WOUND AND WOUND CARE

Definition:

A wound is a break in the continuity of the

tissues of the body either internal or external.

Classification of soft tissue damage :

A. Open wounds:

An open wound is a break in the

skin or the mucous membrane.

B. Closed wound:

Involves injury to the underlying

tissues without a break in the skin or

a mucous membrane.

Types of open wounds

Abrasions- Abrased wounds usually results when the skin is

scraped against a hard surface.

Incisions- body tissue cut on knives or sharp objects

Lacerations- irregular or blunt breaking or tearing of soft

tissues

Punctures- produced by an object piercing skin layers

Avulsions- tissue is forcibly separated or torn from the

victim's body.

MATERIAL FOR WOUND CARE

Dressing- also called a compress, mostly it is sterile

gauze pads mainly to control bleeding

Bandage- Any material used to hold a dressing in

place, need not to be sterile.

General Principles of Emergency Care for

Open Wounds Expose the wound

Clear the wound surface

Control bleeding

Prevent contamination (infection)

Bandage the dressing in place

Keep the patient lying still

Reassure the patient

Emergency Care for Minor Lacerated or

Incised wounds

Most incisions and lacerations can be managed by bandaging

and dressing in place

A butterfly bandage is applied over the wound

Fix the butterfly bandage onto the skin

A gauze dressing is bandaged over the butterfly strip

Emergency Care for Impaled Objects

Do not remove the impaled object

Expose the wound area

Control profuse bleeding by direct hand pressure if

possible

Stabilize the impaled object with a bulky dressing

Provide oxygen at high concentration

Reassure and keep the patient at rest

Carefully transport the patient as soon as possible

Causes of traumatic wounds:

Cause of wound No. of Patients %Blunt object 42Sharp object 34Glass 13Wood 4Bite 6Human 1Dog 3Others 5

Distribution of traumatic wounds:

Location of Wound No. of Patients (%)

Head and Neck 51

Trunk 2

Upper Extremities 34

Lower Extremities 13

Evaluation:

History:• Mechanism• Time• FB• Medical conditions• Allergies• Tetanus status

Exam:• Size• Location• Contaminants • Neurovascular• Tendons

Universal Precautions:

Use of protective barriers:

eg. Gloves/ gowns/ masks/ eyewear

Will decrease exposure to infective material.

Local Anesthesia: 2 main groups

1-  Esters:Cocaine Procaine (Novocain)Benzocaine (Cetacaine)Tetracaine (Pontocaine)Chloroprocaine (Nesacaine)

2-  Amides:Lidocaine (Xylocaine)Mepivacaine (Polocaine, Carbocaine) Bupivacaine (Marcaine)Etidocaine (Duranest)Prilocaine

 

Properties of commonly used local anesthetics:

Agent Class Max. save dose mg/kg

Onset (min)

Duration (hrs)

Procaine Ester 7 2-5 0.25-0.75

Procaine + Epi 9 0.5-1.5

Lidocaine Amide 5 2-5 1-2

Lidocaine + Epi 7 2-4

Bupivacaine Amide 2 2-5 4-8

Bupivacaine + Epi 3 8-16

Methods to reduce pain of Lidocaine local infiltration:

1- Small-bore needles

2- Buffered solutions

3- Warmed solutions

4- Slow rates of injection

5- Injection through wound edges

6- Subcutaneous rather than intradermal injection

7- Pretreatment with topical anesthetic

8 -Digital / Regional nerve block:

A critical skill for all ED physicians

Save time

Decrease possibility of systemic toxicity

Less painful than local infiltration

Do not cause the volume-related tissue distortion

Skin and Wound preparation:

1- Hair removal

2- Disinfecting the skin

3-Wound Cleansing and Irrigation

4-Soaking

2 -Disinfecting the skin:

An ‘ideal agent’ does not exist – either tissue toxic or

poorly bacteriostatic

Simple scrub water around wound should be sufficient

No studies have demonstrated the impact of cleaning intact

skin on infection rate, however it is important to decrease

bacterial load to minimize ongoing wound contamination.

Avoid mechanical scrubbing unless heavily contaminated

(increase inflammation in animal data)

Solution Antimicrobial activity

Mechanism of action

Uses Tissue toxicity

N. Saline - Washing action

Cleanse surrounding skin /

irrigation -

Povidine-iodine 10%, 1% + Germicide Cleanse surrounding skin, ?

Irrigation contaminated

wounds +

Chlorhexidine 1%, 0.1% + Bacteriostatic

Cleanse surrounding skin +

Hydrogen Peroxide + Bactericidal Cleanse contaminated wounds +

Hexachlorophene + Bacteriostatic Cleanse surrounding skin +

Nonionic detergents - Wound

cleanser Wound cleanser -

2 -Disinfecting the skin:

 Wound Closure:

Time

Delayed primary closure

Options

Suturing method

Time:

The Golden Period: the time interval from injury to

laceration closure and the risk of subsequent infection,

(is highly variable)

Delayed primary wound closure:

High risk wounds that are contaminated or contain

devitalized tissue

Wound is initially cleaned and debrided

Covered with gauze and left undisturbed for 4 to 5 days

If the wound is uninfected at the end of the waiting

period, it is closed with sutures or skin tapes

Options:Nonabsorbable sutureAbsorbable suture Tissue adhesive Adhesive tapes Staples

Suturing methods:

Simple interrupted

Simple running

Horizontal mattress

Vertical mattress

Running subcuticular (intradermal)

Simple Interrupted:

Most commonEasy to master Can adjust tension with each sutureStellate, multiple components, or directions wound

Simple Running:

Minimize time of suture repair

Even distribution of tension

Low-tension, simple linear wounds

Removed within 7 days to avoid suture marks

Optimal suture material is nonabsorbable

Horizontal Mattress:

Cause wound edges eversion

Single layer closure with significant tension

Decrease repair time, less knots required

Need delayed suture removal, so risk of suture marks

Vertical Mattress:

High-tension wounds Prone to skin suture marks if left in too long

Running Subcuticular (Intradermal):

Best for areas where cosmetic result is of utmost importance

Time-consumingDifficult to masterLow tension woundsAbsorbable suture

Tetanus:

More than 250,000 cases annually worldwide with

50% mortality

100 cases annually in USA

About 10% in patients with minor wound or chronic

skin lesion

In 20% of cases, no wound implicated

2/3 of cases in patients over age 50

Prophylactic Antibiotics: Bite woundsContaminated or devitalized

woundsHigh risk sites eg. FootImmunocompromisedRisk for infective

endocarditisIntraoral through lacerationsDeep puncture woundsExtensive soft tissue injury

Prophylactic Antibiotics:

Amoxicillin, ClavulinKeflex Erythromycinrecommended course is 3 to 5 days