June 1st, 2023
Bandaging 101: Fractures and Weird Wounds
The webinar led by Elizabeth Thomovsky DVM MS DACVECC from Purdue University offered an excellent update on the general principles of wound management and clarity on when to use the vast and frankly confusing array of dressings currently available to us for use with specific wounds. Elizabeth cited several cases which demonstrated some of the principles discussed and also ‘put to bed’ some perhaps older fashioned techniques which are now frowned upon. These discussions also had a heavy bias towards the practical and Elizabeth ensured all suggestions made could be easily achieved by the general practitioner including how to simply manufacture a closed active suction drain using just a test tube and butterfly catheter!
Lavage of the wound was one of the first stages of wound management discussed by Elizabeth who advised that lavage should always be performed in every wound whether clean, contaminated or dirty and infected. Her advice on this area was, as ever, wholly practical informing us that lavage could be performed with saline and lactated ringers as might be expected but perhaps rather more surprisingly the use of tap water was also advocated. Elizabeth did however advise there appears to be no benefit in using a lavage solution containing an antiseptic such as chlorhexidine.
Stage two of wound management involves debridement and this is usually achieved using a scalpel and/or scissors. Elizabeth advised there is no longer any place for the use of ‘wet to dry’ or ‘dry to dry’ dressings to remove necrotic material. In her words, by using this technique you will be “ripping off the good tissue as well as the bad”. Elizabeth explained it is far better to either use the scalpel and/or scissors to debride any necrotic or infected material or to rely on the natural wound bed which will harbour enzymes allowing for autolytic debridement. Of course, one of the keys to creating a healthy wound bed is to ensure the wound environment remains moist. This is the sole aim of the third stage of wound management and is crucial as a moist wound environment will aid in limiting infection, allow for more rapid epithelialisation, provide the optimum conditions for autolytic debridement and finally allow for better wound penetration of systemic antibiotics. This is when wound dressings can play an important role and Elizabeth offered a table demonstrating the variety of available dressings which fall into three categories, ‘hyperosmotic’ agents, ‘semi-occlusive’ agents and ‘others’. Silver impregnated dressings fall into the ‘other’ category and Elizabeth advocates their use in dirty contaminated wounds as they are bactericidal. However most presenting wounds generally fall into the clean/contaminated class and for these Elizabeth will usually reach for hypertonic dressings which include honey and hypertonic saline. These help by desiccating tissue which aids in killing bacteria, removing dead tissues and promoting epithelialisation. Once a wound becomes ‘clean’ Elizabeth then advises using semi-occlusive dressings which promote wound moisture by using either a hydrogel or hydrocolloid gel and offer all the benefits of a moist wound bed discussed earlier.
After discussing the basic principles of wound management, Elizabeth cited a number of cases some of which had wounds in very awkward places not always conducive to the successful placement of a bandage. For these type of wounds Elizabeth advises using a technique known as the ‘tie over’ bandage where stay sutures are placed around the wound and a gauze is tied in place using these stay sutures. This is made a lot clearer within the webinar where Elizabeth demonstrates this technique using several photographs. This is also the case for the placement of Penrose drains as well the creation of the closed suction drain discussed earlier. Elizabeth also reminded us to never place drains directly under an incision and not to leave drains uncovered.
This was an excellent webinar which offered an enormous amount of information over a short amount of time in a practical and engaging manner. Elizabeth even managed to inform us about the difference in healing properties between cats and dogs, all of which I had no idea about. Apparently, cats tend to heal slower than dogs as they form less granulation tissue meaning sutures in cats should be removed after 10-14 days compared to 7-10 days in dogs. Given that wounds are so common place in day to day veterinary practice and techniques for wound management are continually developing, this is a webinar not to be missed by vets and nurses alike!