Integumentary Wound Healing and Management Techniques for Exotic Pets

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1 Integumentary Wound Healing and Management Techniques for Exotic Pets Vanessa L Grunkemeyer, DVM, DABVP (Avian) Session #274 Affiliation: From Department of Clinical Sciences, North Carolina State University College of Veterinary Medicine, 1060 William Moore Dr, Raleigh, NC 27604, USA. Abstract: Many of the same concepts of wound healing and management can be applied across exotic pet species. However, a thorough knowledge of both the stages of wound healing and the available treatment options should be integrated with an understanding of normal behavior and physiology in each species. Appropriate application of this knowledge will help the practitioner to optimize the healing potential of any wound. The purpose of this manuscript is to review the process of wound healing and to discuss the various aspects of a comprehensive wound management plan. Wound assessment and preparation for treatment, assorted topical therapies, and bandaging techniques are presented. Stages of Wound Healing An understanding of the stages of wound healing allows for more accurate assessment of wounds and their response to therapy. In the mammalian wound healing model, the three stages of wound healing include the inflammatory phase, the collagen or proliferation phase, and the remodeling or maturation phase (Table 1). 1 Wound healing in avian and reptile patients progresses in a similar fashion. 2,3 However, the formation of granulation tissue is reportedly rare in reptiles with the fibroblastic response originating from the wound edges in reptiles instead of the wound bed as it does in mammals and birds. Many reptiles also form a proteinaceous crust under which epithelial migration occurs. 3,4 Table 1. Three phases of wound healing in avian and mammalian species. 1,2 Phase Inflammatory Sequential events of the phase Vasoconstriction and clot formation Vasodilation Aggregation of leukocytes into wound site. Necrotic debris and bacteria are phagocytized by leukocytes. Fibroblasts appear at wound margins Collagen/ Proliferation Maturation/ Remodeling Angiogenesis from nearby capillary beds, fibroplasia and collagen deposition, epithelialization from wound margins, and wound contraction Remodeling of collagen bed with stronger fibers oriented to the normal tension of wound margins ExoticsCon 2015 Main Conference Proceedings 639

2 Unfortunately, many aspects of the patient s general health and of the wound can negatively influence the progression of a wound through the normal phases of healing. A malnourished, dehydrated, anemic, or otherwise compromised patient may not heal wounds as readily. Although an adequate plane of nutrition is important for any animal that is trying to heal a wound, specific dietary components are known to be important factors in wound healing. These components include essential fatty acids, zinc, and vitamin C. Wound healing in reptiles is also temperature dependent with healing being retarded at cold temperatures. 3 Wounds that occur over poorly vascularized or high motion areas and wounds that are contaminated, infected, or desiccated may be delayed in their healing process. 5,6 The formation of bacterial biofilms, multi-species bacterial communities on the surface of wounds held together by extracellular polymeric substances, may contribute to chronic infections and prolong wound healing. 7 Origin of Wounds Integumentary wounds in exotic pets are often the result of trauma with bite wounds and lacerations being very common. In addition, patients are presented for wounds due to self-mutilation, cutaneous neoplasia, chemical or toxin exposure, thermal burns, electrocution, entrapment, and frostbite. Inappropriate husbandry, obesity, and prolonged inactivity can contribute to the formation of ulcerative pododermatitis. Bacterial, fungal, and parasitic infections can be associated with cutaneous lesions as either primary etiologies or secondary complications. 5,6,8-10 Initial Wound Assessment and Preparation Upon presentation, it is important to assess both the patient and the wound with general stabilization of the patient taking precedence over complete inspection of a wound in the emergency situation. It may be necessary to place a sterile saline moistened temporary bandage until the patient is stable enough to undergo thorough wound assessment. The type, location, age, level of contamination, extent of tissue damage, integrity of the vascular supply and innervation, stage of wound healing and any associated orthopedic injuries should all be considered when evaluating a wound. Cutaneous wounds are often complicated by underlying orthopedic disease, which has significant implications for appropriate therapeutics and prognosis. In addition, the species of exotic pet, its housing situation, the relative stress of repeated capture for treatment, any monetary restrictions on the cost of treatment, and the ultimate goals of treatment should all be taken into account when formulating a wound management plan. The goals of initial wound preparation for treatment are to achieve a 2-3 cm area of healthy skin surrounding the wound that is free of fur or feathers and to remove gross contamination from the wound bed. Copious warm lavage of the wound to remove surface contaminants is recommended at a pressure of 7-8 psi, which can be achieved with a ml syringe and an 18-gauge needle. 2,5,6 Commonly used lavage solutions include sterile isotonic saline, dilute chlorhexidine, hydrogen peroxide and dilute povidone iodine. Although very few studies have been performed that investigate the use and effects of these solutions on wound healing in veterinary patients, some of their indications for use and potential effects are described in Table Tissue cultures should be obtained from potentially infected wounds after the removal of gross contamination with lavage. 640 Building Exotics Excellence: One City, One Conference

