1. EO 004.06 Perform Advanced Wound Care Outline Management of traumatic wounds Principles of wound closure Selected skin closures Discuss the complications of suturing Describe the suturing of traumatic wounds Describe cautery devices List the three main factors that promote wound infection Definitions of Infection Types Management of Wound Infections

2. EO 004.06 Traumatic Wounds Wounds under tension/Undermining –push the skin edges of the area together to see how much tension will be placed on sutures –if there is tension undermining will be required –undermining is performed by blunt dissection to mobilize adequate tissue for closing.

3. EO 004.06 Traumatic Wounds Wounds under tension/Undermining cont’d –decrease wound tension by beginning wound closure with the placement of subcutaneous absorbable sutures to approximate the edges –next use interrupted non absorbable sutures to close the skin –One rule of thumb is that one should undermine about the same radius as the maximum width of the wound.

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8. Traumatic Wounds Irregular Wounds –these wounds may need debridement –edges trimmed or deformities corrected Suturing across joints –splinting will be required to immobilize the area –suture in full extended position

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10. Dog Ear Deformity Correction Traumatic Wounds

11. EO 004.06 Traumatic Wounds Avulsion, V or T Shaped and Stellate Wounds –the corner stitch is best used hear to avoid formation of necrotic tissue –use of steri strips will help adhere edges down

12. EO 004.06 Perform Advanced Wound Care Outline Management of traumatic wounds Principles of wound closure Selected skin closures Discuss the complications of suturing Describe the suturing of traumatic wounds Describe cautery devices List the three main factors that promote wound infection Definitions of Infection Types Management of Wound Infections

13. EO 004.06 Cautery Devices Hyfrecator –electrical –actually burns tissue with heat –good for small vessel bleeds –good for base of small lesion excisions skin tags warts small nevi

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16. Cautery Devices Silver Nitrate Sticks –good for small bleeds –often used in epistaxis

17. EO 004.06 Perform Advanced Wound Care Outline Management of traumatic wounds Principles of wound closure Selected skin closures Discuss the complications of suturing Describe the suturing of traumatic wounds Describe cautery devices List the three main factors that promote wound infection Definitions of Infection Types Management of Wound Infections

18. EO 004.06 Management of Injured Tissue Three main factors that promote wound infection –the infectious agent aerobic and/or anaerobic bacteria, fungi etc. –the susceptible host immunosuppressed, trauma, surgery –a closed unperfused space such as a wound or surgical site

19. EO 004.06 Wound Infections Definitions Septicemia –presence of pathogenic micro-organisms in the blood –bacteria invade a superficial area of the body is usually accompanied by sudden high temperature Cellulitis –is a common invasive non-suppurative infection of connective tissue –characterized by hyperemia, WBC infiltration and edema without cellular necrosis

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24. Wound Infections Erysipelas –an acute febrile disease with localized inflammation and erythema of the skin and subcutaneous tissue accompanied by systemic signs and symptoms –has distinct borders Lymphangitis –inflammation of lymphatic channels –channels are swollen and readily palpable

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28. Wound Infections Lymphadenitis –inflammation of the lymph nodes Abscess –a localized collection of pus that results from invasion of a pyogenic bacterium –staph is the most common cause

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31. Management of Infections Bacterial Synergistic Gangrene –is an anaerobic infection in the skin and or soft tissue following trauma, inadequate blood supply or surgery –are commonest in areas that are contaminated by oral or fecal flora –there may be progressive tissue necrosis and a putrid odor

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34. Wound Infections Tetanus –an acute infectious disease of the CNS caused by an endotoxin of the tetanus bacillus –early clinical manifestations are elevated temperature, muscle spasm or tetanic spasm and stiffness or locking of the jaw

35. EO 004.06 Perform Advanced Wound Care Outline Management of traumatic wounds Principles of wound closure Selected skin closures Discuss the complications of suturing Describe the suturing of traumatic wounds Describe cautery devices List the three main factors that promote wound infection Definitions of Infection Types Management of Wound Infections

36. EO 004.06 Perform Advanced Wound Care –Cellulitis –Generalized tetanus –Post operative wound infection –Necrotizing fasciitis –Clostridial myonecrosis –Osteomyelitis

37. EO 004.06 Management of Infections Cellulitis Signs and Symptoms –infection is most common in lower extremities –appears as a brawny red or reddish brown area of edematous skin –skin can be hot and erythematous –infiltrated skin often resembles the skin of an orange –borders are usually indistinct except in erysipelas

38. EO 004.06 Cellulitis Signs and Symptoms –petechiae are common –vesicles and bullae may develop and rupture –systemic manifestations may precede the cutaneous findings, however many patients will not appear ill –leukocytosis is common

39. EO 004.06 Cellulitis Diagnosis –dependant upon clinical findings –unless pus has formed or an open wound is present, the responsible organism is difficult to isolate –strep is the most common cause

40. EO 004.06 Cellulitis Treatment* Uncomplicated: mild –S. Aureus or Group A Strep First line –Cephalexin Second line – Cloxacillin or Clindamycin Uncomplicated severe non facial –S. Aureus or Group A Strep First line – IV Ancef +/- PO Clindamycin Second line – IV Clindamycin

41. EO 004.06 Cellulitis Treatment cont’d Special considerations: facial –S. Aureus or Group A Strep First line – IV Cefazolin or IM/IV Ceftriaxone Second line Clindamycin IV/PO

42. EO 004.06 Management of Infections Subcutaneous Abscess Signs and Symptoms –heat –swelling –tenderness –redness –fever may occur –local pain and tenderness –systemic symptoms

