Hello, thanks to everyone joining us for our members webinar this evening. Tonight we have Chloe Fay, who will be presenting on emergency wound management. Chloe qualified as a veterinary nurse in 2012, gained her vet's now ECC certificate in 2016, and her VTS in 2018.
She has a strong background in ACC and referral nursing. She is currently the clinical lead at New Priority Vets in Brighton, who also provide cardiorespiratory and internal medicine referral services. Chloe is also on the review board for the RCVS In Focus veterinary Journal and is involved in peer reviewing material for the Australian College of Veterinary Nursing ECC certificate.
She most recently gained her recover PLSA. CLS instructor status. Chloe is highly experienced and passionate about all aspects of emergency and critical care nursing, but her specific interest include critical care patients, including renal septic patients and cardio respiratory patients.
Thank you, Chloe, for being here and joining us. Welcome. Thank you very much and thank you for everyone joining us.
So today we're gonna talk about emergency wound management. So we're not gonna go into too much detail about the types of different dressings that we're gonna use. We're gonna talk about how we are gonna address those wounds.
When they come into our clinic, when we first see them as that emergency, and often these patients with wound, with extensive wounds will have other comorbidities going on. So often they've had, you know, been a dog attack, maybe they've been hit by a car, maybe, they're a burn patient and therefore they have things like smoke inhalation. So when we're talking about, our initial presentation, we, we're looking at these patients holistically, so we want to look at these patients.
As a whole, you know, whole body systems, rather than just immediately go into those wounds. It's very easy to, become very focused on those because they're visual, and it's not necessary to say that we shouldn't concentrate on them, but any life-threatening conditions will take priority of those wounds. So we want to do a nice triage, nose to tail, obviously if you're picking up anything on the way that needs immediate resuscitation, then we will correct that before we start going on through the rest of our triage.
So we're gonna do our triage, we're gonna make sure that our patients are hemodynamically stable. And this is really important for our wounds as well, because those wounds need good blood supply. And if our patients have like hypovolemic shock, then that, that wound isn't getting the right blood supply.
Therefore, when we talk about the stages of our wound healing, That blood supply isn't bringing those white blood cells to create phagocytosis. It's not, bringing the red blood cells to bring new cell, you know, to generate those new cells. It's, you know, it's not, creating a, a good environment for those wounds.
So we want to kind of correct everything hemodynamically first before we start thinking about how we're gonna treat our wounds. So we're gonna make sure that all those body organs have been assessed. We're gonna stabilise them, maybe we're gonna oxygenate those patients again.
If a patient isn't well oxygenated, that wound is going to become hypoxic, bad environment for that wound to regenerate cells and heal. So we want to create the most optimum cell environment. And the way to do that is that we go back to basics and that respiratory system, the cardiovascular system, making sure that our body, organs are all functioning normally.
So once we've done our triage, we're then gonna do our secondary assessment. And this maybe at this point is when we are gonna take, those wounds into the priority category. Prior to that in our triage, if we have haemorrhage, we are gonna start to control that haemorrhage.
Obviously that is important and there's part and is part of that stabilisation of circulation because the more blood we lose, the more at risk we are of hypovolemic shock and eventually dehydration as well. So initial management of wounds. So if we have haemorrhage, then we want to put direct pressure on maybe a bandage.
We're potentially gonna use tourniquets, on peripheral limbs, just remembering that these have a very short time, about 10 minutes, and any more than that, we're gonna start to cause damage, and the. To those cells peripherally to that tourniquet. Pressure to arterial supply.
So again, if we're thinking about peripheral limbs that have got arterial supply that are affected that are haemorrhaging, then we potentially can use tourniquets or these pressure cuffs. But if we have haemorrhage, let's, for example, I had a dog, a Labrador that had clumsily walked into a depth chair in the back garden, and actually, the deck chair had gone through, it's axilla. So you can't really put a tourniquet on there, so I had to put direct arterial supply on with, sterile swabs.
Sour gauze and hold that basically until we were ready to go to surgery, which was rapidly as it was arterial supply. So these are things to consider, pressure cuffs. So these pressure cuffs, the same as your when you use yourigometer.
When you're taking a blood pressure, you just put it on, inflate it to about 10 to 20 millimetres of mercury, more than, so your blood flow stops, you then inflate it 10 to 20 millimetres of mercury more than that blood supply stopping, and you can hold that on for much longer than a tourniquet, and it's much less abrasive than a tourniquet. So as we've controlled our haemorrhage, we've got that under control, we're supporting our cardiovascular system, our circulatory system by controlling that haemorrhage. Yes, we do now need to correct that haemorrhage, but it just means that we can carry on with that initial stabilisation if necessary.
As I said, these often have poly trauma, comorbidities. We kind of need to make sure these patients are well enough to be sedated or that they're I'm not gonna be in pain or stress when we start to manage these wounds properly. So covering the wounds with sterile dressings as soon as possible, so this is to prevent desiccation, so.
Once those wounds, are created, the, the more that they're open to the air and they're dried out, they are, open to desiccation. So that just means that the cells just start to like die and things like, are further contaminated. It just gets worse, basically.
The wound, when it's healing in that healing stage, really thrives on a moist environment. And by covering those sterile dressings, we're creating a barrier to the outside, so there's no contamination, no further bacteria. And, and now we're creating a, a bit more of a moist environment for that wound to thrive under, rather than leaving it out to dry and those cells starting to die and become, necrosed.
This can be with You can use your intrasite gel, you can use potentially, we can talk about wet to dry dressings in that initial phase where we're just waiting. We could potentially use this, but this comes with its own sort of risks. I would personally use something like intrasite gel or KY, and then place some dressing over the top of it.
You are gonna come back to that dressing as soon as possible. You're not just gonna leave that, you know, till the next time it needs a dressing change. Because we have to do things like our lavage, our clip and clean, making sure that we're, we're having a real good look at that wound, whether it's pockets anywhere, and, you know, whether there's any translocation.
And so therefore, this is literally just almost like a stick of plaster on it, we'll think about it in a, in half an hour once we've got this cardiovascular system under control once we, you know, once this patient is oxygenated. That is just there, as a, as a plug. To stop any further desiccation of further contamination.
The ultimate goal of wound healing is to restore the epithelial surface, and that's through a series of steps that this does this, and this process involves formation of a fibrin platelet clot, and then what happens after that is you get this recruitment of white blood cells. Things like neutrophils, monocytes, macrophages, and all of these start to phagocytos and create basically this clean slate for neovascularization, so these new blood vessels to be laid down, cellular proliferation and new cells to be put down, and therefore finally tissue remodelling. So these steps make up 3 phases.
