1. Wounds in the ED
July 2015

2. Overview Background Types of wound History Examination Investigation
Management
Antibiotics and tetanus

3. Why are wounds so important?
We see wounds every day in the ED
Mainly in Minor injuries unit
Occasionally in majors
Major Trauma patients
Head injury patients
Seizure patients
Mismanaging wounds can be life threatening if not life altering for patients.

4. Types of wound
Abrasion

5. Types of wound
Abrasion
Contusion

6. Types of wound
Abrasion
Contusion
Laceration

7. Types of wound
Abrasion
Contusion
Laceration
Incision

8. Types of wound Abrasion Contusion Laceration Incision Burn Electrical
Thermal
Chemical

9. Types of wound Abrasion Contusion Laceration Incision Burn Bite
Electrical
Thermal
Chemical
Bite
Human
Animal

10. Special Wounds Lips Face Pre-tibial lacerations
Accurate repair of vermilion border
Face
Careful suturing 5/0 or 6/0 for 5 days
Pre-tibial lacerations
Replace flap without tension
do not suture

11. History Exact history of what happened Pre-hospital treatments PMHx
When?
Where?
What was wounded?
What caused the injury?
Pre-hospital treatments
Irrigation
Creams/ointments
PMHx
Anything increasing risk of poor healing or infection

12. Examination Thorough examination of whole of wound
Must see base of wound
Surrounding tissues/structures
Hands
Tendons, nerves, vessels
Examine wound in full range of movement
Foreign bodies?
Remember this will be sore
Analgesia
Local anaesthetic – blocks or local to wound

13. Writing in notes Very important legally Full description of wound
You may be called to court for certain cases and need to be able to accurately describe the wound sometimes years after the case.
Full description of wound
Size
Shape
Depth
location
Pictures are good
Minors have good stamps for limbs if you are not an artist.

14. Investigation Xray Ultrasound Wound swabs
Foreign bodies – teeth, glass, stones, metal
Ultrasound
Retained FBs in old wounds
Wound swabs
Infected old wounds

15. Management Washout and debridement The most important bit
‘the solution to pollution is dilution’

16. Management - closure Primary or delayed primary? Secondary intention?
Dressings
Sterile dressing, especially if having to return for delayed primary closure.

17. Antibiotics To treat infected wounds Prophylactic
Evidence base is lacking
Use clinical judgement
Grossly contaminated wounds
Devitalised tissue
Bites – full thickness animal or human
Pt increased risk of infection – immunocompromised/diabetic/alcoholic
Will not mask poor wound management
Co-amoxiclav is a broad spectrum antibiotic which will usually cover the most likely organisms

18. Tetanus
Since 1961 tetanus became a routine vaccine in the UK childhood immunisation schedule
Five injections – fully immunised
Different immunisations in different countries – Check
Immunoglobulin in heavily contaminated or delayed presentation of wounds.
Currently being audited in our department – we use more than anyone else in Scotland.

19. Summary Take a good history Describe wounds correctly
Clean and explore all wounds
Decide whether to close or not
Consider options for closure
Consider infection and immunisation