Wounds and Wound Healing DR.

EYAD ABOU ASALI Basic First Aid What Is First

Aid? The immediate care given to an injured or suddenly ill person. DOES NOT
take the place of proper medical treatment. Legal Considerations Implied
Consent involves an unresponsive victim in a lifethreatening condition. It is
assumed or implied that an unresponsive victim would consent to lifesaving help.
Only perform First Aid assistance for which you have been trained. Scene Survey
When confronted with an accident or illness on duty it is important to assess the
situation to determine what kind of emergency situation you are dealing with, for
your safety, the victims safety and that of others. Do a quick survey of the scene
that includes looking for three elements: Hazards that could be dangerous to you,
the victim, or bystanders. The cause (mechanism) of the injury or illness. The
number of victims. Note: This survey should only take a few seconds. Initial
Assessment Goal of the initial assessment: Visually determine whether there are
life-threatening or other serious problems that require quick care. Breathing
Bleeding Shock Burn Choking Heart Attack Fractures Determine if victim
is conscious - by tap and shout. Check for ABC as indicated: A = Airway Open?
Head-tilt/Chin-lift. B = Breathing? Look, listen, and feel. C = Circulation?
Check for signs of circulation. Note: These step-by-step initial assessment should
not be changed. It takes less than a minute to complete, unless first aid is required
at any point. Open Wounds A break in the skins surface resulting in external
bleeding May allow bacteria to enter the body, causing an infection Types of Open
Wounds : Abrasion Top layer of skin is removed. Little or no bleeding Painful
This kind of wound can become infected quite easily because dirt and germs are
usually embedded in the tissues. INCISIONS Incisions, commonly called CUTS, are
wounds made by sharp cutting instruments such as knives, razors, and broken
glass. Incisions tend to bleed freely because the blood vessels are cut cleanly and
without ragged edges. There is little damage to the surrounding tissues. Of all
classes of wounds, incisions are the least likely to become infected, since the free
flow of blood washes out many of the microorganisms (germs) that cause infection
LACERATIONS These wounds are torn, rather than cut. They have ragged, irregular
edges and masses of torn tissue underneath. These wounds are usually made by
blunt, rather than sharp, objects. A wound made by a dull knife, for instance, is
more likely to be a laceration than an incision. Bomb fragments often cause
laceraction. Many of the wounds caused by accidents with machinery are
lacerations; they are often complicated by crushing of the tissues as well.
Lacerations are frequently contaminated with dirt, grease, or other material that is
ground into the tissue; they are therefore very likely to become infected
PUNCTURES Punctures are caused by objects that penetrate into the tissues while
leaving a small surface opening. Wounds made by nails, needles, wire, and bullets
are usually punctures. As a rule, small puncture wounds do not bleed freely;
however, large puncture wounds may cause severe internal bleeding. The
possibility of infection is great in all puncture wounds, especially if the penetrating
object has tetanus bacteria on it. To prevent anaerobic infection primary closures
are not made in the case of puncture wounds. AVULSIONS An avulsion is the
tearing away of tissue from a body part. Bleeding is usually heavy. In certain
situations, the torn tissue may be surgically reattached. It can be saved for medical
evaluation by wrapping it in a sterile dressing and placing it in a cool container, and
rushing it, along with the victim, to a medical facility. Do not allow the avulsed
portion to freeze and do not immerse it in water or saline. AMPUTATIONS A
traumatic amputation is the nonsurgical removal of the limb from the body. Bleeding

