1. Wound Management By Elspeth Frascatore October 2013

2. 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)

3. 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

4. Tetanus • Given at 2 / 4 / 6 / 18 months  5 / 15yrs  every 10yrs thereafter • Immune: if have had at least 3 doses and UTD

5. Tetanus

6. 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)

7. 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

8. How do you tie off an arterial bleeder?

9. 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

10. 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

11. 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

12. 3 2 1

13. 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

14. 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

15. Investigation • Always Xray • Knives can break off under skin • CT angiography • All zone I • Stable zone II • Zone III with evidence of arterial injury

16. Intra-oral Lacerations

17. Eyelid Lacerations

18. Lip Lacerations

19. Tongue Lacerations

20. Nasal Lacerations

21. Facial Nerve Blocks

23. Ear Block

24. Hand Blocks