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การรกษาบาดแผลในสตวเลก

วชาเทคนคการพยาบาลสตว (01600432)

Basic principles of wound healing

Phases การหายของบาดแผลสามารถแบงไดเปน 3 phases ไดแก1. Inflammatory phase2. Proliferation phase (Fibroplastic phase)3. Remodeling phase

Inflammatory phase

การตอบสนองตอการอกเสบจะมากหรอนอยขนอยกบความรนแรงของการ trauma และการควบคม hemorrhage

เมอมบาดแผลรางกายจะหลงสารทเกยวกบการแขงตวของเลอดเพอหยดหามเลอด

Cellular element ของการเกดการอกเสบกจะเคลอนเขาไปยงบรเวณ injured tissue

ระยะนแบงยอยออกเปน early vascular phase และ late cellular (inflammatory ) phase

Vascular phase

Vasoconstriction เกดทนทเพอตอบสนองตอการบาดเจบ ประมาณ 5-10 นาท

Active vasodilatation เกดตามมาทนท ท าใหเกดการแดง บวม รอน และปวด

หลงจากเกด injury ประมาณ 30-60 นาท บรเวณ postcapillary venules จะเตมไปดวยเมดเลอดขาว, fluid และ macromolecules เชน plasma protiens, complement, antibodies, water, electrolytes และ circulating humoral substances ซมผานออกมาทางชองวางของ endothelial cell ของผนงเสนเลอด

Vascular phase (Cont.)

มการซมผานของ transudate ออกมาจากรเยอบ โดยเฉพาะผานผนงหลอดเลอดฝอยเพมขนเรอยๆภายใน 72 h.

Histamine, serotonin, kinins และ fibrin-derived peptides ถกหลงออกมาเพอชวยในการเปลยนแปลงของเสนเลอดบรเวณท injury

Endothelial cells ของ postcapillary venules หดตว เกดชองวางระหวางเซลล

Plasma และ macromolecular constituents ของ plasma สามารถซมผานออกมาแลว form เปนลกษณะ wheal

Cellular phase

พบ neutrophils, macrophages และ lymphocytes พบ neutrophils กอนในชวง 6 h. หลงเกด injury และคอยๆเพมมากขน

จนสงสดประมาณวนท 2-3 ชวยในการปองกน infection และชวยการ debridement Lymphocyes พบนอยในวนแรก เพมสงสดในประมาณวนท 6 Macrophages ส าคญตอชวงการเปลยนไปยง proliferative phase พบเซลลนหลงพบ neutrophils ประมาณ 24-48 h. ชวย debridement และกระตนใหเกด fibroplastic activity

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Proliferative phase

Fibroblast migration และ matrix synthesis (collagen, elastin, proteoglycans, neovascularization และ reestablishment of epidermis)

ระยะเวลาและอตราการเกด epithelialization ไมแนนอน ขนอยกบขนาดของแผลและสภาวะแวดลอมรอบๆแผล

Epithelialization ของแผลเปดจะชากวาแผลปด Fibroblast พบใน new vascular element ซงเซลลพวกนเคลอนเขาไปยง

บาดแผลกอน newly advancing blood vessels Fibroblast จะสงเคราะห matrix component ในชวงระยะเวลาสนๆ

Proliferative phase (Cont.)

สภาวะทเปนกรดเลกนอย และม O2 ประมาณ 20 mmHg เหมาะสมทสดส าหรบการสงเคราะหใย collagen

การสงเคราะห matrix component ทคอยๆเพมขนมความสมพนธกบการเพมแรง tensile strength ในบาดแผล

การสราง collagen เพมสงสดใน 2-3 สปดาหหลงจากเกดแผล

Remodeling phase

มการเพม tensile strength อยางตอเนอง เกด collagenolysis และ new collagen production อยางสมดลยกน เกด regression ของ vascular element ระยะนกนเวลานานเปนป หรอหลายๆป

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Component of wound management

Wound lavage Debridement Dressing

Wound lavage

Pressure lavage : 4-15 psi = adequate lavage 8-10 psi applied by using 20 cc. syringe with 18 needle Not use high pressure pump lavage

Lavage

Ideal solution : Lactate Ringer’s solution Other solution : NSS, Tap/pipe water, Antiseptic solution

- Antiseptic solution : Chlorhexidine & povidone-iodine- Interfere wound healing- Use at low concentration- Most effective : 0.05% Chlorhexidine, 1% Povidone-iodine

Lavage (Cont.)

