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Woundsounds

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WOUND is a mechanicalWOUND is a mechanical

disruption of the normal continuitydisruption of the normal continuity

of skin, mucous membranes orof skin, mucous membranes orunderlying tissues and innerunderlying tissues and inner

organs.organs.

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Wound classificationound classification According to the cause of injuryAccording to the cause of injury

-- operationaloperational -- accidentalaccidental

According to the type of injuryAccording to the type of injury can becan be incised, punctured, chopped, contused,incised, punctured, chopped, contused,

crushed, lacerated, bite wounds, gunshot wounds,crushed, lacerated, bite wounds, gunshot wounds,poisoned and combined.poisoned and combined.

According to the presence of infectionAccording to the presence of infection

-- asepticaseptic -- infectedinfected -- septic woundsseptic wounds According to their relation to bodyAccording to their relation to body

cavitiescavities

-- penetratingpenetrating -- nonpenetratingnonpenetrating

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Wound classificationound classification noncomplicatednoncomp

licated complicatedcomp

licated early complicationsearly complications

shock,shock, bleeding,bleeding,

anemiaanemia

late complicationslate complications wound abscess,wound abscess, secondary bleeding,secondary bleeding,

systemic purulent infection tetanus, sepsis,systemic purulent infection tetanus, sepsis,anaerobic infection).anaerobic infection).

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Clinical presentationslinical presentationsof woundsf wounds

General symptomsGeneral sy

mptoms are determined byare determined by

wound complications (anemia, shock,wound complications (anemia, shock,

infection and so on).infection and so on). LocalLocalsymptomssy

mptoms Wound pain.Wound pain.

Bleeding woundBleeding wound Wound gapingWound gaping

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EXAMINATION OF THE PATIENTXAMINATION OF THE PATIENTAND ESTIMATION OF HISND ESTIMATION OF HISCONDITIONONDITION

consider the place of injury, the circumstancesconsider the place of injury, the circumstances

of trauma, the patients condition at theof trauma, the patients condition at the

moment of injury.moment of injury. general condition is estimated

general condition is estimated::

consciousness, skin coloration, pulse andconsciousness, skin coloration, pulse and

respiration rate, blood pressure.respiration rate, blood pressure.

Aim of examinationAim of examination:: to determine its natureto determine its natureand size, extent of injury and possibleand size, extent of injury and possible

complications.complications.

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Incised woundIncised woundis inflicted by a sharpis inflicted by a sharp

objectobject

Punctured woundPunctured woundis usually small as theis usually small as the

traumatizing object penetrates thetraumatizing object penetrates the

tissues on a limited surface.tissues on a limited surface.

Chopped woundChopped woundis a result of action by ais a result of action by a

heavy sharp object (axe)heavy sharp object (axe)..

Contused woundContused woundis inflicted with a bluntis inflicted with a blunt

objectobject

Lacerated woundLacerated woundcan be inflicted by thecan be inflicted by the

moving parts of various machines.moving parts of various machines.

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Bi te woun di te w ound is a result of being bitten by ans a result of being bitten by an

animal or humannimal or human The worst complication of a bite wound isThe worst complication of a bite wound is

rabies,rabies, so antirabies serum must beso antirabies serum must be

administered, otherwise the patient willadministered, otherwise the patient willdiedie

Infected woundsInfected wounds result from a bite byresult from a bite by

poisonous snakes and insects or frompoisonous snakes and insects or fromcontact with toxic substances (house,contact with toxic substances (house,

industrial, military, radioactive).industrial, military, radioactive).

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G u n s h o t w o u n du n s h o t w o u n d Three areas of damageThree areas of damage

The wound canalThe wound canal containscontains foreign bodiesforeign bodies

The area of traumatic necrosisThe area of traumatic necrosis involves severalinvolves severalcentimeters along the wound canalcentimeters along the wound canal

In the area of molecular commotionIn the area of molecular commotion ofof

tissues hemorrhages and rupture of capillariestissues hemorrhages and rupture of capillaries

are noted; capillary bloodstream is disrupted.are noted; capillary bloodstream is disrupted.

