Good evening and welcome to tonight's platinum webinar. I'm delighted you're able to join us this evening to hear from John Hall, who'll be talking about wound management cases. First of all, the housekeeping, I'm Rich Daly, I'm your chair for this evening and I'm head of sales at the webinar vet, so I'm delighted to be chairing this session tonight.

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So that's enough for the housekeeping. First of all, so I'd just now like to introduce John. John qualified from Cambridge in 2004 and then spent 5 years in small animal general practise.

He spent a year at the RVC completing a small animal rotating internship and then several months working for vets now. He returned to Cambridge for a surgery residency and became an ECBS diploma holder in small animal surgery in 2015. He has since worked as an affiliated lecturer in soft tissue at Cambridge and will soon start as senior lecturer in soft tissue surgery at the University of Edinburgh.

So I'm delighted to welcome back John, and it's over to you. Thank you very much. That's great.

So I'll just, add I should update my bio. So I started as a senior lecturer now at Edinburgh in, February 2017, so I've been there for 18 months. It's been a really interesting 18 months as well.

We seem to get quite an unusual mix of cases up here. And now it's summer, of course, we're starting to see a few more wounds coming through as people are exercising their dogs and going swimming in the lochs. And I'll show you, I'm just gonna share some of those with you tonight and just really discuss some of the principles of wound management again, just to reiterate really what we, what we're up to.

So it's really, it is super important for us to understand the processes of wound healing. It's not just academic. It really helps in a clinical sense with our decision making.

We can recognise when things aren't progressing normally, because we can see that the timing is all off, or that the tissues don't look as they should for each of the phases of healing. And then if we can recognise that something isn't progressing normally, we can then address those factors and result, you know, the fact those factors that would result in an arrest at a particular stage. And then we can move forward.

So we recognise a problem and then we do something about it. Those kind of factors can be systemic. So, generalised disease such as hypothyroidism, hyperadrenal corticism, maybe hypoalbumia, you know, that kind of systemic thing which will delay wound healing.

But then, of course, the, the local factors, which you can divide either into biological factors. So there'll be things such as, bacterial infection or local ischemia, or mechanical factors. So tension, rubbing, self, excoriation.

And, and they, you know, by doing that, by having those broad categories, it can be a little bit easier for us to pin down what exactly is going wrong in that particular environment and take it from there. So, in this, dog that we've got an image of here, we, we can see some of the phases of wound healing, and I would say that that looks like a kind of a, a granulation tissue, actually, relatively rich. So with simple wound healing, we have immediate clotting with the formation of the platelet plug, as long as everything's correct, and then that will stabilise over the next few days as collagen is deposited, in the fibrin seal.

The inflammatory phase should last 3 to 5 days, and that's characterised really by a predominance of neutrophils, and they're in there providing defence against bacterial infection. And they're also going to be debriding away necrotic or unhealthy tissue. So this is kind of actually a largely destructive phase, but super important.

But we don't want it to go on for too long. We need to get into healing or the prolative phase. And that's peaking between 3 days to 3 weeks.

It's quite an extended period, and of course, that's dominated by macrophages and fibroblasts, and they're going to be depositing collagen, which is going to increase the strength of the wound. Around about 7 days in. We will also get myo collagen deposited by myofibroblasts, and they're what are really responsible for the contraction period.

So, we tend to see a big jump in wound contraction at around about the 7 to 10 day mark, and that will reduce the area considerably, particularly in dogs, not quite so much in cats. And then once the area is healed and it's filled in with, fairly generic granulation tissue, then that will reorganise. And that reorganisation will take place over a period of weeks to months.

So that's, that's really what we're looking at. So, particularly then, if we're arrested in an inflammatory phase and we're seeing evidence of inflammation at a week plus, we know that there's something going on there with either those systemic or local factors that's delaying it and pausing it. Similarly, if we're seeing granulation tissue pushing +56 weeks, we know that again, there's, there are local problems which are slowing things down.

So, If we can do things to just ensure that the normal process of wound healing progresses normally, then we're doing a good job. Unfortunately, a lot of the time when we start messing around, we get in the way of that, normal process of wound healing, and we'll look at some examples of that this evening. So this is, again, that dog familiar.

And this dog had had, some kind of, root canal, procedure performed by a very experienced dental vet. They done a good job. And in a report, there was this description of bleeding, which is quite unusual in these procedures.

And we're not really sure exactly what happened. It could well be to do with that, or it could be that there's some, there was some bacterial infection in this dog's lip. It had, had a trauma, which is why it needed the root canal performed.

But effectively what we've got is a sharp delineation. In the mucosal surface here, with sort of oral ulceration. And you can see we've got, again, a similar sharp delineation.

Now, this is, this is probably granulation tissue. It doesn't just look as if we cut it with a scalpel. This looks dead, so it's necrotic.

And usually necrosis, particularly if it's ischemic necrosis, will take 5 to 7 days, to declare itself. And so, I would say, you know, recognising this phase, we're in a sort of late inflammatory, maybe into the prolificative phase if we do genuinely have granulation. This is it a few more days later, and certainly we can see granulation tissue here now.

So this is a measure of the craicity. We know we're about a week or so down the line, and this is this necrotic tissue that's fully declared itself. And so we're just gonna chop that away.

Beautiful. You can see the deep hair follicles of the whiskers. This is after some treatments.

You can see how that granulation tissue's progressed from a relatively pale, nodular, not so happy granulation through to a rich red velvety granulation. So that's responding well to the treatment that we're giving. Now, maybe we did do nothing at all, but I think this dog had, the area cleaned up.

It was thoroughlyvaged, and then we'll use some kind of topical antimicrobial agent. You see how this area of skin was delineated where the necrosis finished, and even, in fact, the rhinarium itself was affected. So really, probably one of the quite large branch arteries in the, in the lip, probably the, middle or ventral labial artery.

But it's quite, it's quite odd, because actually the blood supply to the face is extremely rich. I mean, I cause some serious damage to faces when I take big chunks of them off with tumours. And I've never been unfortunate enough to see an ischemic necrosis following it.

So quite a surprise, really. Something quite unusual here. And we did wonder about, some kind of bacterial infection with, release of, local vasoconstrictive, toxins, and, you know, we will get some of these things.

