So, welcome everybody. It's, lovely to be speaking with the webinar vet again this morning. I don't need any arm twisting, I'm more than happy to come and have a chat this afternoon.

So we're gonna talk really largely about the wound management for nurses for the next 45 minutes, and there will be an opportunity for some questions at the end. And Oh no, there we go. So, first, I want to introduce you to wound healing, and this may seem a little bit esoteric or, you know, you might think, well, how is this relevant to how we do things in the clinic and our, and our patients, but it's super important to understand these, these principles because by recognising the different stages of wound healing, we can then look at how we can move into the next stage in a, a seamless flowing kind of progression.

And encourage that normal, normal process. By encouraging the normal process, we can often get these things to almost heal by themselves. Sometimes what we do, of course, is impede healing, and we can recognise some of the natural ways that happens, but we ourselves can cause it, and that's another thing to really, you know, recognise and, and understand.

So in simple wound healing, the, we have 4 major phases really. So clotting, which is or should be immediate unless the animal's got a clotting problem, and that's a formation of a plug of platelets, followed by reorganisation of that clot and fibrin production, and that, that happens, you know, within the first few minutes, then we expect to see the inflammatory phase, and so that's gonna be from right, right from the word go through to around about 3 to 5 days. And what we're going to get there is, a tonne of neutrophils come in.

And they're gonna be involved in debriding the tissues, removing any bacteria and bugs, protecting the area against infection, and also helping to take away some of the necrotic and dead tissue. The inflammatory phase then moves on to the healing or proliferative phase. This is not, these aren't separate unique peaks, these are peaks of activity, but you can see there's overlap, so we do have a confluent movement from one stage to the next, and it's very difficult, you know, to try and pick up somewhere in the middle, but the proliferative phase is the one that's really characterised by the presence of granulation tissue.

That nice rich velvety smooth red tissue, and that's where we're getting, a lot more macrophage activity, and they're gonna be, helping to draw in certain cells of the immune system using cytokines or signalling messages, and what we'll then get is fibroblasts activated and they will lay down collagen, which increases the strength of the wound and granulation really should be there for about 3 days to 3 weeks. Beyond that, it starts becoming a little bit chronic or sometimes we call it indolent granulation. And when, finally when we've got rid of all granulation and when we're starting to produce a scar, then we get the maturation phase after the, the wound is epithelialized.

So, how do we recognise these phases? So this is a, a, a wound that's clearly in the inflammatory phase. See, we can't really see any granulation tissue there.

It looks quite horrible. We've got some skin necrosis. This, this looks discoloured and unhealthy, and so we would recognise this as a, a wound that's either breaking down or that's infected.

And, you know, we're, we're not into the inflammatory phase, so we're in the inflammatory phase, and we're not getting into that healing or proliferative phase. This so is the same wound and it's been treated in a, using negative pressure wound therapy, which we'll talk about a bit later with a, a worked example. But this is now really nice, rich, healthy granulation tissue, so, This is granulation tissue in a cat, so it's a little bit paler than in a dog, but you can see we've got this matte texture, it's nice and smooth, it's kind of like a generic cement of tissue, and granulation tissue is really characterised by macrophages, collagen, fibroblasts, and blood vessels, and that's why it has this kind of, just matte velvety red texture, so that's really nice and healthy.

And the interesting thing to note in this wound is a little bit of intestine poking out through the abdominal wall, so you can be misled by a wound such as this, if you think it's all superficial, unless it's fully explored, you know, you're not gonna find a penetrating injury underneath like this. And so, it's another strong, lesson or a basic lesson in wound management is never underestimate what, what can be happening underneath the surface. So we've said about the proliferative phase and what happens and these growth factors come in and we get endothelial sprouting and these, these vessels that grow in, and this is the period then when we're having the fibroblasts producing the collagen, that the wound's really gaining strength.

But then what happens as well, around about sort of 10 days or so, maybe a week, 10 days after the wound is, is in the proliferative or the healing phase characterised by that granulation tissue, not only will you have fibroblasts producing collagen, we have myofibroblasts producing myocollagen, and myo, as we know, is, is tends to refer to muscle fibres, and so these actually do have the characteristics of muscle, and that's why we get wound contraction. And so the, the action of these myofibrlasis contracting at around about 7 to 10 days means that that's when we get our most dramatic contraction, and that can be around about 30% of the surface area of the wound, and that can happen over 2 or 3 days. And so we see a sudden jump in progress at that stage, followed by then a bit more of a lag.

As the epithelialization occurs, so here we've got nice rich granulation tissue. Some of these pictures you'll find are taken from Tobias and Johnson, the veterinary surgery book, and around the edge you can see this very pale zone of pink, and that, that's actually the beginning of epithelialization. So this is a zone of epithelial cells.

And those little fellow start on the periphery of a wound, and they crawl across the surface, so they literally start at wound edges, and that's why a bigger wound takes longer to epithelialize because they've got to travel across the surface. And when they meet the epithelial cells coming from the other side in the middle, we get a contact inhibition. So those epidermal cells meet each other, they say, don't go any further, and you've got a very, very thin layer, maybe even one or two cell layers thick, which crawls across the surface of the rich granulation tissue, the healthy granulation.

It can cut underneath the fib. Clot or the scab on the surface, and that's why if you pick a scab off, sometimes this is exactly what you'll see, but it can cut through underneath the scab, secreting these enzymes which dissolve it away called matrix metalloproteinases, and they will dissolve away. And then once you've got a complete covering of epithelium, then those cells will thicken up, and that's when it will really beef up the strength of your skin.