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Penetrating thoracicenetrating thoracic woundound

The signs:The signs:

foaming blood and air escaping from thefoaming blood and air escaping from the

wound,wound, the presence of subcutaneousthe presence of subcutaneous

emphysemaemphysema

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Penetrating wounds ofenetrating wounds ofabdominal cavitybdominal cavity

The signs:The signs:

painful abdomen,painful abdomen,

strained muscles of anterior abdominalstrained muscles of anterior abdominalwall,wall,

tympanitis;tympanitis;

liver dullness diminishes in the presenceliver dullness diminishes in the presenceof gases in the abdominal cavity,of gases in the abdominal cavity,

Blumbergs sign is positive.Blumbergs sign is positive.

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Pathogenesis of woundathogenesis of woundprocessrocessBiological processes in the wound are of complex.Biological processes in the wound are of complex.

They are determined by:They are determined by:

death of cellsdeath of cells

proteolysisproteolysis anaerobic glycolysis dominating over aerobic glycolysisanaerobic glycolysis dominating over aerobic glycolysis

accumulation of biologically active substances (histamine,accumulation of biologically active substances (histamine,

serotonin, kinins and others)serotonin, kinins and others)

microcirculation disorders followed by oxygen insufficiency inmicrocirculation disorders followed by oxygen insufficiency inthe woundthe wound

accumulation of toxic waste products from tissue and bacterialaccumulation of toxic waste products from tissue and bacterial

decompositiondecomposition

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During inflammation in the wound proteinDuring inflammation in the wound protein

metabolism suffers. A great amount ofmetabolism suffers. A great amount of

amino acids accumulates, proteinamino acids accumulates, proteinsynthesis prevailing over proteolysissynthesis prevailing over proteolysis

processes.processes.

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A certain role is played by biologicallyA certain role is played by biologically

active substances (histamine, serotonin,active substances (histamine, serotonin,

heparin and others) which affect vascularheparin and others) which affect vascularpermeability and leucocyte migration.permeability and leucocyte migration.

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Enzymes liberated upon decompositionEnzymes liberated upon decomposition

of leukocytes and other cells (protease,of leukocytes and other cells (protease,

lysozyme, lipase and others) andlysozyme, lipase and others) andbacterial enzymes (collagenase,bacterial enzymes (collagenase,

streptokinase, hialuronidase and others)streptokinase, hialuronidase and others)

break down necrotic tissues.break down necrotic tissues.

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Wound repairound repair Wound repair is a biological process ofWound repair is a biological process of

restoration of tissues (or organs) lost duerestoration of tissues (or organs) lost due

to external effects.to external effects.

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The following stages arehe following stages aredistinguished in the courseistinguished in the courseof wound process:f wound process:

Inflammation stageInflammation stage combining thecombining the

processes of alteration, exudation andprocesses of alteration, exudation and

necrolysis.necrolysis. Proliferation stageProliferation stage formation and formation and

maturation of granulation tissue.maturation of granulation tissue.

Healing stageHealing stage maturation of scar maturation of scartissue and epithelisation of the wound.tissue and epithelisation of the wound.

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The first stage ofhe first stage ofwound processound process This stage begins immediately afterThis stage begins immediately after

the trauma, ending in lysis of necroticthe trauma, ending in lysis of necrotic

tissues, their removal and cleansingtissues, their removal and cleansingof the wound.of the wound.

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The second stage ofhe second stage ofwound processound process This stage begins on days 2-3 after theThis stage begins on days 2-3 after the

trauma. The second stage of woundtrauma. The second stage of wound

process is over in 12-30 days.process is over in 12-30 days. There is no clear border line between theThere is no clear border line between the

stages. Along with the cleansing ofstages. Along with the cleansing ofnecrotic tissue from the wound thenecrotic tissue from the wound the

formation of granulation tissue beginsformation of granulation tissue beginswhere capillary endothelium andwhere capillary endothelium andfibroblasts play a major role.fibroblasts play a major role.

