1. WOUND AND WOUND CARE

2. Definition:
A wound is a break in the continuity of the tissues of the body either internal or external. Or
Abnormal break in the skin or other tissues which allows blood to escape.

3. Classification of soft tissue damage:
A. Open wounds: An open wound is a break in the skin or the mucous membrane. B. Closed wound: Involves injury to the underlying tissues without a break in the skin or a mucous membrane.

4. Types of open wounds
Abrasions- Abrased wounds usually results when the skin is falls against a hard surface.
Incisions- body tissue cut on knives or sharp objects ( a straight deep cut)
Lacerations- irregular or blunt breaking or tearing of soft tissues
Punctures- produced by an object piercing skin layers (e.g when someone step onto a nail)
Avulsions- tissue is forcibly separated or torn from the victim's body.

5. BLEEDING Our body’s mechanism to stop bleeding Clotting of blood.
Scar tissue
Scab
Clot
White blood cell
Skin
Fibrin
Red blood cell
Platelets
Cut ends of a blood vessel will contract.
Blood pressure will drop.

6. MATERIAL FOR WOUND CARE
Dressing- also called a compress, mostly it is sterile gauze pads mainly to control bleeding
Bandage- Any material used to hold a dressing in place, need not to be sterile.

7. General Principles of Emergency Care for Open Wounds
Expose the wound
Clear the wound surface
Control bleeding
Prevent contamination (infection)
Bandage the dressing in place
Keep the patient lying still
Reassure the patient

8. Clean Wound
If the wound is dirty, clean it by rinsing lightly under running water, or use an antiseptic wipe.

9. Elevate and Dressing
Elevate the wounded part above the level of the heart.
Apply adhesive dressing.
If there is a special risk of infection, advise to see doctor.

10. Emergency Care for Minor Lacerated or Incised wounds
Most incisions and lacerations can be managed by bandaging and dressing in place
A butterfly bandage is applied over the wound
Fix the butterfly bandage onto the skin
A gauze dressing is bandaged over the butterfly strip

11. Emergency Care for Impaled Objects
Do not remove the impaled object
Expose the wound area
Control profuse bleeding by direct hand pressure if possible
Stabilize the impaled object with a bulky dressing
Provide oxygen at high concentration
Reassure and keep the patient at rest
Carefully transport the patient as soon as possible

12. Causes of traumatic wounds:
Cause of wound
Blunt object
Sharp object
Glass
Wood
Bite
Human
Dog
Others

13. Evaluation: History: Mechanism Time FB Medical conditions Allergies
Tetanus status
Exam:
Size
Location
Contaminants
Neurovascular
Tendons

14. Universal Precautions:
Use of protective barriers:
eg. Gloves/ gowns/ masks/ eyewear
Will decrease exposure to infective material.

15. Protecting yourself Use disposable gloves.
Wash hands well in soap and water before and after treatment.
Cover any sores or open wounds with waterproof adhesive dressing.

16. Local Anesthesia: 2 main groups
1-  Esters:
Cocaine
Procaine (Novocain)
Benzocaine (Cetacaine)
Tetracaine (Pontocaine)
Chloroprocaine (Nesacaine)
2-  Amides:
Lidocaine (Xylocaine)
Mepivacaine (Polocaine, Carbocaine)
Bupivacaine (Marcaine)
Etidocaine (Duranest)
Prilocaine

17. Methods to reduce pain of Lidocaine local infiltration:
1- Small-bore needles
2- Buffered solutions
3- Warmed solutions
4- Slow rates of injection
5- Injection through wound edges
6- Subcutaneous rather than intradermal injection
7- Pretreatment with topical anesthetic

18. 8- Digital / Regional nerve block:
A critical skill for all ED physicians
Save time
Decrease possibility of systemic toxicity
Less painful than local infiltration
Do not cause the volume-related tissue distortion

19. Skin and Wound preparation:
1- Hair removal
2- Disinfecting the skin
3-Wound Cleansing and Irrigation
4-Soaking

20. 2- Disinfecting the skin:
An ‘ideal agent’ does not exist – either tissue toxic or poorly bacteriostatic
Simple scrub water around wound should be sufficient
No studies have demonstrated the impact of cleaning intact skin on infection rate, however it is important to decrease bacterial load to minimize ongoing wound contamination.
Avoid mechanical scrubbing unless heavily contaminated (increase inflammation in animal data)

21. 2- Disinfecting the skin:
Solution
Antimicrobial activity
Mechanism of action
Uses
Tissue toxicity
N. Saline -
Washing action
Cleanse surrounding skin / irrigation
Povidine-iodine 10%, 1% +
Germicide
Cleanse surrounding skin, ? Irrigation contaminated wounds
Chlorhexidine 1%, 0.1%
Bacteriostatic
Cleanse surrounding skin
Hydrogen Peroxide
Bactericidal
Cleanse contaminated wounds
Hexachlorophene
Nonionic detergents
Wound cleanser

23.   Wound Closure:
Time
Delayed primary closure
Options
Suturing method

24. Time:
The Golden Period: the time interval from injury to laceration closure and the risk of subsequent infection, (is highly variable)

25. Delayed primary wound closure:
High risk wounds that are contaminated or contain devitalized tissue
Wound is initially cleaned and debrided
Covered with gauze and left undisturbed for 4 to 5 days
If the wound is uninfected at the end of the waiting period, it is closed with sutures or skin tapes

26. Options: Nonabsorbable suture Absorbable suture Tissue adhesive
Adhesive tapes
Staples

27. Suturing methods: Simple interrupted Simple running
Horizontal mattress
Vertical mattress
Running subcuticular (intradermal)

28. Simple Interrupted: Most common Easy to master
Can adjust tension with each suture
Stellate, multiple components, or directions wound

29. Simple Running: Minimize time of suture repair
Even distribution of tension
Low-tension, simple linear wounds
Removed within 7 days to avoid suture marks
Optimal suture material is nonabsorbable

31. Horizontal Mattress: Cause wound edges eversion
Single layer closure with significant tension
Decrease repair time, less knots required
Need delayed suture removal, so risk of suture marks

33. Vertical Mattress:
High-tension wounds
Prone to skin suture marks if left in too long

35. Running Subcuticular (Intradermal):
Best for areas where cosmetic result is of utmost importance
Time-consuming
Difficult to master
Low tension wounds
Absorbable suture

45. Tetanus: More than 250,000 cases annually worldwide with 50% mortality
100 cases annually in USA
About 10% in patients with minor wound or chronic skin lesion
In 20% of cases, no wound implicated
2/3 of cases in patients over age 50

46. Prophylactic Antibiotics:
Bite wounds
Contaminated or devitalized wounds
High risk sites eg. Foot
Immunocompromised
Risk for infective endocarditis
Intraoral through lacerations
Deep puncture wounds
Extensive soft tissue injury

47. Prophylactic Antibiotics:
Amoxicillin, Clavulin
Keflex
Erythromycin
recommended course is 3 to 5 days