So number one is that inflammation, as you can see on this diagram, the green hump, and it's also, also known as debridement stage as well. Number 2 is a repair or as you can see on this one, it's called cell proliferation and matrix and deposition. So, .
This is when we start to see those cells starting to lay down and that growth tissue growth factor is a big player in this. And then finally we have stage 3, which is maturation or again, and this diagram is matrix remodelling. They're interchangeable.
So these phases, as you can see on this as well, will often overlap, with the inflammatory and debridement phase that typically lasts about 3 to 5 days after that wound has occurred. So in this stage, what we see is that initial, Wound occurs, we get this vaso constriction for the 1st 10 minutes after that wound has occurred to control haemorrhage. So think about any time that you cut yourself, you know, you do get a little bit of blood, bleeds, bleed, bleeds, and eventually that wound will, you know, it stops bleeding.
Maybe we put pressure on it to help it along, but it will stop bleeding eventually. And that's because on that that cellular surface there's basic constriction to stop any haemorrhage. And at that point, thrombin comes to form and platelets will aggregate and these cause blood to coagulate, forming clots, and providing hemostasis.
So the body's really clever, it knows, let's plug this all up, and once, once it knows that that's plugged, there's no more haemorrhage. What happens now is vasodilation, and that is to allow the entry of fluid and cells and causes that characteristic heat, and redness and swelling that we often associate with that initial wound. I I actually cut my finger today, so I'm just kind of waggling it around because it's, it's nice and red and sore.
And that's because there's all this fluid and these white blood cells that have come now to that cellular level. And creating that inflammation, and that creates that new wound. So with these new white blood cells, this initiates that debridement of the wound.
And as a result, bacteria is eliminated. So with that, we get leukocytes, they phagocytos, debris, and they recruit secondary mediators, they send out little signals. They say, come on friends, come down to my party, like, let's, let's break down all those bacteria, and see the neutrophils come, they break down the bacteria.
Stimulate again, they bring their friends monocytes. These monocytes bring, bring more phagocytosis of that debris, and they also now start to release growth factors. And these growth factors are now inviting their friends to the party, and these are responsible for tissue repair.
This second phase, the proliferation stage, or repair phase is about 3 to 12 days. So again crosses over with that inflammation stage. And this is responsible for replacing lost tissue and closing that wound up.
So with this, we get the production of granulation tissue, contraction of wound and epithelialization. And as well as that we get this angiogenesis. So angiogenesis is a formation of these new blood vessels, because we think that I'm, whether it's a laceration or avulsion, the, the, there's been a disruption to those vessels.
And that we know that they've been plugged, but now we need some more vessels to kind of to bridge the gap between those wound edges so that then that those vessels can help with cell proliferation. And create this new extracellular matrix synthesis, and this ree epithelialization. And this results from growth factors again.
They create collagen, and they provide wound strength. And those myofibroblasts, again, that are as a result of these tissue growth factors and causes wound contraction. So all of this, they make this little bridge, and then they start to bring it together.
So once this, once we start to see these lines, of collagen, fibres, they orient along the the lines of stress. So what I mean by the stress lines is, If you think about, so I'm just gonna use my fingers to tell you an example because I'm looking at it. So it's a straight slide.
So the, the lines of stress are gonna be across, where the wounds are, rather than down. So they go across the, the, the lines of stress, and once the collagens across that, they start to obviously contract and bring those wound edges together, and that can take months and years to complete, starting from around 7 to 10 days following that initial injury. So again, crossover between that second stage.
Cells will undergo apoptosis in this time, so the cells that are there that have been part of that injury will start to have a programmed cell death, to make way for new cells that are now coming together when that contracts. And so the that collagen matures into a scar. We know that we get scars when we, when we have a wound.
And that's part of our matrix remodelling is that now those new cells form that scar. The tensile strength of a scar will only ever match about 70 to 80% of healthy tissue. So our job, when we are treating these emergency wound management, is to try and obtain that 70 to 80%, and we'll talk about the ways of how we do that, and that's through our lavage of making sure that we are appropriately clip and clean, making sure that we have classified that wound properly, that we are then treating that wound.
Appropriately and dressing it or closing it at the appropriate time, otherwise we're then gonna start to cause further problems and therefore create a lesser tensile strength. The nice way I like to remember this, is a little fire, analogy. You may have heard it.
So the, the analogy is that you have a house that's burning, the, this is your wound occurring, so this is like your laceration. The house burns. You get some firefighters coming along, they're gonna stop the fire.
So this is your, like, platelet aggregation, your thrombin, clots forming, controlling the haemorrhage, the house is burning. The house has now stopped, but now there's tonnes of rubble that needs clearing up. So, you know, the firefighters are clearing up the rubble, people from the town start to come and clear up this rubble.
And, and, and those, and the message gets out to an architect. So that rubble stage is your, inflammation stage, you know, the, the phagocytos and they're getting rid of all the debris. Your, your architects are now in, they're now going to lay out the new foundations, well, the builders are going to lay out the new foundations, but, you know, the builders and the architects to lay out those nice new foundations and to rebuild this house.
This is your cell proliferation and matrix deposit stage, so that the angiogenesis, reepitherization. Extracellular matrix synthesis, those collagens, we rebuild the house, great. We're in the matrix remodelling stage now.
That house is never gonna look or be exactly the same as it was before. It's now a different house, so that's just a nice way of remembering it. So nice just a little recap, and so the body usually accomplishes that that wound closure for about 2 to 4 weeks, by that repair phase of wound healing.
So during this, that, that second stage, this is the, the vital stage because it's the one that's obviously forming all this epithelialization, regulation tissue, all that kind of jazz, . This is the stage that's most most important, and that's, and that happens through two simultaneous but independent means and that's epithelialization and contraction. So this is accomplished by the creation of granulation tissue, and this granulation tissue happens when you get this wound bed debridement and that white those white blood cells progress, the ericytos, the cells on the periphery of the wound receive signals to start moving in.
And I'm filling the cleaned out I'm deficit with granulation tissue. I'm that granulation tissue is built by fibroblasts. They secrete new extracellular matrix molecules, so things like collagen, elastin.
And endothelial cells, and they build new blood vessels. So you can see this from our kind of 2nd and 3rd 1, so information proliferation, and you can start to see now we start to build this little bridge. You see my mouse, hopefully you can.
So yeah, on this 3rd diagram in the right hand corner, you start to see these little boxes coming across to join those up. So also we now get this epidermis, and this is, you know, helping this epithelialization and this contraction. And, this epidermis is these epithelial cells on the skin edge, now start to migrate on top of that granulation tissue.
