WOUNDS

Definition
1. An injury to any body tissue caused by mechanical forces with or without a break in the
continuity of the skin.
2. A break in the continuity of any tissue caused by injury or operation

Classification
i. Open wounds; whereby skin or mucus membrane is broken or dissolved
ii. Closed wounds; where skin’s integrity or mucus membrane’s integrity remain intact.

Types of Open wounds

i. Incised wounds: those inflicted with a sharp instrument
ii. Abrasion or excoriation: a painful superficial wound caused by scraping away of the
epidermis.
iii. Lacerated wounds; wounds with torn tissues, jagged edges with a high potential for necrosis,
eg., wounds from barbed wire
iv. Punctured wounds: deep narrow wounds eg., from a knife point, needle, or bullet.

Management of Open Wounds

a. For Clean Fresh Wounds:
i. Arrest haemorrhage
ii. Close by suturing or by use of clips
ii. Apply a sterile dressing
b. For lacerated Fresh Wounds:
i. Arrest haemorrhage.
ii. Excise dead or devitalised tissues.
iii. Close wound by direct suturing. NB. Relieving incision may be necessary ie., skin incised
parallel to the wound so that skin can be drawn across the wound then incision heals by granulation.
iv. Skin graft may be needed to hasten healing.
vi. Immobilization with a splint or splint or plaster if necessary.
c. For Lacerated wounds over 8-12 hr duration post injury:
In case infection is possible and therefore are considered as dirty wounds
i. Arrest haemorrhage
ii. Clean thoroughly with normal saline.
iii. Remove foreign bodies and excise dead tissue and all devitalized tissue, ie., debridement is
done.
iv. Suture with enough tension to approximate edges and allow for drainage to escape.
v. If closure is impossible (due to oedema) wound left open, and closed latter, ie., delayed primary
suturing.
vii. If dead space left in the depth of the wound, a drain tube may be inserted and brought through
the surface via a separate ‘stab’ wound.
Meantime the dead space may be packed to absorb any accumulating exudate.
vi. Asterile dressing is applied.
vii. Area immobilized
viii. Prophylactic systemic antibiotics administered.

c. For Infected Wounds:

i. Tissue is not excised because danger of spreading infection.
ii. Area immobilized
iii. Infection treated with systemic antibiotics
iv. Observe for any complications, such as abscess formation, cellulitis, gas gangrene or secondary
haemorrhage.
v. Wound irrigated with any antiseptic solution.
vii. Slough removed
viii. Secondary suturing or skin graft done once wound is clean.

d. Stab Wounds:
i. If infected laid wide open and treated as infected wounds.
 Complications
i. Haemorrhage
ii. Shock
iii. Infection.
iv. Damage to deeper structures
v. Evisceration especial in abdominal wound
vi. Incisional hernia

Types of Closed wounds

a. Bruise (Contusion): In this case there is straining of the subcutaneous tissue which raptures the
small blood vessels

Cause
Can be a blow with a blunt object or just a fall
Signs & Symptoms
i. pain, ii. Swelling, iii. Discolouration of the skin
Management
i. Rest the affected part
ii Apply ice to cool down the area;
i Compress with a pressure bandage
iv. Elevate to promote venous drainage.
(Pnemonic –RICE)
b. Haematoma: result from a massive leak of blood into body
Signs & Symptoms
There’ fluctuating swelling that contains extra-vasated blood which forms soon after injury.
Management
RICE as above.
 WOUND HEALING
Depends on the condition of the wound
MECHANISMS OF WOUND HEALING:
i. First intention Healing; ie., (Primary Healing)
ii. Second Intention; Healing (necrotic tissue formation, granulation, epithelialization and scar
tissue formation).
iii. Third Intention; (follows secondary suturing)

a. Healing by First Intention:

