Types of Wound Healing

1.) Healing by first intention

• aka. primary wound healing or primary closure
• Describes a wound closed by approximation of wound margins or by placement of a graft or flap, or wounds created and closed in the operating room.
• Best choice for clean, fresh wounds in well-vascularized areas
• Indications include recent (<24h old), clean wounds where viable tissue is tension-free and approximation and eversion of skin edges is achievable.
• Wound is treated with irrigation and débribement and the tissue margins are approximated using simple methods or with sutures, grafts or flaps.
• Wound is treated within 24 h following injury, prior to development of granulation tissue.
• Final appearance of scar depends on: initial injury, amount of contamination and ischemia, as well as method and accuracy of wound closure, however they are often the fastest and most cosmetically pleasing method of healing.

 2.) Healing by second intention

• aka. secondary wound healing or spontaneous healing
• Describes a wound left open and allowed to close by epithelialization and contraction.
• Commonly used in the management of contaminated or infected wounds.
• Wound is left open to heal without surgical intervention.
• Indicated in infected or severely contaminated wounds.
• Unlike primary wounds, approximation of wound margins occurs via reepithelialization and wound contraction by myofibroblasts.
• Presence of granulation tissue.
• Complications include late wound contracture and hypertrophic scarring

3.) Healing by third intention

• aka. tertiary wound healing or delayed primary closure
• Useful for managing wounds that are too heavily contaminated for primary closure but appear clean and well vascularized after 4-5 days of open observation. Over this time, the inflammatory process has reduced the bacterial concentration of the wound to allow safe closure.
• Subsequent repair of a wound initially left open or not previously treated.
• Indicated for infected or unhealthy wounds with high bacterial content, wounds with a long time lapse since injury, or wounds with a severe crush component with significant tissue devitalization.
• Often used for infected wounds where bacterial count contraindicates primary closure and the inflammatory process can be left to débribe the wound.
• Wound edges are approximated within 3-4 days and tensile strength develops as with primary closure.

4.) Partial Thickness Wounds

• Wound is superficial, not penetrating the entire dermis.
• Type of healing seen with 1^st degree burns and abrasions.
• Healing occurs mainly by epithelialization from remaining dermal elements.
• Less contraction than secondary healing in full-thickness wounds
• Minimal collagen production and scar formation.

Source:http://www.medstudentlc.com/page.php?id=67

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FLUID REPLACEMENT IN PAEDIATRICS

Source:Tintenelli 6th edition

 FLUID REPLACEMENT IN PAEDIATRICS (NOT IN SHOCK)

 For example, a 12-kg infant is estimated to be 10 percent dehydrated.
 After a 20-mL/kg bolus of NS, she is alert and perfusion is adequate.

Fluid orders can then consist of:

1. Maintenance is 100 mL/kg x 10 kg/24 h = 1000 mL + (50 mL/kg x 2 kg/24 h) = 100 mL, for a total of 1100 mL/24 h or 46 mL per h.

 2. Deficit = 10 percent of body weight (1.2 kg) = 1200 mL; replace 600 mL over the first 8 h or 75 mL per h; replace 600 mL over the next 16 h or 38 mL per h.

Thus, for the first 8 h, maintenance + deficit = 121 mL per h; for the next 16 h, maintenance + deficit = 84 mL per h.

 Appropriate rehydrating solutions in infants are D5 .25NS or D5 .45NS. In infants, D5 .20NS is utilized for maintenance rehydration in isotonic dehydration. In children, D5 .45NS can be used for maintenance rehydration in isotonic dehydration

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Signs of retroperitoneal bleeding

