Ministry of Health

NZ Government

    
 ©Copyright
 Published: 29/05/2006

Management of Complex Abdominal Trauma Wounds
Grant Christey

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Outline

Management of Complex Abdominal Trauma Wounds.
Trauma Service Experience
November 4 2004
Grant Christey

What’s the problem?
 3 or 4 complex abdomino-pelvic wounds are managed each year by Trauma Services
 Typical LOS 3-6 months; 10-40 operations each
 Success in treatment requires massive and sustained allocation of resources and time.
 The consequences of failure can be major disability or death.
 Rehabilitation and reconstruction can go on for years.
 Wound care dogma can hinder progress

Many Wounds
 Large / Small
 Superficial / Deep
 Complex / Simple
 Clean / Infected / Necrotic
 Tissue loss / no tissue loss
 Dry / Oozing / Draining
 Traumatic / Iatrogenic
 Bone or tendon exposed / Not exposed
 Perineal/ Not perineal

Many Patients
 Well / Unwell
 Co-morbid / Healthy
 Young / Not young
 Thin / Not thin
 Septic / Not septic
 Conscious / Unconcious
 Diabetic / Not diabetic
 Dying / Not dying

Many Products
 Negative pressure / Atmospheric
 Closed system / Open system
 Synthetic / Biologic
 Temporary / Permanent
 Absorbable / Non-absorbable
 Expensive / Cheap
 Simple / Complex
 Efficacious / Not efficacious

Many Systems = Many Doctors
 Trauma surgeon
 General surgeon
 Orthopaedic surgeon
 Intensivist
 Colorectal surgeon
 Urologic surgeon
 Hepatobiliary surgeon
 Plastic surgeon
 Psychiatrist

And Many Nurses..
 Trauma care co-ordinator
 Wound care specialist
 Charge nurse
 Ward nurse
 Stoma therapist
 Diabetes nurse specialist
 District nurse

And Many Allieds.
 Physiotherapist
 Occupational therapist
 Dietician
 Wound care product advisors

Wound healing is an orderly and complex process
• Inflammation (Reaction)
• Proliferation (Regeneration)
• Maturation (Remodeling)
Any wound will heal if it gets a chance

Inflammation
 Essential for wound healing
 Occurs from the time of injury
 Two Major processes:
– Haemostasis: vasoconstriction, clot formation, epithelial migration
– Phagocytosis: neutrophils and macrophages engulf debris and microorganisms, produce cytokines, enhance angiogenesis

Proliferation
 From day 2-3 to day 21 post-injury
 Characterised by granulation tissue
 Several processes
• Fibroblasts synthesize collagen
• Capillaries grow into wound
• Epithelial cells migrate to cover wound

Maturation
 Begins about day 21 and lasts 1-2 years
 Several Processes
 Collagen becomes organised.
 Wound contracts.
 Scar becomes stronger.

Management Phases
• Damage Control
• Wound Preparation
A) Debridement
B) Infection Control
C) Physiologic Support
• Definitive Wound Closure
• Late Restoration of GI and GU continuity

1. Damage Control
 Haemostasis
 Control contamination, effluents and abdominal viscera
 Physiologic restoration
 Early re-look procedures and definitive repairs: bony stabilisation, primary wound closure if possible.

2a. Debridement
 Aim to establish healthy granulation in a clean wound
 Debride all necrotic tissue (may require cyclical returns to theatre)
 Keep wound clean and moist
 Use customised dressing system or negative pressure
 Graduated wound closure may be possible
 Don’t fiddle
Dressings are no substitute for thorough surgical debridement

2b. Infection Control
 Be vigilant for signs of infection.
 Consider all sites: chest, urine, lines, wounds..
 Swab fluids liberally then wait for identification and sensitivities if possible
 Use antibiotics judiciously
 Use closed wound drainage systems if possible
 Cross-infection is a crime

2c. Physiologic Support
 Nutritional: oral, NG, NJ, TPN, etc
 Metabolic
 Fluids and Electrolytes
 Cardiorespiratory support
 Renal protection
 Chest physio
 Pressure cares
 DVT prophylaxis

Definitive Wound Repair Options
 Aim is functional and anatomic restoration
 Technique depends on type, quality and quantity of remaining tissue
 Requires a healing wound, free from infection
 Options:
 Superficial: delayed primary repair, grafts, flaps.
 Deep: fascial closure, mesh, grafts, flaps, planned hernia
 Close stomas and laparostomies at 3-12/12
 Urologic repairs early, or after 3/12

Summary
 Understand
 The physiology of wound healing
 The patient
 The wound
 The products
 Customise the care of every wound
 Look ahead to determine what to do today
 Be vigilant and careful and patient