But it wasn't progressive, so it wasn't a necrotizing problem, or a, a necrotizing fasciitis, I should say. So it could have just been a release of local vasoactive substances, that caused this. Then of course we did discuss this contraction of the myofibroblasts and the peaking of this at 7 to 10 days, and this sort of happens underneath and sort of pushes the, the scab and the lake regulation tissue off the surface.

So here we are, it's all drying up now, and we're starting to get some contraction. And of course, the, the last thing, once it's reduced quite considerably the surface area of the wound, even up to something like 30, 40% sometimes, then we'll start to see epithelialization. So on the left, we have a nice rich granulation bed, and this pale pink zone at the edges is a zone of epithelialization.

So that again gives us an idea of this is going to be about 2 weeks into a wound that's healing by second intention healing. And the epithelial cells creep in from the outside edge. There will be some, you know, even quite far over the surface here, but when you've just got a single cell layer thick, it's not really that visible to the naked eye.

And it'll just be, they'll creep across, so there is a leading edge, and then they'll thicken up and mature as that dermis, becomes more, structured. When they meet each other, when the epidermal cells from this side and from this side creep across and finally contact, we get contact inhibitions. So they don't, they stop at this stage migrating, they don't keep on going, and then that area will thicken.

And they can do this underneath a scab. They don't need to be covered by a dressing. They, they, you know, the normal process of wound healing is that they will basically burrow their way through, secreting matrix withlloproteinases at the leading edge.

And so they will cut through this kind of scab and granulation tissue. And this is why, you know, you can pick a scab off sometimes in the late phases, and it's nice and pale pink, fresh skin under there. So here's our doggy again, and we've got this zone of epithelialization around the edge, you know, this kind of pale pink tray here, it'll certainly be fine.

But we've still got obviously a bit of a defect. It may or may not be a functional problem for the dog, . So, at this stage, one can decide whether to leave it to entirely healed by second intention, or whether you might perform some kind of surgical closure.

Now, surgical closure may be indicated to preserve appropriate function, and surgical closure might be indicated to speed things up a little bit as long as it's healthy. And now, of course, we're aware that all this is going to survive. We've not got that worry that we're just going to be suturing tissue that will declare itself necrotic at a later date.

To a more necrotic tissue because that's just a waste of everybody's time and they they own this money. This is the kind of thing that I'm talking about where you'll get, you know, epithelialization underneath the scab and then it all starts to drop off. You see, a few of these actually in cats with severe tail pull injuries and sometimes pelvic fractures.

What seems to happen in this dorsal lumbar area is that the skin is a vulsed from its underlying blood supply, maybe branches of the deep circumflex iliac artery. And then what'll happen is about 7 to 10 days after the, the trauma, as I say, tail pull or pelvic trauma. Then this big hard scab develops.

Now, the temptation is, if we follow the dogma of wound healing, to say, oh, it's necrotic, we need to cut it away, because dead tissue doesn't come back to life. And, you know, that there wouldn't be a a problem in doing that. But of course, you would then end up with a big large wound over the back of this car, which can be quite challenging to manage.

You know, with these, I've tended to just keep an eye on them. And actually, you know, that, that dead tissue then forms a, a big scab, and it protects the area underneath. And you can see how this whole area is, is new epithelium that has formed underneath this scab, and then that's just flaking away.

So, I just don't think there's a problem with that. Is an evidence of how second intention wound healing, can progress and develop. So, in this, Dougie, he's, clearly been fighting, and, you know, the owners come in telling you that this has only just happened.

Well, they might have only just seen that there's a wound there because all his skin has fallen off. But of course, looking, we can see that we've got some areas that are still within inflammation, but we have got some maturing, if unhealthy looking granulation tissue. So if the owners think this has only just happened, or they're telling you that deceptively, we know that this is at least 7 days plus, really, to have this kind of granulation, even if the necrotic skin is hung on there till it started dropping off like a, I don't know, like a, an apron.

And this is going to extend a long way. This is quite characteristic of, of characteristic of ischemia, where you just get this very sharp delineation, and then you just pull apart, and you can pull it apart with your fingers. And so quite nasty, really.

These guys, it's very kindly given to me by, a, a general practitioner who's attending a CPD course I was giving. So thank you very much for letting me use these images. And you can see how now with their treatment, they did a great job, of getting this to now this much richer, velvety red granulation tissue with, you know, the usual sort of approach of lavage, maybe superficial debridement, probably topical antimicrobials, potentially systemic antimicrobials based on, culture and sensitivity.

Now, I think that's fine, but once we get really rich, healthy granulation tissue that's covering the whole wound, so here we've still got some areas that aren't quite granulating. So something's still going on that's interfering with that. But this is beautiful.

Once we get to the stage of rich, healthy granulation that covers the entire surface, then we can certainly stop systemic cancer microbials, because this tissue is highly resistant to infection, contamination, and this kind of dog I'd be sending home. With hosing off twice a day, if it gets filthy, but generally to just wear a t-shirt at home, I wouldn't be doing anything more clever than that, just really protecting it from the local environment, from major contamination, and from the dog. And this vet was worried because he said, what could I have done differently to avoid this, contraction that we're seeing developing.

You could see every time we have, big areas of granulation, we know we're going to get contraction. Now that's not a problem if it's an area of the dog that can tolerate it. For example, a patch of the anti-brachium or a big area on the flank.

The problem comes when you get granulation tissue that traverses a joint. Because without replacing skin on the surface, then if we get contracture across the joint, we get loss of function. However, I think these guys did a really good job.

And whilst now his elbows are being pulled in a little bit, he was still very functional. He was running around, he was bright and happy, and it's completely healed by second intention healing. So this shows you just how amazing it can be, particularly in the dog.

And cats, it's slower, they have less rich granulation, they don't have such a, a marked contraction response, so they're more dependent on epithelialization, which is clearly going to be much slower. And they don't have quite as, rich, not just rich granulation, but microvascular supplies. So I can't say it's much slower to do this, but dogs it can be very effective, and this dog functionally was fine.

Now, if he ended up with a big band of contracted scar tissue, extending almost from his elbow to his elbow, then we could do surgical things to alter that afterwards and really draw skin in from the surrounding areas, transecting this scarred tissue and bringing in in locally to allow it to all stretch apart. This cat is Daisy. Daisy, went playing on the railway a lot, and went to see, one of our, one of these, these images.

