Wound vs cut? Different types of wound? Management of wound 2+ 6+6

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Wound vs. Cut - Types of Wounds - Management

1. Wound vs. Cut: What's the Difference?

A wound is any disruption of the normal continuity of body tissues caused by physical, mechanical, thermal, chemical, or electrical forces. It is the broad, general term.

A cut (incised wound) is one specific type of wound - a clean, linear division of soft tissue caused by a sharp-edged instrument (knife, scalpel, glass). So: every cut is a wound, but not every wound is a cut.

2. Classification of Wounds

Wounds are diverse and no single system covers all contexts. Multiple classification frameworks are used together:

A. By Mechanism / Causative Agent

(i) Blunt weapon (mechanical, blunt force):

Type	Description
Contusion (Bruise)	Caused by blunt force without breaking skin. Blood extravasates into subcutaneous tissues. Size depends on force applied, tissue type, age, sex, and skin color.
Abrasion (Graze)	Skin scraped or rubbed; only the superficial epidermal layer is removed. Common in road traffic accidents.
Laceration	A tear in the skin from blunt trauma. Has irregular, ragged edges, tissue bridging, and crushed margins. Should not be confused with an incised wound.

(ii) Sharp weapon (mechanical, sharp force):

Type	Description
Incised wound (Cut)	Clean, linear wound from a sharp-edged instrument drawn across the skin. Edges are clean and well-defined; length > depth; bleeds profusely.
Stab wound (Puncture)	Produced by a pointed instrument thrust into the body. Depth > width; may injure deep structures with minimal surface appearance.

(iii) Others:

Firearm wounds - entry, exit, or graze
Bite wounds - puncture or avulsion from teeth
Burns - thermal, electrical, chemical, radiation
Blast/Explosion wounds
Degloving/Avulsion - skin and subcutaneous fat stripped from underlying fascia, muscle, or bone

B. By Contamination (CDC/Surgical Classification)

Class	Type	Description
I	Clean	Uninfected operative wound, no inflammation, GI/respiratory/genital tract not entered
II	Clean-contaminated	GI/respiratory/genital tract entered under controlled conditions
III	Contaminated	Fresh traumatic wounds, major breaks in sterile technique, acute non-purulent inflammation
IV	Dirty/Infected	Old traumatic wounds, perforated viscera, clinical infection present

(Bailey and Love's Short Practice of Surgery, 28th ed.)

C. By Depth

Epidermal
Dermal (superficial or deep)
Full thickness (through all skin layers into subcutaneous fat, fascia, or deeper)

D. By Complexity

Simple - involves skin only
Complex - significant soft-tissue loss, open fracture or joint, visceral involvement

E. By Time Course

Acute - traumatic wounds, surgical wounds - expected to heal within normal timeframes
Chronic - fail to heal within expected time:
- Vascular ulcers (venous or arterial)
- Pressure ulcers
- Diabetic ulcers

F. By Complication Status

Uncomplicated
Complicated: infection, necrosis, haematoma, gas gangrene, compartment syndrome

3. Types of Wound Healing

Type	Also Called	Description
Primary healing	1st intention	Wound edges directly approximated; clean incisions; best scar outcome
Secondary healing	2nd intention	Wound left open; heals by granulation, contraction, and re-epithelialisation; poor scar
Tertiary / Delayed primary	3rd intention	Wound initially left open (contaminated or untidy), then edges surgically approximated once clean

4. Wound Management

Step 1 - Assessment (2 marks worth)

Use ATLS principles - first identify life- and limb-threatening conditions.

