How Wound Care Should Be?
Prepared by the American Plastic Surgery Training Foundation, the educational arm of the American Society of Plastic Surgery, this article provides comprehensive information about common injuries and wound healing in everyday life.
After the biochemical building blocks of wound healing come together, fibroblasts begin to multiply and settle. The main task of fibroblasts is collagen synthesis. As the collagen content increases, the resistance of the wound site increases. Stitches, according to localization 3-14. should be taken between days. However, the wound's collagen content and tensile strength increase within the following weeks; Intra-wound collagen transformation continues indefinitely. This second phase of wound healing is called the “Fibroblastic phase” or “Collagen phase..
Ascorbic acid plays an important role in collagen formation. In the absence of vitamin C, proline cannot be converted to hydroxyproline and hence collagen synthesis stops. Herman Melville's kapan Moby Dick eser in the work of scurvy seafarers to remember long-term wounds, if we remember today, we know why. In ascorbic acid deficiency, collagen resorption continues at the same rate, its synthesis stops and consequently wound healing stops.
The longest stage of wound healing is the last stage. This stage of ur maturation ”or“ remodeling bilir can last for several years and results in an improvement in the appearance of the wound. During this time, progressive collagen replacement results in a soft, less noticeable scar. Maturation is important for gradual healing of the wound.
Wounds with skin loss
Acute traumatic injuries such as severe burns, deep abrasions or avulsions, which result in skin loss, also go through the same stages of recovery. However, wound closure requires two additional biological mechanisms. These include epithelial migration and wound contraction.
Epithelialization: Immediately after collection of biochemical and cellular substrates required for healing and as soon as bacterial contamination falls below 105 organisms / gram, epithelial proliferation begins and epithelial migration to the wound surface. If the wound is a superficial burn or abrasion, the epithelium begins to spread rapidly through sweat glands and hair follicles and covers the entire wound surface within 10-14 days. When all layers of the skin are lost, epithelial migration may occur only from the wound edges. Epithelialization is a very slow event and premature closure of the wound is usually not possible. There is also an epithelial migration without dermal layers and is therefore more susceptible to trauma.
Histology of migrating epithelium is usually neoplastic. Over time, a chronic wound that does not close for years may develop a malignant ulceration, namely Marjolin ulcer, which is the name of the French surgeon who first described it. Therefore, reconstructive surgeons have learned not to rely solely on epithelialization in the face of serious and widespread wounds. Instead, they use grafts and flaps for wound closure.
Wound contraction: Open wounds tend to close with the effect of internal forces over time. “Granulation Yar means that the wound surface is filled with a rough-looking granulation tissue formed by capillary and fibroblast proliferation. The formation of granulation tissue in an open wound corresponds to the fibroblastic phase of primary wound healing. After granulation, the wound lips are pulled towards the edges; however, this shift cannot be explained by epithelization alone. The gradual shrinkage of the wound surface is called wound contraction and is a process that has not yet been fully elucidated. Today, it is believed that myofibroblasts, a highly specialized type of fibroblast, act as smooth muscle cells.
In the presence of severe bacterial contamination, neither epithelial migration nor contraction can progress (105 organisms / gm). Contraction can be slowed down by applying partial thickness skin grafts; With full-thickness skin grafts, contraction can be almost stopped. Some synthetic membranes, such as biobrane, may also inhibit wound contraction.
Large wound defects can be treated with the best surgical closure and should not be allowed to heal themselves.
The goal of wound healing is not to sterilize the wound!
When a public opinion poll is conducted among physicians, the questions are often related to the use of antiseptic solutions or antibiotics to prevent bacterial contamination or to achieve sterility.
The disadvantage of over-emphasis on sterility is that it can overlook many more important elements in wound healing. If infection is present, sterility is a sine qua non condition for the skin surface.
In the absence of a traumatic injury, pathogen and non-pathogenic bacteria coexist in healthy skin. Quantitative tissue biopsy studies have shown that the bacterial density on normal skin is 103 organisms / g. Most bacteria on the surface of the skin live in epidermal recesses such as sweat glands, hair roots and other skin appendages. Thus, the skin is an important barrier against infection.
Bacterial growth in the skin depends on various variables such as skin pH, dryness of the outer skin layers and local secretions. Fatty acids produced in sebaceous glands are highly effective in preventing the proliferation of streptococci.
