Acute and Chronic Wound

dr. Almahitta Cintami Putri, SpBP-RE (K)

 DEFINITION of Wound
◈ Disruption of normal continuity of skin and underlying tissue
integrity because of trauma or surgical incision
Wound edge Wound
corner
Surface of
the wound
Base of the wound
Cross section of a simple wound
Wound edge
Wound Skin surface
cavity Subcutaneus tissue
Surface of
the wound Superficial fascia
Muscle layer
Base of the wound
 Acute Wound
Wound • Heals in predictable manner and
expected duration
• Traumatic acute wound: a
Acute wound or laceration of traumatic
origin with no evidence of
• < 3-4 weeks macroscopic contamination or
signs of active infection
• Traumatic wounds are one of the
most common problems leading
Chronic people to the ED, approximately
• > 4-6 weeks 5.4% of all visits
Classification of Acute Wound
 1) Abraded wound (vulnus
abrasum)
⚫ Superficial part of the
epidermal layer
⚫ Good wound healing
⚫ Treatment: wound is cleaned
and kept moist

Traumatic Wounds
8
 2) Punctured wound (vulnus
punctum)

⚫ Sharp-pointed object
⚫ Depth within the body is much
greater than the dimensions of the
wound
⚫ Irrigate into the puncture, clean
wound with H2O2 and povidone
iodine
⚫ Possible pseudomonal infection
⚫ Assess the need of antibiotics and
Traumatic Wounds anti-tetanus
 3) Incised wound (vulnus
scissum)

◈ Sharp object, regular margins of

wound
◈ Best healing
◈ Treatment: Wound cleansing,
primary suture
◈ wound dressing

Traumatic Wounds
10
 4) Torn wound (vulnus
laceratum)

◈ A tear in tissue caused by

shearing or crushing force
◈ Blunt-trauma mechanism
◈ Treatment: wound cleansing,
primary suture, wound
dressing

Traumatic Wounds
 5) Cut wound (vulnus
caesum)

◈ Sharp object + blunt

additional force
◈ Edges – uneven
◈ Treatment: wound toilet,
primary suture, wound
dressing
Traumatic Wounds
 6) Crush wound (vulnus
contusum)
◈ Blunt force 🡪 Pressure injury
between 2 heavy objects, edges –
uneven and torn
◈ Bleeding 🡪 stop bleeding by
direct pressure
◈ Related damage: bleeding,
bruising, compartment
syndrome, fracture, nerve injury
◈ When severe enough 🡪 affected
muscle fibers and damaged
tissues release cellular
byproducts and electrolytes 🡪
Traumatic Wounds crush syndrome, may lead to
renal failure, arryhtmias, and
even death
 Traumatic wounds
7) Shot wound (vulnus scolperatium)
◈ May be penetrating or perforating
◈ Entrance wound: reddish-brown area
(abrasion ring)
◈ Treatment: control bleeding,
immobilize the object in place, reduce
infection
 Skin Avulsion

Degloving Injury

Special wound
 DEGLOVING - Definisi

Suatu cedera dimana kulit dan jaringan lunak

dibawahnya terlepas (terelevasi) secara paksa dari dasar
(fascia) oleh kekuatan dengan tekanan yang keras dan
mendadak (shearing force), biasanya terjadi karena
tungkai terjebak di bawah ban kendaraan.

Pembuluh daraf perforator terputus

 Jenis Trauma Kulit dan Jaringan Lunak
• Degloving Tertutup
- Dimana kulit dan jaringan lunak dibawahnya terlepas dari dasarnya tetapi
permukaan kulit masih intak.

◈ Degloving Terbuka
- Dimana kulit dan jaringan lunak dibawahnya terlepas dari dasarnya disertai
dengan terputusnya kontinuitas permukaan kulit.

◈ Avulsi
- Dimana jaringan kulit dan atau jaringan lunak dibawahnya terlepas seluruhnya
dari tubuh.
 Patofisiologi
◈ Tekanan + gaya puntir pada kulit 🡪
terputus kontinuitasnya, sebagian kulit
masih melekat seperti flap 🡪 pembuluh
darah perforator yang mensuplai kulit
terputus 🡪 vitalitas jaringan terganggu 🡪
nekrosis

◈ Devaskularisasi lemak flap degloving 🡪

melepas metabolik toksik 🡪 nekrosis
 Tanda Klinis

Kulit yang mudah bergerak / Tidak melekat pada dasar

Tire mark / friction burn

Hematome

Fluktuasi subkutis
 Penilaian Vitalitas Kulit

1. Tes tekan/penilaian CRT

2. Eksisi marginal
3. STSE
4. Prick test (bright red vs purple)
5. Fluorescence test
6. Extra: hair tug test
 Tes vitalitas jaringan lain

