Wounds in the ED July 2015

Overview Background Types of wound History Examination Investigation Management Antibiotics and tetanus

Why are wounds so important? We see wounds every day in the ED Mainly in Minor injuries unit Occasionally in majors Major Trauma patients Head injury patients Seizure patients Mismanaging wounds can be life threatening if not life altering for patients.

Types of wound Abrasion

Types of wound Abrasion Contusion

Types of wound Abrasion Contusion Laceration

Types of wound Abrasion Contusion Laceration Incision

Types of wound Abrasion Contusion Laceration Incision Burn Electrical Thermal Chemical

Types of wound Abrasion Contusion Laceration Incision Burn Bite Electrical Thermal Chemical Bite Human Animal

Special Wounds Lips Face Pre-tibial lacerations Accurate repair of vermilion border Face Careful suturing 5/0 or 6/0 for 5 days Pre-tibial lacerations Replace flap without tension do not suture

History Exact history of what happened Pre-hospital treatments PMHx When? Where? What was wounded? What caused the injury? Pre-hospital treatments Irrigation Creams/ointments PMHx Anything increasing risk of poor healing or infection

Examination Thorough examination of whole of wound Must see base of wound Surrounding tissues/structures Hands Tendons, nerves, vessels Examine wound in full range of movement Foreign bodies? Remember this will be sore Analgesia Local anaesthetic – blocks or local to wound

Writing in notes Very important legally Full description of wound You may be called to court for certain cases and need to be able to accurately describe the wound sometimes years after the case. Full description of wound Size Shape Depth location Pictures are good Minors have good stamps for limbs if you are not an artist.

Investigation Xray Ultrasound Wound swabs Foreign bodies – teeth, glass, stones, metal Ultrasound Retained FBs in old wounds Wound swabs Infected old wounds

Management Washout and debridement The most important bit ‘the solution to pollution is dilution’

Management - closure Primary or delayed primary? Secondary intention? Dressings Sterile dressing, especially if having to return for delayed primary closure.

Antibiotics To treat infected wounds Prophylactic Evidence base is lacking Use clinical judgement Grossly contaminated wounds Devitalised tissue Bites – full thickness animal or human Pt increased risk of infection – immunocompromised/diabetic/alcoholic Will not mask poor wound management Co-amoxiclav is a broad spectrum antibiotic which will usually cover the most likely organisms

Tetanus Since 1961 tetanus became a routine vaccine in the UK childhood immunisation schedule Five injections – fully immunised Different immunisations in different countries – Check Immunoglobulin in heavily contaminated or delayed presentation of wounds. Currently being audited in our department – we use more than anyone else in Scotland.

Summary Take a good history Describe wounds correctly Clean and explore all wounds Decide whether to close or not Consider options for closure Consider infection and immunisation