By Elspeth Frascatore October 2013 Wound Management By Elspeth Frascatore October 2013

Timing of Wound Closure <6hrs: primary closure OK 6-24hrs: primary closure OK unless high risk factor present Heavily contaminated Extensive intra-oral lacerations Foot wounds Stellate lacerations Devitalised wounds: crush injury, under XS tension PMH diabetes, ETOH dependence, PVD, immunosuppression (inc. long term steroids)

Wound Cleaning Tap water is just as good as normal saline Use high pressure irrigation Need 5-8psi Use 30-60ml syringe attached to 19 guage luer Use 50-100ml irrigant per cm of laceration

Tetanus Given at 2 / 4 / 6 / 18 months  5 / 15yrs  every 10yrs thereafter Immune: if have had at least 3 doses and UTD

HISTORY Of TETANUS COURSE AND/OR BOOSTER CATEGORY 1 <5 years (ie. Immune) 2 5 - 10 years 3 >10 years (ie. Full course but out of date) 4 Never / Partial Course / Unknown Clean wound (<6hrs, non-penetrating, negligible tissue damage) Nil Booster ADT ADT course Dirty wound and TIG: 250iu routinely or 500iu if old, contaminated wound or burn injury >10yrs may need further booster doses if <5 doses of ADT previously

Suture Techniques Gaping / high tension wounds (eg. Over joints) Wounds on fragile skin as spreads tension To evert wound edges (eg. Posterior neck, concave skin surface)

Signs of Arterial Injury Large expanding haematoma Severe active / pulsatile bleeding Shock unresponsive to fluids Signs of cerebral infarction Bruit / thrill Decreased distal pulses Paraesthesia

How do you tie off an arterial bleeder?

Human Bites 10-15% infection risk Do not close hand wounds, puncture wounds, infected wounds, wounds >12hrs old Copious wound washout Avoid layered closure Use loose sutures to allow fluid drainage Antibiotic prophylaxis in all cases Although this may change in future Remember punch injuries

Dog / Cat Bites Can close if <6hrs and in low risk area / patient Antibiotic use Meta-analysis has revealed that antibiotics decrease incidence of wound infection in hand wounds only

Neck Lacerations If multiple, assess most important regions first rather than largest Look at the back early Wound size does not correlate with severity of injury

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Structure to Consider Spinal cord – suggested if bilateral symptoms Phrenic nerve – hypoventilation; implies subclavian vein / artery injury Brachial plexus (C5-7) Recurrent laryngeal nerve Cranial nerves Glossopharyngeal nerve – dysphagia, altered gag Vagus nerve – hoarseness; implies common carotid / IJV injury Horner’s syndrome – ipsilateral miosis, enopthalmos, anhydrosis Carotid and vertebral arteries; vertebral, brachiocephalic and jugular veins Thoracic duct, oesophagus, pharynx etc… Thyoid, parathyoid, submandibular, parotid glands

Examination Wound exploration – keep minimal and only perform if stable Identify affected zone and triangle Identify direction tract takes Determine if platysma is penetrated If platysma not penetrated: can be cleared of significant injury If platysma penetrated: 50% risk of other significant injury, mandates OT

Investigation Always Xray CT angiography Knives can break off under skin CT angiography All zone I Stable zone II Zone III with evidence of arterial injury

Intra-oral Lacerations Beware the entrance of the parotid duct and do not suture through it – in cheek, mound of tissue adjacent to 2nd molar; suggested by leakage of clear fluid Don’t take big bites – 2-3mm from edge of wound and include only mucosa, not muscle Sutures can be quite far apart and as few as needed If full thickness – similar to lip lac, wash wound again after closure of mucosa.

Eyelid Lacerations If skin only: close loosely with simple sutures (ROS 3-4/7) If full thickness: place small suture to reapproximate the lash margin (keep knot away from eyeball)  absorable sutures to tarsal plate / orbicularis in 1 layer  skin Consider tearduct injury if full thickness eyelid laceration within 6-8mm of medial canthus

Lip Lacerations 1. Repair mucosa with absorbable – to avoid wound contamination from mouth during closure 2. Irrigate wound again after closure of mucosa to ensure sterile wound 3. Repair obicularis ori muscle – if you catch mucosa in stitches you will cause puckering of muscle 4. Repair skin – align vermillion border first

Tongue Lacerations Tongue is muscle – edges retract when cut making wound appear more complicated Use absorbable sutures If possible, place deep suture – if not, take large bites including the underlying muscle Most don’t need to be sutured

Nasal Lacerations Make sure to align the alar rim Cartilage is usually brought to acceptable position when skin laceration repaired – small, non-absorbable sutures. Placement of sutures direct in cartilage are not recommended Repair of mucosa is tricky – if not properly done, can result in scar inside nostril which impairs breathing. Use absorbable sutures na dpack nostril with gauze coated in chloramphenicol ointment – leave in place for a few days. PO ABx as long as nasal pack in place.

Facial Nerve Blocks To block supraorbital and supratrochlear: supraorbital nerve exits through supraorbital foramen, and supratrocheal 5-10mm medial to this Look straight ahead  follow line up from pupil  feel for notch  raise weal here  go above and infiltrate. To take out supratrochlear also go parallel to medial eyebrow Infraorbital nerve: go through buccal mucosa – go opposite 2nd canine (depth 1.5-2.5cm

Inferior alveolar nerve: mental nerve block plus mandibular teeth and tongue; approach from opposite side of mouth; pierce on medial border of mandibular ramus and hit medial border of alveolar bone but lateral to pterygomandibular fold May need lingual nerve block to take out entire tongue (may miss parts of side)

Ear Block May need wedge excision of pinna; leave overhang of skin; 5mm of cartilage can be removed without significant deformity Avoid suturing cartilage

Hand Blocks Ulnar nerve: between FCU and ulnar artery. Introduce needly under FCU. Radial nerve: Inject into ASB then raise weal around dorsal portion of radial aspect of wrist Median nerve: between PL and FCR; puncture retinaculum between 2 wrist creases and inject 5-8ml