WOUND AND WOUND CARE

Definition: A wound is a break in the continuity of the tissues of the body either internal or external.

Classification of soft tissue damage: A. Open wounds: An open wound is a break in the skin or the mucous membrane. B. Closed wound: Involves injury to the underlying tissues without a break in the skin or a mucous membrane.

Types of open wounds Abrasions- Abrased wounds usually results when the skin is scraped against a hard surface. Incisions- body tissue cut on knives or sharp objects Lacerations- irregular or blunt breaking or tearing of soft tissues Punctures- produced by an object piercing skin layers Avulsions- tissue is forcibly separated or torn from the victim's body.

MATERIAL FOR WOUND CARE Dressing- also called a compress, mostly it is sterile gauze pads mainly to control bleeding Bandage- Any material used to hold a dressing in place, need not to be sterile.

General Principles of Emergency Care for Open Wounds Expose the wound Clear the wound surface Control bleeding Prevent contamination (infection) Bandage the dressing in place Keep the patient lying still Reassure the patient

Emergency Care for Minor Lacerated or Incised wounds Most incisions and lacerations can be managed by bandaging and dressing in place A butterfly bandage is applied over the wound Fix the butterfly bandage onto the skin A gauze dressing is bandaged over the butterfly strip

Emergency Care for Impaled Objects Do not remove the impaled object Expose the wound area Control profuse bleeding by direct hand pressure if possible Stabilize the impaled object with a bulky dressing Provide oxygen at high concentration Reassure and keep the patient at rest Carefully transport the patient as soon as possible

Causes of traumatic wounds: Cause of woundNo. of Patients % Blunt object42 Sharp object34 Glass13 Wood4 Bite6 Human1 Dog3 Others5

Distribution of traumatic wounds: Location of WoundNo. of Patients (%) Head and Neck51 Trunk2 Upper Extremities34 Lower Extremities13

Evaluation: History: Mechanism Time FB Medical conditions Allergies Tetanus status Exam: Size Location Contaminants Neurovascular Tendons

Universal Precautions: Use of protective barriers: eg. Gloves/ gowns/ masks/ eyewear Will decrease exposure to infective material.

Local Anesthesia: 2 main groups 1- Esters: Cocaine Procaine (Novocain) Benzocaine (Cetacaine) Tetracaine (Pontocaine) Chloroprocaine (Nesacaine ) 2- Amides: Lidocaine (Xylocaine) Mepivacaine (Polocaine, Carbocaine) Bupivacaine (Marcaine) Etidocaine (Duranest) Prilocaine

Properties of commonly used local anesthetics: AgentClassMax. save dose mg/kg Onset (min) Duration (hrs) ProcaineEster Procaine + Epi LidocaineAmide Lidocaine + Epi72-4 BupivacaineAmide Bupivacaine + Epi38-16

Methods to reduce pain of Lidocaine local infiltration: 1- Small-bore needles 2- Buffered solutions 3- Warmed solutions 4- Slow rates of injection 5- Injection through wound edges 6- Subcutaneous rather than intradermal injection 7- Pretreatment with topical anesthetic

8- Digital / Regional nerve block: A critical skill for all ED physicians Save time Decrease possibility of systemic toxicity Less painful than local infiltration Do not cause the volume-related tissue distortion

Skin and Wound preparation: 1- Hair removal 2- Disinfecting the skin 3-Wound Cleansing and Irrigation 4-Soaking

2- Disinfecting the skin: An ‘ideal agent’ does not exist – either tissue toxic or poorly bacteriostatic Simple scrub water around wound should be sufficient No studies have demonstrated the impact of cleaning intact skin on infection rate, however it is important to decrease bacterial load to minimize ongoing wound contamination. Avoid mechanical scrubbing unless heavily contaminated (increase inflammation in animal data)

SolutionAntimicrobial activity Mechanism of action UsesTissue toxicity N. Saline - Washing action Cleanse surrounding skin / irrigation - Povidine-iodine 10%, 1% + GermicideCleanse surrounding skin, ? Irrigation contaminated wounds + Chlorhexidine 1%, 0.1% + Bacteriostatic Cleanse surrounding skin + Hydrogen Peroxide + BactericidalCleanse contaminated wounds + Hexachlorophene + Bacteriostatic Cleanse surrounding skin + Nonionic detergents - Wound cleanser - 2- Disinfecting the skin:

Wound Closure: Time Delayed primary closure Options Suturing method

Time: The Golden Period: the time interval from injury to laceration closure and the risk of subsequent infection, (is highly variable)

Delayed primary wound closure: High risk wounds that are contaminated or contain devitalized tissue Wound is initially cleaned and debrided Covered with gauze and left undisturbed for 4 to 5 days If the wound is uninfected at the end of the waiting period, it is closed with sutures or skin tapes

Options: Nonabsorbable suture Absorbable suture Tissue adhesive Adhesive tapes Staples

Suturing methods: Simple interrupted Simple running Horizontal mattress Vertical mattress Running subcuticular (intradermal)

Simple Interrupted: Most common Easy to master Can adjust tension with each suture Stellate, multiple components, or directions wound

Simple Running: Minimize time of suture repair Even distribution of tension Low-tension, simple linear wounds Removed within 7 days to avoid suture marks Optimal suture material is nonabsorbable

Horizontal Mattress: Cause wound edges eversion Single layer closure with significant tension Decrease repair time, less knots required Need delayed suture removal, so risk of suture marks

Vertical Mattress: High-tension wounds Prone to skin suture marks if left in too long

Running Subcuticular (Intradermal): Best for areas where cosmetic result is of utmost importance Time-consuming Difficult to master Low tension wounds Absorbable suture

Tetanus: More than 250,000 cases annually worldwide with 50% mortality 100 cases annually in USA About 10% in patients with minor wound or chronic skin lesion In 20% of cases, no wound implicated 2/3 of cases in patients over age 50

Prophylactic Antibiotics: Bite wounds Contaminated or devitalized wounds High risk sites eg. Foot Immunocompromised Risk for infective endocarditis Intraoral through lacerations Deep puncture wounds Extensive soft tissue injury

Prophylactic Antibiotics: Amoxicillin, Clavulin Keflex Erythromycin recommended course is 3 to 5 days