So that's, that's really the process, and then over the next few months to even years, you'll get reorganisation of that collagen, and your blood vessels will all regress away, and whilst you'll get, for example, if we're talking skin, and that's really what we will be talking about today in terms of wound management, you will have a scar, it will never behave the same as full normal skin, it will never be as strong or resistant to trauma, and it certainly isn't as stretchy or elastic. So a scar isn't necessarily ideal, but they can be fine in, in certain locations. They can be problematic in others, and we'll discuss that in a short while.

In certain other areas like tendons, you know, that can take years, and, and that's why a tendon that's healed with a scar inside of it will never behave quite as well as the original structure because this organisation can never put the cordial fibres absolutely in line and as perfectly organised as they were. As you've grown and as it's adapted to the forces going through. So, we want to understand this process to understand when things aren't healing normally, and then we also want to then address the factors that may have resulted in arrest at a particular stage of healing.

So those factors can broadly be categorised as systemic factors. So for example, the dog may have poor nutrition, be very skinny, or it may have a, a hormonal disease that does that or impairs the immune system, or the local factors, and, and these are largely what we'll talk about today, of course, with wound healing, and they're the things that we can really do something about. So that can be local biological factors, for example, the presence of infection, or it can be mechanical, so the dog licking it, it rubbing against a particular type of dressing, or it being over a joint so it doesn't stop moving, and so they're broad categories that we can think in, and we're then gonna try and address the problems that are arresting our wound at a particular phase.

And if we can encourage the wound to move through into the next phase, we can encourage the wound to heal in a very natural way. We can do that in a variety of ways using dressings, and, and using surgery, and that's what we're gonna really talk about. So, I'll give you an example of a, a dog with a fairly significant wound, and this was, these pictures were kindly donated to me by a, a practising vet at a CPD course, who came to me and he said, we really don't know whether we should have done something differently with this wound, you know, I'm just gonna show you a few photos and then we'd like you to tell us, you know, what we did wrong, and actually they did a cracking job with this, and, and I think you'll agree.

So here what we've got is, we can see that they've got exposed muscle. This is a necrotic skin flap. So, that necrotic skin, that's gotta go.

It's not gonna come back to life. One of the human guy I was chatting to, a medic, a human guy, a human surgeon I was chatting to, once told me that the, the only case report of necrotic skin coming back to life was 2000 years ago, and he's quite right. So dead tissue needs to come off.

And so, that needs to come away. Now, this is chronic granulation tissue, so this wound is trying to move from the inflammatory phase into the healing proliferative phase, but this is not nice looking granulation, is it? It's, it's lumpy, it's, it's, very pale, it doesn't have that, you know, nice smooth matte texture, it looks even a little slimy.

So this dog's trying to move into the, into the proliferative phase, but it's not really managing it, and what it, what it has done is arrested in, in sort of a crossover. And what we need to do with this dog is get rid of the dead tissue, clean everything up, try and get it from the inflammatory phase, which might be, you know, due to infection into that healing phase, and then go on from there. So they've debrided all that tissue away and now you can see this much more rich, healthy tissue.

This is, has to be a week of, of various dressings and things, and we'll go through some of these options. Going really nicely, they're wearing gloves, which I always like to see the vet nurse there. Beautiful, really now into the, into the proliferative phase, and it's starting to contract, contracting more.

Contracting more and then it'll have closed now. What they were concerned about was this level of contracture with the four limbs being pulled into the dog's trunk, and that's true, and we could maybe have avoided that because such a large wound, we could have maybe reconstructed surgically, but the owners didn't have the money. It was clearly a staffy that had been out fighting, and this level of contracture here.

Might impede the dog, but they actually felt that the dog was very active and had a normal life. And so there was no problem with this, and it'll just, it's just an example that dogs in particular, encouraging normal second intention wound healing, which is, you know, just let it getting on by itself whilst we encourage it to move through the normal phases, can actually be an extremely effective way of dealing with some of these problems. Cats as well can work like this.

This was a shabba, a cat that came in. It had a strange abscess over his amputated tail, and this had come and gone, come and gone, and the, the referring vet tried to close it in various ways and nearly got there and then it abscessed and broken again, and all we did with this cat was treat it, open wound healing. We, we debrided it, we, we cultured, we treated with appropriate antibiotics.

And then we, got the owners to clean it off and apply honey, and that, and, you know, this gradually went and it healed down to nothing in the end. So, whilst cats are much slower with this process than dogs, it can work well with cats as well. So when we consider wounds, we want to classify them, and, and I think, again, it might seem like it's a pointless process and maybe overly academic, but wound classification can be really, really handy and then making some good decisions moving forward and dealing with those wounds.

So we wanna think about the location, so that can affect what dressings we might be able to apply. Clearly we can dress a limb relatively easily, but if there's a wound near, near the anus or around the face, or, you know, near the penis where they might need to urinate from. Then they can be difficult and so understanding those locations and therefore various options we can use to address those is very handy.

Also the forces that are acting on the wound and how we might be able to borrow lax skin from nearby to reconstruct. So we, we really want to bear in mind the location. The cause of the injury is a really important thing to consider.

