Wound Management CYCH PS 許晉豪

Goals of Wound Care Patient comfort and safety Obtain wound healing uneventfully (as possible)

Nomenclature Abrasions Lacerations Crush wounds Puncture wounds/ Penetration wounds Avulsions Amputations Combination of wound Burn

Mechanism of Injury Wounds are caused by three different types of forces Shear Compressive Tensile

Shear Forces Result from sharp objects Low energy Minimal cell damage Result in straight edges, little contamination Heals with a good result

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 Result from blunt objects impacting the skin at an oblique angle Results in triangular wound Sometimes produces a flap More prone to infection

Initial Evaluation of Wounds ABC’s first  Always! Ensure hemostasis Saline gauze dressing Compression Tourniquets 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

Wound History Mechanism of injury Age of wound Associated symptoms (Vital structure injury) Systemic Numbness Loss of function

Wound Examination Location Size Shape Margins Depth/ Soft tissue loss? Neuro function Vascular function Tendon function Underlying structures Wound contamination Foreign bodies

How to Describe a Wound Briefly & Precisely An abrasion wound on medial malleolus area, sizing about 5x10cm, with underlying bone and tendon exposure. The margin shows friction burn marks. No numbness in any of the foot areas is noted. All toes can flex and extend fully. No bony fractures detected on the X-ray.

Wound Consultation Tarsal plate or lacrimal duct Open fracture or joint space exposure 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 Topical Solution or paste Xylocaine spray 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 - Anesthesia Drug Max Dose Onset Duration Cocaine 6.6 mg/kg Rapid 1 hour Procaine 10-15 mg/kg 30min-1hr Tetracaine 1.5 mg/kg Moderate 2 hours Lidocaine 5 mg/kg 5-30 min (with Epi) 7 mg/kg 2-3 hours Bupivacaine 2 mg/kg 7-30 min > 6 hours

Minimize the Pain of Injection Use sodium bicarbonate mixed with the anesthetic (1 ml/10 ml solution) Use smallest needle possible?  injection pressure Small needle, small syringe Large needle, large syringe Inject slowly Insert needle through open wound edge and skin that has already been anesthetized

Wound Preparation - Hemostasis Physical vs. chemical Direct pressure Epinephrine Cautery Suture ligation Refractory Use a tourniquet Possible neuromuscular injuries

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 Local anesthesia prior to irrigation Do not soak the wound Use normal saline 20 mL syringe with 18# gauge Do not use iodine, chlorhexidine, peroxide or detergents

Wound Preparation – Debridement Removes foreign matter & devitalized tissue Creates sharp wound edge

Wound Closure Timeframe Morgan et al Arm and hand: 4 hours = difference Baker and Lanuti Arm and hand: 6 hours = no difference Jamaica Face: no time limit Trunk and extremity: 19 hours = difference Morgan et al 1980 Baker and Lanuti 1990 Jamaica 1988 37

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 – Antibiotics Dog & cat bites Cover pasteurella Augmentin Human bites Cover eikenella Puncture wounds Cover pseudomonas Cipro, levaquin

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 Primary closure Secondary closure Tertiary 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)

Ideal Wound Closure Allow for meticulous wound closure Easily and readily applied Painless low risk to provider Inexpensive Minimal scarring Low infection rate 42

Suture Material Absorbable Non-Absorbable Monofilament vs. braided Chromic catgut Vicryl PDS/ PDO Non-Absorbable Silk Prolene Dermalon/ Nylon Monofilament vs. braided

Staples, Adhesives & Tape Quick, poor aesthetic result Adhesives Dermabond- painless, petroleum dissolves Tape Steri-strips

Choosing Your Suture 47

Wound Closure Undermine the wound edges Release tension

Suture Techniques Deep layer approximation Absorbable sutures Buried knot Serves two purposes Closes potential spaces Minimizes tension on the wound margins

Skin Closure Key – wound edge eversion “Approximate, don’t strangulate” Choose appropriate size of suture for location of laceration

Suture Techniques Simple Interrupted Used on majority of wounds Each stitch is independent

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 Techniques Horizontal Mattress Water-tight suture for intra-oral wounds

Horizontal Mattress

Suture Techniques Vertical Mattress Useful for everting skin edges “Far-far-near-near”

Vertical Mattress

Suture Techniques Purse-string Useful for stellate lacerations

Special Anatomic Sites Scalp Forehead Eyebrow and eyelid Nose Ears Lips Oral cavity Joints Hand 62

Suture Techniques Instrument tie

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!

Dressings Ointment Antibiotics Non-antibiotics Spersin: easy contact dermatitis GM: less frequent contact dermatitis Uburn: silver sulfadiazine G-6-PD, < 2m/o Leukopenia Non-antibiotics Povidone

Dressings Wet dressings Duoderm Aquacel-Ag Remove discharge and eschar Hydrocolloid Fibrinolysis, angiogenesis Abdorption of discharge Aquacel-Ag Hydrofiber, silver ion Absoption of discharge 傷口逐漸癒合後，會漸漸鬆脫，將鬆脫部分剪去，待傷口完全癒合