1. Lemak : Warna kuning cerah 🡪 avital: kuning kunyit

2. Otot : warna merah segar, CRT baik, berkedut bila
dirangsang cauter (5, cutting) 🡪 avital: kehitaman
3. Tulang : warna putih berkilat, periosteum + 🡪 avital: kering,
kuning kecoklatan
 Penilaian Vitalitas Kulit
1. Beri tanda dengan methylen blue
daerah yang degloving
2. Jahitkan flap degloving kembali ke
posisi anatomi semula
3. Dalam tahapan ini perlu juga penilaian
vaskularisasi flap degloving
4. Split Thickness Skin Exicision (STSE)
:
- Diagnosis
- Terapi
 Algoritma
Trauma Kulit dan Jaringan Lunak

Degloving Avulsi

Tertutup Terbuka

Tes Vitalitas Jaringan Tes Vitalitas Jaringan

Vital Non Vital Vital Non Vital

Insisi Kecil Eksisi Jahit Tidak Tegang Kulit Kulit

(Jangan Coba Jahit Primer) Baik Tidak Baik
Irigasi
Split Thickness Defatted Eksisi
Skin Graft Split Thickness
Drain
Skin Graft Split Thickness
Skin Graft
Balut Tekan
Full Thickness
Skin Graft
Wound Evaluation

Comorbid
Tetanus status
Past Surgical History
Medications
Allergies
Tetanus Prophylaxis
Types of Wounds and Treatment
 Irrigation & Debridement
1. Debridement – excision of all devitalized, contaminated,
foreign bodies
2. If Possible, Vital sturctures including nerves, blood
vessels, tendons and bones shouldn’t be debribed
3. Irrigation with NaCL 0.9% 🡪 Dilute the bacterial load as
well as clean out debris 🡪 30 cc syringe and 18 G catheter,
full force each time from about 3 mm distance 🡪 provides
maximal irrigation and ‘pressure washing’ (at about 25
psi.), without causing tissue damage 🡪 Repeat 🡪 wound is
irrigated with roughly 50-100 cc for every cm in wound
length
4. Mechanical debridement (sharp& blunt)
5. Gauze debridement
6. Chemical debridement
Closure
1. Closure should be attempted within 6
hours (clean, debrided, free of foreign
bodies, irrigated, hemostatic)
2. Primary
3. Secondary
4. Tertiary
 Goal of Wound Dressing
Maintain wound moist environment

Absorb exudate

Provide barrier againts bacteria

Debride necrotic tissue

Reduce edema

Filling dead space

Protect againts trauma, shear

Promote wound healing

Dressing Selections
Types of Dressing
Types of Dressing
Types Of Dressing
 Luka Kronis
(Chronic Wound)
 Definisi Luka Kronis
◈ Luka yang gagal dalam melalui proses penyembuhan yang normal untuk
menghasilkan suatu integritas fungsional dan anatomis yang memuaskan
◈ Luka yang tidak sembuh dalam 3 bulan / ≥ 4-6 minggu / > 3 minggu

Soedjana H. Penatalaksanaan Ulkus Tekanan (Pressure Ulcer/Decubitus Ulcer). Bandung: CV. Adia. 2016. Edisi 1
Brown DL, Broshcel GH. Michigan Manual of Plastic Surgery. Philadelphia: Lippincott Williams & Wilkins. 2004
Thorne CH, editors. Grabb and Smith’s Plastic Surgery, 7 th edition. Philadelphia: Lippincott Williams & Wilkins. 2014
Penyembuhan Luka Normal vs Abnormal

Thorne CH, editors. Grabb and Smith’s Plastic Surgery, 7 th edition. Philadelphia: Lippincott Williams & Wilkins. 2014
 Penyembuhan Luka Akut vs Kronik

http://www.medicalgraphics.de/en/projects/list-of-projects/projects-2016/illustration-of-chronic-wound-compared-to-the-acute-wound.html
 Alur Inflamasi Kronis pada Luka Kronis

Luka

Inflamasi
Proliferasi Remodelling
Akut

Induksi
Inflamasi
Eksternal

Inflamasi
Kronis

Soedjana H. Penatalaksanaan Ulkus Tekanan (Pressure Ulcer/Decubitus Ulcer). Bandung: CV. Adia. 2016. Edisi 1
 Faktor-Faktor Penyembuhan Luka Kronis
Sistemik Lokal
◈ Nutrisi ◈ Peripheral vascular disease
◈ Penyakit kardiopulmonal ◈ Venous stasis
◈ Kemoterapi ◈ Neuropati perifer (DM)
◈ DM ◈ Radiasi
◈ Merokok ◈ Penekanan
◈ Penyakit autoimun ◈ Infeksi
◈ Edema

Jones CM, et al. Evidence-based medicine: wound management. Plast. Reconstr. Surg. 2017;140(1):201e-16e
 Luka Kronis

Masalah:
◈ Nekrotik / slough
◈ Eksudat
◈ Infeksi

Contoh luka kronis:

◈ Luka terinfeksi
◈ Ulkus dekubitus
◈ Ulkus diabetik
◈ Ulkus vena dan arteri
Perdanakusuma DS. Luka. Basic Course of Plastic Surgical Skill. 2014
 Increasing pain,
edema
malodorous
discharge,
increased
drainage,
purulence

Wound cleansing Debridement Debridement

Exudate management Topical antimicrobial Topical antimicrobial
Exudate management Systemic antibiotics
Exudate management
http://www.worldwidewounds.com/2005/
 Biofilm

