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Wound Management

UNC Emergency MedicineMedical Student Lecture Series

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2 Principles of Wound Management

Goals of Wound Care

Facilitate hemostasisDecrease tissue loss

Promote wound healingMinimize scar formation

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3 Principles of Wound Management

Mechanism of Injury

Wounds are caused by threedifferent types of forces

Shear Compressive Tensile

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4 Principles of Wound Management

Shear Forces

Result from sharp objects Low energy

Minimal cell damage Result in straight edges, little contamination Heals with a good result

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5 Principles of Wound Management

Compressive Forces

Result from blunt objects impactingthe skin at a right angle

Results in stellate or complex laceration Ragged or shredded edges More prone to infection

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6 Principles of Wound Management

Tensile Forces

Result from blunt objects impactingthe skin at an oblique angle

Results in triangular wound Sometimes produces a flap More prone to infection

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7 Principles of Wound Management

Evaluation of Wounds

ABCs first Always!Ensure hemostasis

Saline gauze dressing Compression

Remove obstructions

Rings, clothing, other jewelryHistory

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8 Principles of Wound Management

History

SymptomsType of ForceContaminationEventPotential forforeign body

FunctionNon-accidentaltrauma

Tetanus statusAllergies

MedicationsComorbiditiesPrevious scarformation

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9 Principles of Wound Management

Wound Examination

LocationSize

ShapeMarginsDepthAlignment withskin linesNeuro function

Vascular functionTendon function

UnderlyingstructuresWoundcontamination

Foreign bodies

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10 Principles of Wound Management

Wound Consultation

Tarsal plate or lacrimal ductOpen fracture or joint space

Extensive facial woundsAssociated with amputationAssociated with loss of functionInvolves tendons, nerves, or vesselsInvolves significant loss of epidermisAny wound that you are uncertain about

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11 Principles of Wound Management

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

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13 Principles of Wound Management

Minimize the Pain of Injection

Use sodium bicarbonate mixed withthe anesthetic (1 ml/10 ml solution)

Use smallest needle possibleInject slowlyInsert needle through open wound

edge and skin that has already beenanesthetized

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14 Principles of Wound Management

Wound Preparation - Hemostasis

Physical vs. chemical Direct pressure

Epinephrine Gelfoam Cautery

Refractory Use a tourniquet

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15 Principles of Wound Management

Wound Preparation ForeignBody Removal

Visual inspectionImaging

Glass, metal, gravel fragments >1mm should be visible on plain radiographs

Organic substances and plastics are usuallyradiolucent

Always discuss and documentpossibility of retained foreign body

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16 Principles of Wound Management

Wound Preparation Irrigation

Local anesthesia prior to irrigationDo not soak the wound

Use normal salineLarge syringe (60mL) with Zerowetattachment

Do not use iodine, chlorhexidine,peroxide or detergents

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17 Principles of Wound Management

Wound Preparation Debridement

Removes foreign matter & devitalizedtissue

Creates sharp wound edgeExcision with elliptical shapeRespect skin lines

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18 Principles of Wound Management

Wound Preparation Antibiotics

Infections occur in ~3-5% of traumaticwounds seen in the EDFactors that increase risk Heavily contaminated wound, especially with soil Immunocompromised patients Diabetics Human bites > animal bites

Most important prevention adequateirrigation & debridement

l f d

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19 Principles of Wound Management

Wound Preparation Antibiotics

Dog & cat bites Cover pasteurella Augmentin

Human bites Cover eikenella Augmentin

Puncture wounds Cover pseudomonas Cipro, levaquin

20 i i l f d

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20 Principles of Wound Management

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 P i i l f W d M

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21 Principles of Wound Management

Wound Closure

Primary closure Suture, staple, adhesive, or tape Performed on recently sustained lacerations:

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22 Principles of Wound Management

Suture Material

Absorbable Chromic gut Vicryl

PDS II Non-Absorbable Silk Prolene DermalonMonofilament vs. braided

23 P i i l f W d M t

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23 Principles of Wound Management

Staples, Adhesives & Tape

Staples Quick, poor aesthetic result

Adhesives Dermabond- painless, petroleum dissolves

Tape

Steri-strips

24 P i i l f W d M t

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24 Principles of Wound Management

Wound Closure

Undermine the wound edges Release tension

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25 Principles of Wound Management

Suture Techniques

Deep layerapproximation Absorbable sutures Buried knot Serves two purposes

Closes potentialspaces

Minimizes tension onthe wound margins

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26 Principles of Wound Management

Skin Closure

Key wound edge eversionApproximate, dont strangulate

Anticipate wound edemaChoose appropriate size of suture forlocation of laceration

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27 Principles of Wound Management

Suture Techniques

Simple Interrupted Used on majority of wounds Each stitch is independent

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28 Principles of Wound Management

Suture Techniques

Simple Continuous Useful in pediatrics

RapidEasy removal

Provides effective hemostasis Distributed tension evenly along length Can also be locked with each stitch

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29 Principles of Wound Management

Suture Techniques

Horizontal Mattress Useful for single-layer closure of lacerations

under tension

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30 Principles of Wound Management

Horizontal Mattress

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31 Principles of Wound Management

Suture Techniques

Vertical Mattress Useful for everting skin edges Far

-far-near-near

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32 Principles of Wound Management

Vertical Mattress

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33 Principles of Wound Management

Suture Techniques

Purse-string Useful for stellate lacerations

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34 Principles of Wound Management

Suture Techniques

Instrument tie

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35 Principles of Wound Management

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!

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36 Principles of Wound Management

Practice Time!