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Wound Management. . The Goals. Create optimal conditions for the patient to heal themselves. Preserve function. Minimize complications. Improve the chances of a cosmetically pleasing result. What is a Wound?. Any break in the continuity of body tissue Examples:

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the goals
The Goals
  • Create optimal conditions for the patient to heal themselves.
  • Preserve function.
  • Minimize complications.
  • Improve the chances of a cosmetically pleasing result
what is a wound
What is a Wound?

Any break in the continuity of body tissue

Examples:

grazes, burns, surgical incisions, stabs, leg ulcers, decubitus ulcers ( pressure sores)

wound examination
Wound Examination
  • Adequate setting.
  • Hemostasis.
  • Neurovascular exam
  • Foreign body
  • Radiography
wound preparation
Wound preparation

Anesthesia :

  • Local anesthetic injections
  • Topical anesthetics
  • Regional anesthetics
stages of wound healing
Stages of Wound Healing
  • Stage 1 - traumatic inflammation ( 0-3 days)- redness, heat, swelling
  • Stage 2 -destructive phase ( 2-5 days)- polymorphs and macrophages clear the wound of debris and stimulate new growth
  • Stage 3- the proliferative phase( 3-24 days increased collagen formation
  • Stage 4- maturation phase ( 24 days-1 year) scar tissue decreases granulating tissue gets stronger and changes from reddish to pale
slide7
.
  • Wound healing is complex and affected by intrinsic (patient related) and extrinsic (wound related) factors and this affects the choice of treatment
  • Holistic assessment - treat the whole person (e.g. full medical history, factors which may delay healing such as immobility, poor nutrition, obesity, personal circumstances)
  • Signs of clinical infection
  • tetanus immunization
sterile technique
Sterile Technique
  • Ruthman et al : closure of lacerations without caps and masks did not lead to an increased incidence of wound infection.
  • Worral and later Perelman: sterile versus nonsterile gloves found no difference in wound infection rates.
cleansing wounds an area where ritualistic practice predominates
Cleansing wounds: an area where ritualistic practice predominates

Key questions:

1. Does the wound really need cleaning?

2. What is the safest method that causes no ill effects and maintains the wound temperature?

3. What is acceptable to the patient?

Wounds that are clean and healthy do not require cleaning and should be left alone

sterile technique1
Sterile Technique
  • Non-sterile gloves, which provide “universal precaution “ is appropriate.
  • Latex gloves should also be avoided
irrigation fluid
Irrigation Fluid
  • Sterile saline solution
  • Povidone-Iodine Solution (Betadine®) 10%

- tissue toxic

-did not reduce infection incidence.

  • Diluted betadine : use indeterminate.
irrigation fluid1
Irrigation Fluid
  • Tap water : low cast, available.
  • Sandy : Medline 1966-10/03, 397 papers found
  • Cochrane review database :

although evidence is limited, there is no difference in wound infection rates with the use of tap water as an irrigation fluid.

slide13
NHS
  • Wound care is a high cost area for patients and NHS in terms of prescribing costs, patient Quality indicators and NHS workforce time
  • Value for money for the NHS is an important factor when choosing treatments.
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)
closure methods sutures
Closure MethodsSutures
  • The standard for wound closure
  • Percutaneous sutures are used for low- to medium-tension wounds
  • absorbable suture material for dermal stitches
  • interrupted versus other types of sutures has no effect on infection rate
suture material
Suture Material
  • Absorbable
    • Chromic gut
    • Vicryl
  • Non-Absorbable
    • Silk
    • Prolene
  • Monofilament vs. braided
slide17
Glue
  • Faster repair time
  • Less painful
  • Eliminate the risk for needle sticks
  • Antibacterial effect
  • Does not require removal of sutures
glue octyl cyanoacrylate
Glue :Octyl cyanoacrylate
  • FDA approval in 1998 =Dermabond®
  • 50% of the strength of 5-0 suture material.
  • Cochrane review : comparable cosmetic outcomes compared to standard suturing
glue me
Glue me
  • Short (< 6-8 cm)
  • Low tension (< 0.5 cm gap)
  • Clean edged
  • Straight to curvilinear wounds that do not cross joints or creases
don t glue me
Don’t glue me
  • stellate lacerations
  • Bites, punctures or crush wounds
  • Contaminated wounds
  • Mucosal surfaces
  • Axillae and perineum (high-moisture areas)
  • Hands, feet and joints (unless kept dry and immobilized)
staples
staples
  • Fast ,low wound reactivity and infection rate.
  • Less expensive.
  • Less needle sticks risk.
  • No cosmetic difference.
  • Scalp, trunk, and extremity.
surgical tapes steri strips
Surgical TapesSteri-Strips
  • least reactive of all closure techniques
  • lowest tensile strength
  • May require tincture of benzoin
  • Avoid in hairy and wet area.
delayed primary closure dpc
Delayed Primary Closure (DPC)
  • much underused method of wound care .
  • reduced the infection rate by 50% in 104 extremity wounds
  • recommended technique for contaminated wounds that present to the ED
  • Technique : clean and debride then separate wound edges with gauze, and apply bulky dressing.
secondary intention
Secondary Intention
  • allowing a wound to heal without formal closure .
  • Simple but more wound scaring.
  • Quinn et al in 2002 : conservative management resulted in no cosmetic or functional difference compared to primary closure in selected hand lacerations.
moist wounds
MOIST WOUNDS
  • If its wet……..DRY it!
  • If its dry………MOISTEN it!
  • If its irritated…SOOTHE it!
  • If its chronic…IRRITATE it!
  • If its palliative..COMFORT it!
antibiotic use
Antibiotic Use
  • prophylaxis studies : no benefits.
  • Indications For Prophylactic Antibiotics:

Presence of prosthetic device(s) Class III

Patients in need of endocarditis prophylaxis Class III

Open joint or fractures associated with wound Class I

Human, dog, and cat bites Class II

Intraoral lacerations Class II

Immunocompromised patients Class III

Heavily contaminated wounds (eg, feces, etc) Class III

wound preparation antibiotics
Wound Preparation – Antibiotics
  • Dog & cat bites
    • Cover pasteurella
    • Augmentin
  • Human bites
    • Cover eikenella
    • Augmentin
  • Puncture wounds
    • Cover pseudomonas
    • Cipro
wound preparation antibiotics1
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
the future
The future
  • Growth factors :epidermal growth factor (EGF), fibroblast growth factor (FGF), insulin-like growth factor (IGF), keratinocyte growth factor (KGF), and platelet-derived growth factor (PDGF).
  • PDGF gel has been shown to speed healing of wounds
  • chambers filled with antibiotics and growth factors .