◈ Biofilm: kumpulan bakteri yang menempel

ke reseptor permukaan sel 🡪 mengubah
50% struktur protein: melindungi mereka
dari antimikroba 🡪 barrier penyembuhan
luka
◈ 60% luka kronis
◈ Debridement surgical (+) antimikroba
topikal

Young L. Identifying infection in chronic wounds. Wound Practice and Research;2015(1):38-44

 Infeksi pada Luka (infected wounds)
◈ Luka akut 🡪 flora normal kulit
🞚Staphylococcus aureus, Streptococcus B Hemolyticus
◈ Luka kronis
🞚Anaerob gram negatif (Pseudomonas, Proteus, Klebsiella, E.Coli)
🞚Semakin buruk luka, semakin tinggi risiko infeksi anaerob

Neal R, Chamberlain. The Microbiology of Wounds.

http://www.cmaj.ca/content/183/8/E499
Ulkus Tekanan (pressure ulcer)
► Tekanan antara penonjolan tulang dan permukaan
luar yang melebihi tekanan kapiler (32 mmHg) 🡪
iskemi
► Faktor mekanik: imobilisasi, tekanan, gesekan
(friction), gesek tekan (shear), kelembaban
► Manajemen: redistribusi tekanan 🡪 mempertahankan
aliran darah 🡪 pergerakan dan reposisi pasien, kasur
decubitus; debridement, penutupan luka, NPWT

Soedjana H. Penatalaksanaan Ulkus Tekanan (Pressure Ulcer/Decubitus Ulcer). Bandung: CV. Adia. 2016.
Edisi 1
 Ulkus Diabetikum (diabetic ulcer)
◈ Neuropati 🡪 hilangnya sensasi protektif
dan koordinasi otot 🡪 stress mekanik saat
berjalan
◈ Makro + mikroangiopati: Atherosklerotik,
PAD
◈ Debridement, antibiotik (selulitis,
osteomielitis), dressing yang sesuai,
kontrol gula darah, evaluasi insufisiensi
arteri perifer

Rice JB, Desai U, Cummings AK, Birnbaum HG, Skornicki M, Parsons NB. Burden of diabetic
foot ulcers for Medicare and private insurers. Diabetes Care. 2014. 37 (3):651-8
 Ulkus Vena dan Arteri (Leg Ulcers)
Vena Arteri
◈ ↑ tekanan vena + katup ◈ ↓ aliran arteri --> ↓
vena inkompeten --> oksigen --> iskemia
edema lokal &
ekstravasasi plasma
◈ fibrin cuff sekitar kapiler
--> hambat difusi oksigen
& nutrisi

Neligan PC. Plastic Surgery. Elsevier. 2013

Grey JE, et al. ABC of wound healing. BMJ 2006;332(11):347-50
 Tatalaksana
◈ Debridement adekuat
◈ Tatalaksana infeksi
🞚Selalu curiga adanya infeksi pada luka kronis
🞚Kultur jaringan dan jumlah pathogen
◈ Dressing luka yang sesuai
🞚Moist
🞚Debridement, antimikroba topikal, menyerap
eksudat
◈ Faktor lokal dan sistemik
🞚Penyakit vaskular, DM, malnutrisi, tekanan

Brown DL, Broshcel GH. Michigan Manual of Plastic Surgery. Lippincott Williams & Wilkins. Philadelphia:2004
Perdanakusuma DS. Luka. Basic Course of Plastic Surgical Skill. 2014
 Konsep T-I-M-E

Leaper DJ, et al. Extending the TIME concept: what have we learned in the past 10 years? Int Wound J 2012;9(Suppl. 2):1-19
 Tetanus
◈ Tetanus is an acute, often fatal, disease caused by an exotoxin produced by the bacterium Clostridium
tetani.
🞚 slender, gram-positive, anaerobic rod that may develop a terminal spore
🞚 The organism is sensitive to heat and cannot survive in the presence of oxygen. The spores, in
contrast, are very resistant to heat and the usual antiseptics 🡪 become noninefctious with hydrogen peroxide
🞚 The spores are widely distributed in soil and in the intestines and feces of horses, sheep, cattle,
dogs, cats, rats, and chickens
◈ Characterized by generalized rigidity and convulsive spasms of skeletal muscles. The muscle stiffness
usually involves the jaw (lockjaw) and neck and then becomes generalized.
◈ C. tetani produces two exotoxins, tetanolysin and tetanospasmin. The function of tetanolysin is not
known with certainty. Tetanospasmin is a neurotoxin and causes the clinical manifestations of tetanus.
 Tetanus
◈ All wounds should be cleaned. Necrotic tissue and foreign material
should be removed. If tetanic spasms are occurring, supportive therapy
and maintenance of an adequate airway are critical.
◈ Because of the extreme potency of the toxin, tetanus disease does not
result in tetanus immunity. Active immunization with tetanus toxoid
should begin or continue as soon as the person’s condition has
stabilized.
Terima Kasih
Kasus Luka Akut dan Kronik
Luka Akut
Luka Kronik