However, an injury significantly changes this balance. Even minimal trauma, such as shaving the night before elective surgery, can increase the bacterial level by 10 times or more. Burns destroy the keratin layer that prevents bacterial invasion. A laceration exposes layers of deep tissue. Overwhelming impacts cause more cell damage. The problems increase when treatment is delayed. The number of bacteria increases when the wound is contaminated with soil.
Some of the commonly used cleaning solutions make the recovery medium worse. For example; solutions containing alcohol or hydrogen are also lethal to healthy cells; solutions containing strong detergents are nothing more than a physiological soap. Solutions containing a high concentration of pigment dyes the wound and prevents the difference between viable and inanimate tissues.
Another popular ritual is to shave the wound when the wound is to be treated. However, exaggerating this results in the emergence of patients with hairless areas from the emergency department, especially those admitted to the emergency department with a small laceration on the scalp. Basically, hair is not more dirty than scalp; it is neither sterile nor unusually contaminated. However, the hair is a protein and acts as a foreign body if the wound enters the lips. Therefore, it is not necessary to shave the hair and hair around the wound if care is taken not to penetrate the wound.
What about a satisfactory wound preparation? First draw a physiological saline to a 50 cc syringe and wash the wound under pressure. By acting like a macrophage, you remove clots, necrotic tissues, foreign bodies, and some of the bacteria from the wound. This crucial step dilutes existing bacteria and removes dead tissue from the healing site, reducing the risk of infection and increasing the likelihood of uncomplicated healing. Do not hesitate to perform local anesthesia before performing this procedure; you do not spread the infection; you can even do a pretty good job of resting the nerve endings.
Do not put any substance into the wound that could cause further damage to the cells. Avoid all solutions containing alcohol, povidion iodine and detergent. If you do not know anything, a simple and balanced salt solution can be applied both as a preparation and as an irrigant.
After cleaning the wound, you can now act as a myofibroblast and bring the wound lips closer together.
It is useful to emphasize the measurement of infection in wounds. The biopsy culture allows quantitative determination of bacterial density. Studies have shown that the risk of infection is high if the wound is sutured when quantitative cultures have values greater than 105 organisms / gm. If the values are below this figure, infection is rarely seen unless technical errors such as tense closure and insufficient debridement are made. Streptococci are excluded from this rule; no matter which amount they are found, it is dangerous.
If you often encounter poorly contaminated wounds due to your job, you may prefer to delay closure and ask your microbiology laboratory to support you with biopsy culture technology, if any. Secondary closure can best be completed after the inflammatory phase of wound healing reduces bacterial density to a safe level
Priorities in wound care
The most appropriate care for acute soft tissue injuries should include the following steps:
Inspection: Quickly look at the wound immediately after the patient arrives. You will need to decide whether the bleeding is under control and whether the size of the wound is beyond your possibilities. Remember to look beyond the most visible wound and check the signs of other serious wounds.
You may decide to share responsibility with a consultant for a complex wound. Otherwise, you may be temporarily deprived of your authority due to similar or much more difficult problems. In this case, the appropriate solutions; to ask for help and then to take action or to ask the patient and family to wait if the wound is mild. In the last two cases, you need to convince the patient and his / her relatives that nothing will be lost with a delay of one or two hours. Make sure that the patient stays in a comfortable place. Determine the characteristics of the wound before starting treatment, and take anamnesis including the patient's past medical history, allergies, treatments and vaccines.
Anesthesia: Local anesthesia should be applied to the wound before any intervention. Even if dirt is visible in the wound, first infiltrate the surface; then apply irrigation and debridement. It is not true that your needle will spread contamination. Direct injection into the wound, not from neighboring skin, will not increase the risk of infection, but is less painful. Adequate irrigation and debridement can only be achieved if the wound is well anesthetized. If you prepare the wound without giving anesthetic, your chance of success is reduced.
Antiseptic solution: Many physicians are concerned about which preparation solution to use. However, this issue is the least important of the issues affecting the success of wound treatment.
Never use agents that damage living tissues. Preparation solutions containing alcohol, povidone iodine, peroxide or strong detergents do more harm than good. They kill bacteria, but they also kill fibroblasts and epithelial cells. Solutions containing high concentrations of pigment change the appearance of the wound and make it difficult to determine tissue viability.