And Daisy, a degloved really. They they've taken off the the old. So.

Yeah. They can use now as a daily, a daily crop. So they sent this wound into us and we're gonna clean up all this area and we're gonna do that and then we'll discuss really the management of acute traumatic wounds shortly, just as a refresher.

But with a big wound like this, we need to be very careful about the owner commitment right from the word go. If they're not committed to a lot of decontamination, to surgical reconstructions, which may have some complications, it may require more than one reconstruction, and they're not thinking, you know, weeks and quite a lot of money, and they, they're just getting onto that emotional roller coaster, then really at this stage, I think it'd be very reasonable to consider amputation, of course. If we can't just let this here by a second intention, because it won't be a functional limb.

If we're gonna go for it to clean it up and and and do this, then we want a fully functional limb at the end. And so managing their expectations and getting full buy-in from the word go is super important for these big wins. This is after about 3 or 4 days of, staged debridement of necrotic tissue, and cleaning up the limb.

I still like a wet to dry dressing for cleaning the, the limbs in the initial period, because nothing gets rolled out quite like a wet to dry. There is some sort of controversy to that in the literature now if you read some of the textbooks, they're all about the, autolytic debridement encouraged by hydro gels and coloured dressings, but I've never seen them get rolled out, to be honest. There are some really cool devices now for cleaning off the surface of wounds.

They're coming in at a couple of grand things like the, Versa system. And so do look that up if you're interested in this kind of thing. Though I've got one and I'm still, just waiting for the right case to use it at the moment.

I'm excited to use it, but I've just not had that kind of wound in for a, a couple of months. So here we are just using the standard needle and syringe. I like to use an a green needle attached to a drip giving set and then into a bag and then the bag of fluids is contained within a a pressure set, so I can just hose it off.

Here are my wet to dries. Just, they go on moist. And then the day after on the deep sedation with provision of good analgesia or a GA we peel those off and it'll strip off the superficial contamination.

So wet to dry dressings, I believe, still have their place. And then we're going to give it another rinse. Sometimes if they're stuck, really stuck and it's over an area that you're worried there might be sensitive structures underneath, you know, I will moisten as I peel it away, but you really shouldn't be using these on anything super sensitive like nerves or something like that because we don't want to be mechanically debriding a nerve.

And this is as clean as we've managed to get it, with wet to dry, with lavage, and probably at some stage we'll have used some kind of topical antibacterial agent because that's, you know, gonna be sensitive to superficial contamination and subsequent infection. But that's as good as we've got it with the conventional means. Then we're gonna apply negative pressure wound dressing for Daisy, because we really want rich granulation tissue for when we then reconstruct that area.

So we have, in this case, a non-adherent contact layer. So this is a paraffin impregnated gauze gellinet, and we're going to put a sterile speakerphone basically, but this is a foam that comes with these kinds of negative pressure devices. A little handy tip here if you're trying to get this to stay on the leg, because we've then got to put subsequent dressings on, we, you can staple that together with a sterile skin stapler.

And then we're gonna Wrap the leg in this Non-permeable plastic that comes in these kits, make a little hole, and then we're going to attach the vacuum holes, and then it raisins down as we apply the vacuum with the device that we're using. So there we are. This is the old Smith and nephew one.

We can't get hold of this now. The nephew basically made a commitment. They don't really want to supply us with these things now, which is a bit frustrating.

So we use now one called the Carrato, which is from Infinity Medical. And, and I'm sure, you know, they'd be happy to talk with you if you're interested in these devices. And then this is what you get.

So, this was approximately 5 to 7 days of applying the negative pressure with dressing. And you can see just the richness of the granulation tissue that these devices, you know, will give. Beautiful.

Even starting to think about epithelializing at the proximal and the distal end of this wound, maybe a little bit of bone showing there, or it could be a tendon, a little bit unnerving. You can see this rich, really healthy granulation. And so now we're ready for a surgical reconstruction.

And just what we did with this little cat. Down the flank fold down to approximately the, use a cordal superficial epigastric flap, which wrapped around the crust. And then we did it direct, which was, one of these things where you pocket the leg up the side of them.

So that worked very well, gave her fully haired skin and a good function when she went through a bit of physio afterwards. So with these big wounds, of course, you know, often there are other problems. It's not just about the wound, the patient attached to that wound.

So, it's super important to triage these guys. You know, if we've got multiple pelvic fractures as well as our wounds, then, you know, place a urinary catheter to make sure that, you know, we know it's not going to be up and about, we don't want them urinating on the wounds. So just think about everything in one go, and that I can help make some decisions.

We'll, of course, give them really thorough and appropriate analgesia, a strong indication not to. Then we'll go on to that thorough clinical examination, to see if there's anything else we need to worry about. And, you know, at that stage, we might think about what we're going to do imaging wise.

If we are planning image. Then we will do our wound management at the same time to get the benefit out of acetic or a deep sedation. But, you know, we wouldn't start messing with the wound as a priority.

Much better to get the patient stable, much better to get your plan altogether after you've given them analgesia, then that thorough clinical exam, moving on through our bloods and then beyond that, as you use a GA or a sedation for something at that stage, then you can deal with your wound as well. So, the wound is actually quite low down on the priorities, unless it penetrates the chest or the abdomen, in which case, you know, obviously it has to move quite high up, particularly the severity of the wound and, the amenability of the patient. But we'll be quite quickly thinking about, do we need a urinary catheter to either stop them urinating themselves or to, you know, because they can't get out and about.

Do we need to think about a central line? Are they gonna need repeated blood testing? Are they gonna need provision of parenteral nutrition?

Are they gonna have repeated GAs or sedations? And so, a central line that's gonna stay in there for 5 to 7 days plus, and can therefore be a very useful, thing to do quite early on. And that feeding is super important if they are hypo anaemic.

Then they're not gonna heal very well. And so, we want them to feel good, we want them to feel better. Also, if you've got, feeding tubes and things, then, you know, particularly an esophagostomy tube, which is, you know, generally the best option, unless there's esophageal problems or neck problems, then, you know, you can also get medication down there, and that's often cheaper than intravenous meds.

So that's, you know, a nice way to go as well. Also means you non-steroidals can be quite quickly on board rather than being worried about them not eating and receiving non-steroidals. So I'm gonna give you some now er selected cases.