Burns will often be far more dramatic than you think, and they will develop, and the wound will get worse over the first few days. Similarly, avulsion injuries, you know, you might think that you've got a, a cut in the skin, but if it's, if the, if it's avulsed off the underlying blood supply, then 5 to 7 days later, you're gonna have a much bigger hole than you expected. The depth of the injury is important, and particularly when you're thinking of, of wounds that might penetrate the thorax or the abdominal cavity, and those need exploring, you know, they need an anaesthetic and a full exploration, and so don't, don't underestimate those.

Quite like this dog. This is a dog called Bar, and this was a, a, a surgical dehiscence of a, a quite a large, orbitectomy, maxillectomy, and he got a, a horrible pseudomonas abscess. And so you can see this is all of his skull open.

He's obviously his cranium's not, but this is into where his orbit was and the, and the nasal cavity, and this is his tongue. So this is something else, but I love this picture because for me it's the definition of optimism. That, that this is the dog's wound and we've got a little tube of honey, and surely all will be well.

But in this location, you can see that, you know, it's a difficult place to dress. We needed to dress it at the time, and he's got these little suture loops, and that allows us to pop the dressing in there and then lace over the top with a tie over dressing. And in the notes that accompany this lecture, there are various, bits of advice for the placement of things like tie over dressings in, in awkward locations to dress.

excuse me, so the degree of contamination is, is important, because if it's very dirty, we don't wanna go and surgically close that. We're gonna end up with dehiscance immediately and an abscess. So we wanna get things as, as decontaminated as possible to move from the inflammatory phase into the healing phase, so that we don't arrest in any of the phases, but also if we are considering a surgical reconstruction.

Then we wanna, we wanna make sure that there's, we, we're not doing that too quickly, and that's gonna be one of the big principles of the chat today, is don't try and close a wound too quickly, and encourage your, your, you know, the vets at your practises not to do that. You know, we can, we can open manage wounds really nicely for a few days without any problems for our patients, without any morbidity, and actually improving their outcome, whether we then continue to manage the open or whether we go for the surgical option. The amount of discharge or exudate will help it whilst it's not really a classification thing for the wound, it helps us decide on what dressings we apply, because we wanna keep a wound warm and moist, but we don't want it wet, and we don't want it dry, and we'll talk about that shortly.

And then the age of a, a, a, a wound is quite important, as we saw with that dog before, when you get to the chronic granulation tissue, you need to be thinking about how we can improve that. So I'm gonna introduce you to a couple of patients to go through some of the principles that we have today. So this is Marley.

Doesn't he look sweet? He's a real little treasure, 5 year old pug. He went racing across the road in front of the owners and got tonked by a car, and there he is with a little Christmas tigger, all wrapped up in his bed, but actually he's a little psychopath, and that's what he looks like when he's happy.

He has to go around wearing a, a caution, . A caution harness because he's such a nutter, so he was quite a difficult patient to treat. And this is what he came in with initially.

So, this fella, he's got, abrasions which run all the way down the medial aspect of his, left hind limb, and actually he's got abrasions and cuts on his other hock, which you'll see in a minute. He's got a full thickness skin injury here, which has gone right the way through to the underlying muscle, and this skin looks really unhealthy and unhappy. So, if you start popping any skin sutures in this, in 2 or 3 days, you're gonna be right back to square one.

And whilst at the moment, we don't know if this will definitely die, it's very likely that this is necrotic. So, the sooner we take away necrotic tissue, really the better. This is his little scrotum.

Believe it or not, he wasn't castrated, even though, bless his little heart, he's not particularly well endowed, but this is all extremely painful for him. And because clearly we're gonna have to do something to manage these, he's, he was recumbent because he also had pelvic fractures. We've placed a urinary catheter, to make sure that he can urinate and we can dress over the top of that without worrying about urine soiling of the dressings, and this is gonna be again a, a big, a big principle I'd like everyone to, to be happy with and take away that.

We've really, really got to think about the nursing requirements for these guys and right from the word go. So one of the first jobs we did when we sedated this chap, whilst we're all very interested in his wounds, we want to first make sure that he's stable and doesn't have any other life threatening injuries, for example, a bladder rupture, a pneumothorax, something like that. So he's fully triaged, followed by a full clinical exam.

Then we're gonna get a an IV catheter into him to give him fluids if he's in shock and provide analgesia as a matter of urgency, and from there, we'll think about sedating him. But even before we're gonna really get into the wounds, we're gonna make sure we've got some gloves on so that we don't give him something horrible off our hands and then knows a combular infection. We're gonna make sure that the table is clean and ideally protected with a, a disposable, cover, and then we're gonna start doing things like considering his nursing requirements long term before we're gonna clean all this off and get moving on it.

Here's, here's some more of his wounds, so you can see his other legs also affected and it's just very raw and sore, and this is a quite full thickness cut on his contralateral hock. And then we've got Daisy as well, and I'll, we'll chop and change between these two. So, this is a 2 year old female neutered domestic shot, a cat, a real cute cat.

She went playing on the railway and got hit by a train, as we believe, and she hobbled home. And so what we've got is actually a, a degloving injury, so this is about the level of a greatest cancer, so we've got hip to stifle to hock to toes. And then this is her skin that has been turned inside out and it's hanging off, really nicely contaminated.

So as Marley wasn't too badly contaminated, here we've got real loads of gross, necrotic surface, hair, bits of straw, a real beauty. So we've chop the skin off, there's no point in keeping that on there, that's not coming back, so we get rid of that. And see we're using gloves again, we've got this all on a nice clean surface, often on top of a towel because we're gonna use a lot of fluids now, to try and decontaminate this area.

