55-56 Wound Management & Burns

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What is the common denominator for all kinds of surgery?
Wounds

This is defined as a break in tissue integrity
Image: What is the common denominator for all kinds of surgery?
This type of wound is caused by clean skin tears due to sharp objects. Examples include: Paper cut

o Laceration
o Incision
o Puncture
o Penetration
Incision

* Laceration - jagged, hindi clean ang cut. They just strip away the epidermis (rocks were used as an example).
Image: This type of wound is caused by clean skin tears due to sharp objects. Examples include: Paper cut o Laceration o Incision o Puncture o Penetration
POV: You and your BF are arguing because he is a BBM supporter. You then hold a kitchen knife with intent to slice his mouth. What type of wound would most likely happen?

o Laceration
o Incision
o Puncture
o Penetration
Incision

"A knife that is meant to stab is a penetration wound, a knife that is meant to slice is an incision."
This refers to the traumatic tearing away of the skin and/or deeper tissue from their underlying layers

o Abrasion
o Avulsion
o Contusion
o Hematoma
Avulsion

* Abrasion - top layer lang, parang "scrape".
Image: This refers to the traumatic tearing away of the skin and/or deeper tissue from their underlying layers o Abrasion o Avulsion o Contusion o Hematoma
This refers to the extravasation and pooling of blood in tissues deeper than the dermis due to rupture of blood vessels from an external force

o Abrasion
o Avulsion
o Contusion
o Hematoma
Hematoma

This is similar to a bruise (contusion) but is much deeper.
Image: This refers to the extravasation and pooling of blood in tissues deeper than the dermis due to rupture of blood vessels from an external force o Abrasion o Avulsion o Contusion o Hematoma
Ulcers are wounds due to the formation of a cavity of dead tissue due to chronic weight on that area. How will you prevent this from happening in a bedridden patient?
Regularly change the patient's position
Image: Ulcers are wounds due to the formation of a cavity of dead tissue due to chronic weight on that area. How will you prevent this from happening in a bedridden patient?
Name the 3 phases of wound healing in correct order
Inflammatory > Proliferative > Remodeling
What is the initiating factor for the coagulation cascade?

o Injury breaks through skin and microvasculature
o Pathogens are detected by APCs in circulating blood
o Injury in wound releases inflammatory mediators that activate platelets
o Collagen exposed due to basement membrane defect
Collagen exposed due to basement membrane defect

The platelets will adhere to the exposed collagen via the vWF. Review lang! Hehe
The process associated with the collagen-mediated activation of platelets is mainly:

o Intrinsic
o Extrinsic
o Either
o Neither
Intrinsic

"Because these factors come from exposed collagen."