Source:http://daquandisease.com/signs-of-retroperitoneal-bleeding/ Symptoms of retroperitoneal bleeding High misdiagnosis rate of retroperitoneal bleeding, the reason is the injury complicated abdominal internal organs lack of knowledge of retroperitoneal hemorrhage, splenic rupture, or only pay attention to the diagnosis of pelvic fractures, while ignoring the retroperitoneal injury.The diagnosis of abdominal trauma based on (parts of the level of violence and other medical history) and the typical symptoms and signs, combined with B-mode ultrasound examination, abdominal CT and X-ray, if necessary, to do or excretory urography angiography. Clinical manifestations of hemorrhage depends on the speed, volume, caused by reasons, location and involvement of organs, such as bleeding are small, confined, difficult to have a fixed typical performance, especially when complicated by complex injury, the symptoms more easily concealed. Majority of patients the disease progressed very quickly, in hours or days of the onset of symptoms, clinical course of a few hidden after, late in anemia and mass. The main symptoms are abdominal pain, abdominal pain is the earliest and the most common symptoms of varying degree of severity can be limited or diffuse, position in the abdomen, lateral abdomen, waist or hips in the back or sacral, sometimes squatting can ease.Other common symptoms include nausea, vomiting, constipation or mild diarrhea, decreased bowel, abdominal distension and paralytic ileus and so on.In severe cases, may be associated with hemorrhagic shock and severe anemia, blood loss and retroperitoneal nerve stimulation can cause sweating, palpitations, hypotension, syncope or shock.Some patients had transient fever.With the progression of the disease can occur in paralytic ileus, hematoma, mesenteric vascular compression, it can cause local intestinal loop necrosis.Hematoma, nerve, it can lower extremity neuropathic pain, numbness, and even dysfunction.Hematoma can affect the solar plexus, making autonomic dysfunction, gastrointestinal tract and urinary tract appears peristalsis and excretion dysfunction. Check local abdominal tenderness, and sometimes in the abdomen, side of the palpable mass in the abdomen or the waist or full, in general no or only mild abdominal strain.When the hematoma ruptured into the abdominal cavity, or with intra-abdominal organ injury, may be associated with intestinal paralysis.For severe arterial bleeding, mass can be rapidly swell and even beating.Bleeding near the skin, such as the waist, the Ministry of the abdominal wall and scrotum appear ecchymosis.Hematoma ruptured into the abdominal cavity, often appear shock and peritoneal irritation.Occasional femoral nerve involvement, there quadriceps weakness and knee tendon reflexes special performance. Symptoms of retroperitoneal bleeding High misdiagnosis rate of retroperitoneal bleeding, the reason is the injury complicated abdominal internal organs lack of knowledge of retroperitoneal hemorrhage, splenic rupture, or only pay attention to the diagnosis of pelvic fractures, while ignoring the retroperitoneal injury.The diagnosis of abdominal trauma based on (parts of the level of violence and other medical history) and the typical symptoms and signs, combined with B-mode ultrasound examination, abdominal CT and X-ray, if necessary, to do or excretory urography angiography. Clinical manifestations of hemorrhage depends on the speed, volume, caused by reasons, location and involvement of organs, such as bleeding are small, confined, difficult to have a fixed typical performance, especially when complicated by complex injury, the symptoms more easily concealed.Majority of patients the disease progressed very quickly, in hours or days of the onset of symptoms, clinical course of a few hidden after, late in anemia and mass. The main symptoms are abdominal pain, abdominal pain is the earliest and the most common symptoms of varying degree of severity can be limited or diffuse, position in the abdomen, lateral abdomen, waist or hips in the back or sacral, sometimes squatting can ease.Other common symptoms include nausea, vomiting, constipation or mild diarrhea, decreased bowel, abdominal distension and paralytic ileus and so on.In severe cases, may be associated with hemorrhagic shock and severe anemia, blood loss and retroperitoneal nerve stimulation can cause sweating, palpitations, hypotension, syncope or shock.Some patients had transient fever.With the progression of the disease can occur in paralytic ileus, hematoma, mesenteric vascular compression, it can cause local intestinal loop necrosis.Hematoma, nerve, it can lower extremity neuropathic pain, numbness, and even dysfunction.Hematoma can affect the solar plexus, making autonomic dysfunction, gastrointestinal tract and urinary tract appears peristalsis and excretion dysfunction. Check local abdominal tenderness, and sometimes in the abdomen, side of the palpable mass in the abdomen or the waist or full, in general no or only mild abdominal strain.When the hematoma ruptured into the abdominal cavity, or with intra-abdominal organ injury, may be associated with intestinal paralysis.For severe arterial bleeding, mass can be rapidly swell and even beating.Bleeding near the skin, such as the waist, the Ministry of the abdominal wall and scrotum appear ecchymosis.Hematoma ruptured into the abdominal cavity, often appear shock and peritoneal irritation.Occasional femoral nerve involvement, there quadriceps weakness and knee tendon reflexes special performance.

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Bilirubin metabolism

Bilirubin is not present in the urine of normal, healthy individuals. Bilirubin is a waste product that is produced by the liver from the hemoglobin of RBCs that are removed from circulation. It becomes a component of bile, a fluid that is secreted into the intestines to aid in food digestion. In certain liver diseases, such as biliary obstruction or hepatitis, bilirubin leaks back into the blood stream and is excreted in urine. The presence of bilirubin in urine is an early indicator of liver disease and can occur before clinical symptoms such as jaundice develop. Urobilinogen is normally present in urine in low concentrations. It is formed in the intestine from bilirubin, and a portion of it is absorbed back into the bloodstream. Positive test results help detect liver diseases such as hepatitis and cirrhosis and conditions associated with increased RBC destruction (hemolytic anemia). When urine urobilinogen is low or absent in a patient with urine bilirubin and/or signs of liver dysfunction, it can indicate the presence of hepatic or biliary obstruction. Bilirubin fractions present in blood and urine Unconjugated: Albumin-bound in serum Measured as indirect-reacting bilirubin Never present in urine Conjugated: Unbound in serum Measured as direct-reacting bilirubin Present in urine

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