So we've said, a lot of this, so I'm sorry to jump back on the slide, but all of these things are really important to consider and again are reviewed in your notes, and this is Marley's pelvis, and you can see you've already got the urinary catheter in place. You know, before we even getting this X-ray, we're making sure that those wounds are protected from contamination, that we've got provision for analgesia and for nursing, that we've got him stable, and then we can start getting into all the things like his pelvis afterwards. These large cutaneous defects, you know, are important to consider the systemic effects.

They'll lose a lot of fluid, you know, they might well be anaemic. There's the risk that if they do get infected, they'll go septic. They'll lose a lot of protein as well, that's, that's super important to consider.

So if they're a good eater and they're still eating in this condition, well, fine, they can probably keep on top of that, but if they're anorexic, then we'll often in terms of our nursing, assistance, either syringe feed, but we'll very commonly now if they're gonna be in the hospital a while place feeding tubes, we tend to like to go for an esophagostomy tube which can be placed under a deep sedation or a GA, for example, with Marley, when he had the X-ray, we probably placed an esophagostomy tube in him. Because the minimum complication rates, we don't have the risks of things like the gastrostomies, and we can get much, chunkier food down there, without it being, you know, a nasoesophageal tube, which is very narrow gauge, and I also think that NO tubes, you know, are much more easy to displace. And to be honest, I also wouldn't like to get anywhere near Marley's face, so having a tube coming out from his neck is a very handy thing.

They'll also get edoema, and when we consider, we wanna consider the wound and the wound health and the state of the healing, we also want to consider the peri wound, because that's where your little skin cells are gonna come from. If that's edematous, then the oxygen provision from the blood vessels is poor, so we want to think about not just the wound, but the peri wound and the health of that. So here's a dog having a feeding tube placed, esophagostomy, we talked about the urine catheters.

We do use central lines if it's a really major wound and we think that they're gonna need one or two GAs and we think they're gonna be in the hospital for a while, and they're gonna, we're gonna need maybe a lot of analgesia. So, you know, placing the central line means you've got a catheter in there for 7 days. It's less likely to displace in a peripheral one, and depending on what we plan on doing with it.

So we, we do, we think about the nursing and the ongoing management ASAP as long as the animal's stable. And then in terms of principles of wound management, we can approach this this with a time principles approach. So that's the thinking about tissue management.

So what do we do with the wound itself? How do we manage the peri wound? Do we need to debride it or not?

How do we control the inflammation and the infection risks? How do we keep it warm and moist but not too wet? And then can we think of some way of getting the skin over there more quickly?

So, looking back to Marley, we said that this was all abrasion, not full thickness, and then these are full thickness. If it's not full thickness, I'm not interested. We should get this printed on t-shirts or something, get all American about it, because if there's a thin layer of dermis like this still present, that means there's some deep hair follicles that are surrounded with that have little epidermal cells on them.

And it's incredible the rate that this will heal by itself. So if it's not full thickness, just keep it clean. If it's not clean, you need to decontaminate it, and we'll talk about that now, but that will really quickly repopulate a wound, so it looks sore, it's a bit nasty, but an abrasion, not concerned.

This is more of my concern and the ones on the hocks as well. When we're thinking about contamination then, and we just briefly touched upon that with, you know, is that full thickness, is that, is that partial thickness wound contaminated or not? I mean, this is clearly contaminated on Daisy, but our degrees of contamination, this is working from a, a surgical approach, is that we'll have wounds, we'll rarely have wounds that fall into the clean, the clean category, and they're surgical wounds, OK, and, and general operations where everything's been aseptically prepared.

Some wounds may be clean contaminated, most wounds are actually contaminated, you know, this is generally contaminated, it's got gross, foreign material in there. And likely riddled in bugs. Clean contaminated, if you're talking surgery, is a procedure, for example, where, we have, an enterotomy or a cystomy, so it, it's, it's aseptically clean, but we've entered a luminal structure, so you can't really consider it fully aseptic, or if there's a minor break in aseptic technique, but you don't think it's Meiji.

You know, you're not literally sort of spat in the, in the wound or something, but maybe you touched something you shouldn't, but you can re-glove because, you know, you've done it. Some people consider wounds that are less than 8 hours old, i.e., in the, what you may hear the thing called the golden period, as they're they're clean contaminated, but they're not yet infected, and the idea is that whilst there might be bugs and things in there, they've not had enough time to grow up to decent numbers to be a true infection.

But I think the golden period's a bit of a myth, and I would really just look at a wound as it comes in, it needs cleaning suitably for as long as it takes to get it looking clean, and that could be a day with various dressings and, and treatments, or it could be several days. You won't overdo it, you know, you, you, you can, you can't get them too clean, and it won't be a case that by using too many days of debriding dressings and things. That you're slowing the process down.

If you do it, it's by a day or two, and that's much better than a dehistitance. So some people worry that treating these wounds for longer than, you know, 3 days, 5 days with, with dressings to clean them up, before they do surgery is slowing the process down, and generally it really, really won't, you know, granulation tissue can still develop, in a situation where you're using wet to dry and stuff. You won't tear those cells away.

