Acute and Chronic Wound

DEFINITION of Wound
◈ Disruption of normal continuity of skin and underlying
tissue integrity because of trauma or surgical incision
Wound edge Wound
corner
Surface of
the wound
Base of the wound
Cross section of a simple wound
Wound edge
Wound Skin surface
cavity Subcutaneus tissue
Surface of
the wound Superficial fascia
Muscle layer
Base of the wound
 Acute Wound
Wound • Heals in predictable
manner and expected
duration
Acute • Traumatic acute wound: a
wound or laceration of
•< 3-4 traumatic origin with no
weeks evidence of macroscopic
contamination or signs of
active infection
Chronic • Traumatic wounds are one
•> 4-6 of the most common
problems leading people
weeks
Classification of Acute Wound
 1) Abraded wound
(vulnus abrasum)
⚫ Superficial part of the
epidermal layer
⚫ Good wound healing
⚫ Treatment: wound is
cleaned and kept
moist

Traumatic Wounds
8
 2) Punctured wound
(vulnus punctum)

⚫ Sharp-pointed object
⚫ Depth within the body is
much greater than the
dimensions of the wound
⚫ Irrigate into the puncture,
clean wound with H2O2
and povidone iodine
⚫ Possible pseudomonal
infection
⚫ Assess the need of
Traumatic Wounds antibiotics and anti-tetanus
 3) Incised wound (vulnus
scissum)

◈ Sharp object, regular

margins of wound
◈ Best healing
◈ Treatment: Wound
cleansing, primary suture
◈ wound dressing

Traumatic Wounds
10
 4) Torn wound (vulnus
laceratum)

◈ A tear in tissue caused

by shearing or crushing
force
◈ Blunt-trauma
mechanism
◈ Treatment: wound
cleansing, primary
suture, wound dressing

Traumatic Wounds
 5) Cut wound (vulnus
caesum)

◈ Sharp object + blunt

additional force
◈ Edges – uneven
◈ Treatment: wound
toilet, primary suture,
wound dressing
Traumatic Wounds
 6) Crush wound (vulnus
contusum)
◈ Blunt force 🡪 Pressure
injury between 2 heavy
objects, edges – uneven
and torn
◈ Bleeding 🡪 stop bleeding
by direct pressure
◈ Related damage:
bleeding, bruising,
compartment syndrome,
fracture, nerve injury
◈ When severe enough 🡪
affected muscle fibers and
damaged tissues release
Traumatic Wounds cellular byproducts and
electrolytes 🡪 crush
syndrome, may lead to
renal failure, arryhtmias,
 Traumatic
wounds
7) Shot wound (vulnus
scolperatium)
◈ May be penetrating or
perforating
◈ Entrance wound: reddish-brown
area (abrasion ring)
◈ Treatment: control bleeding,
immobilize the object in place,
reduce infection
 Skin Avulsion

Degloving Injury

Special wound
 DEGLOVING - Definisi
Suatu cedera dimana kulit dan jaringan
lunak dibawahnya terlepas (terelevasi)
secara paksa dari dasar (fascia) oleh
kekuatan dengan tekanan yang keras dan
mendadak (shearing force), biasanya terjadi
karena tungkai terjebak di bawah ban
kendaraan.

Pembuluh daraf perforator terputus

 Jenis Trauma Kulit dan Jaringan Lunak
• Degloving Tertutup
- Dimana kulit dan jaringan lunak dibawahnya terlepas dari
dasarnya tetapi permukaan kulit masih intak.

◈ Degloving Terbuka
- Dimana kulit dan jaringan lunak dibawahnya terlepas dari
dasarnya disertai dengan terputusnya kontinuitas permukaan
kulit.

◈ Avulsi
- Dimana jaringan kulit dan atau jaringan lunak dibawahnya
 Patofisiologi
◈ Tekanan + gaya puntir pada
kulit 🡪 terputus kontinuitasnya,
sebagian kulit masih melekat
seperti flap 🡪 pembuluh darah
perforator yang mensuplai kulit
terputus 🡪 vitalitas jaringan
terganggu 🡪 nekrosis

◈ Devaskularisasi lemak flap

 Tanda Klinis

Kulit yang mudah bergerak / Tidak melekat

pada dasar

Tire mark / friction burn

Hematome

Fluktuasi subkutis
 Penilaian Vitalitas Kulit

1. Tes tekan/penilaian CRT

2. Eksisi marginal
3. STSE
4. Prick test (bright red vs purple)
5. Fluorescence test
6. Extra: hair tug test
 Tes vitalitas jaringan lain

1. Lemak : Warna kuning cerah 🡪 avital: kuning

kunyit
2. Otot : warna merah segar, CRT baik, berkedut
bila dirangsang cauter (5, cutting) 🡪 avital:
kehitaman
3. Tulang : warna putih berkilat, periosteum + 🡪
avital: kering, kuning kecoklatan
 Penilaian Vitalitas Kulit
1. Beri tanda dengan methylen blue
daerah yang degloving
2. Jahitkan flap degloving kembali ke
posisi anatomi semula
3. Dalam tahapan ini perlu juga
penilaian vaskularisasi flap
degloving
4. Split Thickness Skin Exicision
(STSE) :
- Diagnosis
- Terapi
 Algoritma
Trauma Kulit dan Jaringan Lunak