Assess:

Site, size, geometry, and nature of wound
Signs of contamination, infection, swelling, pulsatile bleeding
Skin loss or degloving
Underlying structures visible (bone, tendon, nerve)
Mechanism of injury (high-pressure injection, bites, etc.)
Motor and sensory function before local anaesthesia
Imaging if foreign body, fracture, or dislocation suspected

(Bailey and Love's, p. 49-51)

Step 2 - Key Management Principles (6+6 marks worth)

Preparation

Analgesia / Anaesthesia - adequate pain control before wound exploration
Antibiotic prophylaxis - required for clean-contaminated, contaminated, and dirty wounds; also for clean wounds with high infection risk
Tetanus prophylaxis - assess immunisation status; tetanus-prone wounds include puncture injuries, bites, compound fractures, wounds with heavy contamination (soil/manure), burns with sepsis

Wound Treatment

Haemostasis - direct pressure and elevation; topical agents (chitosan dressings, topical thrombin); vessel ligation/electrocautery if needed
Irrigation - all wounds irrigated early with warm normal saline; reduces bacterial contamination; allows better visualisation
Debridement - remove all devitalised tissue and foreign material until healthy bleeding at wound edges. Methods:

Method	Detail
Surgical	Scalpel, scissors, curette until bleeding edges
Mechanical	Irrigation, wet-to-dry dressings (non-selective)
Autolytic	Hydrocolloid dressings retain moisture; wound enzymes liquefy necrotic tissue selectively
Enzymatic	Topical collagenase or papain-urea
Biological (Maggot therapy)	Lucilia sericata larvae release proteolytic and antimicrobial substances

Exploration - assess for neurovascular, tendon, joint, bone damage; repair under magnification (loupes/microscope) for nerves and vessels

Closure - Reconstruction Options

Primary closure (tension-free)
Secondary closure (leave open)
Tertiary/delayed primary closure
Negative Pressure Wound Therapy (NPWT)
Split-thickness skin graft
Full-thickness skin graft
Dermal matrices
Local, regional, or pedicled flap
Tissue expansion
Free flap (microsurgery)

Skin closure should always be without tension. Use the reconstructive ladder principle: start simple, escalate as needed.

Dressings

Optimal dressings chosen based on wound type - dry, moist, absorbent, antimicrobial
Negative pressure dressings for complex wounds

Follow-up

Suture / splint removal at appropriate time
Physiotherapy where indicated
Monitoring for complications (infection, dehiscence, haematoma)
Scar management

Factors Affecting Healing

Local	Systemic
Skin tension	Advancing age
Hypoxia / ischaemia	Obesity
Vascular insufficiency	Malnutrition
Lymphoedema	Smoking
Contamination / infection	Diabetes mellitus
Foreign bodies	Connective tissue diseases
Radiotherapy	Immunocompromised state
	Medications (steroids, immunosuppressants, chemotherapy)

Sources

Bailey and Love's Short Practice of Surgery, 28th Edition (Chapter 3: Wounds)
P.C. Dikshit Textbook of Forensic Medicine and Toxicology (Chapter 13: Mechanical Injuries)
Roberts and Hedges' Clinical Procedures in Emergency Medicine
Robbins & Kumar Basic Pathology

What is burn? Different types of burn? Degree of burn? First aid of burn patient

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Burns: Definition, Types, Degrees, and First Aid

1. What is a Burn?

A burn is a tissue injury caused by transfer of energy to the body from thermal, chemical, electrical, or radiation sources. Burns cause a multisystem injury, but the skin is by far the most commonly and directly affected organ. Cell damage begins at temperatures above 45°C (113°F) due to denaturation of cellular proteins. The size and depth of a burn depend on the burning agent, its temperature, and the duration of exposure.

Burns cause three concentric zones of tissue injury:

Zone of coagulation - innermost; tissue irreversibly destroyed with vessel thrombosis
Zone of stasis - surrounding area; microcirculation stagnated; can become ischaemic if resuscitation is inadequate
Zone of hyperemia - outermost; increased blood flow; minimal cell damage; likely to recover spontaneously

(Bailey and Love's, p. 686 | Tintinalli's Emergency Medicine)

2. Types of Burns (By Causative Agent)

Type	Cause	Key Features
Thermal	Flame, scalds (hot water/steam), contact with hot surfaces	Most common; scalds common in children; flame burns in adults
Chemical	Acids, alkalis, corrosives	Alkalis penetrate deeper and cause continuing injury; requires prolonged irrigation
Electrical	Electrical current (AC/DC), lightning	Entry and exit wounds; deep tissue destruction often out of proportion to skin appearance; may cause rhabdomyolysis and renal failure
Radiation	UV light (sunburn, arc welding), X-rays, nuclear	UV burns cause keratitis; nuclear/X-ray burns cause deep radiation injury
Friction	Skin rubbing against rough surfaces	Combination of abrasion and heat
Cold (Frostbite)	Extreme cold exposure	Rare thermal injury; also causes tissue destruction

Note: The majority of electrical and chemical burns occur in adults and are frequently work-related. Burns in the elderly are commonly contact burns (falls against radiators).

