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
Symptoms Type of Force Contamination Event Potential for foreign body Function Non-accidental trauma Tetanus status Allergies Medications Comorbidities Previous scar formation History
Location Size Shape Margins Depth Alignment with skin lines Neuro function Vascular function Tendon function Underlying structures Wound contamination Foreign bodies Wound Examination
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!
