Wound Management unc emergency Medicine



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Wound Management

  • UNC Emergency Medicine

  • Medical Student Lecture Series


Goals of Wound Care

  • Facilitate hemostasis

  • Decrease tissue loss

  • Promote wound healing

  • Minimize scar formation



Mechanism of Injury

  • Wounds are caused by three different types of forces

    • Shear
    • Compressive
    • Tensile


Shear Forces

  • Result from sharp objects

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


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


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


Evaluation of Wounds

  • ABC’s first  Always!

  • Ensure hemostasis

    • Saline gauze dressing
    • Compression
  • Remove obstructions

  • History



History

  • Symptoms

  • Type of Force

  • Contamination

  • Event

  • Potential for foreign body

  • Function

  • Non-accidental trauma



Wound Examination

  • Location

  • Size

  • Shape

  • Margins

  • Depth

  • Alignment with skin lines

  • Neuro function



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



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


Wound Preparation - Anesthesia



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



Wound Preparation - Hemostasis

  • Physical vs. chemical

    • Direct pressure
    • Epinephrine
    • Gelfoam
    • Cautery
  • Refractory

    • Use a tourniquet


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



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



Wound Preparation – Debridement

  • Removes foreign matter & devitalized tissue

  • Creates sharp wound edge

  • Excision with elliptical shape

  • Respect skin lines



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



Wound Preparation – Antibiotics

  • Dog & cat bites

    • Cover pasteurella
    • Augmentin
  • Human bites

    • Cover eikenella
    • Augmentin
  • Puncture wounds

    • Cover pseudomonas
    • Cipro, levaquin


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!



Wound Closure

  • Primary 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)


Suture Material

  • Absorbable

    • Chromic gut
    • Vicryl
    • PDS II
  • Non-Absorbable

    • Silk
    • Prolene
    • Dermalon
  • Monofilament vs. braided



Staples, Adhesives & Tape

  • Staples

    • Quick, poor aesthetic result
  • Adhesives

    • Dermabond- painless, petroleum dissolves
  • Tape

    • Steri-strips


Wound Closure

  • Undermine the wound edges

    • Release tension


Suture Techniques

  • Deep layer approximation

    • Absorbable sutures
    • Buried knot
    • Serves two purposes
      • Closes potential spaces
      • Minimizes tension on the wound margins


Skin Closure

  • Key – wound edge eversion

  • “Approximate, don’t strangulate”

  • Anticipate wound edema

  • Choose appropriate size of suture for location of laceration



Suture Techniques



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


Suture Techniques

  • Horizontal Mattress

    • Useful for single-layer closure of lacerations under tension


Horizontal Mattress



Suture Techniques



Vertical Mattress



Suture Techniques

  • Purse-string

    • Useful for stellate lacerations


Suture Techniques

  • Instrument tie



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!


Practice Time!



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