Management of the Open Wound

Chapter 56 Management of the Open Wound



David W. Knapp


Open wound management is a method of treatment which should be considered when immediate primary wound closure is not possible. Wound healing is a complicated biologic process involving inflammatory, debridement, reparative, and maturation phases. When managing a wound in an open fashion, one or all of these biologic phases may come into play. To employ open wound management techniques successfully requires a thorough understanding of the phases of wound healing. For more comprehensive descriptions of basic wound healing, see other texts. As a large percentage of wounds are associated with traumatic events, the following material is focused on traumatic wounds and skin defects. However, the same principles may be applied to defects created by surgical excision of tumors, restrictive scar tissue, or dysfunctional tissues. The goal of wound management is to restore normal anatomy and function to the patient, when possible. Reconstruction of open wounds using skin flaps or grafts is discussed in Chapter 57.



ETIOLOGY OF OPEN WOUNDS



• Vehicular trauma resulting in lacerations and/or degloving injuries or shear forces creating a devascularized section of skin

• Bite wounds resulting in lacerations, punctures, or shearing/tearing defects

• Gunshot, stab injuries, or other forms of penetrating wounds

• Skin loss due to abscesses or embolic vascular events

• Burns resulting from thermal, electrical, chemical, and radiation injury

• Large defects resulting from surgical excision of lesions, especially tumors

• Defects created by circumferential restrictions such as casts, bandages, or choke collars caught in long haired pets, or full thickness defects (i.e., decubital ulcers)


PREOPERATIVE CONSIDERATIONS



Indications


Consider leaving a wound open as a method of treatment in the following situations:


• Grossly contaminated wounds. Consider the “golden period” of 8 hours from time of injury. Wounds are classified as clean (surgically created), clean contaminated (minimal contamination, which can be effectively removed) and contaminated (gross contamination with obvious foreign material).

• Wounds with established infections.

• Wounds with large skin losses or excessive tissue trauma, particularly wounds with questionable vascular supply and tissue viability or incomplete debridement. These wounds will have impaired host local defense systems and are more susceptible to infection if closed prematurely.

• Wounds with inadequate adjacent tissue available for closure. Wounds on the distal extremities and around the face often fall into this category.

• Wounds that would result in increased tension or excessive dead space if closed primarily.

• Wounds that have failed previous closures.

• Temporary wound management while awaiting results of orthopedic or neurologic diagnostics.

• Temporary wound management before grafting techniques, the use of skin expanders or skin stretchers, or while awaiting microscopic examination of wound margins following tumor excision.


Advantages of Open Wound Management



• Provides ability for continual debridement through surgical, mechanical, or chemical means.

• Provides for optimal wound drainage when compared with primary closure combined with other methods of drainage.

• Provides access for daily wound lavage when indicated.

• Provides for daily wound inspection to evaluate progress and to adjust treatment as indicated.


Disadvantages of Open Wound Management



• Labor-intensive, requiring more time and effort on the part of the veterinarian and owner.

• More expensive due to hospitalization and repeated bandage changes, often requiring anesthesia or sedation and tranquilization.

• The wound must be protected from further injury caused by exposure or self-mutilation.

• Increased risk of nosocomial or ascending infection.

• Protein loss from large wounds with excessive drainage.

• May result in increased healing time and prolonged discomfort for the patient.


INITIAL WOUND MANAGEMENT



Patient Evaluation



• Evaluate and treat as needed for concurrent life-threatening injuries, particularly hypovolemic shock, thoracic and/or abdominal trauma, and cerebral edema or hemorrhage.

• Evaluate for concurrent orthopedic or neurologic trauma (e.g., fractures, ligamentous or tendinous injuries, spinal cord injuries, or peripheral nerve damage). If necessary, obtain radiographs when the patient is stable.
• Orthopedic. Orthopedic injuries are common and may be located at the wound site or distant from the open defect. Evaluate for fractures and ligamentous injuries in all cases of trauma-related wounds. Carefully palpate the long bones and joints for pain and stability and obtain radiographs when indicated. Stress views may be necessary to evaluate joint stability.

• Neurologic. Assess neurologic injury through deep and superficial pain perception and motor function. It is uncommon for neurologic limb dysfunction to result from an injury to the lower portions of an extremity since most nerve function originates from higher segments.

• Evaluate wounds involving the extremities for vascular, orthopedic, and neurologic involvement. Any defect that is full circumference will likely create severe vascular compromise.

