伤口管理基本原则

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伤口管理原则2--翻译

伤口上传不来。https://todaysveterinarynurse.com/wound-management/basic-principles-of-wound-care/ 此链接看吧。

Temporarily, the wound can be covered with a sterile huck towel until it can be evaluated.

可以先临时用无菌不掉绒棉布巾覆盖管理原则1和2是同一篇文章分两次发布的。可关注寇明明的学习日记视频号（公众号）

图片死活在伤口上，直到进行伤口评估。

After the patient has been sedated or anesthetized, the wound should be covered either directly with sterile lubricating jelly or with gauze saturated in sterile lubricating jelly or sterile saline.

镇静或麻醉动物后，伤口应直接用无菌润滑凝胶或无菌润滑凝胶或无菌生理盐水浸润过的纱布覆盖。

This covering prevents further debris from entering the wound while the area is being prepared.

覆盖伤口可以避免剃毛消毒伤口周围区域时更多的碎片进入伤口。

The hair around the wound should be clipped generously to enable evaluation of surrounding tissue for further damage and to provide an area for the bandage to adhere.

伤口附近应大面积剃毛，以便对周围组织的进行损伤评估，并为绷带提供粘贴位置。

The surrounding tissue should be cleaned aseptically, taking caution not to get hair or antiseptic fluids into the wound, potentially causing further tissue damage from cytotoxicity.

周围组织应该进行无菌清洁，要注意不能让毛发及消毒液进入伤口，因为可能会因细胞毒性对组织造成更多损伤。

If saturated gauze was used, it can be removed and the wound can be flushed to remove contaminants.

如果使用了浸润过的纱布，可以将它移除并冲洗伤口以清除污染物。

Various irrigation solutions can be used for flushing; most commonly used are lactated Ringer’s solution and 0.9% sodium chloride.

多种灌洗液都可以用来冲洗，最常用的是乳酸林格溶液和0.9%的氯化钠。

Warm fluids provide more comfort for the patient.

温热的冲洗液可以让动物更加舒适。

A fluid pressure of 7 to 8 psi is desirable because it provides enough pressure to remove debris but not so much as to damage the tissue or further seed bacteria into the wound.

较为理想的液体冲洗压力是7-8psi，因为既足以冲走碎片又不会过大以至于损伤组织或使细菌进入伤口深处。

The most reliable way to achieve the desired pressure is to use a 1-L bag of fluids attached to a venoset and a needle (16- to 22-gauge), placed inside a pressure bag and pressurized to 300 mm Hg.

达到理想压力最可靠的方法是将1L的大液袋连接到静脉注射器和针头（16至22G），并将大液袋放在压力袋内并加压至300 mm Hg。

If wound healing seems to be impaired, a culture should be taken after all gross contaminants are removed via lavage to determine if any bacteria remain in the wound.

如果伤口未正常愈合，应在灌洗清除所有肉眼可见污染物后进行细菌培养以确定是否有细菌留在伤口内。

方法	做法
选择性清创
自体溶解	使用乙酰化甘露聚糖，藻酸盐，水胶体，水凝胶，蜂蜜或糖作为第一层敷料
生物疗法	使用医用蛆或水蛭
化学法/酶解法	通过蛋白溶解酶降解伤口内的无活性蛋白
外科手术	使用手术刀片或剪刀进行清创
非选择性清创
水压清创法	灌洗法。冲洗同时也可以使用针头去除坏死组织及碎片
机械清创	利用外力，如黏附性绷带对组织进行清创

FIGURE 1. Hydrodynamic debridement using lavage along with mechanical debridement using a finger.图1. 使用灌洗进行水压清创以及使用手指进行机械清创

FIGURE 2. Surgical debridement using a scalpel blade.图2.用手术刀片进行外科手术清创

Selective debridement targets unhealthy tissue only, whereas nonselective debridement affects all tissue.

选择性清创仅清除坏死组织，但非选择性清创会影响全部组织。

Debridement should continue until granulation tissue has formed.

