4. ACUTE Recent wound
which has yet to progress
through the sequential
stages of healing
CHRONIC Wound that
has arrested in one of the
wound healing stages usually
inflammatory phase
6. SIMPLE WOUND those wounds which are
readily managed by local wound care /contraction,
direct closure, skin grafting, local tissure rearrangment.
COMPLEX WOUND these are large wounds
requiring tissue distant from wound site i.e. regional,
distal transposition or microvascular composite tissue
transfer
PROBLEM WOUND Those wounds which fails
to achieve closure with the above methods or recurres
due to local or systemic causes.
18. Accelerated senescence, diminished
production of growth factors, collagen,
matrix, decreased ability to survive
hypoxic stress,
Aging is irreversible: optimization of the systemic
parameters & supplementation is the solution
AGE
19. Damage to the small vessels
in the wound leads to hypoxia
of the wound relative to the
normal tissue (25mmHg vs
40mmHg), this hypoxia
becomes chronic due to peri-
wound fibrosis in problem
wounds.
ISCHEMIA
26. Bacterial inoculum & virality, presence
of foreign bodies, determines the
severity of the wound
Bacteria: Set up free radicles
environment, secrets toxins &
proteases----bystander damage
BACTERIA
27. Indications for antibiotics: Venous
stasis ulcers, lymphangitis, cellulitis,
critical colonization of the wound,
infection (straw color oozing, pain),
BACTERIA
Never forget to use topical antibiotics
‘cuase peri-wound fibrosis restricts
the the delivery of systemic
antibiotics
29. Debridement : without debridement wound is
exposed to cytotoxic stressors & competes with the
bacteria for scarce oxygen & nutrition resources,
debridement reduces the bioburden and help
ensure healing
31. Eschar : should be excised: Many surgeons still
consider it as a biological dressing & believes in
healing under eschar. Proteinaceous eschar acts as
meal for bacteria.
37. NEGATIVE PRESSURE WOUND THERAPY
Tremendous adjuvent for wound closure
Mechanism: relieves
edema, removes
deletrious enzymes,
exudates, bacterial load,
cyclical compression &
relaxation stimulates
mechanotransductive
pathway of growth
factors.
Precautions: the
sponge should not be
placed on normal skin,
use of optimal negative
pressure of 125mmHg
40. Hyperbaric oxygen therapy
100% oxygen at 2-3 ATA raises
the dissolved oxygen level from
0.3% to 7% in plasma which
increases 4-5 times oxygen
delivery to the wound
41. DRESSINGS
Goals: to clean the wound, creat moist healing
environment to facilitate cell migration & prevent
dessication
Paradigm shift: from moist to dry dressing to
moist dressing.
42. Hydrogel/films/composite dressings: ;used for
light exudating wounds
Hydrocollides are used for moderate quantities of
exudation.
Alginates/foams/NPWT: usefull for heavy
exudation.
CHOICE OF DRESSING IS BASED
ON QUANTITY OF EXUDATE
43. Gauze
Advantages: Traditional first choice used for moist
to dry dressing, low material expense, easily
availble, excellent as surgical bandage for
uncomplicated.
Dis advantages: moist to dry dressings are
traumatizing as gauze is non-selective debrider
causing significant bystander damage, leaves
behind fine microfibers which are irritants and
source of infection.
Impregnated gauze with petrolium, iodinated
compounds for moist dressing is available having
comparable results with the modern dressings.
44. Semiocclusive Dressings
Unpermeable to fluids to keep moist
environment, permit of gas molecules.
To cover freshly closed incisions, skin
graft donor site. Should not be used for
contaminated wounds .
45. Hydrogel dressing:
Autolytic debridement by rehydrating
the wound and facilitat healing. Used
in wound with small amount of
eschar and predisposed to
dessication, infected wounds, require
secondary dressing on top of it.
47. Alginates useful in
wounds with significant
exudated fluids, they can
absorb fluids 20 times their
dry weight, not to be used on
nonexudative wounds as they
will dry up the wound. If used
for dry wound they should be
hydrated with saline prior to
application
48. Pyodine iodine & Chlorhexadine
damages the normal cells,
fibroblasts and growth factors as
well, so newer antimicrobial
agents containing dressings are
favoured i.e. silver and
cadexomer iodine
54. Thorough wound wash
Debridement of the necrosed margins,
conservatively on the face,
Layered closure to obliteration the dead
space
No skin stiches untill skin margins are
<2mm apart by applying intradermal
sutures
Use of fine monofilament sutures with
carefull handling of the skin margins.
55. Timely removal of the sutures, and
application of the scar modification
measurements ensures a fine scare…..
61. Decreases angiogenesis, collagen deposition, cellular
proliferation, prone to infection
Patients should receive Vit-A (25000IU/day PO or
200000 IU topically TDS)
Goal should be to maintain a clean wound with
minimal bacterial colonization
62. Irradiated
wounds
Progressive endarteritis
obliterans, microvascular
damag, fibrotic changes
leading to ischemia, prone to
infection.
Needs very carefull
debridement, antimicrobial
moist dressing while
promoting autolysis are ideal
for these wounds.
Hyperbaric oxygen therapy
and growth factors are also
useful adjuvents. Usually
needs flap coverage.
63. Pressure
sores
Patients are usually
malnourished and
nutritional uplift is
necessory in these
patients along with
the administration of
growth hormones or
anabolic steroids
(oxandrolone) to
counteract the
catabolic s state of the
patients
64. Pressure sores
They needs thorough multiple sessions of debridements and
ultimately fasciocutaneous or musculocutaneous flape coverage.
Frustrating part is its high recurrence rates.
Film drssings are
ideal for stage I & II
to keep the moist
environment. While
for stage III & IV
more absorptive
dressings (hydrogel,
hydrocollides,
foams and
alginates) are
required depending
on the exudatation
level.
65. Pressure
sores
The spasm of the
patients should be
relieved non-
surgically
(benzodiazipins,
dantrolen e.t.c.) or
surgically.
Use of pressure
relieving devices are
helpful in healing
and preventing
recurrence.
66. Diabetic wounds
Combination of microangiopathic, neuropathic and
pressure necrosis ulcers.
Thorough serial debridement , glucose control, pressure
offloading, revascularization, nerve decompression
combination is required.
67. Venous stasis ulcers
Compression therapy is the main stay of theapy i.e.
graduated compression stockings (30-40mmHg
pressure), contraindicated when ABPI is <0.7 and
shloud be used with causion in 0.7-0.9.
Supplementary dressing depending upon the
amount of exudate is used. When edema subsides
then the wounds are closed & compression therapy
contiued post-op for several weeks.
Ulcers resistant to compression therapy should
undergo venous insufficiency studies. The
superficial/perforators insufficiency is the idication
for vascular surgery.