Degloving Avulsi

Tertutup Terbuka

Tes Vitalitas Jaringan Tes Vitalitas Jaringan

Vital Non Vital Vital Non Vital

Insisi Kecil Eksisi Jahit Tidak Tegang Kulit Kulit

(Jangan Coba Jahit Primer) Baik Tidak Baik
Irigasi
Split Thickness Defatted Eksisi
Skin Graft Split Thickness
Drain
Skin Graft Split Thickness
Skin Graft
Balut Tekan
Full Thickness
Skin Graft
 Wound
Evaluation

Comorbid
Tetanus status
Past Surgical
History
Medications
Allergies
Tetanus Prophylaxis
Types of Wounds and Treatment
 Irrigation & Debridement
1. Debridement – excision of all devitalized,
contaminated, foreign bodies
2. If Possible, Vital sturctures including nerves, blood
vessels, tendons and bones shouldn’t be debribed
3. Irrigation with NaCL 0.9% 🡪 Dilute the bacterial
load as well as clean out debris 🡪 30 cc syringe and
18 G catheter, full force each time from about 3
mm distance 🡪 provides maximal irrigation and
‘pressure washing’ (at about 25 psi.), without
causing tissue damage 🡪 Repeat 🡪 wound is
irrigated with roughly 50-100 cc for every cm in
wound length
4. Mechanical debridement (sharp& blunt)
5. Gauze debridement
6. Chemical debridement
Closure
1. Closure should be attempted
within 6 hours (clean,
debrided, free of foreign
bodies, irrigated, hemostatic)
2. Primary
3. Secondary
4. Tertiary
 Goal of Wound Dressing
Maintain wound moist environment

Absorb exudate

Provide barrier againts bacteria

Debride necrotic tissue

Reduce edema

Filling dead space

Protect againts trauma, shear

Promote wound healing

Dressing Selections
Types of Dressing
Types of Dressing
Types Of Dressing
 Luka Kronis
(Chronic Wound)
 Definisi Luka Kronis
◈ Luka yang gagal dalam melalui proses penyembuhan yang
normal untuk menghasilkan suatu integritas fungsional dan
anatomis yang memuaskan
◈ Luka yang tidak sembuh dalam 3 bulan / ≥ 4-6 minggu / >
3 minggu

Soedjana H. Penatalaksanaan Ulkus Tekanan (Pressure Ulcer/Decubitus Ulcer). Bandung: CV. Adia. 2016. Edisi 1
Brown DL, Broshcel GH. Michigan Manual of Plastic Surgery. Philadelphia: Lippincott Williams & Wilkins. 2004
Thorne CH, editors. Grabb and Smith’s Plastic Surgery, 7 th edition. Philadelphia: Lippincott Williams & Wilkins. 2014
 Penyembuhan Luka Normal vs
Abnormal

Thorne CH, editors. Grabb and Smith’s Plastic Surgery, 7 th edition. Philadelphia: Lippincott Williams & Wilkins. 2014
Penyembuhan Luka Akut vs Kronik

http://www.medicalgraphics.de/en/projects/list-of-projects/projects-2016/illustration-of-chronic-wound-compared-to-the-acute-
 Alur Inflamasi Kronis pada Luka Kronis

Luka

Inflamasi
Proliferasi Remodelling
Akut
Induksi
Inflamas
i
Ekstern
al
Inflamasi
Kronis

Soedjana H. Penatalaksanaan Ulkus Tekanan (Pressure Ulcer/Decubitus Ulcer). Bandung: CV. Adia. 2016. Edisi 1
 Faktor-Faktor Penyembuhan Luka Kronis
Sistemik Lokal
◈ Nutrisi ◈ Peripheral vascular disease
◈ Penyakit kardiopulmonal ◈ Venous stasis
◈ Kemoterapi ◈ Neuropati perifer (DM)
◈ DM ◈ Radiasi
◈ Merokok ◈ Penekanan
◈ Penyakit autoimun ◈ Infeksi
◈ Edema

Jones CM, et al. Evidence-based medicine: wound management. Plast. Reconstr. Surg. 2017;140(1):201e-16e
 Luka Kronis

Masalah:
◈ Nekrotik / slough
◈ Eksudat
◈ Infeksi

Contoh luka kronis:

◈ Luka terinfeksi
◈ Ulkus dekubitus
◈ Ulkus diabetik
◈ Ulkus vena dan arteri
Perdanakusuma DS. Luka. Basic Course of Plastic Surgical Skill. 2014
 Increasing
pain, edema
malodorous
discharge,
increased
drainage,
purulence

Wound cleansing Debridement Debridement

Exudate managementTopical antimicrobial Topical antimicrobial
Exudate Systemic antibiotics
management Exudate
http://www.worldwidewounds.com/2005/ management
 Biofilm