Granulation tissue has now created a kind of net, but now the epidermis is sort of growing in towards the the centre. And that now the epidermis is created that's providing oxygen, moisture, and the surface that's required for epithelial cells to proliferate, and that again crosses the wound into the middle to create this new epidermis. And then myofibroblasts finally, so wound contraction occurs when the, when the fibroblasts, of the formed granulation tissue meet in the centre, and then we get these characteristics that are similar to smooth muscle.
So now these are called myofibroblasts because muscle fibroblasts. And these cells, link, are linked to each other by intracellular. Connections up to the wound edge, and they create their attachments to the granulation tissue and they contract and, exert a force, a centripetal force on the skin edges, drawing that, towards the centre of the wound.
So that's the myofibroblasts are the ones that contract and bring into the, Into the centre. So let's talk about classification of wounds. This is what we're gonna start to now think about when we get these wounds.
I have got some pretty gory pictures, just FYI I know we're all in the veterinary, so we're probably all used to it, but like there is a cat but in there somewhere as well. So class one, Is clean. So a clean wound is minimal contamination, not 6 hours duration.
And these are classically our surgical wounds, and these are made under aseptic conditions. So we're not really gonna be thinking about these when we're thinking about our emergency wound management, unless, you know, unless somebody's been slashing, aseptically slashing cats, which we know doesn't happen, unfortunately. And a clean contaminated wound may be created when a non-sterile organ.
I entered this minimal spillage, and a minor breach in aseptic techniques. So again, not something we're gonna be talking about when we think about emergency wound management, but nonetheless important to consider when we are nursing our critical care patients that have had surgery, we know that they've had, say the stomach's been entered or the bladder's been entered. And there's maybe been minimal minimal spillage, and a minor or a minor breach in aseptic technique.
These are ones that we need to watch out for. But yeah, when we're talking about traumatic wounds, these aren't the wounds that we're talking about. So class 2 is significant contamination.
Or 6 to 12 hour duration. So for the most part, this is mostly what we're gonna see, when we think about dog bite wounds, maybe lacerations from like barbed wire. If we see that patient pretty quickly.
Gross contamination for class 3 is gonna be, so gross contamination means anything that's infected with more than 10 organisms per gramme of tissue. Or more than, you know, it's not been seen for more than 12 hours. So anything that's been, hit by a car, if it's been dragged along and it's got lots of, you know, road rash and that rubble, you know, road dirt in there will be significant or most likely gross contamination.
And again, anything over 12 hours, so sometimes you see cats, you know, that have been. You know, even a cat bye abscess is technically a gross contamination if you don't see it immediately. So these are just things to consider.
So these are just examples, and the top picture is a dog, . That was involved, it was a cavalier, that was involved in an RTA and we can see that there's a bit of deep loving, with avulsion injury. I'm, and shearing as well, and there was significant, .
Amount of contamination, so that's gross contamination. And the bottom one is definitely a class 3, this was a cat that I had got trapped in a, In a shed that had, its collars stuck around under its axilla. So not only had it been missing for a couple of days, so therefore more than 12 hours, this was pretty disgusting.
This was after we'd, removed all the maggots. So definitely gross contamination. And by classifying this wound type and assessing the duration and the degree of contamination, this is gonna allow us to plan, you know, plan appropriately, The ones with gross contamination, we're not really going to be closing these up immediately.
Even if we do a really good lavage, we're potentially just going to be monitoring these wounds for a couple of days. Again, when we start to think about the types of wounds that we have as well, whether they're actually appropriate to close. So again, the top picture.
It's not really appropriate to close that wound up. There's no really real clean lines to close back up. There's been gross contamination, you know, with a good lava, but we're probably gonna do secondary wound management on, you know, secondary wound management on this one, which we'll talk about at the end.
Things that we need to think about when we are thinking about our wounds and how we're going to treat them, whether we're gonna dress them, whether we're gonna leave them open, that kind of stuff, all needs to be comes with this consideration of these impediments to healing. And these are really important and shouldn't be forgotten about. So the 1st 3 excessive bacteria, foreign material at presentation and necrotic tissue can all be corrected.
We can correct these by surgical debridement, lavage, and, . You know, we can clean these up, we can get rid of the excessive bacteria, we can remove any foreign materials such as road. We can get rid of necrotic tissue as with this picture, that was a snake bite.
We can remove that necrotic tissue, and, and therefore have a, a clean, almost a clean slate. Things that we can't, . We have much more control over is like things like seromas or hematomas that are formed on the wounds.
So these are gonna create problems for us to create that nice moist clean environment that is able to get lots of oxygen to it. And yes, we can manage these serromas and hematomas, but unfortunately they are gonna have some impediments to healing as well. Movement, so thinking about those Movement lines and where there's gonna be stress, so think about this last patient, with the bottom picture.
That wound on the axilla there is on a is on an area where it gets lots of movement, you know, that limb is moving a lot, so that, that is gonna move lots. If we start to try and close that too early, or there's a lot of tension on that when we close it, so what we're trying to aim for is to close that wound without tension. If there's any amount of tension on that area, which most likely there would be, that when we start to move, we start to obviously start to pull, on that wound and that wound bed.
And all that nice work that they're doing to create those nice little collagen fibres and that little bridge is now being stretched. So we're impeding the healing of that. Poor blood oxygen supplies.
So I mentioned this at the beginning, that we really need to make sure that our patients are cardiovascular stable, that the circulatory system is well supported, that their respiratory system is well supported, and that also goes to things like, you know, that they that they have a good renal support as well. So if, you know, if they have acute kidney injury. That we're supporting that because we know that with acute kidney injury, we can start to see changes to electrolytes, changes to pH, and that pH once that bone becomes really astatic, that's not, the optimal, wound healing, .
PH for it. Obviously the patients becomes sick, their metabolism, it deteriorates and therefore the metabolism and the wound healing is affected as well. And so it's not just thinking about our wounds and going, OK, I'm just gonna slap this dressing on it, it's gonna be great.
We're thinking about these patients as a whole, how we can support them, and how by supporting their majorly major body body organs, we are supporting the the the things that make that wound heal well. So this, you know, again, starts into poor nutritional health. So those patients that are anorexic, or that have been anorexic.
They need to be fed, and we know that the nutrition is key, especially to the sicker animals, to help with their metabolism, to help them get better. You know, food and sleep. The poor nutritional health, they're not gonna have the proteins, they're not gonna have the energy to be able to create those lines of collagen, those fibres, those myofibroblasts.
