Karen M. Tobias, DVM, MS, DACVS, University of Tennessee
Karen M. Tobias, DVM, MS, DACVS, is a professor of small animal soft tissue surgery and a board-certified surgeon at University of Tennessee. She earned her DVM from University of Illinois and completed an internship at Purdue University and a residency at The Ohio State University, where she also earned her master’s degree. Dr. Tobias has published more than 120 scientific articles and book chapters and is the author of Manual of Small Animal Soft Tissue Surgery and coeditor of Veterinary Surgery: Small Animal.
Our team—clinicians, interns, residents, nurses—has developed an effective series outlining the fundamental steps of managing challenging wounds. This introduction gives a basic overview, while subsequent articles will detail specific wound management techniques.
Challenging wounds can be frustrating or fulfilling, depending on patient status, response to treatment, and owner finances. In reality, problematic wounds are labor-, time-, and cash-intensive (Figure 1, above), with no guarantee of a positive outcome. Adding to this is the wealth of available wound medications and treatment regimens.
Figure 1. The financial, emotional, and time investments were considerable for the owners of this 12-year-old Labrador retriever; bite wounds resulted in skin loss, tissue necrosis, and antimicrobial-resistant infection.
Because clinical experience, availability of materials, and personal preferences vary, veterinarians may elect to substitute the choices described so they can develop protocols that best fit their needs and patient population.
Evaluate patients with particular attention to:
Figure 3. Histologic results of debrided tissues were consistent with sterile panniculitis for this 11-year-old dalmatian, in which the wound continued to enlarge despite topical and systemic therapy. The bed of the wound was firm, wrinkled, and unattached to underlying subcutaneous tissue.
Owners should be informed of the time-intensive nature of wound management and the risks involved. In addition, initial cost estimates may change based on various factors:
Practitioners should consider developing a spreadsheet that calculates the cost range to produce a printable estimate; cost estimates may include:
Infections should be treated topically when possible:
By Type of Wound
For infected, effusive wounds with minimal to no granulation tissue (with or without necrotic tissue), options include:
For necrotic wounds that cannot be surgically debrided, options include:
Figure 5. Tissue necrosis extended deep into the distal antebrachium after palliative radiation therapy. The area was treated with medical maggots (seen here), and the majority of necrotic tissue was gone within 2 days.
Infected or Colonized
For infected or colonized wounds that are starting to granulate, use a silver-coated foam pad (eg, Algidex Ag, deroyal.com) with tie-over bandage (optional) and occlusive drape (eg, Ioban 2)
With Granulation Beds
For wounds with formed granulation beds, use nonadherent fine-pore dressing (eg, Telfa, kendallpatientcare.com) with triple antibiotic coating and petroleum-impregnated dressing (eg, Adaptic, systagenix.com); (Figure 6)
Figure 6. A petroleum-impregnated dressing was stapled over the mesh graft in this 10-year-old golden retriever. The outer surface of the dressing was coated with triple antibiotic ointment and covered with an absorptive bandage; the stapled dressing was left in place. The area completely healed within 14 days.
For epithelializing wounds, use a nonadherent pad with a thin layer of ointment (eg, triple antibiotic) or a petroleum-impregnated dressing (eg, Adaptic, systagenix.com)
For maturing wounds (second-intention healing), use a nonadherent pad with thin layer of ointment and petroleum-impregnated dressing
Indications for Wound Closure
Open wound management may be continued regardless of whether the wound is infected or not healing well or is closing quickly on its own. Owners need to be comfortable with associated costs.
Define anesthesia protocols for wound debridement and bandage changes tailored to each patient based on initial assessment
Maintain analgesia throughout long-term therapy
Develop a nutritional plan to support the patient
Monitor body condition score (BCS) and watch for evidence of systemic illness via serial CBC and serum biochemical profiles
Bullet, bite, and burn wounds in dogs and cats. Pavletic MM, Trout NJ. Vet Clin North Am Small Anim Pract 36:873-893, 2006.
Management of hard-to-heal wounds. Amalsadvala T, Swaim SF. Vet Clin North Am Small Anim Pract 36:693-711, 2006.
Management of specific skin wounds. White RAS. Vet Clin North Am Small Anim Pract 36:895-912, 2006.
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