wound management - sea turtle guardian€¦ · proliferation phase aging of injuries ... open wound...
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Wound Management Dr. Nancy Mettee, WIDECASTDirector of Sea Turtle Medicine
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Sharp trauma
• Clean/sharp margins
• Typically from propellor, skeg, or propulsion system but also some bite wounds
• Stab = deeper than long
• Incision= longer than deep
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Blunt trauma
• Ragged wound margins
• Crushing/laceration (tear in dermis, often with bridging)
• Compression/cavitation
• Contusion = bruise, closed injury
• Abrasion, scrape caused by friction or stretching
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Constriction injury
• Slow crushing
• Circumferential loss of blood supply
• Tourniquet effect
• May result in traumatic amputation
• Typically affect mid shaft extremity
• Treatment varies on severity
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Proliferation phase
Aging of injuries
Acute/inflammatory phase
Maturation phase
3 STAGES OF HEALING
by convention, “acute” is
within 24 hours of injury
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• Days
• Active bleeding
• Oozing serum
• Sharp edges
• No necrosis (dead tissue)
• No exudate (pus)
• No malodor
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• Weeks
• Well vascularized (red or pink) scar tissue
• Wound margins rounded
• Necrosis evident
• Infection (pus and malodor) evident, yellowish scab like material adherent to wound
• Tissue reorganization to epitheleize wound (cover over defect)
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• Months
• Tissue remodeling to form dense scar
• Organized, smooth granulation tissue
• Low vascularity (pale or pigmented in final stages)
• No bleeding
• No exudate
• No infection/odor
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Individual factors affecting healing
• All sea turtle wounds are contaminated, culture and sensitivity is ideal
• Common culprits: E. Coli, Pseudomonas (often very resistant), Vibrio, Citrobacter, Aeromonas, and Salmonella
• Anorexia and hypoproteinemia (TS <1.5 mg/dl) will delay healing
• Necrotic tissue in the wound is food for infectious organisms!
• Dry dock results in impaired circulation
• Fungal infections are common in cold stunned and immune compromised individuals
• Appropriate diet, vitamin supplementation, stress
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Wound management technique will depend on resources available
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Environmental factors affecting healing
• Holding temperatures of 75-85 degrees F (23-29 degrees C) will stimulate the immune system and improve metabolism
• Fresh water can damage exposed tissue
• Water quality : “pre load” bacteria present in incoming water, may be reduced or eliminated with filtration or by manufacture of sea water
• Water quality: “load” bacteria originating from patient exudate, decaying food material, or excrement, may be reduced by addition of chlorine to water (0.5-1 ppm chlorine), hygiene, and high flow rate of water
• Water quality: “after load” bacteria originating from other tanks/pipes as backwash, may be prevented with one way valves (require maintenance)
• Ultraviolet light?
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Simplest Remove necrotic tissue (debride) weeklyClean source of high flow waterExtended antibioticsRelatively slow healing, 6-12 month rehab time
Open wound management
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-Short term only due to dry dock issues-Daily bandages changes-Honey pack is a very effective and economical antimicrobial-Wet to dry bandages -SSD ointment, other topical antimicrobials-Can do compression for hemostasis, grenades for drainage-Increased healing time (4-6 months)
Bandaging out of the water
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-Long term therapy, improved circulation + food intake-Negative pressure wound therapy (NPWT), bandage change every q1-7 days-Silverlon bandage, occlusive bandage with tegaderm changed q24-48 hrs-Must have access to patient for bandage changes-More tolerant of poor water quality as wound is sealed-Dramatically increased healing time 2-3 months-Can manage very high mortality wounds successfully
Bandaging in the water
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Lung leaks can result in collapse without interventionNegative pressure needed to prevent lung scarringVAC therapy is ideal
Open pneumocoelom
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Drainage needed to prevent coelomitis/sepsis (ventral placement needed if no suction available)Barrier may be needed to maintain viscera in place if defect is present (implantable mesh, prosthetic)
Open coelom
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Head trauma
• If neurocranium fractured very high mortality
• Head trauma + neurologic signs (tremors, spastic movement, hyperesthesia) is grounds for euthanasia
• Encephalitis common but may take weeks to develop
• MRI or CT scan ideal
• DO NOT VAC!
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• Only if fracture results in marked instability
• Bone to bone healing unlikely (will form fibrous union)
• Drilling holes in carapace is painful,a source for infection, and screws will loosen due to micromovement of shell and localized osteomyelitis
• Fiberglass or other occlusive NOT advised due to risk of infection with out improved outcome
Fracture repair
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Carapace and skull are dermal bone
• Growth occurs at suture lines--not end plates as with osteochondral bone
• Growth can be manipulated by distraction (pulling apart) and compression (pulling together) to reduce defects
• Implants or semipermanent fixtures will actually restrict growth and result in deformities (particularly an issue with juveniles and sub adults)
• Individuals should not be released with an implant in place due to risk of complications
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