That's not gonna happen if we don't have correct nutrition. So, you know, those patients that are anorexic, don't leave them anorexic for a long period of time. Again, we're talking about these emergency patients, they may have comorbidities, poly trauma.
They may have things like fractured jaws, in which case they're not gonna eat because of that, so are we going to place a feeding tube if they have head trauma, we need to consider, you know, placing a feeding tube and how we're gonna do that. To not increase ICP. So all these things we need to think about, you know, we can't just think, oh maybe they'll start to eat and that'll be fine, there on the fluids, it's OK.
Nutrition is really important in these patients, and if we see poor nutrition, that's gonna impede that healing a lot. Mechanical damage in surgery, sometimes we get a bit too, a bit too happy, slicing and dicing, and, and taking, you know, taking off granulated tissue, trimming wound edges. If we start to go a bit crazy with that, we start to cause mechanical damage.
If we're moving, you know, if we're moving things around, like, let's say, for example, this, piece of necrotic tissue, we can cause mechanical damage, removing that. And then foreign material placing at surgery. So, again, thinking about when we're on the vagin, and we'll talk about the angles and pressure.
This is really important because if, if we use the wrong pressures, if we use the wrong angle, we're gonna start to drive that bacteria, drive that foreign material into those cells. Therefore, that's gonna cause problems, right? .
And it's not always necessarily about how much bacteria is present, but it's about the environment and the combination of bacteria populations. Again, thinking about appropriate wound management. I just stuck this picture on here with the, with the foot again, another snake bite but this is in the US, and that was necrosis all the way down to the bone.
Just thinking about whether, you know, what's appropriate for these patients, that's probably amputation in this patient rather than wound management. So let's talk about the types of wounds, because again, this is gonna start, we'll start to think about the, whether we can close them with 10 without without tension as part of our goal, whether we are closing it because often these patients, these types of wounds have gross con you know, they're, they're primed for gross contamination. So this really matters as well.
Lacerations, they are an irregular wound caused by tearing of that tissue which causes a superficial and underlying tissue damage. So often they will have some sort of contamination or foreign material, but less necrotic tissue. Examples of these might be, I mean, potentially dog bites, often things like, barbed wire, you know, catching, you know, catching something on a, on a sharp.
So this is just an example of, one that was caught on barbed wire, and that's it, that's its abdomen. And then, so it's important to note with these lacerations, yes, they have less necrotic tissue. Yes, it looks like there's just tear which causes this superficial maybe underlying like the muscle, tissue damage.
It's also really important because some of the things that cause lacerations, will actually cause punctures as well. So it's just an example of a dog that we had in that had a laceration on its neck, and so he took it to surgery. And we've kind of half explored this wound, and we'd noticed when we were clipping, that there was also a wound, and the, and the axilla of that, that, you know, that for limb.
So we kind of clipped everywhere. You can see it's got a very large clip, and this is what I would advise with any wound is that you do a large clip because if there's any, translocation, pocketing, then you're gonna. Need to start opening that wound up to, to flush and to lavage because there will be bacterial contamination down there.
Just think about that's a nice looking pocket for that bacteria to crawl into. If you then just sort of, well, we'll just debride these edges and close it back up, you've now trapped all that bacteria in that little pocket there and that's gonna get really nasty. So just this really important to check.
So, once we got in there, this, this, this nice little, axilla wound, and again, it's like a little laceration, and you can see, potentially, hopefully you can see, just a little silver thing popping through there and actually that was. You can't see the picture behind so I put it, but actually it was, it was this, . A hole that had gone through, and was all the way through.
So it's really important, and Vital to check these patients all over for wounds. So often we see this one wound and we think, OK, that's it, and especially with the puncture wounds, there's often, an entrance and an exit. So puncture wounds, most commonly dog bite wounds, but again can be things like, metal poles poking through.
Patients can be, again, going back to that story about the Labrador that we saw that had the, arterial haemorrhage in the axilla. With the deck chair, the dexter had actually penetrated all the way into the abdominal cavity, so the dog was really lucky and luckily it didn't penetrate anything in the, in the abdominal cavity, but it had gone through the skin, narrowly missed going into the thoracic cavity and sort of poked into the abdominal cavity. So it's really important to check these things, you know, if you're unsure.
If it's, communicated with the thoracic or abdominal area, ultrasound is really good for this. X-rays, again, making sure that we are doing our diagnostic imaging and to make sure that it doesn't commute the outside with that abdominal cavity, we're not just closing it up. .
So puncture wounds are penetrating wounds caused by a sharp object, they often cause like minimal skin damage, but the underlying tissue damage will be severe and that's because, Of that damaged vasculature, and crushing injuries that we see with bite wounds, and that's a force that apply, that's force that's applied to an area of the body over a period of time, so we get this damaged vasculature, because of those punctures, so there's deep penetrating spaces. And therefore deep penetration of bacteria, so we can get large subsequent infections by this contamination that's introduced at the time of puncture. So .
As well as that on top of that. These closed wounds may include contusions. I think about those crushing injuries.
So you can see all this bruising on this picture, and again, depending on where they've crushed, the abdominal cavity may be, involved, the thoracic cavity may be involved, structures of the neck, and upper airway may be involved. So really important to do our diagnostic imaging. So you can see with this one, this is, I think Jack Russell.
And so where my finger is on the back of that patient is actually where all that pocketing, travelled up to, and it went all the way down to the line of where it's laid down. And all the way around. So quite a large pocket, that needed opening up, and there was a fight on the other side, so we were worried that as it was a crushing injury, that potentially was abdominal up involvement, so we did ultrasound and radiographs of this one.
Luckily it didn't. But you can see all that bruising. That bruising's really bad.
That's gonna cause problems to wound healing. So think about, you know, your wound bed needs good blood supply. There's bruising, that means that those vessels, are damaged and therefore can't bring in, you know, these platelets to aggregate, can't bring in the thrombin can't, it can't bring in the white blood cells like it should do.
It can't bring in. Tissue growth factor and collagen and myofibroblasts, this is gonna be a massive impediment to healing, so we need to kind of help it along, and the way that we're gonna do this is open this up, get rid of a lot of that area of the epidermis. And start to dress that and create that environment for it that's gonna encourage its moist dressings, you know, moist dresses that allow oxygenation and .
All those cells to come in. Sobrasion and shearing, this is a skin damage with a loss of epidermis and a portion of the dermis as well, so you can see an example, with this patient, you can see the dermis has lost like all the furs gone. And then we've got a portion of the dermi is gone as well, so we're starting to come down and you can see it tendons and stuff.
