1. UNC Emergency Medicine Medical Student Lecture Series
Wound Management
UNC Emergency Medicine
Medical Student Lecture Series

2. Goals of Wound Care Facilitate hemostasis Decrease tissue loss
Promote wound healing
Minimize scar formation

3. Mechanism of Injury
Wounds are caused by three different types of forces
Shear
Compressive
Tensile

4. Shear Forces Result from sharp objects Low energy Minimal cell damage
Result in straight edges, little contamination
Heals with a good result

5. 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

6. 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

7. Evaluation of Wounds ABC’s first  Always! Ensure hemostasis
Saline gauze dressing
Compression
Remove obstructions
Rings, clothing, other jewelry
History

8. History Symptoms Type of Force Contamination Event
Potential for foreign body
Function
Non-accidental trauma
Tetanus status
Allergies
Medications
Comorbidities
Previous scar formation

9. Wound Examination Location Size Shape Margins Depth
Alignment with skin lines
Neuro function
Vascular function
Tendon function
Underlying structures
Wound contamination
Foreign bodies

10. Wound Consultation Tarsal plate or lacrimal duct
Open fracture or joint space
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

11. Wound Preparation - Anesthesia
Topical
Solution or paste
LET
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

12. 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

13. Minimize the Pain of Injection
Use sodium bicarbonate mixed with the anesthetic (1 ml/10 ml solution)
Use smallest needle possible
Inject slowly
Insert needle through open wound edge and skin that has already been anesthetized

14. Wound Preparation - Hemostasis
Physical vs. chemical
Direct pressure
Epinephrine
Gelfoam
Cautery
Refractory
Use a tourniquet

15. 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

16. Wound Preparation – Irrigation
Local anesthesia prior to irrigation
Do not soak the wound
Use normal saline
Large syringe (60mL) with Zerowet attachment
Do not use iodine, chlorhexidine, peroxide or detergents

17. Wound Preparation – Debridement
Removes foreign matter & devitalized tissue
Creates sharp wound edge
Excision with elliptical shape
Respect skin lines

18. 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

19. Wound Preparation – Antibiotics
Dog & cat bites
Cover pasteurella
Augmentin
Human bites
Cover eikenella
Puncture wounds
Cover pseudomonas
Cipro, levaquin

20. 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!

21. 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)

22. Suture Material Absorbable Non-Absorbable Monofilament vs. braided
Chromic gut
Vicryl
PDS II
Non-Absorbable
Silk
Prolene
Dermalon
Monofilament vs. braided

23. Staples, Adhesives & Tape
Quick, poor aesthetic result
Adhesives
Dermabond- painless, petroleum dissolves
Tape
Steri-strips

24. Wound Closure
Undermine the wound edges
Release tension

25. Suture Techniques Deep layer approximation Absorbable sutures
Buried knot
Serves two purposes
Closes potential spaces
Minimizes tension on the wound margins

26. Skin Closure Key – wound edge eversion
“Approximate, don’t strangulate”
Anticipate wound edema
Choose appropriate size of suture for location of laceration

27. Suture Techniques Simple Interrupted Used on majority of wounds
Each stitch is independent

28. 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

29. Suture Techniques Horizontal Mattress
Useful for single-layer closure of lacerations under tension

30. Horizontal Mattress

31. Suture Techniques Vertical Mattress Useful for everting skin edges
“Far-far-near-near”

32. Vertical Mattress

33. Suture Techniques
Purse-string
Useful for stellate lacerations

34. Suture Techniques
Instrument tie

35. 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!

36. Practice Time!