Irrigation and debridement: Except for very small and superficial ones, all wounds benefit from washing. This is the main step to prepare a wound for closure. This physiological washing solution dilutes the concentration of bacteria present. It also removes dirt particles and, most importantly, identifies partially broken fat particles and other inanimate tissues. If they are not debrided, they form food for existing microorganisms. Use a 50 cc syringe and 25 gauge needle to ensure optimal irrigation force.
Ruling - Closing or not closing: It is best to postpone the closure for three to five days in the event of a long time after injury or overwhelmingly contaminated injuries. The inflammatory phase of healing is maximized during this time.
One of the most important surgical lessons learned from past wars is that it would be more beneficial to leave a wound temporarily open in a condition treated in worse conditions than ideal. Immediately suturing creates a higher risk of infection. Perhaps the only exception to this general rule is face injuries. When it is ensured that effective irrigation and debridement is ensured, it is not a problem because of delayed suturing of a face laceration and good blood supply to the head and neck.
Tetanus prophylaxis: Even minor minor wounds can cause tetanus. In this regard, it is very important to question the previous tetanus prophylaxis. It is important to know the differences between an earlier tetanus vaccine and complete prophylaxis requiring three injections. If in doubt, first passive immunization to your patient using a human antibody preparation.
Antibiotics: Antibiotics should be used in wounds with the possibility of serious contamination. This includes all animal and human bites. Antibiotics may also benefit patients whose treatment is significantly delayed. Wounds completely covered or contaminated with soil, in particular crush and rupture injuries where blood supply is endangered; are open to infection and thus benefit from antibiotics. Antibiotics may alter balance to improve, but do not replace appropriate debridement and reasonable surgical decision.
Instructions to patients: Never assume that your patient listens to everything you say. An accidentally injured patient will often consider the causes of the accident instead of observing your instructions. Be willing to repeat what you say. Speak in a descriptive and simple language. But most of all, write down the important instructions after treatment on a piece of paper. This can then be used by the patient.
Medications for acute injuries
Unfortunately there is a common misconception that narcotics, sedatives, and almost all such drugs are unsafe for victims of traumatic injuries. This principle applies strictly to patients with multiple system injuries. However, this is not true for those with regional injuries. Do not ignore pharmacological support for such patients. Observe signs of intracranial trauma; if not, have your patient benefit from painkillers and sedatives.
sedation
If the patient has an acute injury, administer all drugs intravenously. Intramuscular injections are less effective and unnecessary suffering for the patient. With an intravenous catheter, it is possible to add other drugs if necessary. This book does not cover the whole pharmacological approach. It is said that simple drugs are likely to be sufficient.
For many patients, barbiturates are an ideal sedative. Of course, before giving anything to your patient, you should be informed about allergies and previous drug intolerances. Also, wait a certain time for the sedative to take effect before administering local anesthesia. Local anesthetic will be more effective in a patient with adequate sedation.
analgesics
A sedative like nembutal is only a sedative, not an analgesic. If the patient is painful or you expect it to be, a medication, preferably a narcotic, should be prescribed to control the pain. Both Morphine and Demerol are suitable for this. Use which medicine you know better. However, if the patient has developed nausea or adverse reactions to the medication you are using, use the other.
relaxants
In addition to a sedative or analgesic, patients may also benefit from a short-acting relaxant such as Diazepam, which is best given immediately prior to administration of the local anesthetic.
Wound Dressing
A good dressing should be able to perform one or more of the functions listed below.
Protection: The dressing protects the wound from additional traumas, heat changes that stimulate pain, and prying eyes of others. A simple bandage protects against unwanted questions caused by an open sutured wound and stain formation on clothing. In addition, dressing closure provides a suitable environment for optimal wound healing. When circulation is impaired, a wound that does not heal cannot maintain its own moisture, and the resulting dryness increases tissue loss. On the other hand, the wound surface can produce large amounts of exudative leakage, which leads to unnecessary metabolic loss. Although some physicians believe that dressing protects the wound from bacterial contamination, a sutured wound is not easily contaminated after several hours of treatment. Once the inflammatory phase of wound healing has begun, the wound is able to protect itself unless there is a circulatory problem.
