Dr Donna Mills FACEM Caloundra Wounds Dr Donna Mills FACEM Caloundra

Lacerations involving the vermillion border Mental block v local infiltration Align vermillion border first Interrupted non-absorbable sutures (greater tensile strength)

Mental foramen

Pinna laceration anaesthesia The greater auricular nerve is a branch of the cervical plexus. It innervates the posteromedial, posterolateral, and inferior auricle (lower two-thirds both anteriorly and posteriorly). The lesser occipital nerve innervates a small portion of the helix. The auricular branch of the vagus nerve innervates the concha and most of the area around the auditory meatus. The auriculotemporal nerve originates from the mandibular branch of the trigeminal nerve. It innervates the anterosuperior and anteromedial aspects of the auricle. The external auditory canal and tympanic membrane have separate innervation. Indications for anesthetizing these areas are distinct from those for performing an auricular block.

Pinna laceration anaesthesia – field block provides anaesthesia to the earlobe and lateral helix (greater auricular and lesser occipital nerve branches)

Pinna laceration anaesthesia – auriculotemporal nerve block provides anesthesia to the helix and tragus (auriculotemporal nerve) Beware facial nerve infiltration

Pinna laceration repair pointers Cover the cartilage Avascular – relies on overlying skin Stretchy – can usually cover defects  Very macerated wounds along the helix: triangular tissue wedge excision to create “surgical” wound edges ~5 mm of cartilage can be safely removed

Pinna laceration repair pointers For deep/extensive wounds, consider layered closure: close the cartilage with simple interrupted sutures (eg 5-0 or 6-0 vicryl) by approximating perichondrium (rather than piercing the mid portion of the cartilage which is more fragile and prone to tear) close the skin with interrupted non-absorbable sutures such as 5-0 or 6-0 nylon Start posteriorly (less cosmetically important!)

Pinna laceration repair pointers Risk of hematoma development Dress with gauze behind and in front of pinna and then bandaged around the head Evacuation of hematoma if develops…

Tongue lacerations

Tongue lacerations

Tongue laceration repair Most tongue lacerations do not require sutures! Indications for repair Bisecting wounds Large flaps Persistent bleeding Wounds larger than 1 cm Gaping wounds U-shaped lacerations Avulsion or amputation injuries

Anaesthesia for tongue repair topical anaesthesia with lignocaine 2% on gauze for 5 minutes Local infiltration with lignocaine 1% Lingual nerve block for the anterior two thirds of the tongue Procedural sedation

Inferior alveolar nerve block Anaesthetises the following: Mandibular teeth to the midline The anterior two thirds of the tongue The floor of the oral cavity

Anaesthesia for tongue repair – inferior alveolar nerve block

Inferior alveolar nerve block use the middle finger and thumb to determine the width of the ramus in its anterior-posterior dimension mandibular foramen lies in the middle of the ramus in this dimension Aim toward the index finger and slowly penetrate the mucosa until bone is contacted Bone is usually contacted within about 2.5 cm – if not re-orient laterally

Bite wounds 10-15% human bite wounds become infected Should not be closed primarily AB prophylaxis as per Etg amoxycillin+clavulanate 875+125 mg bd 5/7

Tetanus immunisation For dirty wounds if >5 years For all wounds if >10 years Add immunoglobulin if dirty wound and have not had 3 x tetanus immunisation during life

Penetrating neck trauma

Neck zones

‘Hard’ signs mandating surgical exploration

Management Stable patients with Zone I and III injury undergo angiography and endoscopy Stable patients with Zone II injury undergo surgical exploration or angio/endoscopy Evaluating with CT Angiography may allow for less utilization of services and is effective and reliable.

Wound haemorrhage

Wound haemorrhage Gauze + adrenaline Infiltration with LA + adrenaline Figure of 8 sutures Haemostatic dressings