wound management unc emergency medicine medical student lecture series
TRANSCRIPT
2 Principles of Wound Management
Goals of Wound CareGoals of Wound Care
Facilitate hemostasis Decrease tissue loss Promote wound healing Minimize scar formation
3 Principles of Wound Management
Mechanism of InjuryMechanism of Injury
Wounds are caused by three different types of forces– Shear– Compressive– Tensile
4 Principles of Wound Management
Shear ForcesShear Forces
Result from sharp objects– Low energy– Minimal cell damage– Result in straight edges, little contamination– Heals with a good result
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Compressive ForcesCompressive 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
6 Principles of Wound Management
Tensile ForcesTensile Forces
Result from blunt objects impacting the skin at an oblique angle– Results in triangular wound– Sometimes produces a flap– More prone to infection
7 Principles of Wound Management
Evaluation of WoundsEvaluation of Wounds
ABC’s first Always! Ensure hemostasis
– Saline gauze dressing– Compression
Remove obstructions– Rings, clothing, other jewelry
History
8 Principles of Wound Management
HistoryHistory
Symptoms Type of Force Contamination Event Potential for
foreign body Function Non-accidental
trauma
Tetanus status Allergies Medications Comorbidities Previous scar
formation
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Wound ExaminationWound Examination
Location Size Shape Margins Depth Alignment with
skin lines Neuro function
Vascular function Tendon function Underlying
structures Wound
contamination Foreign bodies
10 Principles of Wound Management
Wound ConsultationWound 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
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Wound Preparation - Wound Preparation - AnesthesiaAnesthesia 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
12 Principles of Wound Management
Wound Preparation - Wound Preparation - AnesthesiaAnesthesia
Drug Max Dose Onset Duration
Cocaine 6.6 mg/kg Rapid 1 hour
Procaine 10-15 mg/kg Rapid 30min-1hr
Tetracaine 1.5 mg/kg Moderate 2 hours
Lidocaine 5 mg/kg 5-30 min 2 hours
(with Epi) 7 mg/kg 5-30 min 2-3 hours
Bupivacaine 2 mg/kg 7-30 min > 6 hours
13 Principles of Wound Management
Minimize the Pain of Minimize the Pain of InjectionInjection
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
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Wound Preparation - Wound Preparation - HemostasisHemostasis
Physical vs. chemical– Direct pressure– Epinephrine– Gelfoam– Cautery
Refractory– Use a tourniquet
15 Principles of Wound Management
Wound Preparation – Foreign Wound Preparation – Foreign Body RemovalBody 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
16 Principles of Wound Management
Wound Preparation – Wound Preparation – IrrigationIrrigation
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
17 Principles of Wound Management
Wound Preparation – Wound Preparation – DebridementDebridement
Removes foreign matter & devitalized tissue
Creates sharp wound edge Excision with elliptical shape Respect skin lines
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Wound Preparation – Wound Preparation – AntibioticsAntibiotics
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
19 Principles of Wound Management
Wound Preparation – Wound Preparation – AntibioticsAntibiotics
Dog & cat bites– Cover pasteurella– Augmentin
Human bites– Cover eikenella– Augmentin
Puncture wounds– Cover pseudomonas– Cipro, levaquin
20 Principles of Wound Management
Wound Preparation – Tetanus Wound Preparation – Tetanus ProphylaxisProphylaxis
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!
21 Principles of Wound Management
Wound ClosureWound 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)
22 Principles of Wound Management
Suture MaterialSuture Material
Absorbable– Chromic gut– Vicryl– PDS II
Non-Absorbable– Silk– Prolene– Dermalon
Monofilament vs. braided
23 Principles of Wound Management
Staples, Adhesives & Staples, Adhesives & TapeTape Staples
– Quick, poor aesthetic result Adhesives
– Dermabond- painless, petroleum dissolves Tape
– Steri-strips
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Wound ClosureWound Closure
Undermine the wound edges– Release tension
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Suture TechniquesSuture Techniques
Deep layer approximation– Absorbable sutures– Buried knot– Serves two purposes
Closes potential spaces
Minimizes tension on the wound margins
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Skin ClosureSkin Closure
Key – wound edge eversion “Approximate, don’t strangulate” Anticipate wound edema Choose appropriate size of suture for
location of laceration
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Suture TechniquesSuture Techniques
Simple Interrupted– Used on majority of wounds– Each stitch is independent
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Suture TechniquesSuture Techniques
Simple Continuous– Useful in pediatrics
Rapid Easy removal
– Provides effective hemostasis– Distributed tension evenly along length– Can also be locked with each stitch
29 Principles of Wound Management
Suture TechniquesSuture Techniques
Horizontal Mattress– Useful for single-layer closure of lacerations
under tension
31 Principles of Wound Management
Suture TechniquesSuture Techniques
Vertical Mattress– Useful for everting skin edges– “Far-far-near-near”
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Suture TechniquesSuture Techniques
Purse-string– Useful for stellate lacerations
35 Principles of Wound Management
Wound CareWound 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!