So we wanna make sure that that periwound skin is healthy because that will allow a bit of perfusion, reduce the edoema, and if you're in doubt, really don't close them, OK, take away, just don't close them if you've got any concerns at all. So with initial management, what do we do, and we've talked, we wear the gloves so they don't contaminate it, we protect the wound from contamination and further injury. We wanna clip really widely, so we've clip right at the side of the car here, and the reason we do that is so that we don't get contamination coming from the hair, and then we treat the area as we would pre-surgery, we give it a scrub with you know, whichever standard disinfectant solution you usually use, you know, whether that be, diluted chlorhexine or povide iodine, it's up to you.

We protect the wound though by either covering it with something that doesn't allow that solution to get onto the wound, in large volumes. We can pack wounds when we clip in and, and preparing the periwound using sterile gel. I wouldn't use things like intratite and stuff just because it's expensive, you know, you can get small packets of sterile gel, which are, you know, just as good, not damaging, and they're much, much cheaper.

And then you can flush all that out afterwards, so cleansing the wound, and, and what do we do? We use loads of fluids for this. If you're using a 0.5 litre bag, you might not be using enough.

Some wounds, if they're minimally contaminated, maybe, but generally you're looking at a litre, of something like saline or Hartman's. If it's really dirty, you can, you can get a shower on it, you know, there's been, it's been shown that there's no problem with, you know, copious slavage with tap water. To really decontaminate these first before you then maybe use a sterile solution to make yourself feel better, but the research shows that it's not a big deal.

You can use extremely dilute solutions of chlorhex or iodine, but I wouldn't do that for more than the first day or two or unless you think it's truly infected. So here we are, just, we've got the toes held up, we're wearing gloves as usual, and we're busy rinsing this off and rinsing it down. If there's truly devitalized tissue, necrotic tissue, you're better to cut it off and I would do that in either theatre or in a very clean prep, and I would use sharp debridement.

So you wanna take away necrotic skin, a reasonable amount of necrotic fat. Fat isn't completely. You can't completely get rid of all the fat.

If there is uncontaminated or healthy fat there, then actually leaving it does speed up wound healing, so it's not completely sacrificed or sacrificial, however you wanna say it, it's, you know, it does have value being there. And the reason we want to give GAs some of these guys, and we do a lot of these under sedation, is if you are getting towards, you know, clearly dead tissue doesn't have nerves, but if you're getting towards cutting away some living tissue, you know, it's nicer that they're anaesthetized or have excellent provision of analgesia, and some of these things need, need a long time, and so, you know, you can get a much more standard duration of a GA rather than a sedation if it starts wearing off. If you think that there's some vital structures, you know, clearly nerves, tendons and stuff, we wanna try and leave those, of course, and if we are not sure if they're, those vital structures are OK, then you could do several episodes of staged debridement, so you cut off a little bit every day as things die back or declare themselves, and in the meantime, you're gonna dress, but these dresses can also be used to, to debride.

So here we are, a little bit of sharp debridement of a little bit of necrotic fat on the surface. This looks not so bad. I might leave that.

This looks a bit grotty, so that's gonna get cut away, and we're using a number 10 blade, and we're either gonna trim it off or we're gonna scrape it away. This doesn't look too bad. We've got some vessels here, so I would try and preserve this.

This might well even be just looking at that, that could be, tendon or tibialis cranialis or something, so I'd be very cautious about chopping that away willy-nilly over the surface of the joints. And then what do we want from our dressing? So, that's a really important thing.

So do we want to use our dressing to debride and clean the wound up, or do we want it to protect the wound? Do we want to keep it moist or take fluid away? And it's, we wanna be aiming for this nice little red dotted line.

OK, so we're moving through the phases of wound healing. We wanna keep it moist, we don't want it too dry, that's gonna slow down our healing. We don't want it too wet, because then it'll get all excoriated and all nasty and, You know, gooey, and you, then you're gonna get bacterial infection if you're getting wicking of fluid through the dressing, so we need to think about what the functions we're after, how contaminated it is, if we want to debride with it, and Potentially where the location is, so what can we use in that location?

So I, I love a wet to dry dressing, and to, to debride these open wounds that are moderately contaminated. So they're adherent, so good quality cotton gauze swabs, and if you apply them and just moistened, not soaked through, just moistened or if it's just to a very wet wound, even dry, and then you dress them on normally with your usual conforming and, protecting layers. You do have to change these daily under sedation because the idea is that they will stick to the surface as they dry out, and even though you're putting a standard dressing over the top, they will dry out, they'll evaporate through that standard dressing as long as they're not too wet, you just need to make them moist, so they'll stick to the surface.

You may have seen this sometimes if you're moving like melanin dressings and things that, you know, they're quite hard and they're sort of a bit sticky, you're like, oh, you know, and it, it's, you're trying to peel them off and in animals that are conscious, they will not like it. It's not a very, precise way of debriding, but it does drag off all these tiny little bits of grit and hair and things like that. So I, I like a wet to dry dressing, you know, that could be the first day, it could be for 3, even up to 5 days if it's very mucky and you're getting loads of grit.

And if you look at the dressing each time, you'll see how much material you're getting off. Hydrochloroide gels are, are gentler in a way, and they encourage autolytic debridement, so the body's own debridement processes. They need to be flushed off every time.