应一直进行清创直到肉芽组织形成。

Bandaging包扎 

Selection of bandage technique from among the various options depends on the location and type of wound.

具体选择哪种包扎方法取决于伤口的位置及类型。

Bandaging allows for debridement; compression; maintenance of a moist environment; pain management; wound protection; reduction of dead space, edema, and hemorrhage; and stabilization.

包扎可以用于清创；压紧伤口；为伤口提供一个湿润的环境；疼痛管理；保护伤口；减少死腔、水肿和出血；以及有固定伤口部位。

Bandages are typically made of 3 layers: primary (contact), secondary, and tertiary.

包扎通常由三层构成：第一层（接触层），第二层及第三层。

● Primary Layer: This layer contacts the wound and can provide debridement, medicinal therapy, moist wound healing, protection, and transfer or absorption of exudate. 

第一层：该层直接接触伤口，可以提供清创，药物疗法，保持伤口湿润，对伤口进行保护，并可以转移或吸收渗出液。

The primary layer can be adherent or nonadherent, semiocclusive or occlusive.

第一层可以是黏附性或非黏附性的，不透气或透气的。

● Adherent: This type of layer provides nonselective mechanical debridement in either a dry-to-dry or wet-to-dry bandage.

黏附性的：黏附性接触层可以提供非选择性的机械清创，形式可以是干干绷带或湿干绷带。

Although this type of debridement has been commonly used in the past, moist wound healing has proven more benficial for the following reasons:

尽管过去常用该种清创方式，但由于以下几种原因，保持伤口湿润有更多优势

● Bacteria can penetrate the moist gauze

细菌可以穿透湿润的纱布

● Fiber from the gauze can remain in the wound

纱布的纤维可能会留在伤口内

● Pulling dry gauze from a wound can release bacteria into the air

从伤口上撕扯干纱布可能会将细菌释放到空气中

● This technique can lead to wound dehydration, healthy tissue destruction, and/or pain

该技术可能会导致伤口脱水、健康组织破坏和/或动物疼痛

● Nonadherent: Removal of this type of layer is atraumatic to the wound. 

非黏附性的：移除这种敷料时不会对伤口造成创伤。

Dressings that protect healthy granulation tissue to help with epithelialization can be made of cotton, which provides some absorption, or of petroleum-impregnated gauze.

这种保护健康肉芽组织有助于上皮化的敷料可以是棉质的（提供一定的吸收作用），或预浸石油的纱布。

Other types of nonadherent dressings include acemannan, alginates, bioactive dressings, biotherapy, honey, hydrocolloids, hydrogels, and sugar (BOX 1).

其他类型的非黏附性敷料包括乙酰化甘露聚糖，藻酸盐，生物活性敷料，生物疗法，蜂蜜，水胶体，水凝胶和糖（表1）

BOX 1

Nonadherent Autolytic Dressings Used as Primary Layers to Promote Moist Wound Healing

用非黏附性自体溶解性敷料作为第一层可以保持湿润环境促进愈合

● Acemannan: Derived from aloe vera and used on burns, dermal ulcers, lacerations, and radiation therapy wounds.

乙酰化甘露聚糖：提取自芦荟，可用于烧伤、皮肤溃疡、撕裂伤和放疗导致的伤口。

● Alginates: Derived from kelp and used in the inflammatory and repair stages. Absorb fluid from the wound, convert to a gel, and thus should not be used on dry wounds.

藻酸盐：提取自海藻，用于伤口炎症和恢复阶段。可以吸收伤口的渗出液并将其转换为凝胶，因此不应用于干伤口。

● Bioactive dressings: Derived from living tissue and used in the inflammatory and repair stages. Provide a matrix for cell migration.

生物活性敷料：从活性组织中提取并用于炎症和修复阶段。为细胞迁移提供基质。

● Biotherapy: Living organisms such as leeches or maggots. Leeches decrease edema and venous congestion. Maggots debride necrotic tissue, and their secretions provide antimicrobial benefits.

