advanced wound care

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Advanced Wound Care

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Perform Advanced Wound Care

• References• Clinical Procedures for Physician Assistants• Merck Manual• CSDT• C348 Minor Surgery A Text and Atlas

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OutlineManagement of traumatic woundsPrinciples of wound closureSelected skin closuresDiscuss the complications of suturingDescribe the suturing of traumatic woundsDescribe cautery devicesList the three main factors that promote wound infectionDefinitions of Infection TypesManagement of Infected Wounds

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Management of Traumatic Wounds

Wound Closure– most superficial wounds will heal without intervention– a superficial laceration extending into the subcutaneous

tissue should be considered for closure in order to avoid undesirable outcomes

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Indications for suture, staple or adhesive tape closure are:– to decrease the time required for the wound to heal– to reduce the likelihood of infection– to decrease the amount of scar tissue likely to form– to repair the loss of structure or function, or both, of the

tissue– to improve cosmetic appearance

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Contraindications– wounds that have a high likelihood of contamination

should not be closed with sutures– wounds that require suturing to minimize infection and

scar potential should be closed within 8 hours of the injury. Some wounds can be closed up to 24 hours after the injury if the anatomic location is highly vascular

– presence of foreign bodies in the underlying tissues– extensive wounds involving tendons, nerves or arteries

should be carefully considered before closure**

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Irrigation– copious irrigation with saline solution enhances wound

cleanliness– using a 60ml syringe and a 21 gauge needle, repeatedly

squirt saline into the site with short bursts to dislodge remaining particulate matter

– several litres may be necessary for large wounds that are heavily contaminated

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Management of Injured Tissue

Debridement– all traumatic wounds are potentially infected– antibiotics are not enough for total protection– debridement of dead, devitalized tissue and meticulous

removal of foreign elements is the only way to assure infection protection

– lack of debridement and cleansing allows the possible formation of gangrene, tetanus and necrotizing fasciitis

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Skin– first step in debridement is the development of complete

exposure by extending the wound with an incision in the direction of the wrinkle lines

– conservative skin debridement, usually only a narrow edge of skin needs to be sacrificed from the edges of the wound

– purple, discolored, macerated and crushed skin is excised

– scissors better than a scalpel

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Muscle– must be debrided and sacrificed radically (in

consultation only)***– discolored, bruised and non-contractile muscle must be

totally excised– remove all non metallic foreign bodies, dirt and

clothing particles– some metallic fragments (bullets, shrapnel) may be left

in place if they are too deeply imbedded– debridement of muscle is best done with forceps and

scissors or scalpel

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Bone– save if possible– all detached fragments should be removed and set aside

under sterile conditions– all attached fragments are gently cleansed with a

currette and placed in their normal positions when possible

– the wound should then be thoroughly irrigated

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Bone Cont’d– while bone can occasionally be left exposed, a

preferable approach is to cover it with soft tissue by approximating nearby muscle over it with several lightly tied absorbable sutures

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Joints– little resistance to infection and are rapidly destroyed by

it– if a joint capsule is open in the base of the wound it must

be cleansed thoroughly– remove any bone fragments and irrigate with copious

amounts of normal saline– the edges of the capsule are approximated with fine

absorbable sutures**– if possible, the capsule is then covered with viable tissue– no drain is used

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Tendon and Fascia– heal slowly– poor resistance to infection because of poor blood

supply– if they are frayed, badly contaminated or discolored

they should be removed***(in consultation)– the type of fascia will determine to a large extent the

strength of closure– use synthetic non-absorbable sutures as they keep their

strength for a long time

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Blood Vessels– repair is for specialist– arterial injuries usually more extensive than they appear– check circulation frequently– pallor, pain and pulselessness are late signs– if there is any question of vascular injury or if the

wound is near a major vessel the patient should be moved to a facility where and arteriogram can be done

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Hemostasis– prior to wound closing absolute hemostasis must be

established to prevent hematoma formation and further blood volume depletion

– this is accomplished by direct and indirect methods– it is preferable to employ indirect methods first to

carefully assess the wound, injury to important structures and allow time for replacement of significant blood loss

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Indirect Hemostasis– elevation

• elevation of the injured part is least damaging to the tissues

• markedly diminishes capillary oozing– pressure

• direct pressure over a bleeding wound is the most common method

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Indirect Hemostasis cont’d– pressure cont’d

• in extremity wounds, a proximally placed BP cuff is frequently used to minimize bleeding in distal wounds

• the use of tourniquets in extremity wounds should be reserved for isolated digital injuries or complex injuries associated with excessive blood loss or requiring special examination

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Indirect Hemostasis cont’d– application of vasoconstrictive agents

• epinephrine containing solutions*** are frequently used in acute wounds to control capillary oozing

• after infiltration a full 7 minutes is required for maximal vasoconstrictive effect

• Caution – epinephrine decreases local wound defense mechanisms and should not be used in contaminated wounds due to the increased risk of infection

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Indirect Hemostasis cont’d– chemical promoters of clotting

• hemostatic agents such as Avitene, Gelfoam or Surgicel should be avoided in the emergency department setting, since they have been shown to increase the risk of infection in contaminated wounds

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Direct hemostasis– includes ligation and electrocauterization of the cut

vessel ends– direct hemostasis should only be employed for bleeding

that cannot be controlled by indirect methods– an exception to this rule is injury to major vascular

tributaries (e.g. ulnar, femoral and brachial artery)

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Direct hemostasis– Ligation

• simple tying or suture ligation is indicated for most vessels more than 2mm in diameter…make sure to anchor the suture!

