1. Dr Donna Mills FACEM Caloundra
Wounds
Dr Donna Mills
FACEM
Caloundra

3. Lacerations involving the vermillion border
Mental block v local infiltration
Align vermillion border first
Interrupted non-absorbable sutures (greater tensile strength)

4. Mental foramen

7. Pinna laceration anaesthesia
The greater auricular nerve is a branch of the cervical plexus. It innervates the posteromedial, posterolateral, and inferior auricle (lower two-thirds both anteriorly and posteriorly).
The lesser occipital nerve innervates a small portion of the helix.
The auricular branch of the vagus nerve innervates the concha and most of the area around the auditory meatus.
The auriculotemporal nerve originates from the mandibular branch of the trigeminal nerve. It innervates the anterosuperior and anteromedial aspects of the auricle.
The external auditory canal and tympanic membrane have separate innervation. Indications for anesthetizing these areas are distinct from those for performing an auricular block.

8. Pinna laceration anaesthesia – field block
provides anaesthesia to the earlobe and lateral helix (greater auricular and lesser occipital nerve branches)

9. Pinna laceration anaesthesia – auriculotemporal nerve block
provides anesthesia to the helix and tragus (auriculotemporal nerve)
Beware facial nerve infiltration

10. Pinna laceration repair pointers
Cover the cartilage
Avascular – relies on overlying skin
Stretchy – can usually cover defects 
Very macerated wounds along the helix:
triangular tissue wedge excision to create “surgical” wound edges
~5 mm of cartilage can be safely removed

11. Pinna laceration repair pointers
For deep/extensive wounds, consider layered closure:
close the cartilage with simple interrupted sutures (eg 5-0 or 6-0 vicryl) by approximating perichondrium (rather than piercing the mid portion of the cartilage which is more fragile and prone to tear)
close the skin with interrupted non-absorbable sutures such as 5-0 or 6-0 nylon
Start posteriorly (less cosmetically important!)

12. Pinna laceration repair pointers
Risk of hematoma development
Dress with gauze behind and in front of pinna and then bandaged around the head
Evacuation of hematoma if develops…

13. Tongue lacerations

14. Tongue lacerations

15. Tongue laceration repair
Most tongue lacerations do not require sutures!
Indications for repair
Bisecting wounds
Large flaps
Persistent bleeding
Wounds larger than 1 cm
Gaping wounds
U-shaped lacerations
Avulsion or amputation injuries

16. Anaesthesia for tongue repair
topical anaesthesia with lignocaine 2% on gauze for 5 minutes
Local infiltration with lignocaine 1%
Lingual nerve block for the anterior two thirds of the tongue
Procedural sedation

17. Inferior alveolar nerve block
Anaesthetises the following:
Mandibular teeth to the midline
The anterior two thirds of the tongue
The floor of the oral cavity

18. Anaesthesia for tongue repair – inferior alveolar nerve block

19. Inferior alveolar nerve block
use the middle finger and thumb to determine the width of the ramus in its anterior-posterior dimension
mandibular foramen lies in the middle of the ramus in this dimension
Aim toward the index finger and slowly penetrate the mucosa until bone is contacted
Bone is usually contacted within about 2.5 cm – if not re-orient laterally

21. Bite wounds 10-15% human bite wounds become infected
Should not be closed primarily
AB prophylaxis as per Etg
amoxycillin+clavulanate mg bd 5/7

22. Tetanus immunisation For dirty wounds if >5 years
For all wounds if >10 years
Add immunoglobulin if dirty wound and have not had 3 x tetanus immunisation during life

23. Penetrating neck trauma

24. Neck zones

25. ‘Hard’ signs mandating surgical exploration

26. Management
Stable patients with Zone I and III injury undergo angiography and endoscopy
Stable patients with Zone II injury undergo surgical exploration or angio/endoscopy
Evaluating with CT Angiography may allow for less utilization of services and is effective and reliable.

27. Wound haemorrhage

28. Wound haemorrhage Gauze + adrenaline Infiltration with LA + adrenaline
Figure of 8 sutures
Haemostatic dressings