Wound Management for Nurses/Technicians What do we need to know? Laura Owen European Specialist in Small Animal Surgery Lecturer in Small Animal Surgery, University of Cambridge
The Acute Open Wound
PPE & hygiene Gloves as minimum Protect wound from nosocomial infection Protect you from zoonotic infections Aprons Protect clothes from contamination Cover wound during assessment/ stabilisation Cover the examination table Reduce environmental contamination
Acute Open Wounds Initial Management Assess for more lifethreatening injuries Analgesia Sedate/anaesthetise Is wound treatable?? Imaging
Acute Open Wounds Cover wound with water soluble jelly (KY or similar) Clip wide area around wound Clean skin with dilute chlorhexidine (or similar) Change gloves
Acute Open Wounds Flush wound Tap water? Chlorhexidine 0.05%? 0.5-1 L+ sterile warm Hartmann s solution Fluid bag, giving set, 3-way tap, 20-50ml syringe, 18 or 19G needle 8-12 psi Change gloves
Acute Open Wounds Collect swabs/tissue samples for bacteriology Antibacterial therapy after sample collection Broad-spectrum until c/s Surgical debridement if required CAUTION!!
Acute Open Wounds Primary or secondary healing? Suture (Golden period) Dress wound Primary contact layer Assess best method of securing dressing Consider if further support required e.g. splint?
Other considerations
Nutrition Accurate recording of food and fluid intake Daily weighing Consider impact of bandages Careful planning of the timing of dressing changes to reduce starvation periods Nursing care to improve appetite Appetite stimulants? Early consideration of feeding tube
Other Bandage care Understand the importance of the dressing and who to/how to change Owner sheet Soft buster collar Urination & defaecation Bladder expression under sedation? Lactulose Enema
Primary contact layer Other brands are available!!
Choice depends on stage of wound healing Wet Dry Hydrate and debride + control infection Inflammation Absorb exudate, protect fragile vessels low/ non-adherent) Proliferation Wound Healing Maintain hydration, low/ non-adherent Maturation Too Wet Moist Too Dry
Inflammatory Phase Initial 72 hours post injury Key aims: Debridement Protection from invasion by micro-organisms Note: Inflammatory phase in commonly prolonged in cats
Adherent Dressings Gauze swabs (good quality) Wet-dry Function debridement (aggressive) Inflammatory phase only Requires minimum once daily dressing changes Painful to remove requires sedation/ga Materials cheap
Hydrogels E.g. Intrasite, Citrugel Functions Debridement very gentle Autolytic Absorbs exudate Maintain moist environment Useful to cover exposed bone, tendons, ligaments protection from dessication and trauma Must cover with secondary dressing, usually a foam dressing - expensive
Manuka Honey Medical grade Various methods of application Functions Antibacterial Debridement osmotic effect Enhanced healing? - antioxidant
Negative Pressure Wound Therapy Controlled negative pressure applied to a wound -125mmHg Functions Reduction in wound oedema Removal of exudate Reduction in tissue levels of bacteria Production of granulation tissue Wound contraction
Early Proliferative Phase Begins 3-5 days post-injury Deposition of collagen matrix Angiogenesis = GRANULATION TISSUE Key aims: Maintain moist wound environment Prevent damage to cells Note: In cats granulation tissue is later to appear and slower to form Granulation tissue forms at wound edges and progresses across
Foam Dressings E.g. Allevyn, Advazorb plus Non-adherent, highly absorbent dressing Semi-permeable Functions Absorb exudate Maintain moist wound environment
Granulation Tissue Red/pink, fleshy tissue Granulation tissue paler in cats Very resistant to infection Stop systemic antibacterial therapy
Decision Making Surgical reconstruction Healthy granulation bed Consider Complete second intention healing Likely duration of healing by second intention + potential adverse consequences Patient morbidity
Ella
Daisy Complete degloving hindlimb Options amputation or wound management & reconstruction
Daisy
Daisy
Lily
Late Proliferative Phase Wound contraction Epithelialisation Reduced exudate Maintain moist environment As healing progresses can opt to allow to dry out
Dressings Perforated Polyurethane Dressings E.g. Melolin + Primapore Fully permeable Do not prevent wound dessication Can adhere to wounds
How to keep dressings in place? Courtesy of Alasdair Hotston-Moore
Ongoing wound management Always starve in case sedation required PPE Remove dressings straight into bin Clean skin Flush wound with saline, Hartmann s or 0.05% chlorhexidine at each dressing change Dry surrounding skin
Ongoing wound management Decision making at EACH dressing change Same personnel? Long enough appointment PHOTOGRAPHS Questions: Has the wound progressed since the last dressing change? Is there any evidence of inflammation or infection? Is the surrounding skin healthy Is it appropriate to consider surgical closure
What about leaving the wound uncovered?
Ember
Ember
Ember
Ember
What if it becomes infected?
Unusual Pathogens
Infection Systemic antibiotics Broad spectrum cover until granulation tissue covering wound Change according to c/s ONLY if wound not progressing Use later on if patient systemically unwell TOPICAL treatment Manuka honey Silver dressings NPWT
Wound isn t healing as expected?
Delayed healing Remember wound healing is slower in cats compared to dogs Most common reason is poor wound management Identify any underlying cause E.g. tension, abrasion, systemic disease, FeLV/FIV infection etc Address where possible CHANGE the management plan Admit for hospitalisation Change dressings Consider surgical options
Lily
Lily Presumed bite wounds to flank bilaterally 3 weeks duration prior to presentation All wounds dried out and crusty Superficial infection
Lily Work up for systemic disease Pancreatitis No other disease detected Samples for histopathology Panniculitis and inflammation
Lily Crusts removed Wounds flushed Wet-dry dressings 5 days Tie over alleyvn dressings applied
Lily
Lily Almost complete healing 5 weeks later
Scooby
Scooby
Scooby