And some of these series and you know just really to flag some of the funny things that we'll see, but so this cat had been bitter in and around his hind end. He had one of those funny names like Tony or Paul or Dave or something, I forget his name, I'm afraid. And he had been bitten around his hind end and The referring vet had recognised that there was a rectal perforation, and so, they did a little, a little lateral approach and they up his wall and into us.

Now, unfortunately, the thing that struck me very quickly was this, this funny line, and you can see it then when we clipped him widely. It was the first when he came in he was just clipped around his bottom. But what you want to do when you get something like this, and you can see one of these funny lines or the skin doesn't look right, just keep clipping the animal until you get to the edge.

And you can see it's even running along the ventral abdomen. So you've got nice pink skin here, including this nipple, and this is normal-ish skin, but all this stuff was very bruised and very unhappy. If you see that, be afraid because, And that's even in, even if a rectal perforation hadn't been diagnosed, or if you see a cat that's coming with a tail pole or pelvic fractures, even if it's got a normal bladder, no free fluid in the abdomen, and even if it seems to be urinating normally, be instantly worried about the risk of a rectal tear, quite a cold, quite small, or a urine leak, a subcutaneous urine leak.

And again, even if the urinary tract itself might be mostly intact, if there's a, if there's a little hole that's allowing urine to collect beneath the skin. Or We try to issues. The first thing you'll see the bruising.

And then in a more prolonged sort of 5 to 7 days, you see the dead. So that's. And do something They further to, you know.

Quite susceptible to say. At But so, you know, these are. Hi John, I'm just just interrupting.

We're having a few issues with the sound. Hi, John, can you hear us? Hi.

Hi, sorry, John, we're just having a few issues with the sound. It keeps dropping out. I was wondering, could you dial in for us?

Yeah, no worries. Is that right? Cheers, John, thank you very much.

If you just give us a moment, ladies and gentlemen, John will just, go on the telephone, dial in, then that should improve the sound quality for you. So please just bear with us for two seconds. Hi, can you hear me again now?

Yeah, that's perfect, John. That's great, thanks for doing that. Great, sorry about that.

So, I'll just say, just to reiterate then that it's a big concern for us, if we're in a situation. Actually, Mark, can you give me a 10 minute warning as well, because I don't have a timer on now. Yeah, no problem.

Thank you very much. So, this is an necrosis associated with either urine or faecal leak just under the skin. So don't be reassured that the urinary tract's OK to be able to urinate normally and produce large volumes.

You're gonna have to do if you see any bruising in the perineum, a rectal examination, and you know, digitally and do a contrast urine exam. So this is what we're seeing now, we've removed the pen and it wasn't really doing much. We widely clipped in and we're going down both sides.

And then we're going to watch him for a few days with some really strong analgesia, partly to make sure that the rectum's not going to dehis and partly just to see what the hell's going to happen with his skin. And you can just see this kind of progression of this unpleasant line. And if this continues, what you'll find is that a few days in, then you'll be able to put a thumb on this side and thumb on this side, and by just drawing your thumbs apart, it'll just split and it's just very unpleasant.

So it's just progressing, it's just getting worse, and you can see now this is all hardening up, so this is really bad news. And then unfortunately it extending underneath along right the way up to his caudal thorax and then unfortunately faeces started leaking out and we had a complete dehissance. We attempted repair of this and we were attempted even patching with a semitendinosis muscle graft, you know, I think unfortunately it's just on a bit of a height to nothing.

And unfortunately this cat we had to put him to sleep, just because of that skin deterioration was continuing and we, we had discussed with the owners what it would require, but it's affecting both legs, and so we felt that this was untenable. Now this is the case that was sent in a photo by a colleague, and they sent me these images and I said, I gave them the warning. And then they actually formed a rectal exam and found a rectal and euthana that cat.

He had a severe tail pull injury, and these are the similar ones, you know, that you can get, and we actually had to reattach his anus to his skin, and that seemed fine and we, we amputated his tail. And then this is a kind of necrosis that developed, you know, a few days later. And so we debrided all this area and cleaned it up.

This cat had a much better recovery, but what we had to do is because it's necrosis extended right over to the other side, right over to the left great cancer, then we actually amputated the right hind limb, but preserved the skin from the medial aspect up to this point. You can see actually there's a band of dead tissue here around this limb. So we didn't feel It was viable to say this thing, but what we could do is use all of this skin that came up the medial aspect of the mid crust, and we were able to lap that over the top of the cat and bring the skin cordly.

So we actually sacrificed this cat's right hind limb and to basically cover all of this area and and so and so the cat, and he did a, did very well this cat. Bite wounds are a big one and and something that we have to be very careful of in terms of recognising that the tip of the iceberg is the surface and particularly then when there's over the thorax and the abdomen. So here this dog was sent in because the vet was concerned of some respiratory signs and got a dressing over the bite wounds over his thorax.

And then when we removed that we wily clipped and cleaned and you see that you just get some punctures and bruising. Now that might be fine, but we can never be sure unless we explore. Similarly, of course we can use imaging and things.

This dog was very stable and on imaging there was a minor ne a pretty small pneumothorax, so we felt that there probably was a communication through to the thoracic cavity, but they come up surprisingly small. And what happens, of course, is that the teeth. Penetrate the skin and so the teeth of the other animal and the skin are now moving together, but the tissues underneath, you know, which moves, which are separate to the skin, get absolutely shredded as they're shaking around or wriggling.

So the superficial punctures are nothing compared to the damage and the tearing that have been done underneath. Got a little video of this dog, just showing a bit of, you know, sucking in a bit of paradoxical movement of the chest wall. Now maybe we've got some fractures there and what we call a foiled chest.

This can happen even without fractures, and when you open these, what you'll find. Is that the ribs are absolutely just like like a toast rack with no intercostal muscles between them because the teeth have been in there just tearing up and down, backwards and forwards. We've got some stay sutures around the ribs.

There was a little fracture in one of these, so we're just thinking about how we might reoppose those ribs. We don't need to pull them tight together. We actually don't use the chest wall to create an airtight seal.