生物疗法：活生物如水蛭和蛆。水蛭可以减少水肿和静脉淤血。蛆可以清除坏死组织，其分泌物可以提供抗菌的好处。

● Honey: Nonpasteurized honey (e.g., Manuka) provides antibacterial benefits, reduces edema, hastens sloughing of devitalized tissue, and promotes granulation tissue formation.

蜂蜜：非巴氏消毒的蜂蜜（如Manuka麦卢卡）有抗菌作用，可以减少水肿，加速坏死组织的脱落，并促进肉芽组织的形成。

● Hydrocolloids: Composed of hydrophilic polymers. Used during the repair stage on low-exudate to medium-exudate wounds. As exudate from the wound is absorbed, the hydrocolloid liquefies to form a gel.

水胶体：由亲水性高聚体组成。用于低渗出液至中等渗出液伤口的修复阶段。当吸收了伤口的渗出液后，水胶体液化成凝胶。

● Hydrogels: Composed primarily of water or glycerin. Used in the inflammation and repair stages and contribute a large amount of moisture to the wound. Therefore, they should be used in wounds with no exudate or low exudate. 

水凝胶：主要由水或甘油组成。用于炎症和修复阶段，为伤口提供大量的水分。因此，它们应用于无渗出液或渗出液较少的伤口。

● Sugar: Reduces edema and bacterial proliferation and promotes granulation tissue formation. Application should be at least 1 cm thick.

糖：减少水肿和细菌增殖，促进肉芽组织形成。使用时应至少有1厘米厚

Secondary Layer: This layer provides absorption, compression, and stabilization. For a Robert Jones bandage, which is placed on extremities only, roll cotton is used for this layer.

第二层：该层提供吸收、压迫和固定的作用。对于仅放置在四肢远端的Robert Jones绷带，该层使用棉卷。

For a modified Robert Jones bandage, which can be placed anywhere on the body, cast padding is used for this layer.

对于改良Robert Jones绷带，可以放置在身体的任何位置，该层使用石膏衬垫。

Cast padding should be wrapped distally to proximally with a 50% overlap (FIGURE 3).

石膏衬垫应从远端包扎至近端，每圈重叠度为50%（图3）

Figure 3. Cast padding being applied with 50% overlap.

图三：石膏衬垫应50%的重叠

Roll gauze/conforming gauze/stretch bandage is next applied in the same fashion (FIGURE 4).

接下来按同样方式包扎纱布卷/ 弹性纱布卷。

Figure 4. Roll gauze being applied with 50% overlap.

图4：包扎纱布卷50%的重叠

Although cast padding will tear before it is applied too tightly, roll gauze will not, so use extra caution when applying roll gauze.

石膏衬垫包扎太紧时会撕裂，但纱布卷并不会，所以使用纱布卷时应格外小心。

● Tertiary Layer: This layer keeps the other layers in place and protects them from the environment. 

第三层：该层将另外两层保持在原位，并保护它们不受环境的影响。

Materials for this layer are elastic adherent wrap or porous adhesive tape. As with roll gauze, be careful not to wrap too tightly.

该层的材料是弹绷或多孔黏附胶带。与纱布卷一样，注意不要包裹得太紧。

Other bandaging techniques include tie-over bandages, free graft bandages, and negative pressure wound therapy (NPWT).

其他包扎技术包括打包绷带、游离皮片包扎和负压伤口治疗 （NPWT）

Tie-over bandages: Tie-overs are used in areas that are difficult to bandage (e.g., axillary, inguinal, hip, or perineal regions).

打包绷带：用于难以包扎的位置（如腋窝、腹股沟、髋部或会阴区）。

Several stay sutures are placed circumferentially around the wound (FIGURE 5).

在伤口周围放置几处留置线圈（图5）。

Figure 5. Stay sutures placed to hold the layers of a tie-over bandage.