• Evaluate wounds of the thorax and abdomen for potential involvement of the deeper thoracic, peritoneal, and retroperitoneal cavities. If exploring and/or debriding a thoracic wound, always be prepared to assist in ventilation if pneumothorax is created.



Key Point


Vascular compromise may lead to loss of the limb; therefore, tissues distal to the wound should be carefully assessed. Several days may be required to fully appreciate the extent of vascular injuries. Shear and tearing injuries of the skin and subcutaneous tissues of the trunk may also result in delayed tissue necrosis and eventual loss.



• Patient factors to consider which affect wound healing are age, nourished verses malnourished, concurrent metabolic diseases such as diabetes, hyperadrenocorticism and uremia, hypoproteinemia, anemia, hepatic disease, and obesity. Immunocompromised patients are at greater risk of developing infections.

• Wound factors affecting management and healing include foreign material such as dirt, plant material, suture or surgical implants, wound exudates, bacteria/infection, and vascularity.


Initial Wound Evaluation



• Analgesic or anesthetic drugs (if necessary) aid in the evaluation and treatment of the wound, especially if extensive debridement and lavage are required (see Chapters 2 and 6). In cases where general anesthesia may not be safe and sedation alone is not completely effective, consider administering epidural analgesia to provide for a more comfortable and cooperative patient. Local blocks may also be helpful in certain circumstances. Always consider intravenous postoperative analgesia, during the recovery from surgical procedures, then as needed to facilitate comfort and management of the patient. Consider placing transdermal fentanyl patches for hospitalized patients. Continued wound management may require repeated use of analgesics or anesthesia, usually diminishing in use as the wound progresses through the healing stages.

• Use sterile gloves and instruments to help prevent further bacterial contamination.

• Consider the following during the initial evaluation:
• The extent of tissue damage to both soft and osseous structures. Closely evaluate the vascular integrity of the wound.

• The degree of contamination or probability of existing infection. Consider the time lag between the traumatic event and the presentation of the patient to the hospital.

• The feasibility of successful primary closure.

• If a limb is involved, the feasibility of the leg becoming functional again.

• The anticipated time required as well as the expense to the owner.

• Obtain bacterial cultures in advance of wound debridement and lavage. Select antibiotics based on culture and sensitivity results. If necessary, a broad spectrum antibiotic may be used while awaiting culture results.

• If active bleeding is encountered, controlling hemorrhage is best accomplished with direct pressure or isolation and ligation of the vessel. Avoid placing tourniquets, which will result in increased circulatory compromise of an area already suffering decreased vascular perfusion.


Clipping and General Cleaning


Protect the wound from loose debris and hair during the initial preparation and clipping of the adjacent area. Use a sterile water-soluble gel to cover the defect, cover with saline moistened surgical sponges, or sterile towel clamps, sutures, skin staples, or wound clips to provide an economical and efficient temporary closure. Clip a generous margin surrounding a truncal wound or the expected bandaged portion of a limb and scrub with an antiseptic soap or solution.



Cleansing the Wound



Lavage Solution


The ideal lavage solution is sterile, non-irritating, non-cytotoxic, normothermic, and isotonic. Of available solutions, warmed sterile isotonic saline best meets these criteria. Lactated ringers solution may also be used.



• The use of antibiotic or antiseptic solutions for wound lavage is controversial. There is evidence for both beneficial and detrimental effects. Controversy exists between in vitro versus in vivo studies and the antibacterial versus the cytotoxic effects of varying concentrations of chlorhexidine and povidone-iodine solutions. Use a 0.5% to 1.0% chlorhexidine solution due to its broad-spectrum and extended residual activity.

• Tap water is an economical alternative to other commonly used sterile solutions, even though it does not meet all criteria for an ideal lavage solution. When large volumes are anticipated, tap water may be the most practical irrigation solution. Due to the hypotonic nature of distilled or sterile water, their use in lavage is not recommended.

• Effective lavage often depends more on the copious volume of fluid rather than the contents of the solution. The effect of lavage is to loosen and flush away from the wound any foreign material, damaged, necrotic or free tissue, wound exudates, and bacteria.

• Do not scrub the wound, which results in increased tissue damage due to mechanical trauma. Trauma to the tissue will result in increased inflammation, delayed healing, and increased risk of infection.

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  4. Otitis Media and Otitis Interna

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Aug 27, 2016 | Posted by in SMALL ANIMAL | Comments Off on Management of the Open Wound

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