Classification and management of

wound, principle of wound healing,

haemorrhage and bleeding control
1

GYRGYI SZAB
ASSISTANT PROFESSOR

DEPARTMENT OF SURGICAL
RESEARCH AND TECHNIQUES

Basic Surgical Techniques, Faculty of Medicine, 3rd year

2021/13 Academic Year, Second Semester
 2

WOUND
 What is a wound?
3

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
4
Wound edge Wound
corner
Surface of
the wound

Base of the wound

Cross section of a simple wound

Wound edge
Wound Skin surface
cavity
Surface of Subcutaneus tissue
the wound
Superficial fascia
Muscle layer
Base of the wound
 The ABCDE in the injured assessment
5

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
6

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 patients vaccination against Tetanus
Prevention of rabies
The applied first-aid
Classification of the accidental wounds
1. Based on the origine
7

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
8

1.) Abraded wound 2.) Punctured wound

(v. abrasum) (v. punctum)
Superficial part of the epidermal Sharp-pointed object
layer
Seems negligible
Good wound healing
BUT
Anaerobic infection
Injury of big vessels and nerves
 Mechanical wounds
9

3.) Incised wound

4.) Cut wound (v. caesum)
(v. scissum)

Sharp object Sharp object + blunt additional

Best healing force
Edges - uneven
 Mechanical wounds
10

5.) Crush wound 6.) Torn wound

(v. contusum) (v. lacerum)

Blunt force Great tearing or pulling

Pressure injury Incomplete amputation
Edges uneven and torn
Bleeding

(v. lacerocontusum)
 Mechanical wound
11

7.) Shot wound (v. scolperatium)

Close - burn injury

Foreign materials

aperture output

slot tunel unijured tissue

necrobiotic zone
necrotic zone
foreign bodies
 Mechanical wounds
12

8.) Bite wound (v. morsum)

Ragged wound
Crushed tissue
Torn
Infection
Bone fracture

Prevention of rabies
Tetanus profilaxis
 The direction of the flap
13

Distal Proximal

The wound healing is good

 Chemical wounds
14

1.) Acid 2.) Base

in small concentration irritate colliquative necrosis

in large concentration
coagulation necrosis
Wounds caused by radiation
15

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
16

1.) Burning 2.) Freezing

Metabolic change! - toxemia mild, moderate, severe (redness,

bullas, necrosis)
a normal skin
rewarm not only the frozen area
1 - 1st degree superficial injury
(epidermis) but the whole body
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
 Special wounds
17

Exotic, poisonous animals

Toxins, venom - toxicologist

Skin necrosis
 Classification of the wounds
2. According to the bacterial contamination
18

Clean wound
Clean-contaminated wound
Contaminated wound
Heavily contaminated wound
 Classification of the wounds
2. Depending on the depth of injury
19

Superficial
Partial thickness
Full thickness
Deep wound

+ bone, opened cavities, organsetc.

source: http://www.funscrape.com/Search/1/skin+layers.html
 Wound management - history
20

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 Par 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
21

black black-yellow yellow yellow-red red red-pink pink

source: Applied wound management supplement www.wounds-uk.com

 Applied wound management
infection continuum
22

the quantity and diversity of microbes

contamination critical colonisation

sterility colonisation infection

source: Applied wound management supplement www.wounds-uk.com

 Applied wound management
exudate continuum
23

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
24

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
25

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
26

Surgical incision
Stretch and fix
Handling the scalpel
Langer lines
Skin edges
Vessels and nerves
Hemostasis
Langer lines source: http://www.med-
ars.it/galleries/langer.htm

The wound edges

Handling the scalpel

 Tissue unifying and dressing the wound
27

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
28

Hemostasis-inflammation
Granulation-proliferation
Remodelling

capillaries
fibroblasts
lymphocytes
macrophages
neutrophyl gr.
thrombocytes
0 1 2 3 4 5 6 7 8 9 10 11 10 13 14 15

http://www.worldwidewounds.com/2004/august/Enoch/images/enochfig1.jpg
 The main steps of the wound healing
29
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
30