Some people just keep piling it on, and then you get these just layers and layers of gel, but the, you really should, between, you apply hydrocortic gel, you do your dressing change, and you flush it off, again, probably daily, and then reapply. I don't think they achieve the same level of decontamination as wet to dry if you've got, you know, foreign material, bits of hair, but I think they can be handy if you've got a wound where you're not quite sure how much tissue is alive and necrotic, and they can help that declare. And some people suggest that hydro hydrocolor gels like intracy can encourage granulation as well.

So here's wet to dry dressing being stripped off. Peeling it away, you can see the way it's stuck to the surface and we're stripping that off, and then when it's stripped away, we're gonna give it another rinse, and I'm using a litre of saline in a pressure bag like you give for fluid bolusing intravenously on a giving set, and then if you screw on a, a green needle onto the end of that giving set, Sometimes you can leave the needle on or you can snap it away. If you pump that bag up to maximum pressure, that gives you a really good hose, and it means that you use your full 1 litre, it means that it's an appropriate pressure to levise the surface, and it means that, whereas normally you get bored doing it with a needle and syringe and not get through enough volume, this just jets it out and you can just pressure wash it off, without it getting all ingrained in the tissue, so I'd recommend that as a system.

And this is it now after a few days of wet to dry dressing, so you can see the difference. So we sharply brided some of the narcotic stuff, and we've wet to dried it, we're getting this nice healthy granulation tissue coming through, so looking really good. So coming back to Mali, I don't know what I was thinking that.

I mustn't have been able to find any laparotomy swabs that day, so rather than use a nice big laparotomy swab, I've wet to dry the entire surface of this abrasion with a mosaic of little moist swabs. And then after a few days of wet to dry dressings, and I'll show you how I dress that on in a minute, you can see the partial thickness is healing, it's already epithelializing, it's even getting hairs, so that's really good, but this full thickness area, it's declared itself now, so this is gonna get cut away with a scalpel blade back to healthy bleeding tissue. This is how he got his, kept his dressing on, so he's got wet to dries down his legs, he's got wet to dries in his groyne, because he doesn't need to wee, because we've got a urine catheter, we've been able to put our nappy on him.

This had a fentanyl patch underneath just for comfort, and this is our IV fluids. So there he is. He had a, we put a little cape on him at one point, like a little super pug, we thought he had Superman colours, but we kept with a Tigger theme on the nappy.

And of course, like when he needed to defecate, I can't remember if we cut a hole in this or we just allowed him to go out for a poo, whenever we were changing the dressings, I, I forget now. So then when we get into the early proliferative phase, so we've cleaned it all up, now we want the, the wound to get into granulation. We want to protect, protect those little fragile vessels and the epithelial size.

So we want something that doesn't stick at this stage. We want to keep it moist, so this is when we like the things like the, Alein, you know, the polyurethane foam. I'm sure there are other manufacturers available, because it doesn't, it's pretty non-adherent, it pulls fluid away but keeps the surface of the wound warm and slightly moist.

And with its absorb means that you don't get that kind of horrible, kind of, what's the word I'm looking for? I forget, but when the, when the tissue goes all, all wet and, and nasty, and then it just gets damaged from just being constantly moist. So, so, we quite like it for that, and we, we plus or minus manuka honey if we think there could be a superficial infection, and, you know, manuka honey, I think now has been shown quite, quite strongly to have some nice antibacterial properties and we use it a fair amount.

Once you've got healthy granulation tissue, and this is an interesting point, you don't need any systemic antibacterial therapy, really healthy granulation tissue is remarkably resistant to infection. So if it looks slimy and unhappy, well fair enough, there might be an infection, if it looks really healthy, don't keep blasting them with ABs, and there's no need, it's expensive. And and in fact, we'll often leave a lot of our healthy granulating wounds like Shabba the cat earlier with that healthy granulating wound on its tail base that was left uncovered and the owners just hose it off twice a day, because, you know, we just know that it's really resistant to infection and problems.

So now this is looking a bit better, maybe halfway between inflammatory and proliferative, but we've cut away all the necrotic stuff, and now because we don't feel we need to debride this any longer, he's got a, an alle foam, with, just a, a lap swab over the top, and we've placed little sutures, suture loops around the wound, so then what we can do is we can lace the dressing over the top. It's a really nice way of dressing, an awkward area near the willy, near the bone. Without having to, you know, wrap all his tail in and all his trunk, so these are tie-over dressings, and they're very effective in difficult to dress locations.

Granulating beautifully, it's just doing its thing. This was after, this was then removed at this stage, we cut our little suture loops out, and this dog then went home to the owner. We'd fixed the pelvis, just for hosing off twice a day, and that, that wound healed completely normally.

So we didn't do anything with the wounds on that dog other than allow it to go through normal second intention healing. Dressings in the late proliferative phase are very similar to the earlier proliferative, so we still use the leave-ins. Melalins I'd avoid, I think they actually stick to the surface, but if you are gonna use them, then if you moisten them when you remove it, it's not gonna debride the surface.

Each time you do a dressing change, and, and clearly this is really important, reassess what you think stage you think the wound is in, assess whether you think it's going as quickly as it should, or if it's going too slowly, or if there's a problem that you're worried about, and reconsider your current approach every time you do that dressing change. How quickly you do your dressing changes depends on that, that decision that you make every time, and the phase of the healing and the volume of eggate coming off. And then at the same time, you can have a little play, and we will always have a little play if we think, oh this one's going towards the surgery, we'll have a little play in the area, make sure we've got loose skin, both before and after and during surgery if we think that's time for it, just to, just to help make decisions.

