1 Wound excision - debridement Basic Principles 4 Layer by - PDF document

Outcome depends on: BASIC PRINCIPLES in the � Injury: severity of the wound & structures injured � General condition of patient MANAGEMENT OF � Pre-hospital care: evacuation time WAR WOUNDS � Pre-hospital care: triage � Pre-hospital care: first aid � Resuscitation & hospital triage & hygiene � Surgery C. Giannou � Post-operative nursing care Hat Yai � Physiotherapy & Rehabilitation July 2012 Basic Principles 1 Basic Principles 2 � Wound incision for drainage � Examine the patient � Excision of devitalised tissues � resuscitation: ABCDE � Irrigation � hypothermia � Examine the wound � Leave the wound open for drainage – no sutures � grade and type � Large bulky dressing Bulky, absorbent and dry dressing Basic Principles 3 � No unnecessary dressing changes � Delayed Primary Closure (DPC: after 4-7 days) 1

Wound excision - debridement Basic Principles 4 Layer by anatomic layer � Anti-tetanus � Skin: incision, excision � Antibiotics, as adjuvant � Subcutaneous tissues � Analgesics � Fascia, aponeurosis: drainage � General condition of the patient + nutrition + � Muscles: 4 C's hygiene � Periosteum � Physiotherapy + rehabilitation � Bone Exceptions to DPC Metallic Foreign Bodies � Face, neck, scalp and genitals – PC after DBR Should be left unless � Soft tissue of the chest wall – muscles to close open pneumothorax � Jeopardy to organ, major vessels and nerves � Head – brain injury by dura : closure should be effected if possible � Inside of joints � Abdominal wall? � Anterior chamber of eye � Joints – synovial membranes should be closed � Superficial subcutaneous (painful movement) � Blood vessels – muscle cover if repaired primarily; tendons, nerves � Infection around FB (abscess) Principles for the Management of Weapon Wounds Explore the wound “Damaged tissues must be removed in time.” Qanun fi el-Tib (The Laws of Medicine) Avicenna – Ibn Sinna 980 – 1036 CE 2

Shell fragments and detached bone removed Wound opened, track debrided, large foreign body A: Debridement medial aspect A: Debridement lateral aspect B: Gunshot wound femur A: Loose bone fragments removed 3

B: Entry wound B: X-ray pre-debridement B: Exit wound B: Entry wound exploration B: Exit wound debridement B: Bone fragments removed 4

C: Fasciotomy & opening up of the wound cavity C: Excise skin wound & Extend the skin incision After incision of fascia, protrusion of injured muscle C: Cavity excised & clean wound left open Mismanaged wound: primary suture Primary suture of heel without debridement: Mismanaged wound: primary suture infection, tetanus, patient died 5

D: Mismanaged wound: signs of inflammation D: Mismanaged wound: primary suture D: Re-debrided, D: Stitches released, wound is now larger than original injury necrotic edges, subcutaneous oedema D: 5 days later, wound clean D: Partial closure with sutures 6

D: Healing D: Closure with split-skin graft E: Well-managed patient: dirty wound E: Well-managed patient: dirty wound Debrided E: Sticky dressing peals off E: 5 days later, removal of dressing 7

E: Immediate skin graft as DPC E: Fully exposed wound 5 days after debridement Supraclavicular bullet wound Multiple superficial fragments Serial debridement of large wound: Old lessons for new surgeons line of demarcation of necrotic tissue apparent War wounds are dirty and contaminated, from the moment of injury. The rules of septic surgery apply. 8

Surgical infections 1 Surgical infections 2 Septic complication: Primary infection due to initial inoculation at time of injury: culture medium in wound � inadequate surgery or � dead tissue � inadequate sterile technique � devitalised tissue, compromised circulation � haematoma and serum � foreign bodies, soiling Prophylaxis of surgical infections Surgical infections 3 � 1. Primary infection: surgery + adjuvant antibiotics Nosocomial infection: � 2. Septic complication: surgery + sterilisation � (treatment with antibiotics if systemic signs & symptoms; no � inadequate hygiene and longer prophylaxis but treatment of invasive infection) � nursing techniques � biofilm (esp. in chronic bone infection) requires surgery + irrigation (physical disruption of biofilm) � 3. Nosocomial: good hygiene and nursing Old lessons for new surgeons The best antibiotic is good surgery. Antibiotic prophylaxis can only be assured for Clostridia species and β -haemolytic Streptococcus. Penicillin! Anti-tetanus prophylaxis: toxoid + serum 9