3 Table 2. Selected solutions used in the lavage of wounds, their indications for use, and the potential effects of their use on healing. 11 Solution Indications for use Potential effects on healing Chlorhexidine 0.05% Broad spectrum of antimicrobial action Minimal tissue reaction May decrease granulation tissue formation with repeated use Hydrogen peroxide Deep puncture wounds for its effectiveness against Clostridium species Toxic to fibroblasts at concentrations of 3% or less Povidone iodine Small wounds and surgical preparations Toxic to fibroblasts at concentrations of 1-5% Wound debridement to remove compromised or necrotic tissue may be necessary and can be accomplished with selective and non-selective methods. Selective debridement includes surgical excision of necrotic tissue, topical enzymatic or autolytic therapies that target dead tissue, or biotherapy such as maggots that ingest compromised tissue. Non-selective debridement includes mechanical removal of tissue with dressings or lavage and chemical removal with antiseptic solutions. 12 Debridement is often staged over several days so that only definitely devitalized tissue is removed. Thorough wound assessment and debridement is best completed while the patient is under general anesthesia and with adequate analgesia to minimize pain and stress and to maximize effective treatment of the wound. Wound Management Closure After a wound has been thoroughly assessed and prepared by lavage and debridement, the decision of whether to close it primarily or to manage it as an open wound for delayed primary closure or second intention healing should be made. Clean wounds that are less than eight hours old can be sutured closed and allowed to heal by first intention healing if closure will not create excessive tension on the wound. 6 A knowledge of normal anatomy, behavior and physiology is very important in planning the surgical closure of a wound as consideration should be given to preserving of the function of structures. If a wound does not fit the criteria for primary closure, it may be managed as an open wound with topical therapies, dressings, bandages or a combination of treatments. Free skin grafts, xenogeneic grafts, advancement flaps, and axial pattern flaps have been successfully used in exotic pet species in order to close wounds that could not be directly sutured. Topical therapies Topical treatments are designed to enhance wound healing through multiple mechanisms including antimicrobial action, increasing growth factors, providing an energy source, reducing edema, stimulating blood flow, among other things. 12 As bacterial biofilms can become resistant to selective therapies and treatments may be more ExoticsCon 2015 Main Conference Proceedings 641

4 beneficial in specific stages of healing, it is often recommended to combine or rotate topical therapies. 7 Very little objective evidence is available in veterinary medicine that can recommend for or against the use of any one topical product. 11 For example, a single study exists that suggests antibiotic powders and oil-based topical medications may slow wound healing in common garter snakes (Thamnophis sirtalis). 13 However, extrapolating that conclusion to all reptile wounds would be erroneous given the variety of factors involved in wound treatment and individual wound healing. In addition to the topical medications listed in Table 3, there are multiple other therapies that have been used in exotic pet medicine. Other topical treatments include but are not limited to chitosan, hydrotherapy, herbals such as Yunnan Paiyao, pulsed electromagnetic field, and low-level laser light therapy. The reader is referred to other resources that fully discuss the mechanisms of action of these treatments and their indications for use in various stages of wound healing. Table 3. Selected topical medications used in the treatment of wounds, their indications for use, and the potential effects of their use on healing Topical medication Indications for use Potential effects on healing Triple antibiotic ointment of bacitracin zinc, neomycin sulfate, polymyxin B sulfate Honey and sugar Broad spectrum bactericidal activity Small, recent wounds Broad spectrum antibacterial effect Decreases tissue edema May stimulate epithelialization May impair wound contraction May stimulate macrophage migration, angiogenesis, and granulation tissue formation Silver sulfadiazine cream Gentamicin sulfate ointment Hydrogel containing acemannan Tripeptide-copper complex Effective against most grampositive and gram-negative bacteria and fungi Can penetrate necrotic tissue Especially effective against gram-negative bacteria Topical of choice with skin grafts Best in inflammatory or proliferative stage of healing Best in inflammatory or proliferative stage of healing May promote epithelialization May impair wound contraction May stimulate granulation tissue formation May impair wound contraction and epithelialization May stimulate macrophages May enhance fibroblast proliferation, epidermal growth, collagen deposition, and angiogenesis May stimulate macrophages and increase collagen synthesis 642 Building Exotics Excellence: One City, One Conference

