BASIC PRINCIPLES

OF WOUND
MANAGEMENT
z
POENGKI DWI POERWANTORO

PRASASTA ADHISTANA

Plastic Reconstructive and Aesthetic Surgeon

 WOUND is a disruption of
the normal structure and
function of the skin and
skin architecture.

It can be mild, severe, or even lethal.

 PRIMARY SURVEY : ABCDE
Ensure that potentially life threating conditions
are identified and addressed.
 Wound edge Wound
corner
Surface of
the wound
TYPES OF
Base of the wound WOUND :

Cross section of a simple wound Simple Wound

Wound edge Compound Wound
Wound Skin surface
cavity Acute Wound
Surface of Subcutaneus tissue
Chronic Wound
the wound
Superficial fascia
Muscle layer
Base of the wound
KEYS TO SUCCESSFUL WOUND HEALING :

Understanding of the Anatomy of the Skin.

Proper Classification of the wound.

Knowledge of the normal stages of the wound

healing process based on type of wound.
Proper identification of the physiological stage of
the wound at time of treatment.
Anatomy of The Skin
WHERE DO YOU STAND ?
UNDERSTAND YOUR TYPES OF WOUND

Choice of treatment for disease

is always based on diagnosis.
History
Symptoms >> Type of Force, Mechanism of Injury
Contamination >> Potential for foreign body
Function
Tetanus status

Allergies

Medications

Comorbidities >> Diabetes

Wound Examination
Location >> Size, Shape, Margins, Depth

Alignment with skin lines

Neurology function

Vascular function

Tendon function

Underlying structures

Wound contamination
Wound Consultation >> Special Consideration
Tarsal plate or lacrimal duct

Open fracture or joint space

Extensive facial wounds

Associated with amputation

Associated with loss of function

Involves tendons, nerves, or vessels

Involves significant loss of epidermis

Any wound that you are uncertain about

Wound Preparation Anesthesia
Topical Anesthesia :
Solution or paste
EMLA
Local Anesthesia :
Direct infiltration
1% lidocaine with or without epinephrine
Bupivicaine for longer acting anesthesia

Regional Block Anesthesia :

Local infiltration proximally in order to avoid tissue disruption
Smaller amount of anesthesia required
Wound Preparation - Hemostasis
Physical VS Chemical Hemostasis :
Direct pressure

Epinephrine

Gel-foam

Cautery

Refractory Bleeding :
Use a tourniquet
Foreign Body Removal
By Visual inspection OR

Imaging :
Glass, metal, gravel fragments >1mm should be visible on
plain radiographs
Organic substances and plastics are usually radiolucent

Always discuss and document possibility of retained foreign body.

Wound Irrigation
Local anesthesia prior to irrigation

Do not soak the wound, DO IRRIGATE

Use normal saline (NaCl 0.9%)

Use syringe and needle to create turbulent irrigation

DO NOT use povidone iodine, peroxide or detergents

Tetanus Prophylaxis
Clean Wounds :
Incomplete immunization toxoid
>10 years, then give toxoid
Tetanus Prone Wounds :
Incomplete immunization : Toxoid & Immunoglobulin
> 5 years, give toxoid

Remember to think about rabies !!!

8 Wounds Properties for Clinical Assessments :
Size and Depth Measuring the Wound
Margin Sloping or Everted Edge
Location DFU, Bony Prominence
Wound Bed Necrotic, Eschar, Slough
Surrounding Skin Maceration, Cellulitis
Infection Inflammation Signs, Pus
Pain Subjective Pain Assessment
Exudate Exudate Management Plan
Wound is always CONTAMINATED,
but it is not always INFECTED.
A CLINICIAN SHOULD BE :

Able to explain the Microbiology of the Wound

Able to recognize Wound Infection
Able to use Rational Antimicrobial Agents
 z

SIGNS AND SYMPTOMPS

OF INFECTED WOUND
LOCAL SIGNS AND SYMPTOMPS SYSTEMIC SIGNS AND SYMPTOMPS
PAIN FEVER
REDNESS IN PERIWOUND SKIN (RUBOR) MALAISE
WARM IN PERIWOUND SKIN (CALOR) INCREASED WHITE BLOOD CELL
COUNT
EDEMATOUS IN PERIWOUND SKIN OR
LIMBS
MACERATION OR INDURATION IN
PERIWOUND SKIN
PURULENT EXUDATES
FOUL ODOUR EXUDATES
 z
ANTIMICROBES IN WOUND

