Classification and management of
wound, principle of wound healing,
haemorrhage and bleeding control
1
GYÖRGYI SZABÓ
ASSISTANT PROFESSOR
DEPARTMENT OF SURGICAL
RESEARCH AND TECHNIQUES
Basic Surgical Techniques, Faculty of Medicine, 3rd year
2021/13 Academic Year, Second Semester
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WOUND
What is a wound?
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 It is a circumscribed injury which is caused by an external
force and it can involve any tissue or organ.
surgical, traumatic
It can be mild, severe, or even lethal.
Simple wound
Compound wound
Acute
Chronic
Parts of the wound
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Wound edge
Wound
corner
Surface of
the wound
Base of the wound
Cross section of a simple wound
Wound edge
Wound
cavity
Surface of
the wound
Base of the wound
Skin surface
Subcutaneus tissue
Superficial fascia
Muscle layer
The ABCDE in the injured assessment
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The mnemonic ABCDE is used to remember the order
of assessment with the purpose to treat first that kills
first.
 A: Airway and C-spine stabilization
 B: Breathing
 C: Circulation
 D: Disability
 E: Environment and Exposure
Wound management - anamnesis
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 When and where was the wound occured?
 Alcohol and drug consumption
 What did caused the wound?
 The circumstances of the injury
 Other diseases eg. diabetes mellitus, tumour,
atherosclesosis, allergy
 The state of patient’s vaccination against Tetanus
 Prevention of rabies
 The applied first-aid
Classification of the accidental wounds
1. Based on the origine
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 I. Mechanical:
 1. Abraded wound (vulnus abrasum)
 2. Puncured wound (v. punctum)
 3. Incised wound (v. scissum)
 4. Cut wound (v. caesum)
 5. Crush wound (v. contusum)
 6. Torn wound (v. lacerum)
 7. Bite wound (v. morsum)
 8. Shot wound (v. sclopetarium)
 II. Chemical:
 1. Acid
 2. Base
 III. Wounds caused by radiation
 IV. Wounds caused by thermal forces:
 1. Burning
 2. Freezing
 V. Special
Mechanical wounds
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1.) Abraded wound
(v. abrasum)
2.) Punctured wound
(v. punctum)
 Superficial part of the epidermal
 Sharp-pointed object
layer
 Good wound healing
 Seems negligible
BUT
 Anaerobic infection
 Injury of big vessels and nerves
Mechanical wounds
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3.) Incised wound
(v. scissum)
4.) Cut wound (v. caesum)
 Sharp object
 Sharp object + blunt additional
 Best healing
force
 Edges - uneven
Mechanical wounds
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5.) Crush wound
(v. contusum)




Blunt force
Pressure injury
Edges – uneven and torn
Bleeding
6.) Torn wound
(v. lacerum)
 Great tearing or pulling
 Incomplete amputation
(v. lacerocontusum)
Mechanical wound
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7.) Shot wound (v. scolperatium)
 Close - burn injury
 Foreign materials
aperture
output
slot tunel
unijured tissue
necrobiotic zone
necrotic zone
foreign bodies
Mechanical wounds
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8.) Bite wound (v. morsum)
 Ragged wound
 Crushed tissue
 Torn
 Infection
 Bone fracture
 Prevention of rabies
 Tetanus profilaxis
The direction of the flap
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Distal
Proximal
The wound healing is good
Chemical wounds
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1.) Acid
2.) Base
 in small concentration – irritate
 in large concentration –
 colliquative necrosis
coagulation necrosis
Wounds caused by radiation
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Symptoms and severity
depend on:
 Amount of radiation
 Length of exposure
 Body part that was exposed
Symptoms may occur immediately,
after a few days, or even as long
as months.
What part of the body is
most sensitive during
radiation sickness?
bone marrow
gastrointestinal tract
Wounds caused by thermal forces
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1.) Burning
Metabolic change! - toxemia
 a – normal skin
1 - 1st degree – superficial injury
(epidermis)
 2 – 2nd degree –partial or deep partial
thickness (epidermis+superficial or deep
dermis)
 3 – 3rd degree – full thickness (epidermis
+ entire dermis)
 4 – 4th degree – (skin + subcutaneous
tissue + muscle and bone)


Treatment:

Cooling – cold water and clean covering
2.) Freezing
 mild, moderate, severe (redness,
bullas, necrosis)
 rewarm – not only the frozen area
but the whole body
Special wounds
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Exotic, poisonous animals
 Toxins, venom - toxicologist
 Skin necrosis
Classification of the wounds
2. According to the bacterial contamination
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 Clean wound
 Clean-contaminated wound
 Contaminated wound
 Heavily contaminated wound
Classification of the wounds
2. Depending on the depth of injury
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 Superficial
 Partial thickness
 Full thickness
 Deep wound
+ bone, opened cavities, organs…etc.
source: http://www.funscrape.com/Search/1/skin+layers.html
Wound management - history
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 Ancient Egypt – lint (fibrous base-wound site closure), animal grease
(barrier) and honey (antibiotic)
„closing the wound preserved the soul”
 Greeks – acute wound= „fresh” wound; chronic wound = „non-healing”
wound
maintaining wound-site moisture
 Ambroise Paré – hot oil  oil of roses and turpentine, ligature of
arteries instead of cauterization
 Lister pretreated surgical gauze – Robert Wood Johnson 1870s;
gauze and wound dressings treated with iodide
Applied wound management colour continuum
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black
black-yellow
yellow
yellow-red
source: Applied wound management supplement – www.wounds-uk.com
red
red-pink
pink
Applied wound management
infection continuum
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the quantity and diversity of microbes
contamination
sterility
critical colonisation
colonisation
source: Applied wound management supplement – www.wounds-uk.com
infection
Applied wound management
exudate continuum
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Viscosity
volume
high - 5
medium - 3 low - 1
high - 5
medium -3
low - 1
source: Applied wound management supplement – www.wounds-uk.com
The wound managemanet
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 Temporary wound management (first aid)
 clean, hemostasis, covering
 Final primary wound management
 clean, anaesthesis, excision, sutures
 ALWAYS: thoracic cavity, abdominal wall or dura mater injury
 NEVER: war injury, inflammation, contamination, foreign
body, special jobs,
bite, shot, deep punctured wound
 Primary delayed suture (3-8 days)
 clean, wash – saline, cover
 excision of wound edges, sutures
The wound managemanet
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 Early secondary wound closure (2 weeks)
 after inflammation, necrosis – proliferation
 anesthesia, refresh wound edges, suturing and draining
 Late secondary wound closure (4-6 weeks)
 anesthesis, scar excision, suturing, draining
 greater defect – plastic surgery
The surgical wound
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 Surgical incision
 Stretch and fix
 Handling the scalpel
 Langer lines
 Skin edges
 Vessels and nerves
 Hemostasis
Langer lines
The wound edges
Handling the scalpel
source: http://www.medars.it/galleries/langer.htm
Tissue unifying and dressing the wound
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Skin:
 Stiches
 Clips
 Steri-Strips
 Tissue glues
Fascia and subcutaneous layers:
 Interrupted stiches
Fat – fat necrosis!
Dressing: sterile, moist, antibiotic-containing, non-allergic,
non-adhesive
The wound healing
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 Hemostasis-inflammation
 Granulation-proliferation
 Remodelling
capillaries
fibroblasts
lymphocytes
macrophages
neutrophyl gr.
thrombocytes
0
1
2
3
4
5
6
7
8
9
10
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10
13
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http://www.worldwidewounds.com/2004/august/Enoch/images/enochfig1.jpg
The main steps of the wound healing
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1. Hemostasis-inflammation
vasoconstriction
fibrin clot formation
proinflammatory citokines and
growth factors releasing
vasodilatation
infiltration PMNs, macrophages
cytokines releasing
→ angiogensis
→ fibroblast activation
→ B- and T-cells activation
→ keratinocytes activation
→ wound contraction
2. Granulation-proliferation
fibroblast migration
collagen deposition
angiogensis
granulation tissue formation
epithelisation
contraction
3. Remodelling
regression of many capillaries
physical contraction – myofibroblasts
collagen degeneration and synthetisation
new epithelium
tensile strength – max. 80%
Types of wound healing
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 Healing by primary
intention
 Healing by secondary
intention
 Healing by tertiary
intention
source: http://quizlet.com/13665246/chapter-3-tissue-renewal-regenerationand-repair-flash-cards/
Factors affecting wound healing
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 Local




