Wound management
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Wound Management. UNC Emergency Medicine Medical Student Lecture Series. Goals of Wound Care. Facilitate hemostasis Decrease tissue loss Promote wound healing Minimize scar formation. Mechanism of Injury. Wounds are caused by three different types of forces Shear Compressive Tensile.

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Wound Management

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Wound management

Wound Management

UNC Emergency Medicine

Medical Student Lecture Series


Goals of wound care

Goals of Wound Care

  • Facilitate hemostasis

  • Decrease tissue loss

  • Promote wound healing

  • Minimize scar formation


Mechanism of injury

Mechanism of Injury

  • Wounds are caused by three different types of forces

    • Shear

    • Compressive

    • Tensile


Shear forces

Shear Forces

  • Result from sharp objects

    • Low energy

    • Minimal cell damage

    • Result in straight edges, little contamination

    • Heals with a good result


Compressive forces

Compressive Forces

  • Result from blunt objects impacting the skin at a right angle

    • Results in stellate or complex laceration

    • Ragged or shredded edges

    • More prone to infection


Tensile forces

Tensile Forces

  • Result from blunt objects impacting the skin at an oblique angle

    • Results in triangular wound

    • Sometimes produces a flap

    • More prone to infection


Evaluation of wounds

Evaluation of Wounds

  • ABC’s first  Always!

  • Ensure hemostasis

    • Saline gauze dressing

    • Compression

  • Remove obstructions

    • Rings, clothing, other jewelry

  • History


History

Symptoms

Type of Force

Contamination

Event

Potential for foreign body

Function

Non-accidental trauma

Tetanus status

Allergies

Medications

Comorbidities

Previous scar formation

History


Wound examination

Location

Size

Shape

Margins

Depth

Alignment with skin lines

Neuro function

Vascular function

Tendon function

Underlying structures

Wound contamination

Foreign bodies

Wound Examination


Wound consultation

Wound Consultation

  • Tarsal plate or lacrimal duct

  • Open fracture or joint space

  • Extensive facial wounds

  • Associated with amputation

  • Associated with loss of function

  • Involves tendons, nerves, or vessels

  • Involves significant loss of epidermis

  • Any wound that you are uncertain about


Wound preparation anesthesia

Wound Preparation - Anesthesia

  • Topical

    • Solution or paste

    • LET

    • EMLA

  • Local

    • Direct infiltration

    • 1% lidocaine with or without epinephrine

    • Bupivicaine or sensorcaine for longer acting anesthesia

  • Regional Block

    • Local infiltration proximally in order to avoid tissue disruption

    • Smaller amount of anesthesia required


Wound preparation anesthesia1

Wound Preparation - Anesthesia


Minimize the pain of injection

Minimize the Pain of Injection

  • Use sodium bicarbonate mixed with the anesthetic (1 ml/10 ml solution)

  • Use smallest needle possible

  • Inject slowly

  • Insert needle through open wound edge and skin that has already been anesthetized


Wound preparation hemostasis

Wound Preparation - Hemostasis

  • Physical vs. chemical

    • Direct pressure

    • Epinephrine

    • Gelfoam

    • Cautery

  • Refractory

    • Use a tourniquet


Wound preparation foreign body removal

Wound Preparation – Foreign Body Removal

  • Visual inspection

  • Imaging

    • Glass, metal, gravel fragments >1mm should be visible on plain radiographs

    • Organic substances and plastics are usually radiolucent

  • Always discuss and document possibility of retained foreign body


Wound preparation irrigation

Wound Preparation – Irrigation

  • Local anesthesia prior to irrigation

  • Do not soak the wound

  • Use normal saline

  • Large syringe (60mL) with Zerowet attachment

  • Do not use iodine, chlorhexidine, peroxide or detergents


Wound preparation debridement

Wound Preparation – Debridement

  • Removes foreign matter & devitalized tissue

  • Creates sharp wound edge

  • Excision with elliptical shape

  • Respect skin lines


Wound preparation antibiotics

Wound Preparation – Antibiotics

  • Infections occur in ~3-5% of traumatic wounds seen in the ED

  • Factors that increase risk

    • Heavily contaminated wound, especially with soil

    • Immunocompromised patients

    • Diabetics

    • Human bites > animal bites

  • Most important prevention  adequate irrigation & debridement


Wound preparation antibiotics1

Wound Preparation – Antibiotics

  • Dog & cat bites

    • Cover pasteurella

    • Augmentin

  • Human bites

    • Cover eikenella

    • Augmentin

  • Puncture wounds

    • Cover pseudomonas

    • Cipro, levaquin


Wound preparation tetanus prophylaxis

Wound Preparation – Tetanus Prophylaxis

  • Clean wounds

    • Incomplete immunization toxoid

    • >10 years, then give toxoid

  • Tetanus prone wound

    • Incomplete immunization

      • Toxoid & immune globulin

    • > 5 years, give toxoid

  • Remember to think about rabies!


Wound closure

Wound Closure

  • Primary closure

    • Suture, staple, adhesive, or tape

    • Performed on recently sustained lacerations: <12 hours generally and <24 hours on face

  • Secondary closure

    • Secondary intent

    • Allowed to granulate

  • Tertiary closure

    • Delayed primary (observed for 4-5 days)


Suture material

Suture Material

  • Absorbable

    • Chromic gut

    • Vicryl

    • PDS II

  • Non-Absorbable

    • Silk

    • Prolene

    • Dermalon

  • Monofilament vs. braided


Staples adhesives tape

Staples, Adhesives & Tape

  • Staples

    • Quick, poor aesthetic result

  • Adhesives

    • Dermabond- painless, petroleum dissolves

  • Tape

    • Steri-strips


Wound closure1

Wound Closure

  • Undermine the wound edges

    • Release tension


Suture techniques

Suture Techniques

  • Deep layer approximation

    • Absorbable sutures

    • Buried knot

    • Serves two purposes

      • Closes potential spaces

      • Minimizes tension on the wound margins


Skin closure

Skin Closure

  • Key – wound edge eversion

  • “Approximate, don’t strangulate”

  • Anticipate wound edema

  • Choose appropriate size of suture for location of laceration


Suture techniques1

Suture Techniques

  • Simple Interrupted

    • Used on majority of wounds

    • Each stitch is independent


Suture techniques2

Suture Techniques

  • Simple Continuous

    • Useful in pediatrics

      • Rapid

      • Easy removal

    • Provides effective hemostasis

    • Distributed tension evenly along length

    • Can also be locked with each stitch


Suture techniques3

Suture Techniques

  • Horizontal Mattress

    • Useful for single-layer closure of lacerations under tension


Horizontal mattress

Horizontal Mattress


Suture techniques4

Suture Techniques

  • Vertical Mattress

    • Useful for everting skin edges

    • “Far-far-near-near”


Vertical mattress

Vertical Mattress


Suture techniques5

Suture Techniques

  • Purse-string

    • Useful for stellate lacerations


Suture techniques6

Suture Techniques

  • Instrument tie


Wound care

Wound Care

  • Dressing

    • Maintain dry for 24-48 hours

    • Use antibiotic to maintain moist environment

    • If overlying a joint, splint in a position of function

    • Sun protection to prevent scar hyperpigmentation

    • Suture removal instructions!


Practice time

Practice Time!


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