And so with these ones again, often their peripheral limbs. That we see, we often see them as part of things like hit by car. And therefore come with this significant, this gross contamination of road dirt, which is really difficult to get out.
They're often very painful, so the patients don't want us to do anything with those initially, and so, you know, potentially we just, like I say, we're covering those, we're getting a good pain relief, multimodal analgesia on board. Maybe we're doing a ring block around that leg so that we can have a good look at it. And dress it properly, flush it appropriately, because if these patients are conscious when we're doing that, it is extremely painful for them.
You know, think about when you, have a cut and you're, and you're putting it under water, it does hurt. And think about like if you ever put like accidentally like, or you're cleaning it in practise, like let's say you've got a cut on your hands, you're cleaning it, even if you clean it with chlorhexidine, it stings. So think about good multi multimodal analgesia in these patients.
Local anaesthetics, are great because we're gonna stop that transmission and transduction of those pain signals. So again, these, these abrasions here have massive contamination. It's gonna take a lot of lava for us to get that contamination out, large amounts of foreign material, very painful.
We have to make sure that these patients don't have things like fractures because with this kind of abrasion and shearing, they now have an open fracture, and the the same case with any. Any wound management, any, wounds that we see, when we have a trauma, is that we make sure that there's no fracture because if we have, we can have open fractures where we can see the bones broken and it's hanging out. There's also the, open fractures where they've poked through, and now they've come back in.
So it's not obvious that they've got a fracture, but there's a small wound. So, we're checking limbs, we're checking our patients, making sure that they don't have any fractures. I'm just gonna gently touch on thermal burns.
Because there's whole, because there's lots of different types of burns, there's chemical burns, electrical burns, but we're, I'm really gonna just touch on thermal burns because they can happen as a result of, you know, like house fires, cats being caught in cars and things like that, and these are often the ones that we see as part of, emergency wound management. So a burn wound is defined as a thermal damage to two main skin layers, and that causes coagulation and microvascular reactions. So this leads to increased capillary, and extravascular permeability.
So we get this all this leakiness, and we get vasodilation, and these can cause lots of complications like burn, shock, sepsis, severe edoema. Multi-system organ failure and death, and as a result of those leaky capillaries, these leaky vessels, we start to lose a lot of fluid in these patients often will become dehydrated and then this have this burn shock. So when a tissues burned, it involves direct coagulation, and these microvascular reactions, and they can actually cause injury and it spreads into the surrounding dermal layers, so often this is known as the iceberg effect.
So it may seem like the wound's really small when they come. It's a small surface area, but if it's left untreated, these microvascular thermal reactions are gonna continue and cause further devitalization of all those tissues that surround, Surround that bone. I'm, so again, the severity can depend on.
That, what, how the burn happened, the extent of the burn, and then so these larger burn injuries, where the significant loss of skin barrier, we get this extreme release of wound mediators, and we get this systemic response that, we see in, systemic inflammatory response syndrome, which can lead into sepsis, and subsequent infections when we have cause. And so I'm. Again, after they had minimal contamination of foreign material, but they are, now within large areas, and then now.
Going to be at more risk of contamination. So as with all wounds, we want to treat them as asexically as possible, make sure that we are handling them with gloves, preferably sterile gloves. They're still, I think a lot of people forget this, and they just wear, just the nitrile gloves.
But these wounds are technically, you know, we're, we're trying to create the, the correct environment, and the correct environment is aseptic, you know, with as minimal contamination as possible. So when we're lavaging these wounds, when we are addressing these wounds, try to stay as as aseptic as possible. And the same goes for, you know, our preparations, .
To make sure it's a sterile bowl that we're using when we're using, to clean the surrounding area as we would when we are, you know, when we create our area for our surgical wounds, that clean wound, that surgical incision, you know, we scrub it as if it's gonna be a surgical incision. So why are we not doing that with our, wounds? Because we, like I said, we want to create the same environment.
So, again, not gonna really touch on thermal burns, but these are slightly, these are treated slightly differently. Obviously we, we're unlikely to create a, A line, a clean line without tension to close up immediately. We don't want to do that either because although we're gonna lavage and potentially lavage with tap water.
Because, these require a lot, they, they require about 100 mL per centimetre of burn. So that's a large volume of water. So initially, we do a tap water lavage to try and cool it down, that, that initial lava and then maybe we continue with with the sterile Hartman's or lactated ringer solution.
But when we come to dressing these, often we're not dressing these, we potentially might do, but we have to be, mindful of the fact that these actually leak a lot of, you know, they have a lot of edoema, and they have this leakiness. And so if we start to put dresses on this that wick away that, all those, fluids, we're gonna start to see dehydration in our patients. So the, the body's already kind of doing its own job by creating these leaky, these, you know, increased capillary and extras, extravascular permeability, by creating that wound, moist wound environment.
So potentially in the bigger burns we're not gonna be putting dresses on, but we are just gonna be monitoring for dehydration signs for, you know, hyperdynamic, cardiovascular signs as well. Potentially, we're gonna use things like sil silver, sulphur, diazine, the cream that we use, I think everybody's used it. So it's got silver in it, and we'll talk a little bit about, that as part of a, an autolytic debridement tool, to, to help these thermal burns along.
And finally, avulsion. So, this avulsion it's also known as degloving, and there's a tearing of tissue from its attachment. So, often there's high amounts of contamination, and this is often because of where these deglovings happen.
So most commonly happen in around in the the mouth structures, so. You get this damage to underlying vasculature because you basically get this tearing of that top layer off those vessels. So as you can see in this picture, this is a German Shepherd.
You can see it's top lip has bolged off, and so now where that would be stuck down and all those the, those mucous membranes would be stuck together with all the vasculature holding them together, it's now ripped off and we've now got damage to that vasculature. There's a high degree of contamination in this. So we talked a little bit about this, but our goals of treatment are gonna be to try and close that wound without, without tension, or for us to bring that wound together slowly, via secondary intention healing.
Treatment of any wound should be following the the following steps. So clipping, cleaning that wound, lavaging that wound, so that's lavage is part of debridement, infection or inflammation control, so thinking about the medications that we're giving our patients, again thinking about. Non-steroidal anti-inflammatories, is it appropriate to give in our patient that's been hit by a car that has, that's not hemodynamically stable, wait until those patients are hemodynamically stable to then help that inflammation, maybe using something alternative such as paracetamol, .