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The third stage ofhe third stage ofwound processound process This stage scarring andThis stage scarring and

epithelisation of the wound, begins inepithelisation of the wound, begins in

2-4 weeks. Formation of elastic fibres2-4 weeks. Formation of elastic fibresbegins in 4-6 weeks and completesbegins in 4-6 weeks and completes

by the 6th month when scar tissueby the 6th month when scar tissue

has formed.has formed.

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Healing of

wounds

Primary

intention

Secondary

intention

Healing under

the crust.

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Healing by primaryealing by primaryintentionntention

Healing by primary intentionHealing by primary intention can becan benoted in linear wounds when the edgesnoted in linear wounds when the edges

and walls of the wound touch or areand walls of the wound touch or aresutured together. The edges and walls ofsutured together. The edges and walls ofthe wound are glued together with fibrinthe wound are glued together with fibrinWound repair is completed by theWound repair is completed by the

formation of a thin linear scar andformation of a thin linear scar andepithelisation along the edges of theepithelisation along the edges of thewound.wound.

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Healing by secondaryealing by secondary Healing by secondary intentionHealing by secondary intention can becan be

noted when the edges and walls of thenoted when the edges and walls of the

wound do not touch. Healing goeswound do not touch. Healing goesthrough all the stages and is completedthrough all the stages and is completed

by the formation of scar.by the formation of scar.

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Healing under theealing under thecrustrust

Healing under the crustHealing under the crustoccurs whenoccurs whenthere are minor skin wounds (bruises,there are minor skin wounds (bruises,

abrasions and so on) when the woundabrasions and so on) when the wounddefect is covered with crust of drieddefect is covered with crust of driedblood, lymph, and necrotized tissue.blood, lymph, and necrotized tissue.Under the crust which serves as aUnder the crust which serves as a

protective barrier granulation tissueprotective barrier granulation tissueforms, the growing epidermis comingforms, the growing epidermis comingfrom the edges. Then the crust detaches.from the edges. Then the crust detaches.

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Infected complicationsnfected complicationsof woundsf wounds

Wound suppuration.Wound suppuration. ClinicalClinical

presentations of suppuration appear inpresentations of suppuration appear in

2-3 days after the trauma2-3 days after the trauma.. Suppurative wound infection in the first 3-5Suppurative wound infection in the first 3-5

days after injury is calleddays after injury is calledprimary suppurationprimary suppuration,,

if it appears later, it is calledif it appears later, it is called secondarysecondarysuppurationsuppuration..

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Managementanagement In the first stage of suppuration the pus andIn the first stage of suppuration the pus and

necrotized tissue should be removed,necrotized tissue should be removed,

antibacterial therapy administered. For thisantibacterial therapy administered. For this

purpose we administer drains, saline solution,purpose we administer drains, saline solution,

proteolytic enzymes, exposure to laser,proteolytic enzymes, exposure to laser,

ultrasound cavitation. In pronounced necrosisultrasound cavitation. In pronounced necrosis

necrectomy is performed. Dressing is changednecrectomy is performed. Dressing is changeddaily, twice a day if necessary.daily, twice a day if necessary.

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Managementanagement When repair begins administration ofWhen repair begins administration of

physical antiseptics and proteolyticphysical antiseptics and proteolytic

enzymes is contraindicated. Salveenzymes is contraindicated. Salvedressings with components improvingdressings with components improving

regeneration are applied.regeneration are applied.

When inflammation subsides completelyWhen inflammation subsides completelyearly or late secondary suture isearly or late secondary suture is

administered.administered.

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Anaerobic infectionnaerobic infection When wounds are infected with clostridialWhen wounds are infected with clostridial

microbial flora, tissue necrosismicrobial flora, tissue necrosis

progresses quickly with development ofprogresses quickly with development ofedema, gases, severe intoxication.edema, gases, severe intoxication.