43. EO 004.06 Subcutaneous Abscess Diagnosis –culture for C&S or gram stain to determine causative agent Treatment –healing usually requires surgical drainage with thorough removal of pus, necrotic tissue and debris –warm moist compresses –antibiotics either po or IV depending on severity and organism cultured

44. EO 004.06 Management of Infections Tetanus Signs and Symptoms –incubation period 2-50 days with 5-10 being the average –localized tetanus can occur, with spasticity of a group of muscles near the wound without trismus –most frequent symptom is jaw stiffness –difficulty in swallowing –restlessness –irritability

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46. Tetanus Signs and Symptoms cont’d –stiff neck, arms or legs –headache –fever –sore throat –tonic spasms –late signs are difficulty opening jaw (trismus) –facial muscle spasm

47. EO 004.06 Tetanus Diagnosis –history of a wound in a patient with muscle stiffness or spasm –C. tetani can sometimes be cultured from the wound –Diagnosis – can be confused with meningocephalitis of bacterial or viral origin, but the combination of an intact sensorium, normal CSF and muscle spasms suggest tetanus

48. EO 004.06 Tetanus Treatment –on initial patient presentation determine tetanus immunization status and give boost if required –if tetanus has developed therapy involves: maintaining adequate airway early and adequate use of human immune serum globulin preventing further toxin development

49. EO 004.06 Tetanus Treatment providing sedation controlling muscle spasms fluid balance treatment of concurrent infection –Wound care dirt and debris promote growth of C. tetani prompt thorough debridement especially of deep puncture wounds is essential

50. EO 004.06 Tetanus Treatment –role of antibiotic therapy is minor in contrast to wound debridement and general support –Pen G 2 million units IV q6h or Tetracycline 500mg IV q6h should be given for 10 days (adults)

51. EO 004.06 Management of Infections Post Operative Wound Infection –results from bacterial contamination during or after a surgical procedure –infection is usually confined to the subcutaneous tissues Signs and Symptoms –usually appear between the 5 th and 10 th day post op –first sign is fever –may have wound pain –edema may be present due to the tightness of sutures –palpation of the wound may disclose an abscess

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53. Post Operative Wound Infection Treatment –basic treatment is to open the wound and allow it to drain –antibiotics are not necessary unless the infection has become invasive –wound cultures must be taken in order to determine best antibiotic

54. EO 004.06 Management of Infections Necrotizing Fasciitis –invasive infection of fascia –usually due to multiple pathogens –often rapid progression of the disease Signs and Symptoms –usually begins in a localized area such as a puncture wound, leg ulcer or surgical wound –spreads along the relatively ischemic fascial planes causing the penetrating vessels to thrombose

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56. Necrotizing Fasciitis Signs and Symptoms –skin is devascularized –involved site is red, hot and swollen –with progression there may be purplish (violaceous) discoloration of the skin, bullae, crepitus and dermal gangrene –fever is nearly always present –typically accompanied by systemic toxicity –evidence of intravascular volume depletion, including hypotension is frequent

57. EO 004.06 Necrotizing Fasciitis Diagnosis –cultures and gram stains –X-rays of the area often demonstrates soft tissue gas Treatment –red, hot, tender and markedly edematous skin suggests an underlying necrotizing subcutaneous infection –this is a dermatological emergency –incision is usually indicated –thorough surgical debridement

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59. Necrotizing Fasciitis Treatment cont’d –systemic support –identification of causative organism will determine antibiotic Group A Strep - first line – Clindamycin IV + Cefazolin IV or Pen G IV - second line – Vancomycin IV

60. EO 004.06 Management of Infections Clostridial Myonecrosis (Gas Gangrene) –produced by entry of one of several clostridia into devitalized tissue Signs and Symptoms –onset is sudden, with rapidly increasing pain in the affected area –fall in blood pressure –tachycardia –fever is present but not proportional to the severity of infection

61. EO 004.06 Clostridial Myonecrosis Signs and Symptoms cont’d –wound becomes swollen and the surrounding skin is pale –foul smelling brown, blood tinged serous discharge –as disease advances, surrounding tissue changes from pale to dusky and eventually becomes deeply discolored, with coalescent, red, fluid filled vesicles –gas may be palpable in the tissues

62. EO 004.06 Clostridial Myonecrosis Diagnosis –gas gangrene is a clinical diagnosis –gas may be present on xray –anaerobic culture confirms diagnosis Treatment –surgical debridement and exposure of infected areas is essential –radical surgical excision is often necessary –penicillin is effective as an antibiotic

63. EO 004.06 Management of Infections Osteomyelitis –inflammation and destruction of bone caused by aerobic and anaerobic bacteria, mycobacteria and fungi –Staph Aureus is most common organism Signs and Symptoms –long bones and vertebra are common sites –fever if peripheral bones affected but may be absent if in vertebrae –unwillingness to move affected area

64. EO 004.06 Osteomyelitis Signs and Symptoms –history of weight loss and fatigue –localized erythema, warmth, swelling and tenderness –abscess formation is a late and unusual manifestation Diagnosis –Culture of S. aureus from site –Xrays often normal in early stages but may show abnormalities in later stages

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66. Osteomyelitis Treatment –antibiotics such as IV Nafcillin, Oxacillin, Vancomycin or Cefazolin –prolonged therapy is required for staph osteomyelitis –parental regimes are recommended during the acute phase then oral dicloxacillin or cephalexin –surgical debridement may be necessary