3. Degrees of Burn (Burn Depth Classification)

Originally classified by Dupuytren (1832) into degrees. The modern functional classification (used in burn centers) also describes burns as superficial partial-thickness, deep partial-thickness, and full-thickness - based on the need for surgical intervention.

Degree	Also Called	Depth	Clinical Features	Example	Healing
1st degree	Superficial	Epidermis only	Red, dry, painful, no blisters	Sunburn	~7 days, no scar
2nd degree (superficial)	Superficial partial-thickness	Epidermis + superficial (papillary) dermis	Blisters, very painful, red, weeping, blanches on pressure	Hot water scald	14-21 days, no permanent scar
2nd degree (deep)	Deep partial-thickness	Epidermis + deep dermis, sweat glands, hair follicles	Blisters, painful, mottled, moist	Hot liquid, steam, grease, flame	3-8 weeks, permanent scar
3rd degree	Full-thickness	Entire epidermis and dermis destroyed	Charred, pale/white, leathery; painless (nerve endings destroyed)	Flame, prolonged contact	Months; severe scarring; skin grafts necessary
4th degree	Sub-dermal	Through skin into fat, muscle, and/or bone	Devastating, life-threatening	High-voltage electricity, incineration	Months; multiple surgeries; may need amputation

5th and 6th degrees are sometimes described in specialist contexts for burns involving underlying viscera or through extremities.

(Tintinalli's Emergency Medicine, Table 217-2 | Schwartz's Principles of Surgery | Bailey and Love's)

4. Assessment of Burn Size

Rule of Nines (Adults)

Divides body into areas of ~9%:

Head and neck: 9%
Each arm: 9% (x2 = 18%)
Anterior trunk: 18%
Posterior trunk: 18%
Each leg: 18% (x2 = 36%)
Perineum: 1%
Total = 100%

Lund-Browder Diagram

More accurate - accounts for age-related anatomical differences in children (proportionally larger head, smaller legs).

Palm Method

The area of the back of the patient's own hand = approximately 1% TBSA - useful for irregular burns.

5. First Aid (Prehospital Care) of a Burn Patient

(Bailey and Love's, p. 687-688 | Tintinalli's)

Step-by-Step First Aid:

1. Ensure rescuer safety first

Particularly important for electrical injuries (switch off power), chemical burns, and building fires before approaching the patient.

2. Stop the burning process

"Stop, drop and roll" to extinguish flames on a person.
Remove burning/smouldering clothing and jewellery (unless stuck to skin).
For chemical burns: brush off dry chemicals first, then irrigate copiously with water.
For electrical burns: ensure power is isolated before touching the patient.

3. Cool the burn

Apply cool running water at approximately 15°C (tepid water) for 20 minutes.
Effective up to 1 hour after the burn injury.
Particularly important for partial-thickness burns and scalds.
Do NOT use ice water - causes vasoconstriction and worsens injury.
Avoid hypothermia, especially in children and the elderly - use cool water only on the burned area, keep rest of body warm.
Do NOT apply butter, toothpaste, oil, or other home remedies.

4. Cover the wound

Apply a clean, non-fluffy dressing or cling film (plastic wrap) loosely over the burn.
Cling film is ideal: non-adherent, transparent (allows assessment), and reduces pain from air contact.
Do NOT burst blisters in the field.

5. Airway - give oxygen

Anyone exposed to smoke in an enclosed space should receive 100% oxygen by non-rebreather mask.
Signs of airway involvement: hoarse voice, stridor, singed nasal hairs, perioral burns, blistering inside the mouth - these indicate risk of rapid airway oedema.
Sit the patient upright if airway burn is suspected - may be life-saving while awaiting transfer.

6. Elevate burned limbs

Reduces swelling and discomfort.