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Anaerobic infection isnaerobic infection iscaused by spore-formingaused by spore-forminganaerobic flora:naerobic flora:

Cl. Perfrigens,Cl. Perfrigens,

Cl. OedematiensCl. Oedematiens

Cl. SepticumCl. Septicum

Cl. Hystoliticum.Cl. Hystoliticum.

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Examination of thexamination of thewoundound

Examination of the wound revealsExamination of the wound revealsswelling of its edges, vesicles on theswelling of its edges, vesicles on the

skin. The walls of the wound are grey,skin. The walls of the wound are grey,dull; the discharge is grey with a specificdull; the discharge is grey with a specificsmell. The muscles have the typicalsmell. The muscles have the typicalboiled meat appearance.boiled meat appearance.

If you palpate gas in the tissuesIf you palpate gas in the tissues(crepitation sign), the diagnosis of(crepitation sign), the diagnosis ofanaerobic infection is doubtless.anaerobic infection is doubtless.

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Complex prevention ofomplex prevention ofanaerobic infection includes thenaerobic infection includes thefollowing:ollowing: timely administration o medical aid.timely administration o medical aid.

prevention and treatment of shockprevention and treatment of shock

early initial surgical debridement ofearly initial surgical debridement ofwoundwound

administration of polyvalent antigangreneadministration of polyvalent antigangrene

serum 30 thousand active units.serum 30 thousand active units.

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T r e a t m e n tr e a t m e n t of patientsof patientswith anaerobicith anaerobicinfectionnfection Patients should be placed into closed boxes.Patients should be placed into closed boxes.

Wide dissection of tissues in the wound isWide dissection of tissues in the wound isindicated, dissection of fascial compartments,indicated, dissection of fascial compartments,removal of necrotized tissues, especially muscles.removal of necrotized tissues, especially muscles.

In grave casesIn grave cases amputation of the extremity isamputation of the extremity isindicated.indicated.

A therapeutic dose of antigangrene serum,A therapeutic dose of antigangrene serum,150 000 active units, is administered during150 000 active units, is administered duringsurgery.surgery.

Antibacterial drugsAntibacterial drugs

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First aid andirst aid andmanagementanagement arrest of bleeding,arrest of bleeding,

application of dressingapplication of dressing

transport immobilization, if necessarytransport immobilization, if necessary

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Initial surgical debridementnitial surgical debridementof woundf wound early initial surgical debridementearly initial surgical debridementwhich iswhich is

performed within a day after injury,performed within a day after injury,

detained surgical debridementdetained surgical debridement,,performed within a second day,performed within a second day,

late debridement of woundlate debridement of woundwhich is givenwhich is given

later than 48 hours after injury.later than 48 hours after injury.

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Initial surgical debridementnitial surgical debridement consists inconsists in excising the edges, walls and bottomexcising the edges, walls and bottom

of the wound within viable tissue with theof the wound within viable tissue with therestoration of anatomic relationsrestoration of anatomic relations

The depth of removed tissues varies from 0.5The depth of removed tissues varies from 0.5to 1 cm.to 1 cm.

all foreign bodies are removed.all foreign bodies are removed.

damageddamaged major vessels, nerves or tendons ismajor vessels, nerves or tendons isrestoredrestored

After the debridement the wound is sutured.After the debridement the wound is sutured.

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Different types ofifferent types ofsuturesutures Primary suturePrimary suture is placedis placed within the first daywithin the first day

after injuryafter injury

Primary delayed suturePrimary delayed suture is placed within 5-7is placed within 5-7

days after initial debridementdays after initial debridement Secondary sutureSecondary suture is placed on the granulatingis placed on the granulating

wound when the danger of suppuration iswound when the danger of suppuration is

eliminatedeliminated Early secondary sutureEarlysecondary suture is placed within 8-15 days withoutis placed within 8-15 days without

excising the edges of woundexcising the edges of wound

Late secondary sutureLate secondarysuture is placed after more than 15 daysis placed after more than 15 days

excising the scarry tissue around the wounds edges.excising the scarry tissue around the wounds edges.