And if there is necrotic muscle and things associated with these, we do do bride that because it acts as a bacterial culture medium if we don't, and I've seen that in traumatic pneumothorax in cats, where they've then gone on to develop really quite unpleasant pasturella pythorax. And so it's good to actually debride away anything that you think is nonviable, and these are subcutaneous tissues that we use to create air tight seal and subsequently evacuate that pneumothorax using the chest strain. So yeah, quite, quite grim, you know, they need exploring, they need looking into.

And see that dog doing very well, she did very well. This is a little dog that I came into the other week and this dog had been bitten around its sort of flank, the cold thorax, sort of mid abdomen type area, and it had these dressings on and it'd be managed for pain relief overnight. They were a bit concerned about this dog's neurological function, and so I think largely a lot of stuff hadn't necessarily been done with the wounds, but of course I come in blink as a blinkered surgeon.

And I'm deeply interested in wounds around the abdomen and I'm thinking well I really guys, I really don't like the look of this. And so the dog was anaesthetized and had a central line place and was having, you know, I was going to go for. And CT scan just to check for a few bits and pieces.

Also, you know, we weren't sure what was going on with the dog's skull and head at the time we didn't have the MRI available. Now we do have our own freestanding MRI 24/7. So this dog probably would have been an MRI candidate for the head.

We're very useful to get a screening CTs of the thorax and abdomen for these bite wounds. It's one of the quickest and more complete ways how we can image these. But to be honest, you know, I know it's not there it's provision for everybody, but you want to be widely clipping and cleaning these, prep them as if for surgery.

And then actually in this situation on palpation then once the dog, you know, was anaesthetized and couldn't feel what was going on, you know, I was convinced that there was a body wall rupture here and again you can just see how there's just little pinprick wounds, but no major hole. So you know it doesn't look that bad, very bruised, obviously very crushed, but it's the tip of the iceberg. So what we're going to do is take this dog through the theatre.

Go make a nice big incision over an area that we think is viable skin. I know here we've got intestine hanging out in in the subcutaneous area and really unhappy looking in testing at that. So that's been out now for about 12 to 24 hours.

So this is looking ischemic, it's looking devitalized. Some of it is looking particularly bad. There's a hole, so then we've got septic peritonitis, with this necrotic extent of gut.

It's so, you know, severe enteritis and, sort of we've got these big rents in the body walls, so not just the whole that's hanging out of, but also multiple tears and rents. So to give you an idea just to see what's going on here, we've got more tears in the body wall and through this tear, this is your denum. This is the pancreas, and this is an old bit of pancreas, so there's a laceration straight through the pancreas.

This is the the right kidney. And then this is a sub lumbar musculature, all bruised, all unhappy. So really some severe damage.

This is the unhappy gut, and I just put against the colon there to give you an idea of colour. It can be harder these couple of saturations in a whole through the intestine. And there's so much of this intestine that was revitalised, and these are the this is the injury to you can see on the internal surface of the body wall just how incredibly unpleasant these injuries are.

At this stage we actually had a chat with the owner and we elected for euthanasia. Generally with the superficial wounds, our initial management is very similar then, so I've I've touched upon some of it, but just in summary, and this is something that, as well I've spoken about at length in other webinars, and I think you'll hear a little bit at the end about a course of webinars that we gave on wound management. But in a very, in very brief, we want to protect the wound, so we usually put sterile jello in there.

We're going to wear gloves and aprons, and we're going to treat this carefully because we don't want to contaminate it worse. Then we're gonna clip widely and you know, because anything that's underneath the dressing is gonna be an area where bacteria are warming up and it can creep along to the wound. They'll clip super widely anywhere that you're dressing needs to be clipped.

And it's not going to do any harm, and you find things that you don't expect sometimes. Then we're going to prep the periwound for surgery. So I would use, you know, standard surgical scrub, whatever it is you use, not getting into the wound itself but all around it to minimise the bacterial contamination and load on the skin.

And then we're gonna cleanse the wound, so we're gonna lavage that. I don't tend to use detergents if you are going to use things like colhexanidine, super dilute. So you can see here we we're protecting these now for any further clipping or anything we can do.

As I said before, you know, I'm going to revise that. I tend to use the green needle attached to a giving set into your fluid bag and then that's in this cuff, and it just acts as a hose pipe and it's a really good pressure. It's really consistent, and it means you use the whole bag because you don't get bored, keep drawing up a syringe of fluid and squirting it out and drawing it up and squirting it out.

I get bored, but too easily, so my hose pipe keeps me going. And I would usually snap off the steel parts of the needle and just leave the hub because that slightly increases the pressure and that can work very well. We'll sharp debride any tissue that's completely revitalised, you know, around the edges.

Stage debridement is sensible. So if you're not sure if it's going to die or not, leave it for a day or two. Let it declare itself, and then you can consider debridement.

And then as I said before, non-selective debridement using dressing is usually for the 1st 2 or 3 days. And then beyond that, we're going to protect our granulation tissue that develops and allow it to do its normal thing, or we're going to do some surgery. And then again, touring on some cases now of atypical wounds, you've got to be very aware of these.

If something doesn't seem right, listen to your gut feeling, or if, you know, if it just doesn't, if it's just something that's not quite as you would expect, engage your brain and don't just go into automatic, which is very easy for all of us to do when you're busy. But just think what is, there's something not right about this, and, and if you've just done that, if you've just done that little check on yourself, then you won't miss some of these weirder ones. This is an envenomation.

It started off as a puncture wound and then extended. And we just let that heal by second intention healing and it did very well. This German shepherd had just started on a nonsteroidal, and 3 days later he got this big black scab.

We widely clipped and cleaned and it was this big chunk of necrotic tissue from an immune mediated vasculitis, you know, drug-induced vasculitis. So we had to bride that and come up with some. Inventive ways to address it.

Once that's degranulating, it might well be that you could leave that to you by seconding intention. In actual fact, in this speed, we just did a big primary closure, well, I shouldn't say that, a secondary closure, when there was granulation tissue present. So that's surgical closure over granulation.

This dog guy was the one I saw in practise, and he got this big abscess burst out in his groyne, and I closed it and he burst out again and I closed it and he burst out, so not learning from my mistakes. And then I was kind of we got to this healthy ventilation and not much was happening. Then these other lymph nodes came up and I actually biopsied the site, which I should have done probably a bit sooner, and it turned out that he had a really nasty lymphoma that then burst through the skin in this area.