5 When using topical products, ingestion during normal grooming is a significant concern. For this reason, topical products containing glucocorticoids should not be used in many species. In addition, due to a species sensitively to systemic aminoglycosides, it is recommended to avoid topical gentamicin use in ferrets. 6 The use of triple antibiotic ointments that contain bacitracin zinc, neomycin sulfate, and polymyxin B sulfate are of questionable safety in rabbits and rodents as these species may develop fatal enterotoxemia with ingestion of macrolide antibiotics. 5,10 It recommended to use water-based topicals in birds as ointments may damage their feather quality and impair thermoregulation. 2 In addition, there is a potential for systemic absorption of topicals in small patients with prolonged or excessive application. A bandage often is placed to help keep topical medications within the wound bed and prevent patient access to them. Bandages Bandages are usually constructed in three layers and appropriately placed bandages should protect wounds from contamination, desiccation, and further trauma. Bandages are typically changed daily to every other day depending on the stage of healing with the goal of providing a moist, clean environment. The primary layer of a bandage is comprised of a dressing that is in direct contact with the wound bed. This dressing can function to debride necrotic tissue, deliver medication to the wound, convey exudate from the wound, and protect the wound. 2 Many dressings are available for use as primary bandage layers and the choice of which dressing to use should be based largely on the stage of wound healing. Dressings may be either adherent or nonadherent, and nonadherent dressings are either occlusive or semiocclusive (Table 4). Adherent dressings function to debride material during the inflammatory phase of healing. Nonadherent dressings are more appropriately used to help prevent desiccation and disruption of the healing wound bed during the proliferative and remodeling stages. Occlusive dressings are vapor-, moisture-, and oxygen- impermeable. Thus, they provide for better moisture retention in the wound bed than semiocclusive dressings, but caution should be used in their application as the presence of too much fluid can lead to tissue maceration. It is important to note that even dressings that are designed to be nonadherent can adhere to a wound if they are left on for greater than 2-3 days. 1,2 Table 4. Selected nonadherent dressings and their classifications as semiocclusive or occlusive. 2,12 The secondary and tertiary layers of a bandage serve to further immobilize and protect the wound. The secondary layer is usually composed of an absorptive material, such as cast padding, that also helps to draw exudate away from the wound bed. The tertiary layer functions primarily in keeping the bandage in place by conforming to the wound bed and it is usually made up of an elastic wrap or adhesive material. 1 Proper placement of these layers results in a bandage that provides appropriate stabilization and protection of the wound without being bulky or constrictive. Poor bandaging technique can lead to complications including vascular compromise, tissue edema, skin irritation, delayed wound healing, and increased patient discomfort. In order to determine the appropriate bandage type for the injury, multiple factors need to be considered including the anatomic location of the wound, the type of wound, and the patient s tolerance for restricted movement and altered mobility. Cutaneous wounds that are further complicated by orthopedic injuries will require stabilization via surgical intervention or external coaptation. Bandage material selection, duration of bandage placement, and time intervals between bandage changes are often determined by evaluating the chronicity, severity, and extent ExoticsCon 2015 Main Conference Proceedings 643

6 of the wound in addition to the overall health of the patient. Bandages are removed as soon as possible after an injury to avoid bandage related complications such as disuse atrophy, ligament stricture, and joint stiffness. Unfortunately, restraint is required for successful bandage placement and, even when they are properly applied, bandages are often poorly tolerated by exotic patients. Destruction of the bandage and possible mutilation of the wound by the patient may require the placement of an Elizabethan collar, which can be extreme stressful and lead to further complications such as anorexia, depression, and even death. For these reasons, careful monitoring and adequate analgesic therapy is necessary for all patients undergoing wound therapy and bandaging. References 1. Pavletic MM. Atlas of Small Animal Wound Management and Reconstructive Surgery. 3rd ed. Ames, IA: Saunders; Burke HF, Swaim SF, Amalsadvala T. Review of wound management in raptors. J Avian Med Surg. 2002;16: Mitchell MA, Diaz-Figueroa O. Wound healing and management in reptiles. Vet Clin N Am Exot Anim Pract. 2004;7: Keller KA, Paul-Murphy J, Weber S, et al. Assessment of platelet-derived growth factor using a splinted full thickness dermal wound model in bearded dragons (Pogona vitticeps). J Zoo Wild Med 2014;45(4): Langlois I. Wound management in rodents. Vet Clin N Am Exot Anim Pract. 2004;7: Pilny AA, Hess L. Ferrets: Wound healing and therapy. Vet Clin N Am Exot Anim Pract. 2004;7: Rhoads DD, Wolcott RD, Percival SL. Biofilms in wounds: Management strategies. J Wound Care. 2008;17(11): Ritzman TK. Wound healing and management in psittacine birds. Vet Clin N Am Exot Anim Pract. 2004;7: Hernandez-Divers SM. Principles of wound management of small mammals: hedgehogs, prairie dogs, and sugar gliders. Vet Clin N Am Exot Anim Pract. 2004;7: Graham JE. Rabbit wound management. Vet Clin N Am Exot Anim Pract. 2004;7: Fahie MA, Shettko D. Evidence-based wound management: a systemic review of therapeutic agents to enhance granulation and epithelialization. Vet Clin North Am Small Anim Pract. 2007;37: Krahwinkel DJ, Boothe HW. Topical and systemic medications for wounds. Vet Clin North Am Small Anim Pract. 2006;36: Smith DA, Barker IK, Allen OB. The effect of certain topical medications on healing cutaneous wounds in the common garter snake (Thamnophis sirtalis). Can J Vet Res. 1988;52: Mathews KA, Binnington AG. Wound management using honey. Comp Cont Educ Vet. 2002;24(1): Building Exotics Excellence: One City, One Conference

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