Hydrogen peroxide : not use damage cell, delay healing Systemic medication

- Open wound trauma- Prophtlactic ABO give within 3 hrs. before trauma- Contaminated wound effective

Cephalosporin, Fluoroquinolone

Debridement

Normally following lavage Remove debris, necrotic tissue, FB, other Minimize infection and promote healing

Surgical debridementHydroactive debridement

Scrub

Scrub

Chlorhexidine scrub Providone scrub Applied to debride wound Scrub induce granulation tissue

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Dressing and bandage

Reduce dead space Pack wound + immobolize wound Debride wound + absorb exudate Protect wound Vehicle for ABO and antiseptic

Factor affecting wound healing

Local factors : vascular supply, FB, dead space, radiation, infection, tropical medication, technique of wound management

Systemic factors : malnutrition(protein,vitamin), uremia, long term of high dose corticosteroids, chemotherapy, age, cancer, DM

Level of contamination Clean wound : Surgical procedure no break in asepsis,Not

involving GI,resp.,urogenital Clean-contaminated wound : Surgery involving

GI,resp.,urogenital minor break in asepsis Contaminated wound : Fresh truamatic wound (<6 hrs.),

Surgery that major break in asepsis,Surgery in inflammatory area

Dirty wound : Old truamatic wound (> 6 hrs.), Surgery in abcess area

Dirty or contaminated wound

Clean-contaminated wound

Lavage and debridement

Timing of wound closure

Primary closure Delay primary closure Secondary closure Heal by secondary intention

Primary closure

Surgery closure (clean) Limit ischemia injury (clean-con.)

sharp laceration

Acute larvage & debridement

closure

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Delay primary closure

Allow elimination of exudate or contaminated thing

CL-CO or CO wound

Lavage & debride 3-5 d.

Closure

Closure before appearance of granulation tissue

Secondary closure

Con. or dirty >5 day wound treatment Complete debride and control infection before closure

Closure after appearance of granulation tissue

Secondary intention healing

Heal by granulation, contraction, epithelialization Use in only wound in area with abundant surrounding skin

Closure option Wound type Technique

Primary closure Clean or Immediated closure without

clean contaminate tention.May require grafting or flap.

Delay primary Clean contaminate Lavage & debridement of open

closure or contaminate wound.Dressing,closure 2-3 d later,

grafting or flap.

Secondary Contaminate or Lavage & debridement of open

closure dirty wound, grafting or flap.Dressing,

closure carries out 5-7 d.

Secondary Large skin defect, Lavage & debridement of open

intention extensive con. And

wound.Dressing,heal by

granulation,

devitalization contraction and epithelialization.

Factor determining timing of wound closure

Level of wound contamination Viability of tissue surrounding the wound Early wound reconstruction is advised if

- vital structure are exposed- for structural support- open wound management contraction

Limited flexion or extension of limb

Common complications in wound healing

Hematoma and seroma Edema Draining tracts Scarring and wound contracture Wound dehiscence Infection Nonhealing

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Wound drainage

Indication : Eliminate of dead space & Remove fluid accumulation from wound

Reduce wound infection & reduce healing time

Eliminate of dead space

Dead space may be eliminated by- Tacking suture- Pressure bandage- Surgical drains

Removal of fluid

Fluid reduce host resistance to infection + healing by- Antibody is lost in fluid- Interfere phagocytosis- Good media for bacteria- Compromise blood supply- Interfere graft acceptance

Removal of fluid (Cont.)

The use of drains is indicated where- Large seroma- Abcess- Can not complete wound debride- Fluid will remain after surgery- Massive contaminate, trauma after surgery

Technique of drainage

Mechanism of action- Passive drainage : gravity and pressure- Active drainage : source of suction

- Close suction- Vented suction

Active drainage

Close suction :- Negative pressure + single lumen drain- Dry wound- Skin flap early revascularization & healing

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Active drainage (Cont.)

Vented suction :- Continuous source of suction + multi lumen drain- Little use in VET

Home-made active drains- Continuous suction : use of syringe tube, etc.- Intermittent suction : use of 3 way stopcock

Drain placement

Single exit drain technique- Passive and active drain

Double exit drain technique- Passive drain- Larvage

Drain removal

~ 3-5 day normal Until absent of fluid Prolong drainage in

- Trauma wound with muscle trauma (dog bite)- Elbow hygroma

Cut suture and removal implant Exit hole is left to heal by 2nd intention

Complication

Wound infection Wound dehiscence : Drain exit through primary incision Premature loss or retention Failure of drainage

- Obstruction- Improper drain placement- Inadequate size of drain

Complication (Cont.)

Pain & irritation Drain tract cellulitis Misuse & over-reliance

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Specific wound

Bite wound Burns Decupital sore (bedsore) Gunshot Chronic wound, fistulae and sinus tract

Bite wounds

Heavily contaminate Severe trauma in underlying deep tissue Tearing & crushing force Common site neck, thorax, abdomen Techniques : Stabilize pateint, explore and debride, survey

organ invole, usually surgical drain or delay primary closure Remove hair in deep tissue that compressed from bite

Bedsore

Bone prominence Recumbent for long peroid 4 grade :

1. Epidermis slough2. Full thickness skin loss down to SC.3. Ulcer through SC. fat to deep fascia4. Ulcer down to the bone

Bedsore (Cont.)