So it is important to think about biopsying these wounds if those don't seem right, not only for histopathology, but also we'll submit culture of the tissue, for bacteriology because it can be quite different to what you might get just on a superficial swab. And these are these kind of funny things that I spoke about earlier in the account. And there's a different cats and it's just it's just plastic to heal and scab and epithelialized.

So if we do have wound complications, you know, we recognise those because it's a rest for too long in a particular phase of healing, and then we investigate thoroughly and we think about our local physical factors that can impair healing, and so tension, superficial trauma, and we think about our biological factors, whether they be local or systemic as we touched on at the start. And then if you think about these things and you know something's not working, then do act on those findings. So this is one of these think twice moments.

This is a dog called Diesel, and, and Diesel, just basically had this weird necrosis of his toes and you know, it's unclear really what happened with this dog. And you can see how the skin on the toes has declared itself. Now we don't know how deep that goes, if it's just superficial, it may be we can let that heal, you know, it's try.

There seems to be a zone here of granular leg tissue, but then you see it goes pale and funny. And actually on his upper lips as well, he had these marks. Now we just placed this here for a demonstration, it was bilaterally symmetrical and and this dog had gone through a lot.

There was all kinds of complicated things in his history, but probably he had a predisposition to . Getting vascular constriction or maybe thromboemboli and where he'd had a dressing on his leg and where he'd probably had a G tube tied in, we've got these areas of necrosis. So it might well be that it's been exacerbated by interventions, but he's got this dog has got a pretty severe and weird underlying problem to lead to this.

So, then what we're going to do about this foot, well, first we need to decide what's viable. You can see this now after a few days of stage depriving taking his skin off, seeing what's working underneath, bacterial treatment because he had an unpleasant E. Coli that would be producing toxins and nastiness, which would also exacerbate any necrosis.

And so, we then got to think, well, what's going on with his toes? Well, so we'll cut the nail and see if his nail bed bleeds, which it didn't. Well then we're gonna cut the bone and if that bleeds, and it didn't, so we actually had to amputate his toes right up to the point where that superficial epithelium was, sorry, that superficial granulation tissue was doing.

And then we're gonna dress it again for 2 or 3 days to see if that all remains viable, which it did. And so then we're going to remove these bones higher up. We're gonna fill it to these toes and remove all the bones, and then we're gonna just basically suture the skin to his, his, his meta, carpal pad.

Is it metacarpal metatars, I forget, metacarpal, I think. Oh, it's like a tarsil doesn't it? So I met a tarsil pad and so we've created a big bingo stopper, and I've actually done this in a couple of animals now and they've got various weird things going on and they can walk very well on this because this pad is the main weight bearer, so that can be functional, very effective, and, you know, with Not with pretty much nigh on normal, functions.

So they don't rely on the toes as much as we do for balance. And whilst the toes do take some weight distribution, it's that big pad, the, the metatarsal or metacarpal pad that takes the vast majority. So that's a, an innovative solution.

Another think twice moment, any wound around the face and the head isn't clearly because of something like a bite, . So we see some odd things, we see infected mucous seals, but you know, the big ones to think about are teeth and the ear canal. So this dog had been managed for this repeated abscess that kept forming.

It's had a tie over dressing place, and then that's been held on, you know, with these little loops, and they've got a beautiful granulation tissue, but it just wasn't going anywhere. And, so it was sent to us because we were worried about contraction around the eye, so for a reconstruction, and we gave it just another good once over around the mouth, and we found that there was this little pocket there. And this dog had had a tooth extraction at a previous time and actually dental radiographs which a colleague did for me.

I'm rubbish at these. You can actually see this little retained tooth root there. Again, it's just you can see where the barriers has reached to this point we're saying no in and so we removed that last little remnant which is great fun, not.

And dressed the dog and Phantom of the opera style and then she had a anguaris oris flap reconstruction of this area. Little bit of d up back on the edge that was probably a little bit of tension. It doesn't look like it was a very big flap to me.

It was, I didn't do this one myself, and I think that's a little unfortunate because he can do very, very well with these flats, but that'll just, that will deseal by second tension. I actually don't think it did be his. I think what happened was there was just a little bit of superficial loss of epithelium, but the underlying sort of thick wood of dermis was all very healthy.

So this did very well this dog she did great. So with these wounds then you've just got to think, continually reassess, reconsider your current approach, every dressing change. The frequency and type of dressing, you know, is is a talk all in itself.

But keep manipulating around the wounds, you know, pull on skin, pull on limbs and tissues, keep an accurate record, and I think this is where we go wrong a little bit sometimes if we have multiple people involved over the time. Period. That's when this arrest in a particular state of wound healing is most likely to get missed because we're just seeing a snapshot.

We're not seeing, you know, 23 weeks down the line. Why hasn't it changed? So, you know, we really are very keen to take photographs so that we don't lose things in the gaps between people, you know, between staff handovers.

And if something's not going right, do change the plan based on your investigations. The real. 1.

It's a real, yeah, if it looks weird, get worried. So I this is I've seen only two cases like this now, but both of them were stinger one did OK and this, this one unfortunately didn't. So often with ischemia, and this is an area on this dog's anti-brain that was ischemic, it was around a catheter site, often with ischemia, you, we have, we can be patient as surgeons, and we get into this real routine.

So 99% of the time we would go, oh well, let's see what it looks like tomorrow. Because I'm not sure if it's all going to die off, and then when it's declared itself, we'll debride it, you know, as you saw me do with those cats, as you saw me do, you know, with the diesel's toes. So you did Stacey bride and taking away what's definitely dead, leaving what you're not sure, give it a few days.

If it's dead, cut it off. If it's not, you think, great, I'm glad I didn't make a massive hole. Now, in cases, so sometimes there is an exception.

And you can see we've drawn a line because we didn't like the coloration on this dog's flank. We kept clipping, clicking, clipping until we find normal skin. None of this look good, so we've drawn a big line and marker pen around it.

You can see it's this dodgy area of darker blue skin. This is erythematous but not bad. This is normal.

So we've mapped it. And then it extended beyond that line. And so this is a necrotizing fasciitis.

It's the spread of necrosis, and unfortunately in these situations, you can't, you don't, you can't be patient. You don't have time. You've got to be aggressive with your debridement, and this is what they have to do in people because of things like gangrene.