Healing by primary
intention

Healing by secondary
intention

Healing by tertiary
intention

source: http://quizlet.com/13665246/chapter-3-tissue-renewal-regeneration-
and-repair-flash-cards/
 Factors affecting wound healing
31
Local Systemic
Ischemia Age and gender
Infection Sex hormones
Foreign body Stress
Edema, elevated Ischemia
tissue pressure Diseases
Obesity
Hyperbaric oxygen Medication
treatment Alcoholism and smoking
Immunocompromised
conditions
infection
Nutrition

foreign IMPAIRED
ischemia
bodies HEALING
edema/
elevated
tissue
pressure
 Complications of wound healing
I. Early complications
32

Seroma
Hematoma
Wound disruptin
Superficial wound infection
Deep wound infection
Mixed wound infection
 Early complications of wound healing
33

1.) Seroma 2.) Hematoma

Filled with serous fluid, lymph Bleeding, short drainage time,

or blood anticoagulant
Fluctuation, swelling, redness, Risk of infection
tenderness, subfebrility Swelling, fluctuation, pain,
redness
TREATMENT:
Sterile punture and TREATMENT
compression Sterile puncture
Suction drain Surgical exploration
 Early complications of wound healing
34
A. partial dehiscenece
3.) Wound disruption B. complete - disruption

Surgical error
Increased intraabdominal
pressure
Wound infection
Hypoproteinaemia

TREATMENT:
U-shaped sutures
 Early complications of wound healing
Superficial wound infection
35

1.) Diffuse 2.) Localized

Located below the skin Anywhere

TREATMENT TREATMENT
Resting position
Surgical exploration
Antibiotic
Drainage
Dermatological consultation
X-ray examination

e.g. erysipelas e.g. abscess

 Early complications of wound healing
Deep wound infection
36

1.) Diffuse 2.) Localized

TREATMENT Inside the tissues or body cavities

Surgical exploration TREATMENT

surgical exploration
Open therapy drainage

H2O2 and antibiotics

e.g. anaerobic necrosis

 Complications of wound healing
I. Early complications
37

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
38

Hyperthrophic scar
Keloid formation
Necrosis
Inflammatory infiltration
Abscesses
Foreign body containing abscesses
 Late complications
39
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
 40

BLEEDING AND HEMOSTASIS

 Bleeding
41

Anatomical Diffuse

Arterial bright red, Capillary can become

pulsate serious
Venous dark red, Parenchymal
continuous
 Bleeding
42

Severity of bleeding the volume of the lost blood and

time

source: http://lifeinthefastlane.com/2012/03/trauma-tribulation-025/
 The direction of hemorrage
43

External
Internal
In a luminar organ (hematuria, hemoptoe, melena)

In body cavities (intracranial, hemothorax, hemascos,

hemopericardium, hemarthros)
Among the tissues (hematoma, suffusion)
 Bleeding
44

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
45

Local General

Pale skin, cyanosis, decreased

Hematoma, suffusion,
ecchymosis
Compression in the pleural
cavity, in pericardium, in the
skull
Functional disturbancies e.g.
hyperperistalsis
BP. and tachycardia, difficulty
in breeding, sweeting,
decreased body temperature,
unconsciousness, cardiac and
laboratory standstill, laboratory
disorders, signs of shock
 Surgical hemostasis
46

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
47

Digital pressure direct pressure,

e.g. Pringle maneuver
Tourniquet
Ligation
Suturing
Preventive hemostasis
Clips
Bone wax
other
 Thermal methods
48

Low temperature
Hypothermia eg. stomach bleeding

Cryosurgery
dehidratation and denaturation of fatty tissue
decreases the cell metabolism
vasoconstriction
 Thermal methods
49

High temperature
Electrosurgery electrocauterization

Monopolar diathermy

Bipolar diathermy

Laser surgery
coagulation and vaporization
for fine tissues
 Thermal methods
50

High temperature
Electrocoagulation

Electrofulguration (A)

Electrodessication

Electrosection
 Hemostasis with chemical and biological
methods
51

vasoconstriction coagulation hygroscopic effect

Absorbable collagen
Absorbable gelatin
Microfibrillar collagen
Oxidized celluloze
Oxytocin
Epinephrine
Thrombin
Hemcon
QuikClot
Hemostasis with chemical and biological
methods
52

HemCon