ANTISEPTICS
ANTISEPTICS is a powerful agent to stop bacteria from growing
and may even kill the bacteria effectively.
However, antiseptics MAY NOT BE FAVORABLE for the wound
surface, as its components may be jeopardizing and killing the
progenitor cells that work for wound healing.
POVIDONE IODINE (10%) is considered to be toxic to FIBROBLAST,
and may halt the collagen production.
Thus the use of 10% Povidone iodine is NOT recommended.
When it comes into the choice of wound cleansing agent,
the Povidone Iodine has to come in lower concentration (1%).
Another Recommended Antiseptic Solution is Chlorhexidine
(0.05%) for Pre Operative Wound Cleansing and Wound Irrigation.
Infection occurs when the Bacterial loads has exceeded
the cut off point (105 Colony Forming Unit/CFU per mL
exudate or per gram tissue).

Systemic Antibiotics is chosen based on empirical data

before conforming it with the bacterial wound culture as
well as bacterial resistance test.

Topical Antimicrobial use is best if it is not antibiotics that

available for the purpose of systemic therapy.
e.g. : Neomycin, Bacitracin.
EXUDATE CONTROLS
In chronic wound, the amount of
exudate reflects changes in bacterial
loads.

In order to manage the exudate, various

methods could be used, ranges from
ABSORBENT PRODUCTS to NEGATIVE
PRESSURE WOUND THERAPY (NPWT).
Wound Bed Preparations
is a systematic approach to eliminate any
barriers that impede healing process.

By understanding the components of wound bed

preparations, doctors and nurses are assumed to be able
to bring NON-HEALING WOUND back into the HEALING
PATHWAY.
 BARRIERS OF WOUND HEALING PROCESS

NECROTIC BACTERIAL
EXUDATE
TISSUE LOAD

WOUND HEALING

IMPAIRED WOUND HEALING

 BACTERIAL
DEBRIDEMENT LOAD
MANAGEMENT

WOUND BED PREPARATION

MOISTURE
Strategy of CONTROL
Wound Bed Preparation
 Dry VS Moist Wound Healing
Moist wound environment has been accepted by wound experts to support wound healing and
reduce the risk of infection.

Dry Wound Healing Moist Wound Healing

Dry wound healing scab/crust Wound heals faster and better in moist environment
Scab protects the wound from contamination Moist wound environment prevents the formation of scab
However, scab also delays wound healing because Less scar, therefore a better cosmetic result
it becomes a physical barriers for cell proliferation
Surgery supplement. Keep wounds moist or dry? Available at: http://www.surgerysupplements.com/keep-wounds-moist-or-dry. Accessed on: 19/03/2015.
 A MOIST ENVIRONMENT IS THE
IMPORTANT FACTOR OF WOUND
HEALING PROCESS.
Provision of RIGHT and JUST moist environment, debridement,

as well as bacterial load control; can be done by

CHOOSING THE RIGHT DRESSINGS.

WOUND CLINICAL ASSESSMENT SKILL IS THE POWER !

 FOR YOUR ATTENTION
Correspondence :

poengkid@yahoo.com | prasastaadhistana@gmail.com
An acute wound has normal wound physiology and
healing is anticipated to progress through the normal
stages of wound healing, whereas a chronic wound is
defined as one that is physiologically impaired.
To ensure proper healing, the wound bed needs to be well
vascularized, free of devitalized tissue, clear of infection,
and moist. Wound dressings should eliminate dead space,
control exudate, prevent bacterial overgrowth, ensure
proper fluid balance, be cost-efficient, and be manageable
for the patient and/or nursing staff. Wounds that
demonstrate progressive healing as evidenced by
granulation tissue and epithelialization can undergo
closure or coverage. All wounds are colonized with
microbes; however, not all wounds are infected
 z
Wound healing is a complex process involving different
biologic and immunologic systems.

Despite improvements in diagnostics and therapy, wound

failures remain a clinical problem.

Better understanding of the complex wound-healing

cascade helps our approach to wound healing and its
possible failure.
z