Treatment - Grade 1 : Lavage, debride, 2nd intention- Grade 2 : Wet to dry dressing, 2nd closure- Grade 3 : Wet to dry dressing, drains, 2nd closure- Grade 4 : Remove infected bone, debride, drain, 2nd closure

Chronic wound,fistular tract

Nonhealing wound Infection, exudate, purulent discharge Treat :

- Sinus tract treated by exicisional dissection using strile dye (methylene blue) - Re-wound management

Individual bandaging techniques

วชาสขภาพสตวเบองตน (01600481)

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Individual bandaging techniques

Robert Jones bandage : Only fractures below the elbow and below the stifle (knee).

Velpeau Sling : Stabilize fractures to the humerus and scapula (the bones above the elbow).

Ehmer Sling : A sling to the hind leg for a femoral fracture.

Ear Bandage : Ear tips damaged in dogfights or cut especially on wire fences.

Robert Jones bandage

1. Apply two strips of 2.5 cm. wide zinc oxide tape to the cranial and caudal aspects of the lower third of the limb. Allow another 10 cm. of tape to overhang the toes, and gently stick together.

2. Apply cotton wool around the entire length of the limb. Pay particular attention to any bony prominences. Use at least three layers, depending on the size of the animal. Ensure that it is of an even thickness throughout.

3. Compress the cotton wool by bandaging it with a conforming bandage appropriate to the size of the animal. Leave two nails showing at the bottom.

Robert Jones bandage (cont.)

4. Continue applying conforming bandage until sufficient tension has been created.

5. Separate the zinc oxide tapes from each other. Twist the tape 180๐ and stick to the conforming layer

6. Apply a layer of cohesive bandage over the conforming bandage.

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Velpeau Sling

1. Apply cotton wool padding to the carpal and metacarpal areas of the affected limb.

2. Apply conforming bandage, appropriate to the animal’s size, above the carpal for several turns.

3. Flex the elbow and shoulder and, at the same time, take the bandage over the shoulder, under the chest, medial to the other front leg and back to the carpal.

4. Flex the carpus and include this in the bandage. Continue up over the shoulder and under the chest as before.

Velpeau Sling (cont.)

5. Continue in this manner until the whole limb is held securely.

6. Apply a layer of cohesive bandage over the conforming bandage.

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Ehmer Sling

1. Apply cotton wool padding to the metatarsal area of the affected limb.

2. Apply conforming bandage, appropriate to the animal’s size, around the padding for several turns. Ensure that the last bandage turn finishes on the lateral side of the metatarsal.

3. From this point, take the bandage up the medial aspect of the stifle, pad the top of the femur, and bring the bandage over to the lateral aspect of the thigh. The limb should be held in flexion.

Ehmer Sling (cont.)

4. Take the bandage down to the medial aspect of the metatarsals, and around to the lateral aspect. Can back at the starting point.

5. Continue in this manner until the whole limb is securely held.

6. Apply a layer of cohesive bandage over the conforming bandage.

Ear Bandage

1. Apply cotton wool padding to the top of the head, above the ear flap. Fold the affected ear(s) up on to the padding.

2. Ensure that any wounds are dressed. Cover the ear(s) with cotton wool padding. Ensure that the padding is the same size as the ear flap.

3. Apply a layer of synthetic padding. Start at the top of the skull, run cranially around the ear that is down (if only), under the jaw, and back up to the start point.

Ear Bandage (cont.)

4. Continue as above, but apply the padding caudally around the healthy ear. Ensure that the bandage is not too tight around the larynx and trachea. Continue until the ear(s) and padding are covered.

5. Apply a cohesive bandage, appropriate to the animal’s size, in the same manner. Continue until the padding layer is covered.

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Chest Bandage

1. Start the bandage between the shoulder blades. Apply a layer of synthetic padding material cranially over the right lateral scapula. Bring the bandage through the front legs, caudal to the left scapula. Bring the bandage up to the start point.

2. From the start point, take the bandage caudal to the right scapula, through the front legs, cranial to the left scapula. Bring the bandage over the left lateral scapular back to the start point.

3. Continue in this manner several times, moving the end point caudally, half the width of the bandage.

Chest Bandage (cont.)

4. Wind the bandage around the chest, working caudally, until the desired size is achieved.

5. Apply a cohesive layer, appropriate to the animal’s size, in the same manner. Continue until the padding layer is covered.

Limb Bandage

1. Apply cotton wool padding between the digits and pads of the affected limb.

2. Apply a secondary layer of synthetic padding. Start on the cranial aspect of the limb, over the toes to the caudal aspect, and return to the start. Turn the bandage by 90๐ and cover the toes in a figure-of-eight. Work from distal to proximal. Overlap the bandage by half its width.

3. Continue up the limb until over the joint above the injury.

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Limb Bandage (cont.)

4. Apply a tertiary layer, again working from distal to proximal.

Tail Bandage

1. Following the dressing, cover any wounds by placing an empty syringe case over the end of the tail. Ensure the end of the case is pierced with a hole for ventilation.

2. Apply a layer of cohesive bandage caudally to cranially over the syringe case.

3. Continue applying the bandage, working the animal’s hair into each wind.

4. Elastoplast may be applied to the top of the tail bandage.

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