Absorption: The dressing can absorb exudative leakage on the wound surface. This reduces the likelihood of bacterial proliferation and subsequent wound infection. Moist dressing acts as a suppository, drawing fluid from the wound. Thus, it prevents the exudate from mold crusting in the wound.
Remember, neither the wound surface nor the skin is sterile. Bacteria are inevitably present on these surfaces. If we allow bacterial proliferation, of course the bill will be heavy. Delayed wound healing due to developing infection and a marked scar ending is an undesirable end.
Pressure: A good dressing should be able to exert reasonable pressure to prevent edema in the wound. However, excessive pressure that may cause ischemia should be avoided.
Immobilization: A good dressing should be able to provide immobilization in the healing area. A constantly moving wound cannot heal as quickly and well as an immobile wound. Efficient immobilization is essential for neovascularization of skin grafts.
Characteristics of a good dressing
The suitability of the dressing to the patient's living conditions should always be considered. The choice of dressing may be different from that of an inpatient, a patient in the emergency room who will return to work soon. An uncomfortable and dysfunctional dressing will reduce patient compliance. Therefore, the outer layer of the dressings should be clean, neat and tidy.
The first layer of dressing should not stick to the wound surface. For this purpose, lightly lubricated gauze with liquid permeability is preferred. The gaps of the gauze are sufficiently wide to allow fluid passage. Telfa, Saran and other impermeable materials are not suitable as they cause maceration.
The second layer should be capable of absorbing liquids leaking from the wound. While folded gauze or pads are sufficient in small wounds, larger wounds require a large number of flaf gases with greater absorption. Cotton is a building block traditionally used in gauze. However, synthetic materials with a high degree of absorption are also produced. Wrapping around the limb with soft gas coils after flame gases increases both the absorption capacity and stabilizes the first layer of dressing. However, these soft materials relax very quickly and may not provide sufficient pressure and stability of the dressing. Initially controlled printing with non-elastic dressings is best. Elastic bandage is useless in this type of dressing. Because increased pressure can cause ischemia. If this layer of dressing is supported by adhesive tapes, the durability of the dressing increases. The aim is to provide pressure. It does not create strangulation or ischemia. Fluffy application of gauze and supporting with adhesive tapes significantly helps immobilization of the extremity. For further immobilization, an additional splint is required. But be careful when using splint. If you do not use enough cotton, you will cause pressure and ischemia. The dressing must be skillfully and aesthetically pleasing.
Open wound care
Dressings for abrasions, burns or open wounds should also function as protection, absorption, compression and immobilization as in closed wounds. However, the dressing of such wounds requires some regulation.
Partial thickness damage, such as superficial burns and abrasions, should be removed from all foreign objects and covered with a protective but non-adherent layer such as Bactigras. When removing this layer, the new proliferative epithelium should never be damaged, the second layer should be absorbent. As the dressing is renewed, the upper layer is changed without removing the first layer. The first layer is separated automatically when the wound heals.
Wet / damp dressing
Wet-moist dressing and perhaps one of the new hydrocolloid dressings is always preferred to dry dressing. Any dressing is slightly soaked when opening; because dry dressing causes pain when removing. A further advantage of wet-moist or hydrocolloid dressings is that it provides a moist environment that provides epithelial migration and granulation tissue formation.
Wound care in burns
As our title suggests, this section will discuss exactly what mild burns are. Mild burns may be underestimated by surgeons. We surgeons may say that “mild burns are the problem of others, not our concern” or “mild burns do not require a specialist or burn center”. But this may not always be true.
Mild burns;
Usually less than 5% of the body area.
Partial thickness injuries.
Burns that do not involve the face, hand, foot or genital area.
In this section, we consider only the treatment of mild burns. The basic principles described here can also be applied to larger burns; however, it is recommended that you send patients with major burns to a specialist or burn center.
Type of wound
Mild burns are like abrasions of partial thickness. They are superficial and do not fully penetrate the skin. Note, however, that a partial-thickness burn today may be a full coat tomorrow, or its depth may be incorrectly detected initially. So be on the lookout for greater damage.