* Extrinsic activation occurs from the release of Tissue Factor (VII) that flowed into the wound
This is the structure formed during the inflammatory phase of wound healing that is vital for the continuation to the second phase.Fibrin Mesh Fibrin matrix serves as scaffolding for cell recruitment and attachment during next phases of wound healing.Neutrophils arrive at the primary wound site at how many hours post injury? o 0-24 o 4-24 o 0-48 o 4-480-48 * Macrophages follow shortly after at 48-72 hours post-injuryNeutrophils are effective in killing pathogens due to the secretion of this compound.Reactive Oxygen Species (ROS) However, this also kills ALL LIVING CELLS within the vicinity which is why neutrophils should not stay longer in the wound site.The Proliferative Phase occurs at how many days postinjury? o 3 to 24 o 4 to 21 o 3 to 21 o 4 to 244 to 21 days Here's what happens: o Fibrin matrix gradually replaced by granulation tissue o Epithelialization at wound surface "The redder the granulation tissue, the healthier it is"Which cells are necessary for the success of the proliferative phase?Macrophages These are responsible for secreting vascular endothelial growth factor, fibroblast growth factor 2, angiopoietin 1, and thrombospondin, which are all vital for angiogenesis and fibroblast proliferation.The ff. are the components of granulation tissue EXCEPT: o Fibroblasts o Endothelial cells o Blood vessels o Macrophages o EscharEschar This is dried and dead tissue on the wound surface which serves as a protective cap for the healing wound.Which cells in the proliferative phase are vital for the success of epithelialization?Keratinocytes Once fully epithelialized and a scar is in place, proliferation will stop along with the fibroblasts and BVs.A keloid is an example of failure of what mechanism?Failure to shut off proliferation of fibroblastsThe remodeling phase is the final and longest part of wound healing. This occurs during which days postinjury? o 21 days to 6 months o 21 days to 12 months o 21 days to 18 months o 21 days to 24 months21 days to 12 months The major events here are: Collagen Remodeling (Type 3 to Type 1) and Wound Contraction * Wound strength increases from 20% at 3 weeks to 80% at 1 yearWhat is the purpose of wound contraction?To minimize scar area The problem with this part of wound healing when it happens over joints, for example on your fingers, where you have joints, and a scar forms over it, because of wound contracture, the wound begins to contract over time causing what we call a contracture. * A contracture is a fixed tightening of muscle, tendons, ligaments, or skin. It prevents normal movement of the associated body partWhat are the two major factors implicated in wound healing?Oxygen (good) and Infection (bad)Is circumcision considered minor surgery?Yes but debatable Characteristics of minor surgery: o Little risk of life o Can be done quickly o Involves only skin, connective tissues, or mucous membranes o Does not enter major body cavity o Does not require general anestheticWhat type of suture technique should you use for thick skinned areas? o Vertical mattress o Horizontal mattress o Continuous o Skin staplesHorizontal mattress "This is doc's favorite for partly-closed wounds" Suture is passed from one side of the wound, exits the other side, reenters wound on the same side and passes out on the initial side.What type of suture technique should you use for wounds that need to be closed ASAP in the mucosa, mouth, bladder, or uterus? o Vertical mattress o Horizontal mattress o Continuous o Skin staplesContinuous "It's actually fast. If something is bleeding and you have to stop it, this is a good thing to use"For proper wound healing, the wound should be kept optimally o Dry o Wet o Either o NeitherNeither "Not wet OR dry. There's a misnomer that dry things heal faster. Dry wound becomes mummified. Our skin is moist that is why there is a multibillion-dollar industry in skin moisturizers"In preparing for a reconstructive rhinoplasty, which of the following sutures would be preferred? a). Skin Staples b). Subcuticular c). Vertical mattress d). Simple InterruptedSubcuticular This is best for aesthetic procedures because almost no sutures are seen at the skin surfaceYou are shadowing Dr. Tumaneng and was guided to perform a modified Vacuum Assisted Closure. Which principles would rethink? a). Aseptic techniques must be respected at all phases of the procedure b). The VAC should be free of air leaks c). Apply continuous suction pressure of 60-120mmHg d). Perforations on the feeding tube must cover the length of the spongeApply continuous suction pressure of 60-120mmHg Should be cycles of pressureWhich of the following is untrue about critical mass of bacteria? a). Wound healing would hasten b). When bacterial exceeds the critical mass, there will be systemic ramifications c). Fever, Pain & Sepsis are examples of systemic manifestations d). The value of Critical mass is: 105/gm of tissueWound healing would hastenGive the key events that happen in the ff. phases of wound healing: 1. Inflammatory 2. Proliferative 3. RemodelingInflammatory - Coagulation Cascade > Fibrin Mesh Formation > Recruitment of Phagocytes Proliferative - Replacement of Fibrin Mesh by Granulation Tissue > Epithelialization Remodeling - Collagen Remodeling > Wound ContractionThis is said to be the worst tragedy an individual can experienceAng pagiging pilipino Pero sabi ni doc burns idk whyThis is the most important zone in handling burn patients o Zone of coagulation o Zone of stasis o Zone of hyperemiaZone of stasis This is zone that further from the heat source and if proper resuscitation is done, the tissue may survive. Kaya we have to prevent this from becoming necrosed. * Zone of coagulation - damage here is irreversible as this is the most severely burned part of the tissue. * Zone of hyperemia - there is vasodilation here and tissue will recover unless patient suffers from prolonged hypotension and/or sepsis.Burns initiate this kind of inflammatory response which lead to the release of intracellular substancesLocal Inflammatory Response What happens: Vasodilation, Increased capillary permeability, Recruitment of more inflammatory cellsWhat is the cutoff percentage for Burns that initiate the onset of irreversible damage or problems? o 18% o 20% o 26% o 30%20% TBSA "Entire body begins to react to your burn injury and the entire body becomes an inflammatory response."A systemic response due to massive burns cause the ff. responses EXCEPT: o Wound hypoperfusion with concomitant decreased CO o Decreased peripheral vascular resistance o Intravascular depletion of fluids o Decompensated catabolic stateDecreased peripheral vascular resistance Should be increased. What's being described here is the cascade of events that lead to Burn