7. Analgesia

Administer analgesia before or during transfer to hospital to alleviate pain.

8. ABC check and transfer

Perform an ABC (Airway-Breathing-Circulation) assessment.
Check for coexisting injuries (blast, fall, fractures).
Transfer urgently to hospital / burn unit.

6. When to Transfer to a Burn Unit

(American Burn Association / Bailey and Love's)

Full-thickness (3rd degree) burns - any age
Partial-thickness burns > 10% TBSA (children > 15%)
Burns of the face, hands, feet, genitalia, perineum, or crossing major joints
Electrical burns (including lightning)
Chemical burns
Inhalation injury
Burns with concurrent trauma
Extremes of age: children < 10 years, adults > 50 years
Burns with significant comorbidities (diabetes, cardiac disease, immunosuppression)
Any suspicion of non-accidental injury

7. Fluid Resuscitation (Parkland Formula)

For burns > 20% TBSA:

Adults: Lactated Ringer's = 4 mL × weight (kg) × % TBSA burned

Half given over first 8 hours from time of burn
Other half over the next 16 hours

Children: 3 mL × weight (kg) × % TBSA + maintenance fluids

Target urine output: 0.5-1.0 mL/kg/h

Sources

Bailey and Love's Short Practice of Surgery, 28th Edition (Chapter 46: Burns)
Tintinalli's Emergency Medicine, A Comprehensive Study Guide (Chapter 217)
Schwartz's Principles of Surgery, 11th Edition
Current Surgical Therapy, 14th Edition
Schwartz's Key Points: Early excision and grafting of full-thickness and deep partial-thickness burns improves outcomes

Wound vs cut? (2marks )Different types of wound? (6 marks )Management of wound (6marks)

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Wound vs Cut | Types of Wound | Management of Wound

Q1. Wound vs Cut (2 Marks)

Feature	Wound	Cut (Incised Wound)
Definition	Any disruption of the normal continuity of body tissues caused by physical, mechanical, thermal, chemical, or electrical force	A specific type of wound - a clean, linear division of skin/soft tissue by a sharp-edged instrument
Scope	Broad, general term	Narrow, specific type of wound
Cause	Any agent - blunt, sharp, thermal, chemical, electrical	Sharp-edged instrument only (knife, glass, scalpel)
Edges	May be ragged, irregular, or clean depending on type	Always clean and well-defined
Relationship	Every cut is a wound	But not every wound is a cut

In short: A wound is the parent term; a cut is one specific subtype. All cuts are wounds, but wounds include many other types beyond cuts.

Q2. Different Types of Wound (6 Marks)

Wounds are classified by multiple systems. The key classifications are:

A. By Causative Agent / Mechanism

(i) Blunt Force Wounds

Type	Description	Key Features
Contusion (Bruise)	Caused by blunt force without breaking the skin; blood extravasates into subcutaneous tissues	Intact skin surface; discoloration; tenderness
Abrasion (Graze)	Skin scraped or rubbed against a rough surface; only epidermal layer removed	Superficial; common in road traffic accidents; no scarring
Laceration	Tear in skin from blunt trauma	Ragged, irregular edges; tissue bridging across wound; crushed margins; less bleeding

(ii) Sharp Force Wounds

Type	Description	Key Features
Incised Wound (Cut)	Clean division of tissue by a sharp-edged instrument drawn across the skin	Clean edges; length > depth; profuse bleeding
Stab Wound (Puncture)	Pointed instrument thrust into body	Depth > width/length; may injure deep structures with minimal skin wound

(iii) Special Types

Type	Description
Firearm Wound	Entry (small, inverted) and exit (large, everted) wounds; caused by bullet/projectile
Bite Wound	Puncture or avulsion from teeth; high infection risk (human > animal)
Degloving / Avulsion	Skin and subcutaneous fat stripped from underlying fascia/muscle/bone; caused by shearing forces
Burn Wound	Thermal, chemical, electrical, or radiation injury

B. By Contamination (CDC Surgical Classification)

Class	Category	Description
I	Clean	Uninfected; no inflammation; GI/respiratory tract not entered
II	Clean-contaminated	GI/respiratory tract entered under controlled conditions
III	Contaminated	Fresh traumatic wounds; major breaks in sterile technique
IV	Dirty/Infected	Old wounds; frank infection present; perforated viscera

