreases viscosity of exudates (dilute)

 - promote drainage to 2nd layer

Dry gauze - VERY adherent, tissues may incorperate fibers into the matrix

Alginates & hydrogels (synthetic hydrophilic polymers)

 - amorphous gel

 - wiped/lavaged away

Bandage considerations:

Pain

Pain /\ healing time b/c of corticosteroid response

- frequency of changes

- analgesics - opioids (quickly reversible)

Bandage considerations:

Wound moisture

Masceration vs desiccation

- too wet: friable, poor wound strength

too dry: dehydration, cell death, tissue fractures, scarring, needs to be debrided

**Contact layer dictates how much moisture is kept there**

- Calcium alginate - fibrous, VERY absorbent - turns into nonadherent gel (less painful to remove) & can leave on 3-4 days

Bandage considerations:

Exudates

- RAPID REMOVAL

- thick vs aqueous

- secondary layer accomidation (wicking, storage)

Bandages:

- saline gauze - thins exudate

- abdominal pad - expensive but fast wicking, tons of storage

- cotton - inexpensive, limited wicking & storage

Volume vs. Weight

1 gram =

Wound considerations:

Temperature

Hypothermia = vasoconstriction

  - \/ nutrients, oxygen, waste removal)

  - \/ cell metabolism/activity

Warm lavage fluids

Warm topical agents/dressings

bandage considerations:

Pressure

- minimal dead space

- diffuse pressure over entire wound -> prevent edema

- blood flow

- cell activity

- oxygenation (thoracic/abdominal bandages)

- exudates (moving to 2nd layer inhibited by pressure)

- NO pressure on open wounds, especially skin grafts

Drains:

Considerations & Types

Considerations:

 - deadspace

 - remove fluids - continued SQ lavage

 - contamination - superhighway for microbes

Types:

 - passive - always bandage, SUPERHIGHWAY for microbe entry!

 - active (vacuum)

used to secure a bandage to the body when you do not want to wrap it around the entire body

- loops in skin and tie bandages down there

Stage: Good granulation bed

- ABSOLUTELY NO WEEPING

- bio-occlussive

- change 5-7 days (weekly)

- non-bulk bandage

- clear so you can see progress

Stage: little weeping, granulation tissue

- perferated film with minimal cotton

*caution - if wound desicates, may adhere to wound*

Basically sterile vaseline

Stage: little to no weeping, granulation tissue

- change a little more often to hydrogel but an alternative

- if there is weeping, pick the one with small holes to let exudates through

Stage: mild-moderate weeping/granulation tissue

- nothing but aqueous can get though

- may desiccate tissues

- if dry at margins, it may become adherant :-(

- primary or secondary over gel & alginates

Come in toothpaste tube

Stage: VERY gentle debridement

- Can leave for a couple days

- increase size when absorbing fluids

- transitional period from debridement to granulation (blue pad w/ gel)

- granulation bed (for 2nd intention healing or secondary closure)

Stage: further debridement (3-4 days)

- can leave on for 3-4 days before it morhs to a gel

- easy to flush away with lavage

- turns to nonadherant gel

*LOTS of SUCKAGE!

Stage: wet to dry debridement (1-2 days)

- PAINFUL removal (imbeded into tissues, rips good and bad stuff away)

1. Moist contact layer - heavy to moderate thick exudation

2. foam - mild to moderate exudation/serous drainage

3. telfa - mild serous drainage

4. adaptic - minimal serous draininga

5. film (weekly change) or adaptic - nondraining wound