1. Wound Management

2. Wound Management Objectives Preserve viable tissue
Restore tissue continuity and function
Avoid infection
Minimize scar formation

3. Wound Management
Lacerations-are one of the most common problems treated in the ED
Accounts for more than 25% of malpractice
Failure to dx. Retained foreign body
Failure to dx. nerve or tendon injury
infection

4. Initial Approach ABC’s Relevant H&P History Allergies, tetanus status
Wound mechanism, contamination, potential FB
Other injuries
Occupation, handedness

5. High Risk Wounds Location Configuration Mechanism Hand, foot, joints
Scalp or face
Configuration
Puncture, linear, stellate
Mechanism
Crush, object causing lac

6. High Risk Wounds History of patient Diabetic Age >50
Chronic alcoholic
HIV, chronic steroids
Peripheral vascular disease
Prosthetic cardiac valve
Asplenic

7. Physical Exam Control local bleeding
Expose pt and look for other wounds
Evaluate distal neurovascular function
Motor function, 2 point sensation
Describe the wound
Laceration, puncture, abrasion, avulsion, crush, bite
Consider X-rays
R/O FB, bony injury

8. Steps in Wound Closure Inspection Preparation Anesthesia Irrigation
Exploration
Debridement
Closure
Dressings

9. Inspection Physical exam Description of wound Location, length, width
Neurovascular check

10. Preparation First step in reducing infection and optimizing cosmesis
Positioning patient
Universal precautions
Gloves, gown, goggles
Skin cleansing
Povidine-iodine (betadine)
Polaxamer-188 (Sur Clens)

11. Anesthesia
Topical
Local
Nerve blocks
IV sedation

12. Local Anesthesia Through the open edge of the wound
At the junction of dermis and superficial fascia
Laceration length equals cc’s of anesthetic
Use small needle (27 or 25) and slow infiltration to minimize pain

13. Irrigation
Purpose is to remove foreign material and debris without damaging tissue
High pressure, large volume
16 or 18 gauge angiocath attached to 30cc syringe
NS or sterile water

14. Exploration After wound in anesthetized
With fingertip, q-tip or hemostat
Liberal use of X-rays

15. Wound Closure Materials
Suture
Steri-strips
Staples
Tissue adhesive (Dermabond©)

16. Suture Types Absorbable Non-absorbable Plain gut Chromic gut Monocryl
Vicryl
Non-absorbable
Silk
Nylon
Prolene
Polyester/dacron

17. Debridement Removal of foreign matter, bacteria and devitalized tissue
Creates sharp wound edges which are easier to repair
Results in more cosmetically acceptable scar

18. Debridement

19. Suture Techniques Simple interrupted Continuous (running)
Vertical Mattress
Horizontal Mattress

20. Suture Tips First sutures are most crucial Handle tissue gently
Should be placed with regards to aligning landmarks
Handle tissue gently
Approximate and evert wound edges
Do not strangulate tissue
Align knots on one side of wound
Decreases inflammatory response

21. Eversion of wound edges

22. Eversion of wound edges

23. Handling the Needle Holder

24. Motion of the Needle Holder

25. Simple Interrupted Suture

26. Vertical Mattress

27. Horizontal Mattress

28. Stellate Laceration

29. Parallel Lacerations

30. Aftercare Check tetanus status Pre-printed wound care instructions
Wound check hrs
Hand wounds
Bites
Heavily contaminated
Wounds requiring antibiotics
Pt must understand signs of infection

31. Aftercare Dressings Avoid sun exposure
Non-adherent
Antibiotic ointment
Avoid sun exposure
Consider splinting digits, joint surfaces

32. Suture Removal Face 3-5 d Joint surface 10-14 d Scalp 7-10 d
Arm/hand 10 d
Joint surface d
Leg/foot 8-14 d
Trunk d

33. The End

34. Thank you