Wound Management

By Elspeth FrascatoreOctober 2013

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)

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 50-100ml irrigant per cm of

laceration

Tetanus

Given at 2 / 4 / 6 / 18 months 5 / 15yrs every 10yrs thereafter

Immune: if have had at least 3 doses and UTD

TetanusHISTORY Of TETANUS COURSE AND/OR BOOSTER

CATEGORY 1

<5 years(ie. Immune)

2

5 - 10 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 Full course but out of date)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 Nil Booster ADT ADT course

Dirty wound

Nil Booster ADT Booster ADT

ADT course

and

TIG: 250iu routinely or 500iu if old, contaminated wound or burn injury

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)

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

How do you tie off an arterial bleeder?

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

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

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

3

2

1

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

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

Investigation

Always Xray Knives can break off under skin

CT angiography All zone I Stable zone II Zone III with evidence of arterial injury

Intra-oral Lacerations

Eyelid Lacerations

Lip Lacerations

Tongue Lacerations

Nasal Lacerations

Facial Nerve Blocks

Ear Block

Hand Blocks