2. Principle
The primary goal of wound care is
not technical repair of the wound
but to provide optimal conditions so
that the natural reparative processes
of the wound may proceed
4. Tensile Strength of the Wound
Lysis of the old collage with
laying down the new collage
Up to 2 years
5. Type of Wound Healing
• Healing by First Intention (aka primary wound
healing)
• Wound closed by approxiamtion of wound
margins or by pacement of a graft or flap, or
wound created and closed in OT
• Indication:
– Recent (<24H)
– Clean
– Viable Tissue
– Tension-Free
• Treated within 24H
6. • Healing by second intention (aka secondary
wound healing)
• Wound is left open to allow to close by
epithelialization and contraction
• Usually for contaminated or infected wound
• There is presence of granulation tissue
• Compliaction
– Late wound contracture
– Hypertophic scarring
7. • Healing by third intention(aka tertiary wound
healing or delayed wound closure)
• Wound that are too heavily contaminated for
primary closure but appear clean and well
vascularized after 4-5 days of open observation
• Indication:
– Unhealthy wound
– Wound with a long time lapse since injury
– Wound with crush component with significant of
tissue loss
• Wound edges are approximated within 3-4 days
9. Factors affecting cosmetic outcomes
• Concave surface
• Wound size
• Depth of the wound
• Skin color (lighter skin better)
• Exposure to sun (Pigmentation)
10. Evaluation of Wound
• History
– Time of injury
• Less contaminated if within 6-8 hours
• Highly vascularized area (face, scalp) can up to 24h
– Mechanism of injury determine type of wound
– Environment where the wound occurred
– Medical co-morbidities
– Others medication/tetanus status
11. • Physical examination
– Location of the wound
• High endogenous bacterial counts hairy scalp, axilla,
groin, mouth, foreskin of penis
– Amount of tissue destruction
– Degree of contamination
– Involvement of underlying structures
12. Management
• Wound Preparation
– Cleaning large amount of NS (high pressure
irrigation to dislodge FB, contaminants)
– Soaking wound in NS or antiseptic solution
little value and may increase the bacterial load
– Antibiotic solution for irrigation inconsistent
effectiveness in reducing infection rates
– Hair removal clipping NO SHAVING
16. Foreign Body
• FB can cause chronic inflammation which will
affect the healing process
• Suspect with point of tenderness
• Imaging
– Glass, metals, gravel fragments >1mm should be
visible in plain X-ray
– Organics and plastic usually radiolucent
17. Foreign Body Removal
• Indication
– Presenting with neurovascular compromise or
infection
– Ongoing pain
– Functional impairment
– Sensation of foreign material
– Weaker indication cosmetic / patient request
• Contraindication
– Clean wound without signs of infection OR sensation
of foreign material ( attempt of removal > trauma)
– Delayed removal if infection
18. • Debridement
– Devitalized tissue
– Excision is made parallel to the skin crease
• Hemostasis
• Primary closure of the wound OR Dressing
25. Bite Wound
• 1% of emergency visits
• 80-90% of the cases are due to dog bites
• Followed by cat bites and human bites
• Serious infection can cause from the bites
wounds
26. Dog bites
• Incidences of dog bites is higher in the
younger children than in adults
• The bites in the children usually involving
head, face and neck
• 2-20% of dog-bites wound become infected
• Each year, more than a dozen deaths are
caused by dog-bites
27. Cat Bites
• Account for 5-15% of bite wounds
• Cat bites are more common in women
• It is always puncture wounds and the rate of
infection is high
28. Human Bites
• Account for 2-3% of all reported bites with ¾
caused by aggressive acts
• Usually seen in sexual crimes or child abuse,
or clenched fist, the result of punching a
person in the mouth
• 10-50% of human bites become infected
29. Microbiology
• Streptococcus pyogenes has been found in
human bites
• Pasteurella multocida in animal bites (60% of
bacteremia cases) with Pasteurella septica
causing CNS symptoms
• Eikenella corrodens in both animals and
human bites ( > common in human bites)
• Serious infection : Leptospirosis (rodents and
dogs), Rabies (dogs and other mammals)
30. Management
• Dog bites
– 2-5% dog bite wounds become infected
– The dog’s rabies status needs to be ascertained
– Gram’s stain and culture for both aerobic and
anaerobic bacterial should be obtained
– Wounds contaminated by soil or vegetative debris
should be cultured for mycobacterium and fungi
31. • Good wound management :
– Evaluation
– Proper wound care
– Antimicrobial agents
– Report to local health authorities (dog bites)
32. Evaluation
• Patient’s medical history
• Type of attack
• Examining the wound
• Obtain wound culture
• Determine wound approximation
33. Local care
• Irrigation
• Devridement
• Exploration
• Dressing
• Suturing controversy
– Most of the bite wound should left open
37. Wound Dressing
• Goal of dressing
– Protect wound from infection
– Maintain the moist environment
– Promote gas exchanges
– Encourage rapid epithelialization
• Key for wound care
– Indentify the causative factors
– Improve local environments
38. Transparent Films
• Advantages:
– Waterproof and Bacteria-proof
– Allows visualization of the wound.
