Wound Management

Wound Management Objectives Preserve viable tissue Restore tissue continuity and function Avoid infection Minimize scar formation

Wound Management Lacerations-are one of the most common problems treated in the ED Accounts for more than 25% of malpractice Failure to dx. Retained foreign body Failure to dx. nerve or tendon injury infection

Initial Approach ABC’s Relevant H&P History Allergies, tetanus status Wound mechanism, contamination, potential FB Other injuries Occupation, handedness

High Risk Wounds Location Configuration Mechanism Hand, foot, joints Scalp or face Configuration Puncture, linear, stellate Mechanism Crush, object causing lac

High Risk Wounds History of patient Diabetic Age >50 Chronic alcoholic HIV, chronic steroids Peripheral vascular disease Prosthetic cardiac valve Asplenic

Physical Exam Control local bleeding Expose pt and look for other wounds Evaluate distal neurovascular function Motor function, 2 point sensation Describe the wound Laceration, puncture, abrasion, avulsion, crush, bite Consider X-rays R/O FB, bony injury

Steps in Wound Closure Inspection Preparation Anesthesia Irrigation Exploration Debridement Closure Dressings

Inspection Physical exam Description of wound Location, length, width Neurovascular check

Preparation First step in reducing infection and optimizing cosmesis Positioning patient Universal precautions Gloves, gown, goggles Skin cleansing Povidine-iodine (betadine) Polaxamer-188 (Sur Clens)

Anesthesia Topical Local Nerve blocks IV sedation

Local Anesthesia Through the open edge of the wound At the junction of dermis and superficial fascia Laceration length equals cc’s of anesthetic Use small needle (27 or 25) and slow infiltration to minimize pain

Irrigation Purpose is to remove foreign material and debris without damaging tissue High pressure, large volume 16 or 18 gauge angiocath attached to 30cc syringe NS or sterile water

Exploration After wound in anesthetized With fingertip, q-tip or hemostat Liberal use of X-rays

Wound Closure Materials Suture Steri-strips Staples Tissue adhesive (Dermabond©)

Suture Types Absorbable Non-absorbable Plain gut Chromic gut Monocryl Vicryl Non-absorbable Silk Nylon Prolene Polyester/dacron

Debridement Removal of foreign matter, bacteria and devitalized tissue Creates sharp wound edges which are easier to repair Results in more cosmetically acceptable scar

Debridement

Suture Techniques Simple interrupted Continuous (running) Vertical Mattress Horizontal Mattress

Suture Tips First sutures are most crucial Handle tissue gently Should be placed with regards to aligning landmarks Handle tissue gently Approximate and evert wound edges Do not strangulate tissue Align knots on one side of wound Decreases inflammatory response

Eversion of wound edges

Eversion of wound edges

Handling the Needle Holder

Motion of the Needle Holder

Simple Interrupted Suture

Vertical Mattress

Horizontal Mattress

Stellate Laceration

Parallel Lacerations

Aftercare Check tetanus status Pre-printed wound care instructions Wound check 24-48 hrs Hand wounds Bites Heavily contaminated Wounds requiring antibiotics Pt must understand signs of infection

Aftercare Dressings Avoid sun exposure Non-adherent Antibiotic ointment Avoid sun exposure Consider splinting digits, joint surfaces

Suture Removal Face 3-5 d Joint surface 10-14 d Scalp 7-10 d Arm/hand 10 d Joint surface 10-14 d Leg/foot 8-14 d Trunk 10-14 d

The End

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