Ischemia
Infection
Foreign body
Edema, elevated
tissue pressure
 Systemic





Hyperbaric oxygen
treatment




infection
foreign
bodies
IMPAIRED
HEALING
edema/
elevated
tissue
pressure

ischemia
Age and gender
Sex hormones
Stress
Ischemia
Diseases
Obesity
Medication
Alcoholism and smoking
Immunocompromised
conditions
Nutrition
Complications of wound healing
I. Early complications
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 Seroma
 Hematoma
 Wound disruptin
 Superficial wound infection
 Deep wound infection
 Mixed wound infection
Early complications of wound healing
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1.) Seroma
2.) Hematoma
 Filled with serous fluid, lymph
 Bleeding, short drainage time,
or blood
 Fluctuation, swelling, redness,
tenderness, subfebrility
anticoagulant
 Risk of infection
 Swelling, fluctuation, pain,
redness
TREATMENT:
 Sterile punture and
compression
 Suction drain
TREATMENT
 Sterile puncture
 Surgical exploration
Early complications of wound healing
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3.) Wound disruption
 Surgical error
 Increased intraabdominal
pressure
 Wound infection
 Hypoproteinaemia
TREATMENT:
 U-shaped sutures
A. partial – dehiscenece
B. complete - disruption
Early complications of wound healing
Superficial wound infection
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1.) Diffuse
2.) Localized
 Located below the skin
 Anywhere
TREATMENT
 Resting position
 Antibiotic
 Dermatological consultation
TREATMENT
 Surgical exploration
 Drainage
 X-ray examination
e.g. erysipelas
e.g. abscess
Early complications of wound healing
Deep wound infection
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1.) Diffuse
2.) Localized
TREATMENT
 Surgical exploration
 Open therapy
 H2O2 and antibiotics
 Inside the tissues or body cavities
e.g. anaerobic necrosis
TREATMENT
 surgical exploration
 drainage
Complications of wound healing
I. Early complications
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Mixed wound infection
e.g. gangrene
 necrotic tissues
 putrid and anaerobic
infection
 a severe clinical picture
TREATMENT
 aggresive surgical
debridement
 effective and specified
(antibiotic) therapy
Complications of wound healing
II. Late complications
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 Hyperthrophic scar
 Keloid formation
 Necrosis
 Inflammatory infiltration
 Abscesses
 Foreign body containing abscesses
Late complications
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Hypertrophic scar
 Develop in areas of thick
chorium
 Non-hyalinic collagen
fibres and fibroblasts
 Confine to the incision
line
TREATMENT
 Regress spontaneously
(1-2 yrs)
Keloid
 Mostly African and Asian




population
Well-defined edge
Emerging, tough structure
Overproliferation of collagen
fibers in the subcutaneous tissue
Subjective complains
TREATMENT
 Postoperative radiation
 Corticosteroid + local anaesthetic
injection
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BLEEDING AND HEMOSTASIS
Bleeding
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Anatomical


Arterial – bright red,
pulsate
Venous – dark red,
continuous
Diffuse


Capillary – can become
serious
Parenchymal
Bleeding
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Severity of bleeding – the volume of the lost blood and
time
source: http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/
The direction of hemorrage
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 External
 Internal
 In a luminar organ (hematuria, hemoptoe, melena)
 In body cavities (intracranial, hemothorax, hemascos,
hemopericardium, hemarthros)
 Among the tissues (hematoma, suffusion)
Bleeding
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 Preoperative hemorrhage
Prehospital care! – maintenance of the airways, ventillation and circulation
bandages, direct pressure, turniquets
 Intraoperative hemorrhage
anatomical and/or diffuse
depending on the surgeon, the surgery, position,
the size of the vessel, pressure in the vessel
ANESTHESIA!
 Postoperative bleeding
ineffective local hemostasis, undetected hemostatic defect, consumptive
coagulopathy or fibrinolysis
Signs of the bleeding
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Local
 Hematoma, suffusion,
ecchymosis
 Compression in the pleural
cavity, in pericardium, in the
skull
 Functional disturbancies – e.g.
hyperperistalsis
General
 Pale skin, cyanosis, decreased
BP. and tachycardia, difficulty
in breeding, sweeting,
decreased body temperature,
unconsciousness, cardiac and
laboratory standstill, laboratory
disorders, signs of shock
Surgical hemostasis
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Aim – to prevent the flow of blood from the incised or
transected vessels
 Mechanical methods
 Thermal methods
 Chemical and biological methods
Surgical hemostasis
Mechanical methods
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 Digital pressure – direct pressure,
e.g. Pringle maneuver
 Tourniquet
 Ligation
 Suturing
 Preventive hemostasis
 Clips
 Bone wax
 other
Thermal methods
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 Low temperature
 Hypothermia – eg. stomach bleeding
 Cryosurgery
dehidratation and denaturation of fatty tissue
 decreases the cell metabolism
 vasoconstriction

Thermal methods
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 High temperature
 Electrosurgery – electrocauterization
 Monopolar diathermy
 Bipolar diathermy
Laser surgery
coagulation and vaporization
for fine tissues

Thermal methods
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 High temperature
 Electrocoagulation
 Electrofulguration (A)
 Electrodessication
 Electrosection
Hemostasis with chemical and biological
methods
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vasoconstriction
coagulation
hygroscopic effect
Absorbable collagen
Absorbable gelatin
Microfibrillar collagen
Oxidized celluloze
Oxytocin
Epinephrine
Thrombin
Hemcon
QuikClot
Hemostasis with chemical and biological
methods
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HemCon