i. Occurs in wounds created aseptically and edges brought into apposition by suturing ie.,properly
closed,
eg., surgical wounds whereby there is minimal tissue destruction.
ii. In such wounds there is little tissue reaction and healing is by union/ first intention.
No granulation tissue is visible, and scar tissue is minimal.
b. Second Intention Healing/ Healing by Second Intention:
Occurs in infected wounds or in wounds whose edges are not approximated, eg., abscesses or
lacerated wounds.
Healing occur in stages as follows:
-Necrotic tissue formation stage;
Initially dead and dying cells are being released and thereby forming necrotic material.
This disintegrates and escapes from the wound as exudate.
-Granulation;
Later a red soft and sensitive tissue easily bleeds forms.
This is composed of minute, thin-walled capillaries and buds called granulations.
These granulations enlarge and fill the area left behind by the destroyed tissue.
Scar tissue formation
Takes place when the cells surrounding the capillaries become elongated thin and intertwined to
form a scar.
-Epithelialization
In this case the skin cells grow over the granulation buds.
Surgical wounds may also be allowed to heal by secondary intention ie., granulation following
initial cleaning and packing of the wound to allow for granulation to take place.

c. Third Intention Healing/ Healing by Third Intention (Secondary Suture)

i. Indicated for deep wounds or previously sutured wounds that break down
ii. Suturing brings together two opposing granulation surfaces.
iii. Consequently there is formation of a deeper and wider scar.
Iv. Wounds for secondary suturing may also be packed so as to allow for granulation to take place
before edges can be approximated.

Phases of Wound Healing

These include;
i. Inflammatory phase
ii. Proliferation phase/ Fibroblastic or Connective tissue phase,
iii. Maturation phase

a. Inflammatory Phase
i. Takes 1-4 days
ii. Blood clot forms, wound become edematous
iii. Debris of damaged tissue are phargocytosed.
b. Proliferative Phase
Duration 5-20 days
Collagen tissue is produced
Granulation tissue forms
Wound tensile strength increases
c. Maturation Phase
Duration 21-days to months to years
Fibroblasts leave the wound
Tensile strength increases
Collagen fibres reorganize and tighten to reduce scar size.

FACTORS THAT ENHANCE WOUND HEALING

Local factors:
1. Adequate hemostasis -results in clot formation
2. Resting the area-0 essure clot formation
3. Apposition of skin edges if possible, ie., in surgically cut wounds and not lacerated ones.
4. Adequate blood supply to area to ensure nourishment and oxygen supply
5. Freedom from infection –therefore aseptic technique to be observed.
General Factors:
1. Age- younger individuals have more active cells
2. Nutrition-Proteins, Vitamins A, and C for healing, and K for blood clotting
3. Adequate circulation which depend on the heart action, state of blood vessels, composition of
blood eg., normal Hb, WBCs, body fluid, oxygen and nutrients

FACTORS THAT DELAY WOUND HEALING

1. Hamorrhage;
Accumulation of blood creates dead spaces as well as dead cells.
This also becomes a growth medium for mild organisms
2. Inadequate immobilization;
Causes injury or disturbs haemostasis and thereby delaying wound healing, eg vigorous exercises,
straining of abdomen from chronic cough, vomiting or constipation.
3. Presence of;
a. Foreign objects/bodies, eg., a drain tube, debris such as soil and pieces of glass or dead tissue
b. Fistula or sinus- ie presence of pus or exudate delay healing.
c. Neoplasms- presence of abnormal interfere with growth of normal cells for healing
d. Excessive tissue damage or skin loss- healing only possible granulation/secondary intention or
third intention following secondary suturing.
e. Edges of the wound inverted; resulting in failure of union of skin edges.
f. Sutures too loose thereby allowing too much movement
g. Sutures too tight thereby cutting down blood supply
h. Wound infection
i. Inadequate venous drainage of area leading to accumulation of exudate
General Factors
i. Old age
ii. Malnutrition
iii. Obesity
iv. Systemic disorders eg. Haemorrhagic shock, Acidosis, Hypoxia, Renal Failure, Spsis,
Immunosuppression and Heart Failure
Cortisol therapy