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Wounds

  • Evaluate via history and examination
  • History:
    • Host factors (eg: age, medical history, co-morbidities, medications, vaccination status)
    • Injury factors (eg: type of wound, how the injury occurred, initial wound management)
    • Other factors (eg: social situation, occupation, activities of daily living)

Examination:

  • Host factors (eg: general health, other conditions, venous/arterial disease)
  • Injury factors (eg: wound depth, bleeding/debris)

Does the wound need suturing? Should it be open or covered?

  • Suturing is not performed unless wound is clean and risk of infection minimal
    • Other factors (eg: can they care for the wound? Etc)

Types of healing

  • Primary wound healing – 1st intention
  • Delayed wound healing – left open, then healing by 1st intention
  • Secondary wound healing – 2nd intention (deep burns, etc)
  • Re-epithelialisation

Phases of healing

  • Haemostasis --> inflammation --> granulation --> remodelling
    • Maximum tensile strength of the wound is achieved by the 12th week
    • Resultant scar has only 80% of tensile strength of original skin

Johnny

  • Assuming superficial graze
    • Should have:
      • Told mother
      • Cleaned wound with water, cleaned debris
      • Washed with antiseptic and covered with a non-occlusive bandage
      • Cleaned wound each day and watched progress to check for infection
  • Assuming deep penetrating wound
    • Should have:
      • Told mother
      • Gone to see their GP
      • Checked tetanus immunisation status

When to suture

  • Pros
    • Faster healing
    • Cleaner scar
  • Cons
    • Infection
  • Thus, may have to delay suturing until infection clears up

Impaired healing

  • Mechanical injury, artery disease, infection (eg: staph)
  • Vitamin C deficiency
    • Symptoms: easy bruising, gingivitis, dry/splitting hair, rough/dry skin, impaired healing
  • Iron deficiency
    • Symptoms: fatigue, pallor, weakness, impaired immune response, impaired healing
    • Assessed by full blood count – can identify microcytic anaemia

Non-resolving infection

  • Purulent wound with redness and swelling
    • Carbuncle/boil – caused by bacteria and infection
    • Treatment: drain to remove bacteria and swelling – thus allows the immune system to reach bacteria
  • NB: pus is made up of neutrophils and inflammatory agents
  • Lump around scar, explanations:
    • Another infection (deep fungal or mycobacteria)
    • Over responsive repair mechanism (eg: granulation)
  • Immune-suppressed are particularly at risk of infection

Diagnosis of infected wounds

  • Skin swabs for surface bacteria
  • Skin biopsy for deep infection

Note: Vaseline gauze may be effective to keep skin moist and encourage epithelial migration