신체조직의연속성이파괴된상태
Open Wound( 개방창상 ) 피부나점막의손상이있는경우 ex)abrasion, Burn,Laceration 등 Closed Wound( 폐쇄창상 ) 피부나점막의손상이없는내부조직의손상 ex)closed Fracture, Ligament tear 등
Partial Thickness Skin Injury - dermis 의일부만손상을입은경우 - abrasion, 2 nd degree burn,gr.1,2 Pressure sore - spontaneous healing by epidermal appendages ( pilosebaceous unit ) Full Thickness Skin Injury -dermis의전층이손상을입은경우 -laceration,3 rd degree burn, Gr.3,4 Pressure sore
Epidermis -stratum corneum -stratum lucidum -stratum granulosum -stratum spinosum -stratum germinativum("stratum basale") Dermis -papillary layer -Reticular layer
Dermoepidermal Junction Rete pegs ridge
Keratinocyte Melanocyte Langerhans Cell Merkel Cell
Epidermal appendages are intradermal epithelial structures lined with epithelial cells with the potent -ial for division and differentiation. Epidermal appendages include sebaceous glands, s weat glands, apocrine glands, mammary glands, an d hair follicles. These are important as a source of epithelial cells, which accomplish re-epithelialization should the ov erlying epidermis be removed or destroyed in situa tions such as partial thickness burns, abrasions, or split-thickness skin graft harvesting.
Healing by First Intention -primary repair Healing by Second Intention -spontaneous healing by epithelialization or with wound contraction Healing by Third Intention -delayed repair
1. 염증단계 (Inflammatory Phase) 2. 상피화단계 (Epithelialization Phase) 3. 증식단계 (Proliferative Phase) 4. 성숙단계 (Maturation Phase)
Adequate inflammatory response 는창상치유에필수적 Coagulation mediated by platelet and platelet factors are released to enhance fibroblast migration and proliferation Altered Vascularity increased capillary permeability Imflammation Neutrophil,monocyte,Macrophage control bacterial proliferation & remove debris induction of fibroblast proliferation and collagen synthesis
창상후 24-48 시간지나면일어난다 세포역분화 (Cell Dedifferentiation) 창상을입으면세포가분화를중단하고세포분열을하면서이동하게된다 Contact Inhibition Marjolin s Ulcer: 상피세포가장기간분열을계속해야하는상황이주어지면세포분열이가속화되어상피암
Stress Ulcer Cushing Ulcer Curling Ulcer Marjolin Ulcer
수상후 5-7 일에시작하여 2-3 주간지속 육아조직 (Granulation Tissue) 으로형성 모세혈관이자라들어오고 Fibroblast 가증식되어 Collagen( 교원질 ) 을합성
혈관생성및 fibroblast 의증식의감소 Collagen 의합성과 Collagenase 의의한분해 수상 6 개월이지나야평형
Contraction( 수축 ) vs Contracture( 구축 ) 수축이란줄어드는생물학적진행성과정을말함구축이란수축하는과정의결과를말함 Myofibroblast plays major role in wound contraction Contracture Deformity 창상수축이주름살이나관절에직각방향으로일어날때생긴다
(Above) Myofibroblast group showed 30 to 40 percent of the alpha-smooth muscle actin-positive cells. (Below) Fibroblast group showed no alphasmooth muscle actin positive cells in most cases. Distribution - 육아조직 (Granulation tissue) -palmar fascia in Dupuytren s disease - 폐섬유화 (Pulmonary fibrosis) - 신병증 (Nephropathies) - 간경변 (Liver cirrhosis) - 유방삽입물주위피막 (Capsules around Breast Implants)
비후성반흔은보통원인이있는경우가많고주위조직에침범의정도가미약한반면켈로이드는특별한원인이없고주위조직을침범하는경우가많다 치료법 -Steroiod Intralesional Injection Triamcinolone Acetonide -Silicone Gel or Sheet -compressive Garment -Operation -Radiation
Shoulder Presternal Area
A therapeutic or protective material applied to a wound Apply therapeutic or protective materials to a wound
Dry Dressing Moist Dressing Wet Dressing
Saline and Antibiotics in Wound Chamber
Protection from external environment Stop bleeding Absorb exudate Ease pain Debride the wound
Promotion of Healing
Nature 193:293-294,1962 Moist dressing with polyethylene film:more rapid epithelialization compared with dry dressing exposed to air in the pig model.
Growth factors & Antimicrobial peptides Easier migration of Epidermal cells Enhanced Epidermal Regeneration
Foam Dressing Hydrocolloid Dressing Hydrofiber Dressing Hydrogel Dressing Alginate Dressing
Polyurethane film and foam 으로구성 Exudate 가비교적많은 Open Wound 에사용 Gas,Vapour :permeable / bacteria,liquid:impermeable Mediform Allevyn Mepilex
Excess Exudate - too wet Tissue Maceration No Exudate too dry Reepithelialization Impairment
흡수력 + 증발력 : g /100cm 2 /24hrs Medifoam Allevyn Mepilex nonadhesive adhesive 50g X 250g 160g 80g 120g
Outer layer: semipermeable polyurethane f ilm Inner layer: a cross-linked adhesive mass containing a dispersion of gelatin, pectin and carboxy-methylcellulose
Exudate 가적은창상에사용하기적합 Duoderm
-made from sodium carboxymethylcellulose. -produced as a textile fiber -dressing absorbs and interacts with wound exu date to form a soft, hydrophilic, gas-permeabl e gel Aquacel Versiva
Aquacel Versiva
- 펙틴, Carboxy Methylcellulose, 프로필렌글리콜과물 - Amorphous, Sheet, impregnated Gauze 형태 - assists autolytic debridement Hydroactive Gel (ConvaTec)-tube IntraSite (Smith & Nephew)-tube
- 알지네이트는갈색해조류에서나오는알긴산과칼슘으로구성 - 삼출물속의나트륨이칼슘이온과교환되어그결과나트륨알지네이트 (sodium alginate) 로젤형태가되어습윤환경을만든다. - 알지네이트는자기분자량의 15 20 배용량의삼출물을흡수할수있으며지혈효과가있다 Kaltostat (ConvaTec) nonwoven pad Algisite (Smith & Nephew) textile fiber
Acticoat & Acticoat Absorbent(S& Nephew) - an absorbent rayon/polyester inner core sandwiched between outer lay ers of nanocrystalline silver-coated, lower adherent polyethylene net - effective agai nst microorganisms range of Gram-positive and Gram-n egative bacteria Aquacel Ag(ConvaTec) -In the presence of sodium ions from wound exudate, the silver ions are released from the NaCMC to exert a sustained antimicrobial effect against a wide range of organisms Mepilex Ag
Acticoat Ag Aquacel Mepilex Ag Aquacel Ag
Two types of foam polyurethane black foam and polyvinylalcohol white foam (silver coated foam available) continuous negative pressure (75-125 mmhg)
Negative Pressure Wound Therapy -acute traumatic wounds or chronic wounds such as diabetic ulcers, vascular ulcers, and pressure ulcers. Decrease edema & bacterial contamination Increase blood flow to the wound Promote granulation tissue formation and wound contraction
http://www.dressings.org SMTL(Surgical Materials Testing Laboratory,UK)