And it can be really helpful if you're going to do this and make those types of decisions that the same person sees the animal every time, or at least photos are taken and attached to the animal's records are kept somewhere where everybody can get access so that appropriate decisions can be made. Why might we surgically reconstruct? Well, if the wound's very large, because second intention healing is slow, if we're getting thin epithelium, maybe over a distal limb or over a joint which might be susceptible to trauma, we want full thickness skin maybe.

If the wounds cover the entire limb, so in Daisy the cat, if we left that to heal by scarring, then the contraction would mean that it would be a non-functional limb, and cosmesis has a, has an element involved, but not a big deal really. And sometimes it is worth considering that surgery might be. More cost effective, and may produce a more satisfactory outcome in some animals if dressings are gonna take forever, and depending on the pricing structure in your clinic and the cost of dressings, hospitalisation, repeated sedations, that kind of thing.

So whilst I would never, you know, advocate a surgery, right from the word go, that, you know, before the wound is clean enough, if you've got a nice clean wound and no concerns, Then, I would, I would say that, you know, it's, it's always a reasonable option. Be careful of atypical wounds. If it doesn't look quite right or you're worried about it for some reason, then do consider that there might be something a bit strange going on.

So, this is an example of a dog that had a snake bite and a venomation, so that wound got worse before we could get it better. So always be thinking about the unusual things, and that got better by itself, second intention healing. This was a dog that had had a carrofen and got a necrotizing fasciitis as a result of the drug, so this is clearly strange and atypical, managed with tie-over dressings, but because that was gonna take forever to heal, we then went for a surgical reconstruction of that once we'd had it healthy enough.

So, always be careful with atypical looking wounds, that there might not be something strange going on. And this dog had neoplasia, so it had lymphoma burst out through its groyne. No inciting trauma, exploded out.

I was letting this heal by a second intention, you know, you can see it's granulating well. Interesting that it's tendon or vessel there, so a bit scary. But you're thinking, well, why did this do this, you know, it makes no sense.

It didn't fight or anything. Had a little feel, and all its other lymph nodes suddenly went up, and this was a lymphoma that burst out through the inguinal lymph node. So that did heal my second intention whilst we were treating for the lymphoma, but biopsying an atypical wound is very sensible sometimes.

With a necrosis due to an avulsion injury after a road traffic accident. And again that just here by second intention just left the scab to fall off. And sometimes we'll get flank abscesses, with migrating foreign bodies, so this is a, a little piece of dye showing us where there's a grass seed up in the abdomen just up near the aorta.

So delayed healing has to be dealt with. We need to understand why it's been paused, you know, why we've got prolongation of the inflammatory phase, and some of the biggest things, and it, it involves, you know, testing and thoughtful, thought processes. Is it infected?

Do you have foreign material that we need to get rid of, so this will be antibiotics and, more debridement or more dressing management. Is it too dry? Do we need to get this a bit more moist, and we can use our colloid gels or our reclusive dressings.

Or is it continued tissue damage, you know, do we need to stop the animal licking at it? If you do have a problem, do something to solve it, you know, you identify it first, but then do something. And we've said already about helping to make changes by having that continuity.

This dog hasn't been clipped widely enough, so that would, I would, you know, clip this more widely, give it a clean. This is chronic indolent granulation tissue. So we need to do some investigations, we either need to think about biopsying it, culturing it, seeing if the dog's got other health problems, seeing if the dog's been licking it, seeing if it's been protected with an appropriate dressing to allow it to get into a healthier granulation tissue and actually deal with it, not just ignore it.

So what we did with Daisy, just to finish off really and give you an idea of some of the more interesting pressure, the wound dressings out there. This is a negative pressure wound dressing, and so we use this in the inflammatory and early proliferative phases, and that helps to reduce the wounded he and reduce fluid. And what we do is we apply a vacuum over the wound over a period of a few days, maximum a week, and that promotes incredible granulation tissue.

So here is her wound. So here's us, so you place a little bit of gauze over the surface, and this is basically a posh speaker foam. And then we put our plastic over the top, and this is cola paste, OK, which just creates a little seal, and this is our vacuum tube.

We create the raisin, so we switch it on, so it all collapses down, creates a raisin, and these guys tolerate this really well, really comfortable, and then this is the kind of granulation tissue you get, absolutely beautiful, and so at this stage now we can think about closing that, that wound down. We need to manage owner commitment, we, you know, we need the owner commitment with these, and I'm aware we're at the end of the talk now, so I'll, I'll, get finished shortly, that, these guys, you know, we need to manage the owner expectations. These are huge wounds that are gonna take a lot of time and a lot of money.

You will get a setbacks. The emotional roller coaster I always start with with these people, I say, look, you, you're buying into this now, we think that's great, we think we can do this, but you will have days where it's all going well, and we're really positive, and then suddenly something will go wrong, and, you know, they've got to be prepared to come backwards and forwards, but when people do buy into that, and if they're aware of what they're getting into at the start, these can be incredibly rewarding, to deal with these huge wounds. I really love these cases.

So this is Mimi who was de-gloved right down to pretty much the femur on the lateral side of this wound. He sees his necrotic skin that's gonna die away, that needs cutting away. So we get rid of all the dead tissue, it's had a bolus dressing on, you know, we've wet to dried it, we're down now to something that's clean, but we're thinking, God, we need some granulation from somewhere.