图5：留置线圈在固定打包绷带层

To keep the bandaging material in place, after the primary and secondary layers are applied, umbilical tape is passed through the stay sutures and tied (FIGURE 6).

为了保持包扎材料在原位，在包扎第一层和第二层后，用脐带线穿过线圈并系紧（图6）。

Figure 6. Tie-over suture with umbilical tape.

图6.脐带线系紧。

Last, an impervious layer (e.g., a laparotomy sponge plastic wrapper or transparent medical dressing) is applied to help decrease the risk for wound contamination. 

最后，外面覆盖不可渗透层（例如，开腹大纱布的塑料包装袋或透明医用敷料）以帮助降低伤口污染的风险。

● Free graft bandage: This bandage uses the same or similar supplies as a modified Robert Jones bandage. To allow the graft to attach without disruption, this bandage is left on for 3 days.

游离皮片包扎：该包扎使用与改良Robert Jones绷带相同或相似的材料。为了保证皮片不受干扰地附着在创面上，该包扎要放置三天。

● NPWT: With foam as the primary layer, NPWT involves application of a continuous pressure of –125 mm Hg to the wound, thereby increasing blood flow to the wound, removing bacteria and edema, and accelerating the rate of granulation tissue formation. Use of NPWT is contraindicated on exposed blood vessels or nerves, fistulas, necrotic tissue, organs, wounds with malignancy, or in conjunction with osteomyelitis or coagulopathies.

负压伤口治疗：用泡沫作为第一层，负压伤口治疗为伤口持续提供-125毫米汞柱的压力，继而增加伤口的血供，减少细菌和水肿，并加快肉芽组织形成的速率。该方法禁用于暴露的血管或神经，瘘管，坏死组织，器官，有恶性肿瘤或伴有骨髓炎或凝血病的伤口。

Two additional therapy options are shown in BOX 2.

表格2 列出了另外两种治疗方法。

治疗伤口的其他方法

激光治疗法

~减轻痛苦

~减少炎症

~加速组织恢复和细胞生长

~促进血管形成

~减少纤维组织的形成

富含血小板血浆（PRP）（图7）

~使用PRP装置对动物进行抽血（自体供血）

~使用前，向PRP中添加凝血酶或氯化钙来激活血小板形成凝胶

~生长因子与细胞因子可刺激和加速伤口愈合

~PRP可有效对抗耐甲氧西林金黄色葡萄球菌

图7blood collect for PRP 为PRP收集的血液

Bandage Care绷带护理

How often a bandage should be changed depends on the amount of exudate, the type of bandage, and the status of the bandage.

更换绷带的频率取决于渗出液的量、绷带的类型以及绷带的状态。

Bandages should be observed for strike-through, contamination, proper placement, and quality.

应观察有无渗出液穿透绷带、污染、绷带位置和质量。

The following bandage care should be discussed with clients at the time of patient discharge, along with instructions for them to bring their pet in for a bandage change should they observe any status changes.

在动物出院时应与客户讨论后续的绷带护理，除了告知主人应在何时带宠物来医院更好绷带，在情况有变时也应将动物带回医院更换绷带。

● If there is strike-through, the bandage should be changed.

如果有渗出液穿透绷带，应进行更换

● Keep the bandage dry by:

通过以下方法保持绷带干燥

● Keeping the patient’s bedding clean and dry 

保持动物的床铺干净及干燥

● Securing food and water bowls so that they cannot be spilled or stepped in

将食碗和水碗放在安全位置，以免其溢出或动物踏入

● Covering the bandage if the patient goes outside in a wet environment and removing it after the patient is back inside, so moisture does not collect and soak the bandage

当动物外出进入潮湿环境时，应遮挡绷带，当动物回到室内时再将遮挡物取下，这样绷带就不会被浸湿。

● Observe the tightness of the bandage (FIGURE 8).