– Won’t traumatize wound when removed.
• Disadvantages
– Not rec. for wound with moderate/heavy
exudate.
– Not rec. for wound with fragile surrounding
skin.
– Provides no cushioning to wound.
40. Foams-polyurethane pads
-Indications: Noninfected, draining granular wound
• Advantages
– Non-adherent
– Won’t injure surrounding skin
– Can repel contaminants
– May be used under compression
– Cushions wound surface
– Maintains moist wound evironment
– Highly conforming
– Gas permeable
41. Hydrocolloids
in pad,sheet or filler form for occlusive use.
Forms a “gel” as it absorbs water from the wound bed
that sits on wound
Indications: Small, solitary non-draining ulcers
or light-to-moderate exudate wounds
• Advantages
– Impermeable to bacteria and other contaminants
– Promotes autolysis, angiogenesis, and granulation
– Self-adhesive and molds well
– Limited-to-moderate absorption
– Creates moist environment
– May be left in place for up to 5 days
– May be worn in the shower
43. Hydrogels
-cross-linked hydrophilic matrix impregnated into gauze-type
pads which allows transmission of water, vapor and CO2 but
discourages dehydration.
Indications: full thickness wounds with moderate drainage
– Soothing and conforms to wound
– Fills in dead spaces
– Highly absorptive
– Can be used on infected wounds
• Disadvantages
– Difficult to keep in place
– Encourages gram negative organisms
45. Honey
• Medical grade honey
• Promotes moist wound healing
• Supports autolytic debridement
• Helps to lower pH of a wound which can
increase healing
46. Stoma
• Surgically created openings of small or large
intestine onto the anterior abdominal wall
• Type
– Colostomy
• End colostomy
• Loop stoma
– Ileostomy
47. Routine care for ostomies
• Pouch placement
– Closed end pouches
– Open end pouches (reusable)
• Empty the pouch when 1/3 full to prevent
leakage due to excess weight
• Changing the pouch 1-2/week
• For foul odor
– Chloride tab in bag
– Bismuth sub galiate
– Cholorophylline complex can be taken orally
48. • Diet – minimal modification needed, avoid
unchewed nuts, fruits with skin, popcorn that can
obstruct the stoma
• If gas is bothering patient, then avoid
– Beans, cabbage, cauliflower, broccoli asperagus
• Low car diet with less potatoes, corn, noodle and
wheat products
• Adequate fluid intake
• Patient should be educated regarding signs of
dehydration and electrolytes imbalance
49. • Physical activity
– No restriction
– Bathing can be done with pouch on or off
• Most sports can be performed except extreme
contact sports
• Sexual activity does not affect organic
function
50. Complications
• Overall complications rate are between 14 to 79%
• Life time risk
– Colostomy – 25%
– Ileostomy 50-70%
• Known complications
– Skin dermatitis, excoriation, ulceration
– Bleeding
– Retraction
– Prolapsed
– Stenosis
– Parastomal herniation
51. Skin compliactions
• Dermatitis
– More common with ileostomies (enzymatic nature
of the effluent with high volume)
– Severely denuded skin along the inferior surface
of the stoma
– Skin irraitation can also due to
• Allergic to pouch product
• Fungal infection
• Antibiotic related
52. • Treatment
– Identify the underlying causative factors
– Elimination of the allergen
– Denuded area cover with skin barrier
– Antifungal nystatin or miconazole
– Topical steroid for severe allergic reaction
53. Stomal Bleeding
• Major bleeding uncommon
• Usually due to stomal laceration due to poor
fitting appliance
• Management
– Direct pressure
– Local cauterisation
– Ligation with sutures
54. Stoma retraction
• Defined as stoma
0.5cm or more below
the skin surface
• Incidence 1-40% of all
ostomies
• It causes skin irritation
due to difficulty in
fitting a pouch
• Management
convex pouch system
55. Stomal Prolapse
• Telescoping of the intestine out from the stoma
• Highest with loop transverse colostomyand
descending colostomies
• Difficulty in applying stoma
• If prolonged edema strangulation
• Uncomplicated cool compression or using
osmotic agents to reduce the edema then
followed by manual reduction
• Complication ischemic changes surgical
intervention
56. Parastoma hernia
• Type of incisional hernia
• Unsightly bulge at the stoma
• Can cause poor fitting of the appliances
• Can cause obstruction and strangulation
• Treatment
– Surgical repair