• to avoid excessive tissue trauma, precisely identify and clamp vessel end prior to ligation

• cut arteries usually only require simple tying

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Direct hemostasis cont’d– Ligation

• veins do not hold ligatures well and suture ligation is preferred

• Caution – arteries and veins should not be ligated en masse, since this may predispose to arteriovenous fistula formation

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Tie Ligature Suture Ligature

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Direct hemostasis cont’d– Electrocautery

• effective in coagulating small vessel ends• pinpoint coagulation is preferred, with the delivery

of the least amount of current needed for vessel thrombosis

– Chemical cautery• silver nitrate and other caustic agents achieve

hemostasis through tissue coagulation but are not recommended for wound hemostasis because of the amount of tissue necrosis they produce

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Tetanus Prophylaxis– preventable endotoxin-mediated disease– if possible determine last tetanus immunization– classify wound as either tetanus prone or non tetanus prone

Tetanus Prone– greater than 6 hours old– greater than 1 cm deep– stellate or have an avulsion configuration– associated with devitalized tissue

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Tetanus Prone cont’d– contaminated with soil, feces, or saliva– from a missile (e.g. gunshot)– from a puncture or crush– associated with a burn or frostbite

All other wounds can be considered non tetanus prone**

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Non Tetanus Prone Wounds– up to date adult requires Td if more than ten years years

since last booster– adult patient with unknown status or inadequate

immunization requires TdTetanus Prone Wounds

– adult with up to date status but five or more years since last requires Td

– adults with inadequate immunization receive both Td and Tetanus immune globulin

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Tetanus ProphylaxisHistory of Tetanus

Immunization ( Doses )

Clean minor Wounds

All otherWounds

Td TdTIG TIGUncertain

0 - 1

2

3 or more

Yes

Yes

Yes

Yes Yes

Yes Yes

Yes

No

No

NoNo2 NoNo3

No1

No

1. unless wound is more than 24 hours old2. unless it has been more than 10 years since last dose3. unless it has been more than 5 years since last doseTd: tetanus and diphtheria toxoids for adults ( > 7 y.o. )

DPT for children

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• Outline• Management of traumatic wounds• Principles of wound closure• Selected skin closures• Discuss the complications of suturing• Describe the suturing of traumatic wounds• Describe cautery devices• List the three main factors that promote wound infection• Definitions of Infection Types• Management of Wound Infections

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Principles of Wound Closure

Wound Handling– wounds treated gently and closed precisely will heal

with minimal scarring– in contrast rough treatment of wounds with crushing of

tissues, failure to achieve hemostasis, incomplete cleansing and tight, strangulating sutures will lead to infection, breakdown and unsightly painful scars

– for optimal healing the wound should have fresh edges and be clean

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• Wound Handling cont’d– prior to closure, all loose fat, clot and other debris

should be removed from the wound– copious irrigation with saline solution enhances wound

cleanliness– the well prepared wound is red, clean, odorless and

remarkably painfree– even badly contaminated wounds will heal nicely with

minimal scarring if these basic principles are followed

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Primary Closure– immediate repair with suture to heal by primary

intention– used on tissues that are clean and free of infection– all layers are closed– best chance for minimal scaring

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Secondary closure– the deep layers are closed whereas superficial layers are

left open to granulate on their own from the inside out– often leaves a wide scar and requires frequent wound

care consisting of irrigation and assorted types of packing and dressings

– is a prolonged process– reasons for use include excessive tissue loss and

infection

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Delayed Closure– the deep layers are closed primarily whereas the

superficial layers are left open until reassessment on the forth or fifth day after initial closure where wound is checked for infection

– if it looks clean and granulation has begun the wound is irrigated and closed

– if infected it is left open to heal by secondary intention– these wounds often arise from contaminated wounds

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Suture Technique– most important to achieve optimal results– protect tissues from dying and contamination– clean sharp dissection– minimal and skillful use of cautery, ligatures and

sutures– good handling of tissues (no crushing, use toothed

forceps)

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Suture Technique cont’d– prevent excessive tension and strangulation– use least amount of sutures as possible– proper material selection– anatomical approximation of layers– subcuticular sutures at base of dermis help prevent

tension from forming in the upper dermis and also causes the surface planes to be even

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Suture Technique cont’d– epithelial edges can then be sutured with interrupted or

running monofilament sutures which can be removed within a week so that suture tracts can be avoided

– steri-strips placed across the incision will also prevent surface marks and can be used primarily or after surface sutures have been removed

– sutures should be removed as soon as possible given the location of the wound…consider splinting certain wound areas and certain patient types!!

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Suture Material Properties– Wound type and the location dictates the selection of the material– Size– Permanent or absorbable– Type of suture technique

• Subcuticular• Interrupted vs continuous• Mattress

– Time of removal

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Special Considerations– hair can be shaved for better wound exploration,

irrigation and closure but it is no longer a necessity**– cutting suture tails or using different colored sutures

especially on the scalp is useful– never shave an eyebrow, as the hair may not grow back

or will grow back irregularly and it is critical to line up hair and skin borders to avoid misalignment

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Special Considerations– also critical to align the vermilion border of the lips by

placing the first stitch at the border of the skin and mucosal areas

– if an incision must be made, it is important to recognize and follow the natural skin tension lines. Scar visibility is minimized when it runs parallel to these lines

advanced wound care

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