You actually have to remove that area of necrosis as if it's a tumour with a margin of normal tissue, otherwise you've lost. And probably we waited a little too long with this dog because we were in our mindset of. Well, you know, we, we see what we're doing, we decline necrosis, but this extension of necrosis that's falling the cephalic vein and falling up within the fascial plane, you know, when we started debriding this leg, and I mean, only waited too long by say 6 to 12 hours.

The dog started not doing very well. We went in for progressive debridement and we found all this extending under the tissues. Well, that's gone.

And even if we just take away the necrotic skin, we've still got all this pleasant necrotic tissue underneath. So then we amputated the entire limb and we we took a massive area of skin on the flanks of this dog, so full, full course amputation. Leaving a big hole that we then applied negative pressure wound on, but unfortunately, despite all this, the dog went into unrelenting, sirs, well, really sepsis and sirs.

And so, you know, the one proviso really is in these rare situations, if you feel that it's spreading rather than just delineating along something that you recognised, then you've got to be more aggressive and unfortunately just being able to monitor and keep taking it a bit at a time. So that's the main body of the talk, and I would ask you if you'd like to submit any questions and I'm sure you have been going on. I can give you another 5 minutes if you like, so then we've got 5 minutes for questions.

Where are we up to Mark? How long have we got, mate? Yeah, it's 25 now, so, if you want to do one more maybe and then we can questions or you're happy to, we have had some questions already, so.

Yeah, yeah. OK, so thank you. Well, I'll just finish by describing this dog and then yeah.

So I, so I just finish by describing this dog and then will be the questions, is that right? Yeah, fine. Great, great.

So this is just to show you how, how these angular saurus flaps really, it's not to do with the wounds as such, although I did make a big wound in this dog, so you can imagine that this is a traumatic wound. This is actually moving a sarcoma. So using the bone surface as a margin stripping the periosteum, going into the nose and into the mouth, so a big old hole, and what we've done is we've raised a flap that extends along the ventral board of the zygomatic arch down to the wing of the atlas.

And then the same distance again from the zygomatic arch to the angle of the mouth below, and then we've elevated this as a an axial pattern flap, and then we've flipped it over onto the face. I always use Twcom to close it to make sure there's no tension when I start to drink and then this is what. Do I afterwards.

So these are the kind of surgical reconstruction you can do as well if you're in a position where second intention healing isn't, you know, what you want. And of course in an oncological resection, you want to do a primary closure, so we plan carefully. But you know, these, these things can be very useful for some of these wounds as well.

So thank you for your attention and I'll be happy to answer any questions as they come through. Thank you very much for that, John. I think there is a slight time delay between me speaking and you hearing me, so, just to imagine that you're in Russia and we're here in the UK and you're reporting back.

But no, that was fantastic, thank you very much. Thank you. Well, I'm in Scotland, they might as well be Russia sometimes.

Right. I'm sure we've got some of the Scottish, colleagues on the, on the webinar tonight. So yeah, so first of all, as I'll give you a couple of minutes just to think of a few questions.

We have had a couple in which I will get to shortly. But as John, did allude to, he put together a fantastic, wound expertise course last year, which consisted of 4 webinars. And they were focusing on the management of traumatic and open wounds, surgical wounds and reconstruction, oncological surgery of the head, neck and distal limbs, and also oncological surgery of the body wall.

So for those of you who are on our diamond membership, they are available for you to watch online by just logging in and go searching on the courses for wound management. For those of you who are our platinum members, and if it is something you are interested in, accessing. We do have an offer on at the moment, which is both our pain and wound management course as a bundle, which is fantastic value for money at just 97 pounds plus VAT.

So if that is something you're interested in getting more information in terms of the wounds, what John spoke about today, then please do get in touch with myself, who's, my email's Richard at the webinar vet or send an email to office at the webinar vet. And obviously, we'll, more than happy, speak to you about that and help to give you access to that. So that's that little pitch and then back to the questions.

So the first one for you, John. Er Andrew has asked, what kind of fluid do you use to lavage? Yeah, cool.

So if it's massively contaminated, I'll use a tap or a shower head, just to rinse off the worst of the sort of straw and things like that. And then that's absolutely fine to do that. Beyond that though, I can't help myself using something sterile, so I will tend to use, Hartman solution or, you know, lactated ringers, basically, or compound sodium lactate.

It's technically the most balanced. I mean, saline would also be absolutely fine. But I, I tend to use Hartman's solution, and, and if it's, you know, and both at the first rinse, if it's not particularly bad or after the tap water, and then it subsequent revises after that.

Fantastic, thank you very much. Gordon has, sent a couple of messages. What he first one he said is one of the most interesting webinars he has seen, so, praise indeed.

Oh, thank you very much. That's very kind. And then he sticks you with a really tough question.

No. He's, Gordon said, with the cat that had the the gloving injury. Did you do the epigastric flap first, followed by the pouch flap on the chest wall at a later date or was that within the same procedure?

So we actually did it a single session. So what we did, so we have, you have the flank fold, which is a really useful, interesting flat that was described nicely by Geraldine Hunt, and what we actually did was really just loosen up the skin around the top of the cat's knee. And we just slipped it down it's like almost, almost like pulling a sock.

If you were to pull your sock up, we almost pulled the sock down from the top and we were able to suture then around, just distal to the stifle. And in the same procedure, we then raised the caudal superficial epigastric flat and wrapped it around the cross, and then in the same procedure we then posted that cat's distal limb through a tunnel in its flank. Now we had been very careful by picking the cat, so we knew that she was very tolerant and for a few days, we had had a leg dressed up to the side of her body to make sure that she could tolerate it and still use litter tray and eat and wouldn't just roll around doing a classic cat paralysed thing.

So she tolerated that super well. So we actually did all three of those surgeries in the same go. And then what you would tend to do about 44 weeks or so later, you start to lower the limb, so you make little incisions either side of the distal limb, just to make sure that the flank, skin has taken to the leg, and then a week or two later you take it the rest of the way and suture it all up.

So it, it, it was, it did, I suppose, involve one large procedure and then two subsequent smaller ones. But she was, she was a great cat and, she did. Very well with it.

