Complex Wounds and the Complex Patient

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Complex Wounds and the Complex Patient

• Chet A. Morrison, M.D
• Assistant Professor of Surgery
• Director of Surgical Critical Care
• Michigan State University

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Introduction

• Complex wounds represent a widespread problem
• Incidence is increasing
• Variety of causes

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Introduction

• Earliest medical documents known deal with wound
  treatment
• References found in ancient texts frequent
  references in the Talmud
• Galen of Pergamon, physician to Roman Gladiators
  wrote on necessity of keeping wounds moist

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Introduction

• . . . But wounds and bruises, and festering
  sores they have not been pressed, neither bound
  up, neither mollified with oil.
• Isaiah 16

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Diagram of Wounds
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Complex Wounds the Basics
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Complex Wounds the Basics
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Complex Wounds the Basics
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Complex Wounds the Basics
Singer AJ NEJM 341 10 738-746
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Wounds in Combat
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Grade V Hepatic Injury
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Damage Control Laparotomy

• Well described trauma technique
• Patients are cared for in ICU warmed and
  resuscitated prior to Return to OR
• No attempt made to establish bowel continuity
• Often leads to complex open wounds

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A Frequently Encountered Problem
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A Frequently Encountered Problem
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A Frequently Encountered Problem
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Natural Disaster Wounds
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Wound Care Basics

• Nutritional deficits --calories and
  essential nutrients
• Radiation Damage
• Immunosuppression
• Foreign Bodies

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Wound Care BasicsWound Infections

• Will stop healing dead in its tracks 105CFU/g
  diagnosed by tissue biopsy and culture
• More common in the immunosupressed and the
  diabetic
• Removal of foreign bodies glycemic control
  important

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Wound Care BasicsWound Infections

• Staph most common organism
• Can also be Strep, mixed, E Coli, unusual
  pathogens
• Distinguish between contamination, colonization
  and infection

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Wound Care BasicsWound Infections

• Supra or subfascial
• May not be obvious postoperative fever, usually
  low-grade development of a mild and unexplained
  leukocytosis or the presence of undue incisional
  pain
• Attention to wound at bedside or in OR

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Complex Wounds the Basics

• Clean the wounds with nontoxic solutions
• Wound inspection and gentle exploration
• Sharp debridement to remove all necrotic tissue

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Complex Wounds the Basics

• Open and drain all abscesses
• High pressure wound irrigation to start
• If you use gauze, saline is adequate
• Supplemental oxygen

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Complex Wounds the Basics
Singer AJ NEJM 341 10 738-746
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Complex Wounds the Open Abdomen

• Five reasons to leave the abdomen open -Severe
  Infection -Mesenteric ischemia -Damage
  Control laparotomy -Abdominal Compartment
  Syndrome -Necrotizing abdominal wall infection

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Abdominal Compartment Syndrome
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Abdominal Compartment Syndrome
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Abdominal Compartment Syndrome
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Abdominal Compartment Syndrome

• Management involves identification, fluid
  resuscitation and support
• Open decompressive laparostomy needed for
  refractory ACS with organ failure or pressure gt
  25 mm HG
• Abdomen closed when process controlled and
  pressures , 12 mm HG

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Complex Wounds the open Abdomen
Schecter HC J Am Coll Surg 203 3 390-396
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Complex Wounds the open Abdomen
Schecter HC J Am Coll Surg 203 3 390-396
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Complex Wounds the open Abdomen
Component Separation
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Complex Wounds the open Abdomen
Component Separation
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Open Abdomen The alloderm closure
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The horrendous wound Treatment with alloderm
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The horrendous wound Treatment with alloderm
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The horrendous wound Treatment with alloderm
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Open Abdomen The V.A.C closure
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Open Abdomen The V.A.C closure
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Open Abdomen The V.A.C closure
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Open Abdomen The V.A.C closure
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Difficult wounds graft and V.A.C
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Entero-atmospheric fistula a catastrophic
complication

• Seen in prior open abdomen
• High mortality, no quick fix
• Not going to heal on its own!

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Entero-atmospheric fistula a catastrophic
complication

• Try to prevent it
• Seal and pray (works if God particularly likes
  you patient).
• Control fistula effluent
• Cover fistula with vascularized soft tissue
• Very delayed resection
• Constant attention by senior surgeon

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Entero-atmospheric fistula a catastrophic
complication
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Entero-atmospheric fistula a catastrophic
complication
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Entero-atmospheric fistula a catastrophic
complication
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Entero-atmospheric fistula a catastrophic
complication
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Complex Wounds A Characteristic Patient

• 41 male, motorcycle disaster
• Open pelvic fracture
• Multiple extremity fractures
• Bladder disruption, urethral injury

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Complex Wounds A Characteristic Patient

• Required packing and pelvic embolization for
  hemorrhage
• Developed necrotizing fasciitis with pelvic
  sepsis
• Required ostomy, open abdonimal wound and
  extensive perineal debridement

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Complex Wounds A Characteristic Patient

• Wounds initially managed with V.A.C dressing and
  gauze
• Alloderm used to close abdominal wound
• Skin grafting, primary closure used to control
  perineum

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Complex Wounds A Characteristic Patient

• Developed large (grade 4) sacral decubitus
• Treated with V.A.C dressing as well
• Ultimately required myocutaneous flap
• Insurance issues kept pt in hospital 7 months!

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A Parting Thought