shock. " Perfusion drops. They die because of shock in the first day, actually, first hour. They can actually converse at the start, but they quickly deteriorate if not treated properly they shock out. Because the fluid that's supposed to be in their lungs, kidneys, blood vessels goes in edema fluid and that's what kills them."When a patient comes in with a burn injury, what is the most important part of the history that you should elucidate?HOW THE PATIENT GOT BURNED Kasi malay mo nakipagdebate lang pala si jam magno kay madumb leni ng pure english for a 1v1 debate 1. Burns sustained in an enclosed space raises the possibility of an Inhalation Injury, so masusunog ang lungs mo (different management) 2. Electrical injury may be due to High voltage injuryWhile watching Antman, BBM's boiling lugaw fell on his lap while jabuling which mixed with his seminal fluids that exploded into Sandro's face. What type of burn is this? o Scald o Flame o Flash o ContactScald "Liquids from soups are worse because they are much more viscous and tend to stay longer on our skin causing a deeper burn."When suspecting signs of abuse in scald injuries, which distributions should you look for? o Head and neck o Trunk and extremities o Glove and stocking o Boots and capGlove and stockingThis type of burn is due to an intense heat for a very brief period of time. Patients often present with no eyebrows. o Scald o Flame o Flash o ContactFlash Seen in bakery workers who open the ovens too early and in explosions. * Flame - most popular burn. Due to house fires and flammable liquids. * Contact - from direct contact with hot metals, plastic, glass, or hot coals.Chemical burns may either be acidic or alkaline. Which among the two combines with skin fat? o Acid o AlkaliAlkali This will lead to a saponification process, dissolving the tissue until neutralized, so para kang nag"melt". * Acid - "tans" the skin, creates leathery barrier which limits further penetration of acid, so less severe.What is the cutoff value in volts for low and high voltage? o 750 o 1000 o 1500 o 20001000 Low: <1000 High: >1000 "Most lightning injury patients do not make into the ER. Actually, they have to be picked up in separate body bags because they tend to explode."This is extremely important in estimating burn size and fluid requirement o Type of burn o Burn location o Burn depth o Degree of burnBurn depthNot counted in estimating burn size and will heal in 7 to 10 days without scarring. o Superficial o Superficial Partial o Deep Partial o Full thicknessSuperficialSkin is very moist, pink, painful, blanches, and with blisters o Superficial o Superficial Partial o Deep Partial o Full thicknessSuperficial Partial (2nd degree)Skin is white to pale pink with a waxy texture and is slightly anesthetic. o Superficial o Superficial Partial o Deep Partial o Full thicknessDeep Partial (3rd degree) May also have hypertrophic scarring and burn contractures. * Full thickness - extends through full depth of skin, leathery feel, anesthetic, visible thrombosed vessels.The Rule of Nines is the most popular method to estimated TBSA but has the problem of: o Overestimates TBSA o Inaccurate for children o Either o NeitherEither * Lund and Browder is a method that is more accurate in estimation.According to the Lund and Browder method, the patient's palm represents approximately how many percent of the TBSA? o 1 o 3 o 5 o 91% "The nice thing about this method is that it accounts for ages. There is going to be some differences in the %TBSA depending on the age."What should you suspect when your patient presents with soothy phlegm, singed nostril hairs, facial burns, hoarseness, and stridor?Inhalation InjuryFor partial thickness burn in adults, what classifies as moderate burn injury? o <15% BSA o 15-25% BSA o >25% BSA15-25% BSA 20% BSA or more require hospitalizationT/F For minor burn wounds, small blisters may be aspirated and left for 2-3 days while bigger blisters have to be unroofed.TThe ff. are indications for intubation in a burned patient EXCEPT: o With burns 50% BSA o With smoke inhalation o With circumferential chest burn o Unconscious at sceneNOTAWhat is the most common cause of mortality in the first 48 hours post-burn injury? o Sepsis o Systemic Inflammatory Response o Multiorgan failure o Inadequate fluid resuscitationInadequate fluid resuscitationWhat is the simplest and most effective method for calculating the amount in fluid resuscitation?Parkland formula * For children: D5 Lactated Ringer's (D5LR) 3mL x kg BW x TBSA PLUS Maintenance (Holiday-Segar)Urine output adequacy for adults after resuscitation: o 0.5mL/kg o 1.0mL/kg o Either o Neither0.5mL/kg * 1.0mL/kg for childrenT/F In performing fluid resuscitation, colloids are an acceptable alternative within the first 24 hours.F Do not give colloid. Giving colloid in the first 24 hours will exacerbate edema and fluid requirements for day 2 resuscitation. Give them at day 2.Compartment syndrome is common in electrical injuries or circumferential burns. Why is this so?A compartment syndrome happens when an extremity swells so much because of the injury that there is too much fluid in that area that it begins to compress the neurovasculature of the areaWhat is the treatment for Compartment syndrome in burns?Escharotomy An escharotomy is an emergency surgical procedure involving incising through areas of burnt skin to release the eschar and its constrictive effects, restore distal circulation, and allow adequate ventilation. Unlike fasciotomies, where incisions are made specifically to decompress tissue compartments, escharotomy incisions do not breach the deep fascial layer.This is the most common wound dressing used for burns and is effective against Pseudomonas, enterics, S. aureus, and Klebsiella. o Silver Sulfadiazine o Silver Sulfadiazine + Cerium Nitrate o Daikin's Solution o Silver NitrateSilver Sulfadiazine SSD leaves a yellow-green psudo-eschar which must be removed suring dressing.Used in preparing granulation tissue for grafting o Silver Sulfadiazine o Silver Sulfadiazine + Cerium Nitrate o Daikin's Solution o Silver NitrateDaikin's Solution Dilute sodium hydrochlorite 0.025% solution, prepared by mixing 15 mL sodium hypochlorite solution and 985 mL NSS. "Daikin's is nothing more than Zonrox and NSS LOLS"Was the previous dressing of choice as it does not injure the regenerating epithelium in the wound. o Silver Sulfadiazine o Silver Sulfadiazine + Cerium Nitrate o Daikin's Solution o Silver NitrateSilver Nitrate This, however, leaches electrolytes, especially NA and Cl. * Cerium induces calcification of dermal collagen which produces a leathery crust that acts as a barrier against bacterial contamination.This is a chinese product that dr. Tumaneng loves to use for wound dressingszzzzMEBO (Moist Exposed Burn Ointment) Active ingredient is Beta-Stetostirol