Wound Management unc emergency Medicine

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

• Rings, clothing, other jewelry

• 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

• Simple Interrupted

• Used on majority of wounds
• Each stitch is independent

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

• Useful for everting skin edges
• “Far-far-near-near”

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!