I've got a video, so I couldn't find it this afternoon, but I do have a video of someone running around the kitchen happily. But it did take some time for physioing because, you know, she'd had a leg up on her side for about 6 weeks or so. And so she did need quite a bit of physio to get her functioning properly again.

Fantastic. Thank you for that explanation. Claire has messaged in, what topical antibiotic preparations do you use on wounds?

Yeah, so, so if it's in the sort of early mid-inflammatory phase, then I'll use Sort of more, not so much antibiotics, but antimicrobial agents, so bactericidal things. So, honey is good. In the later inflammatory phase or into granulation, I would er more towards things like silver containing dressings or preparations.

And recently, we've been using an awful lot of hypochloous acid. So Vitirein is one of the brands, there are other brands, they're just not coming straight to my, they're just not coming to mind, and so hypochloric acid is brilliant. It's sensitive on the tissues, it's massively bactericidal, and it's not so bad for fibroblasts and things.

So we've been using that for a lot of the multi-resistant wounds, and it's really effective. It breaks down biofilms as well. You can make up solutions using .

TriyDTA and acetylcysteine as well to break down biofilms. And one of our dermatologist Tim Nuttall, he's a great fellow, he knows a lot about bugs. He occasionally does make up creams using flamazine and gentamicin, but generally that's based on the bacterial culture and sensitivity results.

If it shows that it's that kind of bug that will respond to that, but I must admit. I do, I do rely on Tim to do those kinds of things. I do sort of cutting stuff and he does the thinking and, applications of, of, of the therapeutics.

So that's, that's kind of, a, a, a review of the antibacterial things that I'll use actually on the wound. Fantastic. And, it was Gordon's asked the question that, I was just thinking in my own head then.

In terms of when you mention honey, is manu manuka honey all really all that, or is any honey fine and should it always be raw honey just with you touching on the honey aspect, I'm sure it pricked a couple of people's ears. Yeah, yeah, I imagine so. So here's, here's what I think about that.

So, so the honey, honey works really for a few reasons. So there's a little bit of a hydrogen peroxide activity in it. It's obviously very hypermola because it's sugar, and so it makes things, it makes bacteria and cells like that burst.

But there is this weird thing, Manuka honey factor, which is, you know, they put, it was actually paper a while ago and I need to dig it out where they took something like 30 different honeys from the supermarket shelf and they compared it against Manuka honey and actually manuka honey did do better and then, and I may be wrong in this, then they were able to sort of grade in terms of the zone of inhibition. On an agar plate with the bacteria, which were the next best ones. So whilst they all do have some degree of antibacterial activity, it does seem quantifiable that the manuka honey will have more, and it wasn't the manuka honey producer who, you know, commissioned this paper, but there was, there was this list of stuff from the shelf, you know, and, and.

There are other supermarkets and there are other brands of honey, but I'm sure it was something like, you know, Heather honey from Sainsbury's came next and then there was this sort of falling off list of how effective they were. So it doesn't seem to be that just pouring sugar on does just as well as Manuka honey, though it will do something. And, and the thing is, you know, the manuka honey is treated, in, in many ways because actually, just like pregnant women that shouldn't have raw honey, apparently and, and seafood and stuff because of what it can contain, this is the other thing about the medical grade manuka.

Honey is it has gone through various treatments that consumer consumable honey hasn't and so I would, I would use it just to cover my ass, I think. Fair enough, no problem. So, just don't nip down to your local, supermarket and pick whatever's on the shelf.

But that's great. Thanks. I certainly can do, but I just, I know I would struggle to defend myself if I didn't use the stuff I had to buy from the from the pharmacist, yeah.

Appreciate that. Jill has, messaged him, she said, what is your take on silver-coated dressings such as active coat for granulating wounds? Yeah, I like them.

Now, if it was healthy granulation tissue, I wouldn't see a need to use it. If it was unhealthy looking granulation tissue and I'd always worried about a biofilm on the surface or, you know, some kind of contaminant bacteria that's causing me a problem, then I think they're very effective. I also, there are silver dressings that you can use with negative pressure wound therapy as well.

And currato even infinity produce a silver impregnated foam. I think they're great. I tend to resort to them, .

When either it's a bit of a wet wound and I think adding honey makes wounds wetter, so I do, I do move away from honey from wet wounds and I like, I really like them on feet, because I'll, I'll stick them on there, because honey melts and sort of drops out, you know, it sort of oozes out unless you can get these impregnated dressings like the active on Tully impregnated dressing. So I like them if you're worried the money's gonna run out, I'll certainly I'll see. I'll use the silver dressings, and I think they're great.

You do have to be, you do have to use them properly, so you do have to wet them with, distilled, water. You can't, you shouldn't use saline. So, or not distilled sterile, you know, water for injection.

And so you do have to moisten them and apply them, but I think they're really, really good, particularly on feet, and I leave most foot wounds to granulate, unless there's, you know, some reason like. Weight bearing surface, but a lot of foot wounds I use them on. I think they're good.

Fantastic. Thank you very much. And just one last question I think we have here, and that's also another one from Jill, is what is best tone for flaps and their positioning?

What is? Oh, I see a book, a book, yeah, yeah, that was, yeah, sorry, is is, yeah, what is, I presume what is the best home for flaps in their positioning, yeah, what's the best book? Pavletic, he's, he's, the reconstruction master, so it's a, I can't remember the exact name, but it's a big blue book and it's Pavletic, is the, is the author, and it's, it's just great.

And in there there is even a menu of, you know, there's even like a map of a dog and a menu for what reconstruction techniques are in each area. And I would say the BSAV manual of wound reconstruction is good, in terms of sort of how to sort of things. Fantastic.

Thank you very much. Well, I think, from the questions and some of the comments, it's been a roaring success tonight and people have taken away very valuable and useful tips. So that's what it's all about.

So thank you very much for that, John, really appreciate it. My pleasure, thanks everybody for your attention and have, have a lovely evening. Thank you and thank you to my colleague Dawn, who's been on the on the computer answering any questions and keeping a track of things.

So thanks to Dawn. And all he can say is, next Thursday, we've got our next platinum webinar, which is by our friend Douglas Tm from over the pond in America, and he's going to be talking about bladder and prostate tumours more than just NSAIDs. So, I hope you can join us next week for that too.

So all these can say is, enjoy the rest of your evening and I look forward to seeing you on a webinar soon. Thank you very much. Good night.