Instead, infection control, do we think there's been gross contamination? Should we be, taking a swab of that wound to, tailor our antibiotics if we end up giving antibiotics to these patients? If it's a gross contamination, think back to the cat with the axilla wound, think back to the dog with, the, The Jack Russell with the shearing injury, these are probably candidates that we're gonna start antibiosis in, so we must be protected from further contamination, or trauma that we do that by covering it with a sterile and freedressing.
So from that beginning, triage, that delay between examination and that definitive debridement where we sit and age it properly, should be minimised to decrease bacterial contamination. So although we stuck something on it, we do need to address it very quickly. So again, if that wound is infected, collect a sample for culture and sensitivity testing.
Again, in traumatic or infected wounds, antimicrobials should be administered as soon as possible. So things like first generation cephalosporin. Or laviioninic acid, so like amoxicillin, a good first line choices.
When we talked about that bleeding should be controlled, you can use things like, diluted adrenaline to to swabs, and that will help with vasoconstriction. But don't use those upper extremities, or if you have a cardiac arrhythmia, which you may do in a patient that has poly trauma. Again, putting pressure on brachial or femoral arteries, if there's arterial haemorrhage present, that tourniquet, .
So you just use a band that's 5 to 10 centimetres wide and that can be used for up to 30 minutes. I wouldn't leave it for 30 minutes, to be honest, I would leave it for slightly less than that. Sorry, narrow tourniquets of, 5 to 10 minutes and then bands a little bit wider, 5 to 10 centimetres could be left up to 3.
And there's blood pressure cuffs where you inflate it to 20 centimetres of water or 20 millimetres mercury higher than arterial pressure. They can be left up to 6 hours for much longer. And then ligation may be needed for larger vessels, so, we may need to apply direct pressure and then.
Sort them out afterwards. So after we've achieved that, the wound should be dressed, and covered with that sterile dressing. So again, pack the wound with sterile gel, like insight, soap swabs, and clip the hair, from the wound outwards as well.
Prior to that full debridement, we're gonna start to clip and clean this, . So we're clipping and cleaning, we are gonna pack our wound with sterile lube, whether that's KY we could do intrasite, we can do lactated ringers or Hartman's, soap swabs, or a combination of all these. I just like to use KY, to be honest, when we're just.
And cleaning, if it's particularly bad wound or there's lots of, wound edges that I'm gonna potentially be using my scissors on, I may put a soap swab over the top of that, gel just so I, I'm less likely to sort of flip into that, into that wound. Clean sharp scissors is really important. Don't just whack them out of your pocket, get some aseptic, you know, some, some sterilised scissors, and then clippers as well.
Try and use a new clipper blade on the wound rather than just the one that you pulled off the side that potentially can use for like a cat bum. So we're gonna clip around Again, try and clip, big clips. I'm Yes, owners often, when we're thinking about our goals, our goals are to get a nice, clean, line to get that healed, but often owners, their goal is to do it with.
The least amount of money is possible and the least amount of time, and also to look the best. So yes, clipping them is gonna affect that, but it's really important. We talked about those puncture wounds, we talked about those lacerations, anything that potentially is gonna have pocketing.
And translocation, we need to make sure we're doing a wide clip so that we can check that and then if necessary we can open it up. We don't have to then mid-surgery have to then clip again and clean, and this is going to delay our control of that contamination. So use those scissors at the skin edge to trim the hair as much as possible, obviously being careful not to snip, snip bits of skin off in this initial stage.
Once we've done that, we would remove that gel from inside the wound with sterile swabs. Again, trying to keep everything as aseptic as possible. In these initial phases before we start doing all this clip and clean, think about whether your patient is going to be sedated.
It probably should be, they probably should be sedated because it's gonna be uncomfortable for them. We should think about if they're not gonna be, sedated, local anaesthetic. And so whether that's a ring block, line block, splash block, something with local anaesthetic, make sure they've got good analgesia on board.
To make sure that they're well supported because again any pain is gonna release or things like adrenaline or corticosteroid, you know, like cortisone, which is all bad for wound healing, . Because again it's gonna cause vaso constriction, the adrenaline, that peripheral vaso constriction, so we wanna make sure that we Or creating the right environment by having the least amount of stress and the least pain. I'm.
So I've removed the gel from inside the wounds, I prepared the skin aseptically, so as you would do with the surgical wound, with appropriately diluted, antiseptic. Bhexidine is fine. You can use poine iodine, just make sure that you don't get that antiseptic on the wound bed.
Now we come to our important part of our control of contamination, so we want to remove the impediments to healing and reduce the infection risk. So Levar reduces the number of bacteria that are present, it helps to loosen any necrotic material or debris, that foreign material, . And it will dilute that bacterial contamination, so it's not going to necessarily get rid of it all, it will dilute it.
The solution to pollution is dilution. I'm sure everybody knows that phrase. Try and avoid properties, solutions that contain antibacterial properties, because they can cause cell damage, they can slow wound healing, and they actually may result in bacterial resistance.
So the most ideal type that we should be using is lactated ringer solution or Hartmans. And that's the best choice because it's the least cytotoxic and has a nearly neutral pH. So, in heavily contaminated wounds, you can actually use tap water to begin with.
We talked about tap water in those burn patients initially and to cool that wound down and to do that initial lavage. And the same with those heavily contaminated, those gross contaminated, because we're gonna need a large amount of fluid. For that, for that, so then, then we can follow up with a sterile solution.
So yeah, lactated ringers, heart meds the best solution, saline, unfortunately, although most commonly used, is very acidic and therefore so toxic to these cells. And the pressure for all of our solution needs to exceed the adhesive and cohesive forces of the contaminant. So all the little foreign material and the grated material, bacterial contaminations all kind of like sat on there, with these forces, and we want to try and push these off.
But what we want to avoid is pushing the debris and these, into the tissues, causing damage to those vital tissues. So the pressure that they recommends about 8 to 12 PSI go about in the middle of about 10 PSI. And in practise, this can be achieved by using an 18 to 20 gauge needle, so again 19 gauge needle is perfect.
And you attach that on, you can attach that onto a giving set. That's attached to a bag, you put it on a pressure bag and inflate that to a 400 millimetres mercury, . Or you can use a three way tap, and a 20 mil syringe and that will give the same pressure around the same 8 to 12 PSI.
And what we wanna do is direct this at 45 degrees, and the reason why we're doing this, if we're doing it at 90 degrees. We're driving those straight down into the tissues. 45 degrees, we're gonna be like pushing those off.
Hopefully, that's what we're aiming for. The volume of lavage solution is equally important, so for small superficial wounds, 500 mLs to a litre is generally used. So again, I think often we pick a 100 mL bag of saline, and flush that I think that's enough.