is heavy and requires a tourniquet, which will be discussed later, to stop the flow.
Shock is certain to develop in these cases The limb can often be successfully
reattached. Wound Cleaning Scrub hands with soap and water. Clean wound.
For shallow wound: Wash with soap and water. Flush with clean water under
pressure. Clean wound (contd). For wound with higher infection risk: Clean
wound. Seek medical care for additional cleaning. Use tweezers to remove
remaining embedded debris. Apply direct pressure to control bleeding. Covering a
Wound Apply thin layer of antibiotic ointment. Small wounds only Cover with a
sterile dressing. Do not pull off sticy or blood-soaked dressing. Change any wet
or dirty dressings. Wound Healing Three basic types of healing Primary Delayed
Primary Secondary Primary: Wound surfaces opposed Healing without
complications Minimal new tissue Results optional Delayed Primary: Left open
initially Edges approximated 4-6 days later Secondary: Surfaces not
approximated Defect filled by granulation Covered with epithelium Less
functional More sensitive to thermal and mechanical injury Secondary Wound
Healing Phases of healing Early Intermediate Late Terminal Early wound
healing events Hemostasis: Platelet aggregation Intrinsic and extrinsic
coagulation cascade Thrombin, fibrin Vasoconstriction Inflammation:
Vasodilatation Increase in vascular permeability Chemotaxis Cellular response
Homeostasis: Neutrophils 48-72h- macrophages 5-7 days- few inflammatory
cells. Intermediate wound healing events Mesenchymal cell chemotaxis and
proliferation Angiogenesis Epithelisation 2-4 days after injury Mediated by
cytokines Mesenchymal cell chemotaxis and proliferation Fibroblasts- migration
and proliferation Smooth muscle Angiogenesis - reconstruction of vasculature
Stimulate: High lactate, acidic Ph, low O2 tension Endothelial cell migration and
proliferation Epithelisation Partial thickness- Cells derived from wound edges and
epithelial appendages. Incisional wound: cellular migration over less then 1 mm.
Wound sealed in 24-48h. Cellular detachment Migration Proliferartion
differentiation Late wound healing events: Collagen synthesis 3 helical
polypeptide chains Lysine and proline hydroxylation Required for cross-linking
Collagen synthesis 3-5 days post injury Primarily by fibroblasts Maximum
synthesis rate 2-4 weeks Declines after 4 weeks Type 1 collagen most common (
80-90% of skin collagen) Type 3- seen in early phases of wound healing Wound
contraction Centripetal movement of the wound edges toward the center. ( 0.6-0.7
mm/day) Begins at 4-5 days Maximal contraction 12-15 days Trivial component
in closed incisional wounds, significant for closure of open wounds Rate- depends
on tissue Circular wounds- slower closure but avoid stenosis Mechanism- cell
mediated processes, not requiring collagen synthesis Myofibroblasts- fibroblasts
with myofilaments in cytoplasm Appear in wound day 3-21 Located in peripherypull wound edges together. Contractures- contraction across joint surface Terminal
wound healing events Remodeling- turnover of collagen. Type 3 replaced by type 1
Day 21- net accumulation of wound collagen becomes stable Wound bursting
strength- 15% of normal. Week 3-6- greatest rate of increase 6 weeks- 80-90%
of eventual strength. 6 months maximum strength ( 90% ). Process continues for
12 months Local factors affecting wound healing Infection foreign body/ necrotic
tissue, hematomas local/ systemic factors type of surgery Signs of Infection
Swelling and redness around the wound Sensation of warmth Throbbing pain
Pus discharge Fever Swelling of lymph nodes Red streaks leading from wound
toward heart Care for Infected Wounds Keep area clean. Soak in warm water or
apply warm, wet packs. Elevate limb. Apply antibiotic ointment. Change

dressings daily. Seek medical help if infection persists or becomes worse. Hypoxia
and smoking O 2 delivery necessary for cellular respiration and hydroxylation of
proline and lysine Smoking- vasoconstriction, atherosclerosis, carboxyhemoglobin.
Radiation Collagen synthesized to abnormal degree- fibrosis Fibrosis of vessels(media)-occlusion Thinned epidermis, pigmentation Limited access of
inflammatory cells and cytokinesimpaired healing Damage to fibrocytes and
keratinocytes. Systemic factors Malnutrition Limited AA supply for collagen
synthesis Consumption of proteins d/t CHD and fat deficiency. Vit C deficiencydiminished hydroxylation of lysine and proline, Vit D- impaired bone healing
Zinc- inhibition in cellular proliferation and defficient granulation tissur formation
Cancer Old Age Diabetes Impaired healing ( decreased chemotaxis and phagocyte
function ) Risk of infection Steroids, immunsuppression Inhibits all aspects of
healing process Impaired cellular function, deficiency in inflammatory cell
function, cytokine production, fibroblast proliferation All effects ( except
contraction ) reversed by Vit A. Types of wound closure Primary closure
Approximation of acutely disrupted tissue with sutures, staples or tape Delayed
primary closure Approximation of wound margin delayed for several days
Prevents wound infection in cases of contamination/foreign bodies/tissue trauma
Less bacterial colonization in open wound Normal healing progress occurs
Secondary wound closure Open wound margins approximate by biologic
contraction Seek Medical Care for High -Risk Wounds Wounds with embedded
material Bites Puncture wounds Ragged wounds, or wounds where skin edges
do not come together Visible nerve, joint, muscle, fat, or tendon Wound entering
joint or body cavity Tetanus Caused by toxin-producing bacterium Travels to
nervous system Causes muscle contraction (lockjaw) No known antidote to toxin
Tetanus vaccine and boosters can prevent the disease. Seek vaccine and/or
booster if: Never immunized No tetanus booster in past 10 years Dirty,
contaminated wound and no booster in past 5 years Must receive within 72 hours
Closed Wounds Caused by strike with blunt object Skin is not broken, but tissue
and blood vessels are crushed. Types of closed wounds: Bruises and contusions
Hematomas Crush injuries Care for Closed Wounds Apply an ice pack. Injured
limb: Apply elastic bandage for compression. Splint limb. Check for fractures.
Elevate extremity above heart level. Wounds Requiring Medical Care Still bleeding
after 15 minutes of pressure Long or deep and needs stitches Over a joint
Impairs function of eye, eyelid, or lip Removes all layers of skin Animal or human
bite Involves damage to underlying nerves, tendons, joints, or bones Over a
possible broken bone Crushing injury Object embedded in wound Caused by a
metal object or a puncture wound