观察绷带的松紧度（图8）

● If a bandage is too loose, it may slip, exposing the wound or causing the bandage layers to slip and/or rub

如果绷带太松，它可能会脱落并暴露伤口，或导致绷带每层之间松动且/或摩擦。

● If a bandage is too tight, it may cause biting or licking of the bandage, abnormal swelling of the surrounding areas, and potential necrosis and sloughing of the skin

如果绷带太紧，可能会导致动物撕咬或舔舐绷带、周围区域异常肿胀，以及可能会导致皮肤坏死和脱落。

● Keep an Elizabethan collar on the patient at all times, to prevent bandage destruction.

让动物一直带着伊丽莎白圈，以避免绷带被损坏。

● Restrict the patient’s exercise for the duration of bandage care (i.e., keep the patient crated and take outside on a leash for urination and defecation purposes only).

在绷带护理期间应限制动物的活动（即对动物进行笼养，仅在大小便的时候牵遛出去）。

Drains引流

Drains—passive or active—can be used to remove fluid from wounds and should be handled with aseptic technique. Drain fluid should be evaluated for volume and character.

引流-被动或主动-可以用于去除伤口渗出液，操作时应采用无菌技术。引流出的液体应进行定量和定性分析。

● Passive: These are open drains that work via capillary action and gravity, removing fluid from the wound along the outside of the drain, and exiting the body. Although less expensive than active drains, they do not allow for quantification of the drainage and can lead to ascending infections. A bandage is required to absorb the fluid.

被动引流：指开放式引流条，通过毛细作用和重力使伤口内液体沿着引流条的外壁流出体内。虽然被动引流较主动引流花费更少，但被动引流的引流液无法进行定量分析，且可引起上行性感染。需要包扎绷带来吸收引流液。

● Active: These are closed drains and work via suction. A closed negative-pressure device is placed at the end of the drain, suctioning and storing fluid from the wound. Fluid from active drains can be quantified, qualified, and cultured. A homemade version can be made by using a butterfly catheter and a sterile Vacutainer (BD, bd.com) blood collection tube.

主动引流系统：主动引流为封闭式引流，通过抽吸实现。将一个封闭的负压装置放在引流条的末端，从伤口吸出液体并储存。主动引流采集的液体可进行定量定性分析和细菌培养。可用蝶形导管和无菌真空血液采集管（BD,bd.com）自制引流装置。

Drains should be removed when fluid accumulation decreases to 1 to 2 mL/kg/day16 or when drainage has reached a plateau and the fluid quality is normal. After drain removal, a small bandage can be placed to absorb any residual drainage before the insertion site is healed.

当引流量下降至 1 -2 mL/kg/day或稳定不变且液体性质正常时，应移除引流条。移除引流条后，在其插入位置愈合前可以稍微包扎下来吸收任何残留的渗出液。

PAIN MANAGEMENT

疼痛管理

Most patients need to be sedated or anesthetized for initial wound management, and analgesics (e.g., opioids or nonsteroidal anti-inflammatories) should be a part of the pain management protocol. In addition, local or splash blocks in or around the wound can add to patient comfort. Although chemical restraint may not be required in the later stages of treatment, pain should still be managed, not only for patient comfort but also because pain can impede tissue perfusion, thereby delaying wound healing.

首次处理伤口时，大多数动物都需要镇静或麻醉，并且还应使用镇痛药（例如阿片类或非甾体类抗炎药）。除此之外，可在伤口内或周围进行局部或喷洒阻滞使动物更舒适。尽管治疗的后续阶段可能不需要化学保定，仍应进行疼痛管理，不仅仅是为了使动物舒适，还因为疼痛会阻碍组织灌注，继而减缓伤口愈合。

CONCLUSION总结

Wounds are complex and vary in severity. Understanding the basic principles of wound management will help veterinary nurses aid in proper wound care and management to maximize the healing process.

伤口的情况可能很复杂，每个伤口的严重程度也很复杂。了解基本的伤口管理原则可以帮助兽医护士更好地进行伤口护理并使伤口愈合的过程最大化。

本文已经经过小柿子老师校对。

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