IWOUND MANAGEMENT Maximising wound healing FACTOR 3: Foreign Body - REMOVE ALL FOREIGN MATTER PROSPECTIVE: Foreign body in a wound can be obvious or less so. Gross foreign body removal is usually easily accomplished but microscopic contamination of a wound can be highly problematic. Sand, vegetation and small metal or glass objects can be almost impossible to identify unless wound exploration is PERFECT! A gloved finger is usually the most sensitive way of identifying foreign matter. Radiography and ultrasonography can be helpful. Flushing with a physiological solution under pressure (limited to 7- 12 psi / 0.8 bar) is usually enough to remove most foreign mater. Sutures / implants bodies as well as chemicals and ill advised wound “dressings” e.g. mastitis cream can act as foreign bodies. RETROSPECTIVE: When a wound fails to heal very a long period with repeated draining tracts and a static wound bed are cardinal signs of the presence of a foreign body. Foreign bodies may be detected by radiography or ultrasonography but surgical exploration is sometimes the only way to find them!. All foreign bodies MUST BE REMOVED from a chronic wound. Remember that in effect necrotic tissue acts as a foreign body! Suture materials and swabs left in a wound should always be considered when surgical wounds fail to heal – castration ligation is a common example of an iatrogenic foreign body. FACTOR 4: Tissue Deficit - RESTORE TISSUE DEFICITS WHERE POSSIBLE OR WAIT FOR DEFICIT TO BE FILLED BY HEALTHY GRANULATION TISSUE PROSPECTIVE: Where large tissue deficits occur the prospects for rapid wound healing are low! In some circumstances it can be possible to restore some sort of tissue congruity by reconstructive surgery but in others there is no option but to wait for granulation tissue to cover the wound. From that point options for tissue restoration usually involve SKIN GRAFTING of an appropriate type. The loss of vital tissue can be a critical event even if it is a small area only (e.g. the cornea or the upper eyelid). Tissue deficit is invariably complicated by vascular compromise and consequent or incidental necrotic tissue. Tissue deficits can also result in catastrophic loss if function or neurologic disaster RETROSPECTIVE: Large or small tissue deficits usually require significant second intention healing prior to natural healing or reconstructive surgery. Dealing with the sites with historical tissue deficits is dependent on what other factors are present. Vascular, neurological or physical compromises can be significant; reconstructive surgery and/or skin grafting procedures are often required. Attempts to reconstruct these wounds requires a full understanding of other factors that might have been involved at the outset; a VERY GOOD HISTORY of the wound is vital. An unhealthy and/or exuberant granulation tissue bed is usually an indicator of other inhibiting factors. Skin grafting is a useful and practical way of addressing the consequences of tissue deficit. www.kruuse.com
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