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Dr Tejus MN Moderator: Dr Ramesh TS

Skin
y Largest organ of the body y Primary function is protective y Composed of several layers
y Outer Epidermis y Dermis, containing the capillary network y Subcutaneous layer (hypodermis, adipose

layer)

To be regenerated
Cell egeneration vascular Regeneration C regeneration

Wound
A wound can be defined as A cut or break in the continuity of any tissue, caused by injury or operation

Wounds can be classified according to their nature:


Abrasion Incision Laceration Open Penetrating Puncture Septic etc

Types of healing
Healing by primary intention Healing by secondary Intention Delayed primary healing

Healing by primary intention

Two opposed surfaces of a clean, incised

wound are held together.


No significant degree of tissue loss

Healing by secondary intention


If there is significant tissue loss, healing will begin by the production of granulation tissue y Granulation results in a broader scar y Healing process can be slow due to presence infection y Daily dressing with debridment to allow granulation tissue formation

Delayed primary healing


y If there is high infection risk patient is

given antibiotics and closure is delayed for a few days e.g. bites y Delayed primary closure or secondary suture y The wound is initially cleaned, debrided and observed y The wound is purposely left open

Phases of healing
y All wounds heal following a specific

sequence of phases which may overlap y The phases are: y Inflammatory phase y Proliferative phase y Remodelling or maturation phase

Phases of healing

Inflammatory phase
y HEMOSTASIS

In the inflammatory phase clotting takes place in order to obtain hemostasis y INFLAMMATION various factors are released to attract cells that phagocytose debris, bacteria, and damaged tissue and release factors that initiate the proliferative phase of wound healing

Inflammatory phase
y Day 0 5 y The inflammatory phase is characterised by

heat, swelling, redness, pain and loss of function at the wound site y Early (haemostasis) y Late (phagocytosis) y This phase is short lived in the absence of infection or contamination

Proliferative phase
y Angeogenesis y Epithelialization y Extracellular matrix

Angiogenesis
y Collagen first detected at day 3 and rapidly

increases for approx. 3 weeks


y Fibroplasia (fibroblast proliferation and

synthesis) continues in parallel with revascularisation

Angiogenesis
y Endothelial cells from the side of vessels

closest to the wound begin to migrate in response to angiogenic stimulus forming capillary buds y VEGF, TGF

ranulation
y Day 3 14 y Granulation tissue consists of a combination

of cellular elements including: Fibroblasts, inflammatory cells, new capillaries embedded in a loose extracellular collagen matrix

Epithelialization
y The epidermis immediately adjacent to the

wound edge begins to thicken within 24hrs after injury y They migrate to the wound breaking collagen in healing wound

aturation
y Can last up to 2 years y New collagen forms, changing the shape of

the wound and increasing the tensile strength y Scar tissue, however is only ever approx. 5080% as strong as the original tissue y During the remodelling process there is a gradual reduction in cellularity and vascularity of the tissue

Contraction
hen there is unacceptable tissue loss and an unsatisfactory cosmetic result y Wound contraction usually begins from day 5 and is complete at approx. day 12 - 15
y

Factors affecting
y Immune status y Blood glucose levels (impaired white cell

function) y Hydration (slows metabolism) y Nutrition y Oxygen and vascular supply y Corticosteroids (depress immune function)

rowth factors
y EGF y PDGF y FGF y TGF-B y Interlukins y Interferons

Wound assessment
Signs of infection Size, depth & location

Odour or exudate

WOUND ASSESSMENT
Wound bed: necrosis

Wound edge

Surrounding skin: colour, moisture,

granulation

Wound dressing
y y y y y y y y

Non-adherent wound contact materials Films Hydrogels Hydrofibre dressings Hydrocolloids Foams Alginates Miscellaneous

Film dressings
y Semi-permeable primary or secondary

dressings y Clear polyurethane coated with adhesive y Conformable, resistant to shear and tear y Do not absorb exudate y Examples: Tegaderm, Op-site

Hydrocolloids
y Pectin, gelatin, carboxymethylcellulose and y y y y

elastomers Environment for autolysis in sloughy or necrotic wounds Occlusive --> hypoxic environment to encourage angiogenesis Waterproof e.g. Urgotul

Foam dressings
y Advanced polymer technology y Highly absorptive y Semi-permeable y Various types

Adhesive and non-adhesive

Hydrogels
y Sheets or gels y Starch and polyacrylamide (94% water) y Low exudate, shallow wounds y Re-hydrates necrotic tissue y Secondary dressing needed y May cause skin maceration

Alginates
y Seaweed dressings y Form a gel over the wound y Moderate to high exudate wounds y Easily removed y Can cause pain y Help to debride a wound