500 mLs to a litre, I would generally go to the latter end for the more heavily contaminated wounds. The larger wounds, several litres of sterile, lava solution may be needed. And as I said with those wound burn wounds, 100 mL per centimetre of wound is really important, to lava that.
So before we start doing all of this, and, well, before we start doing like Our surgical department, make sure you take pictures. After you've done surgical depriment, take pictures. At every stage, take pictures, again, any redress, take pictures, you're gonna start to see how the wounds healing, you're gonna start to see that granulation bed form, and that's gonna, again, influence your choice of what dresses you're gonna use and whether we're gonna start to close it or not.
The cat but, so there's 4 ways in which the wound may be, may heal, or be treated, and so we have first intention, and then there's, I've put the bottom third intention, but actually 3rd intention comes sort of in between 1 and second intention. So first intention healing describes that primary wound healing or closure that's the best choice for healthy wounds with good vascularization. So maybe a laceration if there's no pocketing, it's not heavily contaminated, you can polished it really well, and you can trim the edges, so you've got new, fresh edges that have got lots of vasculature that now you can put those together and they're gonna sort of blend together and create that own wound healing.
Great, those are first intention. Some, some, . Some wounds, they kind of look like maybe they're gonna close, but you just want to give them a little time, you maybe want to do a couple of arges, just because it's infected or it's slightly unhealthy looking, and so they can't undergo primary closure.
So they may be well vascularized after and clean after a couple of days. So 2 days and you close it up, so that's your third intention. Secondary intention describes as secondary wound healing, so, but it's also known as spontaneous.
So you leave the wound open and that closes through epithelialization and that contraction of granulation tissue. So this is best for our contaminated or infected wounds. Following that secondary closure, is that similar to that 3rd intention.
But this happens after more than 5 days following that initial injury, so that granulated tissue and those epithelized skin edges that have started to form and now it's size and the fresh tissue edges are closed. So we kind of let the wound do a little bit of its own work, and then we just speed it along by just . By using our surgical departments, so using our, scalpel blades to kind of scrape a little bit of that granulated tissue, scrape the FDLI skin edges, get fresh blood flow, to bring that together to create, wound healing.
So, again, when we bring that together, it still is doing that wound healing in those stages that we talked about, but we've just brought that skin together rather than it taking a long time to build those bridges. We just kind of cheat a little bit and put those bridges together. I'm.
So just the cap but actually so this was closed as a third intention, but think about where your wounds are. This obviously is a contaminated area, and this wound ended up being closed as a secondary intention, and dressed because I'm, because there's just too much contamination around that area, and therefore the skin edges every time I try to bring it together break down, and so it's just, it's not a candidate for first intention, secondary closure, third intention. Any traumatic wound will, require the debridement of devitalized tissues, and foreign material in order to prevent infection and necrosis, and therefore, promote that optimal wound healing.
So we may use this for a different, lots of different methods. We can use several different methods. There's nothing saying that you have to use just one.
And so when we think about what we're using, We often use surgical, which is our sharp debridement, so, these are selective, so we can select which tissues we're gonna debride. We may use . We're gonna use hydrodynamics, so this is our lavage, and this is non-selective, we are lavaging all those tissues, we're not being selective of one tissue over another, we're now just lavaging all those tissues, but that is a, a method of debridement.
Most likely we are gonna use some form of autolytic debridement if we are using secondary intention, . You know, the secondary closure. Our third intention may in between use autolytic dressings, and these are primary layers such as honey, sugar, hydrogels, hydropolides, and these are all things that create autolytic debridement, and these again are selective over tissues that are devitalized.
Biotherapy, not very commonly used in veterinary medicine. This is medical maggots, leeches, and chemical or enzymatic. This is, not degrading non-viable proteins via protelytic enzymes.
So hydrogen peroxide, again, not something that we're doing up pouring hydrogen peroxide on wounds, these days. And then Mechanical force. So this is, adherent, dressing, dressings such as wet to dry.
So these are kind of fallen out of paper, but wet to dry dressings, they wick all that moisture. They kind of, weave to that wound. And when we pull those off, they're adherent, they pull off that granulation tissue.
They're very non-selective. Again, if we're placing them on. Wounds that the healthy tissue were also creating that debridement there as well.
So boliriman I just mentioned those silver also falls into this . It's not recommended in, infecting wound like hydrogens aren't, recommended in infected wounds. So honey is one that we now sort of have seen.
It's very popular, and that's because it has this antibacterial activity, and this is because of methylgloxy, which is a plant-derived photochemical. So manuka honey is like the most amount of that. And as well as that, it has its high osmolarity and low pH.
So whilst we talked about, we want to be at least cytotoxic when we're doing our lavage, now this, low pH acidic, environment creates this micro microbial proliferation, when it's just sat there. And that's similar to those, kind of, the enzymes that we see with neutrophils. So that manuka honey, like I said, really high levels of methylgloxal, more bioactive, and it's most effective for medicinal purposes, .
So we can use it alongside other dressings like mechanical debridement. You can get dressings that are impregnated with honey. We have to do, take care with honey because it can be inhibited by bacterial spores such as Clostridium and botulism.
So again, making sure that we are looking at. Keeping everything sterile, if we're opening it, keeping it assigned to that patient, using it maybe over 24 hours. These manuka dresses can be left on for 5 days, so they're much more cost effective.
And I, you know, we don't have to then have the mechanical damage, and that's very painful when we have to rip off our, wet to dry dressings, which includes like, you know, we have to have sedation or general anaesthetic in these patients, . So a lot more comfort for these patients. So because of that high osmolarity, we get this hyper osmotic effect, and the antibacterial environment as well, so we get this nice moist environment.
Same for our sugar. It's a 1 centimetre layer, of granulated sugar, and should be changed daily where obviously, so it's much, much less effective than manuka. Obviously don't put the honey or the sugar on healthy tissues because that will also cause desiccation of those tissues.
If there's large wounds, take care because, that because of that, colloid andcotic pressure, we may start to see, dehydration, hemodynamic, instability as well. Silver can be used as a topical agent. It can be impregnated into antimicrobial dressings, or as a cream, that's sulfasulvidiazine, and that has a properties, as well as antimicrobial properties.
So it can be used in the inflammatory phase, maybe useful in the in that repair that proliferative phase, and maybe, can actually promote some angiogenesis. The honey can only be used in the inflammation stage. Once we start to degranulation beds, we must continue or discontinue that because we can start to desiccate that wound.