◈ Biofilm: kumpulan bakteri yang

menempel ke reseptor permukaan
sel 🡪 mengubah 50% struktur
protein: melindungi mereka dari
antimikroba 🡪 barrier
penyembuhan luka
◈ 60% luka kronis
◈ Debridement surgical (+)
antimikroba topikal

Young L. Identifying infection in chronic wounds. Wound Practice and

 Infeksi pada Luka (infected wounds)
◈ Luka akut 🡪 flora normal kulit
🞚 Staphylococcus aureus, Streptococcus B Hemolyticus
◈ Luka kronis
🞚 Anaerob gram negatif (Pseudomonas, Proteus, Klebsiella,
E.Coli)
🞚 Semakin buruk luka, semakin tinggi risiko infeksi anaerob

Neal R, Chamberlain. The Microbiology of

Wounds.
 Ulkus Tekanan (pressure ulcer)
► Tekanan antara penonjolan tulang dan
permukaan luar yang melebihi tekanan
kapiler (32 mmHg) 🡪 iskemi
► Faktor mekanik: imobilisasi, tekanan,
gesekan (friction), gesek tekan (shear),
kelembaban
► Manajemen: redistribusi tekanan 🡪
mempertahankan aliran darah 🡪
pergerakan dan reposisi pasien, kasur
decubitus; debridement, penutupan luka,
NPWT

Soedjana H. Penatalaksanaan Ulkus Tekanan (Pressure Ulcer/Decubitus Ulcer).

Bandung: CV. Adia. 2016. Edisi 1
 Ulkus Diabetikum (diabetic ulcer)
◈ Neuropati 🡪 hilangnya sensasi
protektif dan koordinasi otot 🡪
stress mekanik saat berjalan
◈ Makro + mikroangiopati:
Atherosklerotik, PAD
◈ Debridement, antibiotik (selulitis,
osteomielitis), dressing yang
sesuai, kontrol gula darah,
evaluasi insufisiensi arteri perifer

Rice JB, Desai U, Cummings AK, Birnbaum HG, Skornicki M, Parsons NB. Burden
of diabetic foot ulcers for Medicare and private insurers. Diabetes Care. 2014.
 Ulkus Vena dan Arteri (Leg Ulcers)
Vena Arteri
◈ ↑ tekanan vena + ◈ ↓ aliran arteri --> ↓
katup vena oksigen --> iskemia
inkompeten -->
edema lokal &
ekstravasasi plasma
◈ fibrin cuff sekitar
kapiler --> hambat
difusi oksigen & nutrisi

Neligan PC. Plastic Surgery. Elsevier. 2013

Grey JE, et al. ABC of wound healing. BMJ 2006;332(11):347-50
 Tatalaksana
◈ Debridement adekuat
◈ Tatalaksana infeksi
🞚 Selalu curiga adanya infeksi pada luka
kronis
🞚 Kultur jaringan dan jumlah pathogen
◈ Dressing luka yang sesuai
🞚 Moist
🞚 Debridement, antimikroba topikal,
menyerap eksudat
◈ Faktor lokal dan sistemik
🞚 Penyakit vaskular, DM, malnutrisi,
tekanan
Brown DL, Broshcel GH. Michigan Manual of Plastic Surgery. Lippincott Williams & Wilkins.
Philadelphia:2004
 Konsep T-I-M-E

Leaper DJ, et al. Extending the TIME concept: what have we learned in the past 10 years? Int Wound J 2012;9(Suppl. 2):1-19
 Tetanus
◈ Tetanus is an acute, often fatal, disease caused by an exotoxin produced by the bacterium Clostridium
tetani.
🞚 slender, gram-positive, anaerobic rod that may develop a terminal spore
🞚 The organism is sensitive to heat and cannot survive in the presence of oxygen. The spores, in
contrast, are very resistant to heat and the usual antiseptics 🡪 become noninefctious with hydrogen
peroxide
🞚 The spores are widely distributed in soil and in the intestines and feces of horses, sheep, cattle,
dogs, cats, rats, and chickens
◈ Characterized by generalized rigidity and convulsive spasms of skeletal muscles. The muscle stiffness
usually involves the jaw (lockjaw) and neck and then becomes generalized.
◈ C. tetani produces two exotoxins, tetanolysin and tetanospasmin. The function of tetanolysin is not
known with certainty. Tetanospasmin is a neurotoxin and causes the clinical manifestations of tetanus.
 Tetanus
◈ All wounds should be cleaned. Necrotic tissue and foreign material
should be removed. If tetanic spasms are occurring, supportive therapy
and maintenance of an adequate airway are critical.
◈ Because of the extreme potency of the toxin, tetanus disease does not
result in tetanus immunity. Active immunization with tetanus toxoid
should begin or continue as soon as the person’s condition has
stabilized.
Terima Kasih
Kasus Luka Akut dan
Kronik
Luka Akut
Luka Kronik