1. Wound management 세브란스병원 응급의학교실 강사 이진희

2. Goals 1.Wound healing 의 pathophysiology 를 이해 한다 2.Wound evaluation and management skills 을 익힌다. 3.Wound closure techniques 을 배운다. 4. 적절한 disposition 과 referral skills 을 배운 다. 5. 적절한 follow-up techniques 을 배운다.

3. Anatomy

5. Wound healing Control of bacterial growth, suppression of infection Phagocytosis, Ingestion of wound debris

6. Final appearance Scar revision 고려

7. Categories of wound healing Primary closure –Clean, minimally contaminated, minimal skin loss –Within 6-8hr –No hard & fast rules Secondary closure –Skin infarction, ulceration, abscess cavities, punctures, small animal bites, partial thickness abrasion –Not closed with suture Tertiary closure –Too contaminated to close –Observed for 4-5days –Saline-soaking dressing

9. Wound assessment Initial steps –Patient comfort and safety –Initial hemostasis simple pressure and compression dressing –Jewelry removal –Pain relief Wound care delay –Saline-moistened dressing

11. Wound cleansing P84 Table 7-1

12. Wound cleansing -preparation 1.Hand washing 2.Personnel precautions 3.Wound area hair removal 4.Anesthesia 5.Foreign material 6.Wound periphery cleansing 7.Irrigation 1)Saving : wound infection rate ↑ 2)Clipping hair around the wound with scissors 3)Absolutely not saved or clipped site : eyebrow !!!! 1)Most effective method of reducing bacterial counts 2)High-pressure streams(5 to 70psi(0.35-4.9kg/cm 2 )) of saline : 35cc syringe attached to a 19G catheter 26G 24G 23G19G

13. Wound cleansing -procedure 1.Periphery cleansing 2.Irrigation : 100-250cc or more

14. Local anesthesia Onset of action –Technique of injection –Concentration of the solution –Nerve fiber diameter –Total dose –The addition of epinephrine –pH manupulation –Physiochemical determinants : pKa,lipid solubility, protein binding

17. Local anesthesia -reducing the pain of anesthesia 1.Anesthetic buffering : acidic pH  significant discomfort : 1cc of bicarbonate(1mEq/1cc) + 9cc of 1% lidocaine : 7 일 이상 방치하면 안된다 2.Anesthetic warming 3.Choice of needles : 25G, 27G, 30G 4.rate of injection 26G 24G 23G19G

18. Local anesthesia -technique

19. Local anesthesia -digital nerve block

21. Wound dressing -principles * Face & scalp : left open 1.Tidiness 2.Nonadherent, porous base material 3.Moist environment Synthetic dressing, ointment 4.Protection 5.Partial immobilization ** never to wrap tape circumferentially

22. Soft tissue foreign body -clinical evaluation Glass injury, loss of dentition, needle, nail, splinter 에 의한 injury  Possibility of a retained foreign object Gently running Gentle probing

23. Soft tissue foreign body -imaging Plain radiography –AP & lat –80% can be visualized –Radiodense : metallic, glass(2mm 95%, >0.5 50-60%), pencil graphite, some plastic, gravel –Nonradiodense : wood, thorn, chicken bone, some plastic U/S, CT, MRI

25. Soft tissue foreign body -technique for removal ** 30 분을 넘는다면 consultation 을 고려하라 !! Radiodense objects –Careful localization –Cleansing & anesthesia –Small incision –Exploration Nonradiodense objects –Generous incision & thorough exploration by direct visualization

26. Soft tissue foreign body -technique for removal Protruding objects –Small incision –Foreign body remove –Copiously irrigation –Incision must not be closed with suture

27. Guidelines for consultation There are no definitive rules! Standard of care Logistics of care –30 분이 넘을 경우 Cosmetics and patient expectation Continuity of care

28. Bite wounds 1.Cleanse, irrigate, debride 가 가장 중요 ! 2.Face 는 가능하면 primary closure 를 고려 3.Irrigation 이 용이한 large wound 는 hand 와 foot 이 아니라면 primary closure 를 고려할 수 있다 4.Hand 및 high risk wound 는 secondary 또는 tertiary closure 를 고려한다 5.Primary closure 를 하는 경우 deep closure 는 하 지 않는다

30. Bite wounds -rabies postexposure prophylaxis

32. Tetanus

33. Wound aftercare Home care –Protection, elevation, cleanliness –Vulnerable to direct sunlight : sunblock agent Wound cleansing and bathing –Can be cleansed gently 12-24hrs –Bath or shower : 12-24hr –Wound is not immersed and soaked in water

34. Suture removal

38. Reference By Alexander T. Trott, MD