So, this is why it's important to know there's wound stages because we're gonna start to think about our dressings. So these are the ones that are most popular. And the optimal, dressing qualities that we want to create a moist, not dry, not overly wet wound environment.
We want to eliminate debris, any sloughs, necrotic tissue. We want to reduce that bacterial contamination. We want to keep that wound warm.
So again, optimal wound environment is a warm, moist, You know, oxygenated, and blood rich area. So protect the wound from abrasion or contamination. So think about again, where the wound is, how we're addressing it, covering those wounds if we're going out anywhere, keeping them as aseptic as possible, and prevent adherence to any newly formed tissues.
So again, this is when we start to think about a wet to dry. This is gonna create this adherence and keep ripping it off. We're gonna be delaying that wound, for formation.
And then keep this disturbance of granulation wound to a minimum, so again. Wet to dry have their place in a new wound that maybe you are wet to dry on and overnight and then maybe the next day you're going to do a third intention and enclosure. Or maybe you're then gonna start to look at that wounds so you can provide it and then use those autolytic debridement dressings, but there's wet to dry and not a long-term solution because every time we rip those off we're gonna rip off any granulating tissue.
And they're painful, so we want to minimise as much pain. And again, as I said earlier, that we really want to try and achieve a good cosmetic outcome. It's not necessarily our top priority, but to that owner that only sees that wound, and the way that that heals, that is very important to them.
And they obviously are the ones that we're working with to try and keep this wound, Dressing and also good owner adherence. So when we think about these wounds and I just talked about this wet to dry or the sugar, we're gonna be redressing those every day, that's very difficult for that owner to give up time to keep coming into the practise to come change those. It's gonna cost a lot to keep them in hospital.
So maybe we're using the manuka for those initial stages, so we only have to redress them every 5 days unless it, you know, unless it's got massive edit date. We talked about the surgical debridement, so we trim back to fresh lying tissue. We may need to lavage again after this step.
Again, drape, prep, and treat like any other surgical wound to prevent birogenic contamination. We may need to do unblocked debridement, if it's a very large wound, we might need to do one bit at a time, and staging in more severe wounds. So, harking back to that necrotic tissue one, maybe we'll just, debriding that necrotic tissue, and then in another stage we'll then debride and do surgical debring of the surrounding tissues.
Again, if you're in doubt, place a debr dressing you can, you can interchange and you can use them together. Deriment dressings include those wet to dry, again, the, the most valuable dressing for a traumatic wound in that initial 24 hours. They're relatively easy to do, but they can be done wrong.
So we just want to make sure that we are, Again, we can use them in between staging surgical detriment or closure, but remember to measure and photograph in between those dressings, so make sure that we are using sterile swabs, for that primary layer. We're soaking them, with, Saline wringing them out, they need to be damp, not wet, so the, the name is kind of misleading but wet, so damp, dry them out and then we're putting a secondary layer on something absorbent, so more sterile swabs, or a cotton wool layer, to wick any moisture away. And these need to be, again, avoid, putting on healthy tissue because we risk of desiccating those.
Mm. So yeah, aseptic, sterile surgical swabs, moist and sterile saline and ring out, damp, not soaking, place on top of the wound or pack into the wound. And then a secondary dry layer, but very absorbent to draw that moisture out.
And then a tertiary layer on top of that. So again, it depends on where it is. The one that, I just showed you in that picture, you would just place a couple of different, You can place a couple of different Sterile swabs.
So you can put like a, you can get these like little bags that go over the top so then you're avoiding any, contamination coming into the wound. So common mistakes are gonna be too wet, placing on to healthy tissue, using things like ortho bands, so your soft band instead of cotton wool, so it's not wet to dry anymore. .
No secondary layer, so nothing to work with that first layer. So again, you rip off in 24 every 24 hours, you can't leave it on any longer than that, otherwise it starts to desiccate those tissues, but it will be extremely painful because they start to, weave into that granulation tissue. And, that's also another issue is that it weaves into that granulation tissue, you get these microfibers from those swabs that are now in that wound of creating foreign material.
So just an example, this dog in between staging, for our wound debridement, and we packed this, so we did our lavage, so 45 degrees with our three-way tap, and our syringe. And, lavaged it, then we actually opened it so that we, we're going around clockwise, so we opened this up, it had actually pocketed more, . But we put a wet straw in this before we did any further investigation so we did our soaked swabs run out and then our secondary layer, you can see.
In this bottom picture, I've got sterile gloves on, I'm really important like I said we're treating this as a sterile wound. So with closure, they get primary closure, that primary delayed closure or 3 intention at 3 to 5 days, secondary closure at 5 to 7 days of secondary intention healing. So think about that necrotic tissue with the type of wound that we talked about, the level of contamination.
So soon it's considered clean contaminated, and we've got no lines of stress or high movement lines, then we should close it where possible. And if in doubt, you can manage an open wound, wet dry dressings, preferably moisture retentive dressings, like with the ortolytic debridement, things like those honey, and the, silver impregnated dressings, or we can leave them open in the case of bones to allow the coagulation tissue to form. So we talked a lot about this throughout, so I'm just gonna quickly run over this.
So environments provide a clean, comfortable environment if they're gonna stay in with us, which often not poly traumas will do, and minimise stress to that patient. So those requiring wound care are no exception to how we would treat any of our other inpatient, and actually these are a high risk of requiring infection, so we can't, overstate the amount of infection control that we need in these patients. Minimise the stress.
I've mentioned this many times. I'm not gonna go over this and at that point because we're kind of running out of time, but just make sure that we are pain scoring these patients, that we're creating a nice, environment, TLC, rest periods. Owner visits if possible, if they've got drain systems or bandaging, making sure that we again are grouping those that they're comfortable with those if we need to place, local anaesthetics, you know, down into wound, catheters and making sure that we're doing that, so those patients are have less stress, less pain.
Monitoring those bandages, making sure that we've not got any abnormal swelling of limbs or areas around that bandage, approximately obviously, which can cause tissue damage, thinking about things like Robert Jones is, . That they can cause swelling of the toes. So just making sure we keep an eye on those drain drain care, if you've got Penrose drain like open drains, again, keeping those nice and clean, looking at the type of fluid that's being produced, whether it's serous, serro Aangguas, Purulent, and looking for any abrupt changes, so volume, you know, change in volume.
Thank you very much for listening. If you've got any questions, I'm happy to answer them. You can either ask now or email me, that's fine.
Thank you, Chloe. Great topic, a great webinar and thank you everyone else for joining. If anyone has a question, please feel free to ask them in the Q and A box.
And if not, thank you so much for your time, Chloe and see everyone else in another webinar. Thank you.