Wound healing and patients with altered or delayed healing cover the entire spectrum of surgical care. This chapter will review wounds, wound healing and closures, coverage options, and abnormalities in wound healing. It will focus on general principles and concepts rather than specific topics since the majority of these are dealt with in greater detail in other chapters. First, the biology and pathophysiology of wound healing will be explored in depth. Next, bites and stings, including emerging threats in the United States, will be detailed as our knowledge in these areas continues to advance.
Each year in the United States, millions of individuals sustain traumatic injuries but the overwhelming majority of these are simple and readily treated with minor interventions. In practical terms, satisfactory healing of wounds such as these would take place regardless of the treatments that they received. This chapter will focus on more severe wounds or those wounds that would not have a satisfactory outcome without special attention. The main principles in treating these wounds are preventing infection, retaining maximal function, and achieving acceptable cosmesis. The spectrum of health care providers who care for these wounds is extensive, including emergency medicine physicians, advanced practice nurses, family physicians, surgeons, and surgical subspecialists, but the treatment philosophy is the same. The nature and mechanism of the wound, its anatomic location, preexisting comorbidities, and the current clinical situation all dictate the approach to the wound but in general the simplest technique that fulfills the previously stated objections should be embraced. Fig. 47-1 provides a treatment algorithm for acute wounds that is applicable to a wide array of clinical scenarios and wounds.
Algorithm for the treatment of an acute wound. aAppropriate tetanus, rabies, and antibiotic prophylaxis. bIntermediate- risk wounds require more judgment. cSee Table 47-9.
Wound healing has always held an important status in medical care throughout recorded history. The Egyptians practiced advanced wound care as evidenced by the Edwin Smith and Ebers papyruses as did the ancient Greeks whose doctrine on the care of acute and chronic wounds in gladiators was described by Galen of Pergamum.1 The ancients observed that dead tissue and foreign bodies had to be removed in order for normal wound healing to progress and that cleanliness prevented infection. They recognized that organized collections of pus required drainage and that honey (a hypertonic, hygroscopic, and bactericidal fluid) could prevent infections while dirt and dung promoted them. However, the biology of this effect was a mystery to them.2 Later in the 1500s, the scholarly treatise on wounds by French surgeon Ambroise Pare established a truism that is still applicable today: “Do not put anything in a wound that you would not put in your own eye.” Despite the seminal contributions of Lister, Semmelweis, Ehrlich, Fleming, and Florey, it was not until the very end of the 20th century ...