So 5 days of wet to dry dressings to get to this. Stick the vac on. This is what we get after 8 days of the therapy to get granulation, but now we can't really be bothered waiting for this to close, so we're just gonna do a quick surgical closure, advance some skin, and there we go.

So a huge wound that's closed in basically 9, 10 days, really nice success story. This is a last picture of, of Daisy, so. Get your head around this one.

So we actually borrowed the skin from around the top of her leg and shrugged it down to her knee and stitched it on. We then borrowed, we did a caudal superficial epigastric flap, which is in effect a flat base in the groyne that runs all the way up the nipples, and we've run that around the, the, this is a stifle and this is a hock. We've run that up and down the leg and closed it there.

And then finally, we've created a little tunnel in the side of her flank, and we've posted a foot through it. So this was a single stage reconstructive procedure, which might think, might look absolutely horrifying, but then when we've taken that down after about 2 to 3 weeks, this is what we've got, really nice skin that's all headed and growing. And And at the end of the day, after all of that, you know, we've got a nice functional cat, and that's, of course, the outcome.

So it's, it's not just all about, can we close it, can we save the leg? You know, there's no point in saving a leg that's not gonna be functional. You could have amputated her limb right from the word go, and that would have been completely reasonable, but we've got a nice, happy cat there with a functional leg and a, and a really satisfying case.

So thanks everybody for your attention, and if you've got any questions, I'm very happy to answer them. That's excellent. Thank you very much, John.

Beautiful pictures for a lunchtime webinar. Couldn't have gotten better. I've got, I've got nastier if you like.

I think that'll do for this time. Maybe we'll, grab those for the next one that you do for us. That, that cat.

With the gra, that's amazing. Oh yeah, you know, it's, and it's so satisfying these things, you know, not just from a professional level, and the fun of the surgery, which, you know, I've, you know, I, I completely, full disclosure, I mean, I love a bit of it, but you know, also for her, and she tolerated all of it extremely well. I mean, to get it to this stage, we dressed her leg up for a couple of days, before the surgery to make sure she tolerated it.

We didn't just go straight for that and hope she did OK. So there's things you can do to, to select your patient carefully. I mean Marley Lunnon, the, the pug, he would not have been a dog for this kind of job, you know.

Awesome. Thank you so much. I'm just gonna see if anybody has any questions, then do type them into the question box and we'll keep connected, for a little longer to go through those questions.

Do you remember, everybody, that this is being recorded. So, I'm sure you've got colleagues that would benefit from this, or if If you'd like to go back over it again, then the recording will be available within a day or two. It gets sent off after we finished today, and to be edited and then uploaded onto our website.

So you will need to log in with your member details to access this. It will be in the nursing archive in the nursing section. So make sure you go back and have a look at that again, and you'll also be able to access the, notes in a PDF format, that John Murray kindly provided for us.

Let me have a look, John, to see if we've got any questions. Yeah, is that the Q&A box that I can access? Oh, crumbs, can you see it as well?

That's gonna be scary. So only nice comments for everybody. Oh no, I can't see any comments actually.

I can just see open 0 answered 0. OK dokes. So get stuck in though, I don't mind, you know, people can write what they like.

I can take it. OK dokes. Anything you want, man, get it written in that question box.

If you have any clinical questions about my presentation. Oh yeah, Rob has put. Well, fantastic.

But ruddy clients keep coming in. So I have to watch your recording. Well, it's a, it's a good job we work record more for you, Rob.

Sorry, it's been interrupted for you. But, we do need those clients coming in the doors, Rob. Yeah, exactly.

We need to get the cases from somewhere. You do, you do. So if anybody has any questions, then.

Do type them in, and we can, we can go through those. And also, if you've got any suggestions on topics and or speakers for the monthly nurse webinars, then do let us know. I, type it into the question box here or email me at Wendy@the webinar vet.com, because, I do want to provide these nurse.

Webinars on topics that you want as nurses. I know there's a few vets on the, on the webinar, which we don't mind. But if the nurses have any particular speakers that they've really enjoyed listening to, or if any, they have any particular topics they'd like us to cover, then do just let me know and I will do my best to try and, get them booked in.

In in the next few months. As I say, I was listening to John's presentation to our, our veterinary coffee morning webinars and thought, yeah, we'll have someone out for our nurse webinars. It was a great presentation.

Thank you so much, John, for agreeing to come. My pleasure, pleasure, of course. And I, yeah, I mean, I'm happy to talk about, pretty much any soft tissue subject, so.

Do feel free to come up with some interesting ideas and I'll be more than happy to help out. That's excellent. There's no more questions.

You've been, very comprehensive presentation there, John. I think, destroyed everybody. Yeah, they were trying to settle their stomachs before they grab some lunch, before we go back to surgery.

But thank you so much. And for giving up your time, John, to speak to the, to, to our pleasure, of course. Thanks for inviting me.

No problem. I really do appreciate it and thank you all of our attendees today for joining us. It's great to, to see you on the live webinars and do remember you can go back and watch the recording whenever you want.

And, this evening we have, An SQP webinar. We do SQP webinars as well. So I'm back online in a few hours for another webinar for SQPs.

If you'd like information about that, if any of your nurses are online, our SQPs as well, just get in touch and I can give you the details about that. I'll let you go and enjoy the rest of a lovely sunny afternoon if you can manage to get outside, and hopefully see you all on a webinar soon.