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Wound Management CYCH PS 許晉豪
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Goals of Wound Care Patient comfort and safety
Obtain wound healing uneventfully (as possible)
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Nomenclature Abrasions Lacerations Crush wounds
Puncture wounds/ Penetration wounds Avulsions Amputations Combination of wound Burn
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Mechanism of Injury Wounds are caused by three different types of forces Shear Compressive Tensile
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Shear Forces Result from sharp objects Low energy Minimal cell damage
Result in straight edges, little contamination Heals with a good result
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Compressive Forces Result from blunt objects impacting the skin at a right angle Results in stellate or complex laceration Ragged or shredded edges More prone to infection
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Tensile Forces Result from blunt objects impacting the skin at an oblique angle Results in triangular wound Sometimes produces a flap More prone to infection
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Initial Evaluation of Wounds
ABC’s first Always! Ensure hemostasis Saline gauze dressing Compression Tourniquets Remove obstructions Rings, clothing, other jewelry History
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History Symptoms Type of Force Contamination Event
Potential for foreign body Function Non-accidental trauma Tetanus status Allergies Medications Comorbidities Previous scar formation
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Wound History Mechanism of injury Age of wound
Associated symptoms (Vital structure injury) Systemic Numbness Loss of function
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Wound Examination Location Size Shape Margins Depth/ Soft tissue loss?
Neuro function Vascular function Tendon function Underlying structures Wound contamination Foreign bodies
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How to Describe a Wound Briefly & Precisely
An abrasion wound on medial malleolus area, sizing about 5x10cm, with underlying bone and tendon exposure. The margin shows friction burn marks. No numbness in any of the foot areas is noted. All toes can flex and extend fully. No bony fractures detected on the X-ray.
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Wound Consultation Tarsal plate or lacrimal duct
Open fracture or joint space exposure Extensive facial wounds Associated with amputation Associated with loss of function Involves tendons, nerves, or vessels Involves significant loss of epidermis Any wound that you are uncertain about
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Wound Preparation - Anesthesia
Topical Solution or paste Xylocaine spray EMLA Local Direct infiltration 1% lidocaine with or without epinephrine Bupivicaine or sensorcaine for longer acting anesthesia Regional Block Local infiltration proximally in order to avoid tissue disruption Smaller amount of anesthesia required
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Wound Preparation - Anesthesia
Drug Max Dose Onset Duration Cocaine 6.6 mg/kg Rapid 1 hour Procaine 10-15 mg/kg 30min-1hr Tetracaine 1.5 mg/kg Moderate 2 hours Lidocaine 5 mg/kg 5-30 min (with Epi) 7 mg/kg 2-3 hours Bupivacaine 2 mg/kg 7-30 min > 6 hours
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Minimize the Pain of Injection
Use sodium bicarbonate mixed with the anesthetic (1 ml/10 ml solution) Use smallest needle possible? injection pressure Small needle, small syringe Large needle, large syringe Inject slowly Insert needle through open wound edge and skin that has already been anesthetized
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Wound Preparation - Hemostasis
Physical vs. chemical Direct pressure Epinephrine Cautery Suture ligation Refractory Use a tourniquet Possible neuromuscular injuries
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Wound Preparation – Foreign Body Removal
Visual inspection Imaging Glass, metal, gravel fragments >1mm should be visible on plain radiographs Organic substances and plastics are usually radiolucent Always discuss and document possibility of retained foreign body
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Wound Preparation – Irrigation
Local anesthesia prior to irrigation Do not soak the wound Use normal saline 20 mL syringe with 18# gauge Do not use iodine, chlorhexidine, peroxide or detergents
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Wound Preparation – Debridement
Removes foreign matter & devitalized tissue Creates sharp wound edge
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Wound Closure Timeframe
Morgan et al Arm and hand: 4 hours = difference Baker and Lanuti Arm and hand: 6 hours = no difference Jamaica Face: no time limit Trunk and extremity: 19 hours = difference Morgan et al 1980 Baker and Lanuti 1990 Jamaica 1988 37
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Wound Preparation – Antibiotics
Infections occur in ~3-5% of traumatic wounds seen in the ED Factors that increase risk Heavily contaminated wound, especially with soil Immunocompromised patients Diabetics Human bites > animal bites Most important prevention adequate irrigation & debridement
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Wound Preparation – Antibiotics
Dog & cat bites Cover pasteurella Augmentin Human bites Cover eikenella Puncture wounds Cover pseudomonas Cipro, levaquin
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Wound Preparation – Tetanus Prophylaxis
Clean wounds Incomplete immunization toxoid >10 years, then give toxoid Tetanus prone wound Incomplete immunization Toxoid & immune globulin > 5 years, give toxoid Remember to think about rabies!
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Wound Closure Primary closure Secondary closure Tertiary closure
Suture, staple, adhesive, or tape Performed on recently sustained lacerations: <12 hours generally and <24 hours on face Secondary closure Secondary intent Allowed to granulate Tertiary closure Delayed primary (observed for 4-5 days)
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Ideal Wound Closure Allow for meticulous wound closure
Easily and readily applied Painless low risk to provider Inexpensive Minimal scarring Low infection rate 42
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Suture Material Absorbable Non-Absorbable Monofilament vs. braided
Chromic catgut Vicryl PDS/ PDO Non-Absorbable Silk Prolene Dermalon/ Nylon Monofilament vs. braided
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Staples, Adhesives & Tape
Quick, poor aesthetic result Adhesives Dermabond- painless, petroleum dissolves Tape Steri-strips
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Choosing Your Suture 47
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Wound Closure Undermine the wound edges Release tension
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Suture Techniques Deep layer approximation Absorbable sutures
Buried knot Serves two purposes Closes potential spaces Minimizes tension on the wound margins
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Skin Closure Key – wound edge eversion
“Approximate, don’t strangulate” Choose appropriate size of suture for location of laceration
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Suture Techniques Simple Interrupted Used on majority of wounds
Each stitch is independent
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Suture Techniques Simple Continuous Useful in pediatrics
Rapid Easy removal Provides effective hemostasis Distributed tension evenly along length Can also be locked with each stitch
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Suture Techniques Horizontal Mattress
Water-tight suture for intra-oral wounds
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Horizontal Mattress
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Suture Techniques Vertical Mattress Useful for everting skin edges
“Far-far-near-near”
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Vertical Mattress
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Suture Techniques Purse-string Useful for stellate lacerations
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Special Anatomic Sites
Scalp Forehead Eyebrow and eyelid Nose Ears Lips Oral cavity Joints Hand 62
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Suture Techniques Instrument tie
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Wound Care Dressing Maintain dry for 24-48 hours
Use antibiotic to maintain moist environment If overlying a joint, splint in a position of function Sun protection to prevent scar hyperpigmentation Suture removal instructions!
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Dressings Ointment Antibiotics Non-antibiotics
Spersin: easy contact dermatitis GM: less frequent contact dermatitis Uburn: silver sulfadiazine G-6-PD, < 2m/o Leukopenia Non-antibiotics Povidone
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Dressings Wet dressings Duoderm Aquacel-Ag Remove discharge and eschar
Hydrocolloid Fibrinolysis, angiogenesis Abdorption of discharge Aquacel-Ag Hydrofiber, silver ion Absoption of discharge 傷口逐漸癒合後，會漸漸鬆脫，將鬆脫部分剪去，待傷口完全癒合
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