C. By Depth

Epidermal - superficial only
Dermal - superficial or deep dermal
Full thickness - through all skin layers into fat, fascia, or deeper structures

D. By Time Course

Type	Examples
Acute	Traumatic or surgical wounds that heal within expected time
Chronic	Venous/arterial ulcers, pressure ulcers, diabetic ulcers - fail to heal in expected timeframe

E. By Complication Status

Uncomplicated
Complicated: infection, haematoma, necrosis, gas gangrene, compartment syndrome

(Bailey and Love's Short Practice of Surgery, 28th ed. | P.C. Dikshit Forensic Medicine)

Q3. Management of Wound (6 Marks)

Wound management follows a structured framework covering preparation, treatment, closure, and follow-up.

1. Assessment

Use ATLS (Advanced Trauma Life Support) principles:

Identify and treat life- and limb-threatening conditions first
Assess: site, size, geometry, depth, contamination, skin loss, pulsatile bleeding
Test motor and sensory function before local anaesthesia
Imaging if foreign body, fracture, or dislocation is suspected
Correlate wound with mechanism of injury (e.g., high-pressure injection injuries appear minor but cause massive deep damage)

2. Preparation

Step	Detail
Analgesia / Anaesthesia	Adequate pain control before wound exploration and debridement
Antibiotic prophylaxis	Required for clean-contaminated, contaminated and dirty wounds; also for clean wounds with high infection risk
Tetanus prophylaxis	Assess immunisation status; give booster or tetanus immunoglobulin based on wound type and vaccination history
Wound irrigation	Early copious irrigation with warm normal saline; reduces bacterial contamination; allows better visualisation

3. Wound Treatment

Step	Detail
Haemostasis	Direct pressure and elevation; topical agents (chitosan, thrombin); ligation or electrocautery for vessel bleeding
Debridement	Remove all devitalised tissue and foreign material until healthy bleeding at wound edges
Exploration	Identify damage to underlying nerves, vessels, tendons, joints, and bones
Repair	Repair damaged structures once wound is clean; nerve and vessel repair under magnification (loupes/microscope)

Methods of Debridement:

Method	Description
Surgical	Scalpel, scissors, curette - selective; gold standard
Mechanical	Irrigation, wet-to-dry dressings - non-selective
Autolytic	Hydrocolloid dressings; wound enzymes selectively liquefy necrotic tissue
Enzymatic	Topical collagenase or papain-urea
Biological (Maggot therapy)	Lucilia sericata larvae release proteolytic enzymes; remove necrotic tissue and directly promote healing

4. Wound Closure

Skin closure should always be without tension. Options (Reconstructive Ladder):

Primary closure - direct apposition of wound edges
Secondary closure - wound left open; heals by granulation and re-epithelialisation
Tertiary (delayed primary) closure - wound initially left open, closed later when clean
Negative Pressure Wound Therapy (NPWT)
Split-thickness skin graft
Full-thickness skin graft
Local/regional/pedicled flap
Free flap (microsurgery)

5. Dressings

Chosen based on wound type - dry, moist, absorbent, or antimicrobial
Aim: maintain moist wound environment, absorb exudate, prevent contamination

6. Follow-Up

Step	Detail
Suture/splint removal	At appropriate time depending on site and healing
Physiotherapy	Where joint/tendon involved
Complication monitoring	Infection, dehiscence, haematoma
Scar management	Pressure garments, silicone gel, steroid injections for hypertrophic/keloid scars

Factors Affecting Wound Healing

Local Factors	Systemic Factors
Skin tension, ischaemia, vascular insufficiency	Advancing age, obesity, malnutrition
Contamination, infection, foreign bodies	Smoking, diabetes mellitus
Lymphoedema, radiotherapy	Steroids, immunosuppressants, chemotherapy

(Bailey and Love's Short Practice of Surgery, 28th ed., Chapter 3)

Enlist the steps for prevention of Burn?