Initial treatment of burn injuries
As with all wounds initially, gently clean the wound surface. Leave small, unexploded and uninfected blisters intact to protect the wound surface. If blisters have exploded, debride the epithelial layer to prevent bacterial contamination. Then cover with an oily gauze, cover with absorbent material. Replace the upper dressing every 24-48 hours. Topical antibacterials such as povidone, mafenide or silver sulfadiazine are not very necessary. They have limited benefit in patients with extensive burns and risk of sepsis. Topical antibacterials inhibit wound healing. If wound care is initiated immediately, systemic antibacterials are not required in minor superficial burns.
Tracking through bullae
Do not take your patient with a mild burn to follow-up without giving advice. You will often need to re-examine. Partial thickness burns may be an incorrect diagnosis or damage may progress. If your diagnosis is correct, mild burns will heal in 10-12 days. If the burn expands to the dermis, healing is delayed and sometimes hypertrophic scarring may occur. Deep dermal burns heal better with skin grafts. Consult a plastic surgeon if you feel there is no successful recovery.
Bite Wounds
Bite injuries account for 1% of patients admitted to the emergency department, with approximately 2 million bite injuries per year in the United States. 80-90% of all bite wounds constitute dog bites, the second is cat bites. The rate of this is 5-15%. human bite accounts for less than 5%. Although most bites can cause minor injuries, they can end up with great morbidity.
Dog Bites
Most of the time the person recognizes the dog and often provokes the dog. It is more common in children. Young dogs and female dogs are more likely to bite. Most bites occur on the extremities, especially in young children, and are more common in the head and neck. Fatal dog bites occur with large dogs and death may occur as a result of bleeding from large neck vessels. Dog bites become infected by 2-20%. This is one of the lowest rates in mammal bites. The risk of infection, tenosynovitis and septic arthritis is increased in hand bites. Microorganisms found in the oral cavity of dogs include Pasteurella multocida, Staf. aureus, Staf. intermedius, Alpha-hemolytic streptococcus, Eikenella corrodens, and Capnocytophaga canimorsus.
Cat Bites
Cat bites and scratches are more likely to get infected than dog bites. This is because the cats' teeth are small and sharp, so they can easily penetrate the joints and periosteum. Mouth flora of cats is similar to that of dogs and Pasteurella is the most produced microorganism from cat bites. (50-70%).
Human bites
Most people will bite during a fight and usually delay medical attention. A classic example of this is the bite wound when punching. The patient punches someone in the mouth, puncturing the female metacarpophalangeal joint, causing the microorganisms to pass into the joint.
Human bites can cause serious infections. The human oral cavity is highly contaminated and Streptococcus viridans, Staf. aureus, Eikenella, Haemophilus influenza and oral anaerobic bacteria may be the causative agents of infection.
Treatment
Anamnesis important points; delay in treatment, tetanus vaccine status and the possibility of rabies transmission. Patients with immunodeficiency require intensive treatment because they carry a higher risk of serious infection. Physical examination requires attention to the degree of crushing and disintegration; because these wounds are more prone to infection. If the injury includes the tendon and nerve, it is necessary to refer the patient for a possible surgical intervention. Joint penetration is another indication for referral. If bone or joint damage is considered, direct X-ray should be performed. The foreign bodies seen in the film may be dental fragments; they must be removed. All bite wounds should be washed and cleaned thoroughly, and the inanimate tissues should be debrided. Most dog bites can be safely closed if less than 8 hours have passed. Cat and human bites should be left open due to higher infection rates. Hole-shaped bites should not be covered. Human bites on the face and cosmetically important areas can be closed after a good debridement. Closure technique is the same as other lacerations. Once the wounds have been closed, they should be carefully monitored for infection.
Prophylactic antibiotic use is controversial. It is not necessarily used in uninfected, fresh dog bites. Prophylactic antibiotic therapy is usually initiated in cat and human bites. Amoxicillin / Clavulonic acid is the first drug of choice for all these wounds. In patients with penicillin allergy, doxycycline (contraindicated in children and pregnant women) and Ciprofloxacin are the options. Empiric treatment can be initiated with these drugs in seated infections; culture is taken and treatment is continued according to the result.
10AXX
Band-Aid Brand SKIN-FLEX? Adhesive Bandages for First Aid and Wound Care, Extra Large Size, 7 ct
