1. By Elspeth Frascatore October 2013
Wound Management
By Elspeth Frascatore
October 2013

2. Timing of Wound Closure
<6hrs: primary closure OK
6-24hrs: primary closure OK unless high risk factor present
Heavily contaminated
Extensive intra-oral lacerations
Foot wounds
Stellate lacerations
Devitalised wounds: crush injury, under XS tension
PMH diabetes, ETOH dependence, PVD, immunosuppression (inc. long term steroids)

3. Wound Cleaning Tap water is just as good as normal saline
Use high pressure irrigation
Need 5-8psi
Use 30-60ml syringe attached to 19 guage luer
Use ml irrigant per cm of laceration

4. Tetanus
Given at 2 / 4 / 6 / 18 months  5 / 15yrs  every 10yrs thereafter
Immune: if have had at least 3 doses and UTD

5. HISTORY Of TETANUS COURSE AND/OR BOOSTER
CATEGORY 1
<5 years
(ie. Immune) 2
years 3
>10 years
(ie. Full course but out of date) 4
Never / Partial Course / Unknown
Clean wound (<6hrs, non-penetrating, negligible tissue damage)
Nil
Booster ADT
ADT course
Dirty wound
and
TIG: 250iu routinely or 500iu if old, contaminated wound or burn injury
>10yrs may need further booster doses if <5 doses of ADT previously

6. Suture Techniques Gaping / high tension wounds (eg. Over joints)
Wounds on fragile skin as spreads tension
To evert wound edges (eg. Posterior neck, concave skin surface)

7. Signs of Arterial Injury
Large expanding haematoma
Severe active / pulsatile bleeding
Shock unresponsive to fluids
Signs of cerebral infarction
Bruit / thrill
Decreased distal pulses
Paraesthesia

8. How do you tie off an arterial bleeder?

9. Human Bites 10-15% infection risk
Do not close hand wounds, puncture wounds, infected wounds, wounds >12hrs old
Copious wound washout
Avoid layered closure
Use loose sutures to allow fluid drainage
Antibiotic prophylaxis in all cases
Although this may change in future
Remember punch injuries

10. Dog / Cat Bites Can close if <6hrs and in low risk area / patient
Antibiotic use
Meta-analysis has revealed that antibiotics decrease incidence of wound infection in hand wounds only

11. Neck Lacerations
If multiple, assess most important regions first rather than largest
Look at the back early
Wound size does not correlate with severity of injury

12. 3 2 1

13. Structure to Consider Spinal cord – suggested if bilateral symptoms
Phrenic nerve – hypoventilation; implies subclavian vein / artery injury
Brachial plexus (C5-7)
Recurrent laryngeal nerve
Cranial nerves
Glossopharyngeal nerve – dysphagia, altered gag
Vagus nerve – hoarseness; implies common carotid / IJV injury
Horner’s syndrome – ipsilateral miosis, enopthalmos, anhydrosis
Carotid and vertebral arteries; vertebral, brachiocephalic and jugular veins
Thoracic duct, oesophagus, pharynx etc…
Thyoid, parathyoid, submandibular, parotid glands

14. Examination
Wound exploration – keep minimal and only perform if stable
Identify affected zone and triangle
Identify direction tract takes
Determine if platysma is penetrated
If platysma not penetrated: can be cleared of significant injury
If platysma penetrated: 50% risk of other significant injury, mandates OT

15. Investigation Always Xray CT angiography
Knives can break off under skin
CT angiography
All zone I
Stable zone II
Zone III with evidence of arterial injury

16. Intra-oral Lacerations
Beware the entrance of the parotid duct and do not suture through it – in cheek, mound of tissue adjacent to 2nd molar; suggested by leakage of clear fluid
Don’t take big bites – 2-3mm from edge of wound and include only mucosa, not muscle
Sutures can be quite far apart and as few as needed
If full thickness – similar to lip lac, wash wound again after closure of mucosa.

17. Eyelid Lacerations
If skin only: close loosely with simple sutures (ROS 3-4/7)
If full thickness: place small suture to reapproximate the lash margin (keep knot away from eyeball)  absorable sutures to tarsal plate / orbicularis in 1 layer  skin
Consider tearduct injury if full thickness eyelid laceration within 6-8mm of medial canthus

18. Lip Lacerations
1. Repair mucosa with absorbable – to avoid wound contamination from mouth during closure
2. Irrigate wound again after closure of mucosa to ensure sterile wound
3. Repair obicularis ori muscle – if you catch mucosa in stitches you will cause puckering of muscle
4. Repair skin – align vermillion border first

19. Tongue Lacerations
Tongue is muscle – edges retract when cut making wound appear more complicated
Use absorbable sutures
If possible, place deep suture – if not, take large bites including the underlying muscle
Most don’t need to be sutured

20. Nasal Lacerations Make sure to align the alar rim
Cartilage is usually brought to acceptable position when skin laceration repaired – small, non-absorbable sutures.
Placement of sutures direct in cartilage are not recommended
Repair of mucosa is tricky – if not properly done, can result in scar inside nostril which impairs breathing. Use absorbable sutures na dpack nostril with gauze coated in chloramphenicol ointment – leave in place for a few days.
PO ABx as long as nasal pack in place.

21. Facial Nerve Blocks
To block supraorbital and supratrochlear: supraorbital nerve exits through supraorbital foramen, and supratrocheal 5-10mm medial to this
Look straight ahead  follow line up from pupil  feel for notch  raise weal here  go above and infiltrate. To take out supratrochlear also go parallel to medial eyebrow
Infraorbital nerve: go through buccal mucosa – go opposite 2nd canine (depth cm

22. Inferior alveolar nerve: mental nerve block plus mandibular teeth and tongue; approach from opposite side of mouth; pierce on medial border of mandibular ramus and hit medial border of alveolar bone but lateral to pterygomandibular fold
May need lingual nerve block to take out entire tongue (may miss parts of side)

23. Ear Block
May need wedge excision of pinna; leave overhang of skin; 5mm of cartilage can be removed without significant deformity
Avoid suturing cartilage

24. Hand Blocks
Ulnar nerve: between FCU and ulnar artery. Introduce needly under FCU.
Radial nerve: Inject into ASB then raise weal around dorsal portion of radial aspect of wrist
Median nerve: between PL and FCR; puncture retinaculum between 2 wrist creases and inject 5-8ml