Wound Healing Hemostasis and Inflammation

Nilo C. de los Santos, M.D., FPCS Day 0 5

Platelets
Objectives o Hemostasis and serves as scaffolding for
A. Phases of wound healing migrating inflammatory cells
B. Healing in Specific tissues PMN
C. Classification of wounds o neutrophils wound debridement
D. Treatment of wounds (phagocytosis)
Macrophages
Phases of Wound Healing
o from monocytes
Hemostasis and Inflammation
o wound debridement (phagocytosis)
Proliferation
T lymphocytes
Matrix Synthesis
o Not fully defined
Maturation and Remodeling
Epithelialization Inflammation is the normal acute reaction of the
Role of Growth Factors in Normal Healing tissues after any injury
Wound Contraction Immediate response of the blood supply to the area is
a constriction of the vessels
Followed immediately by vasodilation that allows
fluid to exit the capillaries and flood the area. The
fluid, plasma, contains fibrinogen which is cleaved to
form fibrin strands that form substantial portions of
the blood clot.
Chemicals in the plasma and on injured tissues attract
white blood cells (PMNs and macrophages) that
enter the area and start to clean up foreign material,
bacteria and dead cells.

Proliferation
Day (3 14)
Fibroblast
o Fibroblast proliferation and synthesis
(fibroplasia).
o For matrix synthesis and remodeling
Endothelial cells
o Revascularization of the wound proceeds in
parallel with fibroplasia
o Formation of new capillaries (angiogenesis)

Matrix Synthesis
Collagen
A. Its deposition, maturation, and remodeling
are essential to the functional integrity of
the wound
B. Type 1 major component of extracellular
matrix
C. Type 3 more prominent during the repair
Components of Wound Healing process
Proteoglycan synthesis
A. Ground substance that makes up
granulation tissue

Maturation and Remodeling

Reorganization of previously synthesized collagen
(remodeling 6 to 12 months)

Epithelialization
Proliferation and migration of epithelial cells
Begins within 1 day of injury and is completed in less
than 48 hours in incised wound

rainwater@mymelody.com || 2nd semester, AY 2011-2012

 Wound Contraction
Inward movement of the wound edge
Incised wounds without significant tissue loss closes
by primary intention
Large wounds, particularly those associated with
significant tissue loss, heal by secondary intention
Begins around the fifth day and is complete by 12-15
days
A. Fibroblasts appear to be responsible
Specialized fibroblasts called
myofibroblasts provided the
motive force for wound
contraction via a musclelike cell
contraction.

Classification of Wounds
Primary closure, that is, to close the wound at the
time of initial presentation
Growth Factors in Normal Healing Secondary closure, that is, to allow the wound to heal
Epithelial Growth Factor on its own
A. 53-amino acid polypeptide chain Tertiary closure, that is, to close the wound after a
B. Released during platelet degranulation period of secondary healing.
C. Stimulate re-epithelialization, angiogenesis,
Factors Affecting Wound Healing
and collagenase activity
Healing does not always occur in a straightforward,
Fibroblast Growth Factor
undisturbed fashion. Both local and systemic factors
A. Stimulate angiogenesis
can interfere with healing.
B. Stimulate endothelial cell proliferation
Local factors include
C. Stimulate collagen synthesis
A. Infection
D. Stimulate wound contraction
B. Foreign bodies
E. Stimulate matrix synthesis
C. Tissue hypoxia
F. Stimulate epithelialization
D. Venous insufficiency
G. Produces keratinocyte growth factor
E. Local toxins
Platelet-Derived Growth Factor
F. Mechanical trauma
A. Produced by the alpha granules of the
G. Irradiation
platelet
H. Cigarette smoking
B. Activates TGF-beta
Systemic factors include
C. Stimulates neutrophils and macrophages
A. Malnutrition
D. Stimulates chemotaxis
B. Cancer
E. Stimulates mitogenesis of fibroblasts and
C. Diabetes mellitus
smooth muscle cells
D. Uremia
F. Stimulates collagen synthesis and
E. Jaundice
collagenase activity
F. Old age
G. Stimulates angiogenesis
G. Corticosteroids
Transforming Growth Factor - Beta
H. Chemotherapeutic agents
A. Found in the platelet alpha granules
I. Alcoholism
B. Reverse the inhibition of wound healing
caused by glucocorticoids Wound Contraction
C. Stimulates monocytes to secrete FGF, The regulation of wound contraction remains poorly
PDGF, Tumor Necrosis Factor Alpha defined. Information regarding the effects of specific
(TNF-alpha), and Interleukin-1 cytokines on contraction is limited and often
D. Stimulates fibroblast chemotaxis and conflicting.
proliferation A. TGF-b has been found to promote
E. Potent stimulator of collagen synthesis contraction even in the absence of serum
F. Decreased dermal scarring B. PDGF has also been found to either increase
Transforming Growth Factor - Alpha contraction or have no effect
A. Variant of Epithelial Growth Factor C. FGF and EGF have been found by different
B. Produced by activated platelets, authors to either have no effect or cause a
macrophages, and keratinocytes moderate enhancement of contraction.
C. Stimulates mesenchymal, epithelial, and
endothelial cell growth
D. Stimulates endothelial chemotaxis
Interleukin 1
A. Stimulates lymphocyte proliferation
B. Influences collagenase activity