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Prevention of Burns

Burns are largely preventable. High-income countries have significantly lowered burn death rates through a combination of prevention strategies and improvements in care. An effective burn prevention plan must be multisectoral - addressing hazards, educating vulnerable populations, and training communities.

The cornerstone of burn prevention programs is "The Five E's":

Engineering/Environment, Enforcement, Education, Emergency Response, and Economic Initiative (Schwartz's Principles of Surgery, 11th ed.)

Steps for Prevention of Burn

1. Legislative and Regulatory Measures (Enforcement)

Enact and enforce flame-retardant standards for clothing and furniture
Regulate hot water heater/thermostat temperature - set at a maximum of 60°C to prevent scald injuries (especially in children and elderly)
Implement and enforce building fire codes and structural fire safety regulations
Enforce workplace health and safety regulations to prevent occupational burns (chemical, electrical, flame)
Mandate gas appliance safety standards for cookers and gas fires

2. Engineering and Environmental Measures

Install smoke alarms / fire detectors in all homes and buildings - known to decrease mortality from structural fires
Use cordless kettles (virtually eliminates hot water spill injuries from cord-tripping)
Safe design of cookers, gas fires, and heating appliances to minimize accidental contact
Install fire sprinkler systems in buildings
Use safety switches/circuit breakers to prevent electrical burns
Keep hazardous chemicals properly labelled and stored out of reach of children
Use protective goggles in workplaces with chemical/radiation hazard

3. Public Education and Community Awareness

Educate parents: "Hot water burns like fire" - awareness of scald danger from bathwater, hot drinks, kettles
Teach children: "Stop, Drop and Roll" technique if clothes catch fire
Educate about dangers of leaving hot hair straighteners near children
School-based education programs on fire safety and burn prevention - shown to have long-term retention of safety knowledge
Community programs teaching first-aid for burns
Educate on dangers of flammable liquids (especially in adolescents who experiment with fire)
Raise awareness about non-accidental burn injuries in children (reporting and safeguarding)
Promote setting bath water thermostat to safe temperature before bathing children

4. Occupational Safety Measures

Implement worker safety programs in industries dealing with electricity, chemicals, and fire
Provide and enforce use of personal protective equipment (PPE): gloves, aprons, goggles, fire-resistant clothing
Train workers in fire safety and evacuation procedures
Regular equipment maintenance and inspection (electrical systems, boilers, chemical storage)
Adequate ventilation systems in chemical workplaces to prevent toxic fume exposure

5. Emergency Preparedness

Train community members in basic first aid for burns
Ensure availability and accessibility of fire extinguishers
Conduct regular fire drills in schools, workplaces, and public buildings
Establish clear emergency evacuation plans
Ensure rapid emergency response systems (fire brigade, ambulance) are functional

6. At-Risk Population-Specific Prevention

Population	Specific Measures
Young children	Keep hot liquids away from table edges; supervise near kitchens; screen for non-accidental injury
Elderly	Assistive devices to prevent falls onto hot surfaces; home safety assessments
Epileptics / alcohol/drug users	Special supervision near fire/heat sources (these conditions underlie up to 80% of admissions in some populations)
Mentally ill	Close supervision; remove access to flammable materials
Industrial workers	PPE, chemical safety training, electrical isolation procedures

7. Specific Type-Based Prevention

Burn Type	Prevention
Thermal (scalds)	Cover hot pots; use back burners on stoves; test bath temperature before bathing children
Flame	Flame-retardant clothing; fire-safe cooking practices; no open fires indoors
Electrical	Insulated wiring; safety covers on outlets; isolate power before repair work
Chemical	Proper labelling, storage, PPE; immediate washing facilities nearby
Radiation (UV)	Protective goggles for welders; sunscreen; avoid prolonged UV exposure

Summary Box (Bailey and Love's, 28th ed.)

A significant proportion of burns can be prevented by:

Implementing good health and safety regulations

Educating the public

Introducing effective legislation

Sources

Bailey and Love's Short Practice of Surgery, 28th Edition (Chapter 46: Burns)
Schwartz's Principles of Surgery, 11th Edition (The Five E's of Burn Prevention)
Park's Textbook of Preventive and Social Medicine (Chapter on Burns Prevention)

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