rainwater@mymelody.com || 2nd semester, AY 2011-2012

Treatment of Wounds Timing of Wound Closure
Priorities are a careful, complete history and a Primary closure, that is, to close the wound at the
thorough physical examination time of initial presentation
Most cutaneous wounds are obvious and easily Secondary closure, that is, to allow the wound to heal
diagnosed but are not life threatening. on its own
The wounded patient may also have less apparent Tertiary closure, that is, to close the wound after a
problems that are potentially lethal and demand period of secondary healing.
immediate attention.
The management of such potentially life-endangering Classification and Infection Rates of Operative Wounds
problems takes precedence over wound management. Classification Infection Wound Characteristics
The patient's tetanus immunization status should be Rate (%)
considered. Clean (class I) 1.55.1 Atraumatic, uninfected; no entry
Antirabies treatment should be considered for of GU, GI, or respiratory tract
patients who have been bitten by domestic and wild Clean- 7.710.8 Minor breaks in sterile technique;
animals such as skunks, raccoons, foxes, and bats. contaminated entry of GU, GI, or respiratory
(class II) tract without significant spillage
Wound Classification
Contaminated 15.2 Traumatic wounds; gross
Clinical Features Tetanus-Prone Non-Tetanus-Prone
(class III) 16.3 spillage from GI tract; entry into
Wounds Wounds
infected tissue, bone, urine, or
Age of wound > 6 hr 6 hr
Configuration Stellate wound, Linear wound bile
avulsion, abrasion Dirty (class IV) 28.0 Drainage of abscess;
Depth > 1 cm 1 cm 40.0 debridement of soft tissue
Mechanism of Missile, crush, Sharp surface infection
injury burn, frostbite (e.g., knife or glass)
Signs of Present Absent Method of Wound Closure
infection The types of wound closure are
Devitalized Present Absent A. Direct approximation
tissue Sutures, staples, tapes, and tissue
Contaminants Present Absent adhesives
(e.g.,dirt, feces, B. Skin graft (autograft)
soil, or saliva)
C. Local flap
Immunization Schedule Random or axial
History of Tetanus Tetanus-Prone Non-Tetanus-Prone D. Distant flap
Immunization Wounds Requires microvascular
(Doses) Td TIG Td TIG anastomoses
Unknown or < 3 Yes Yes Yes No Dressings
3 or more No No No No The purpose a dressing is to serve must be carefully
For children < 7 yr, diphtheria, tetanus toxoids and pertussis considered before the dressing is applied.
A. Warm, moist environment
vaccine adsorbed (or diphtheria and tetanus toxoids adsorbed,
Biologic dressings (e.g., allograft,
if pertussis vaccine is contraindicated) is preferable to tetanus
amnion, or xenograft)
toxoid alone. For persons 7 yr of age and older, Td is preferable
Synthetic biologic dressings (e.g.,
to tetanus toxoid alone.
Yes, if more than 5 yr since last dose. Biobrane)
Yes, if more than 10 yr since last dose. Hydrogel dressings
Dressings of semipermeable or
Td--tetanus and diphtheria toxoids adsorbed (for adult use)
nonpermeable membranes (e.g.,
TIG--tetanus immune globulin (human)
Op-Site or Duoderm)
Antibiotic Prophylaxis B. Wounds containing necrotic tissue, foreign
Prophylactic antibiotics are not indicated for most bodies, or other debris
wounds. Wet-to-dry dressings
Indicated for Wet-to-wet
A. Contaminated wounds in Enzymatic agents (e.g., Travase,
immunocompromised or diabetic patients Santyl, and Accuzyme)
B. Extensive injuries to the central area of the C. Lower the bacterial count in infected
face wounds
C. Patients with valvular disease Silver sulfadiazine
D. Patients with prostheses D. To prevent bacterial contamination
E. Lymphedematous extremities Xeroflo, a fine-meshed gauze
F. Stool-contaminated and human-bite wounds impregnated with a hydrophilic
G. Dog-bite wounds substance
H. Wounds with extensive amounts of N-terface, a synthetic fine-
devitalized tissue (e.g., farm injuries). meshed gauze.

rainwater@mymelody.com || 2nd semester, AY 2011-2012