3.13 - Wound Mngmnt - 2 Hour Lecture-tz

8/12/2019 3.13 - Wound Mngmnt - 2 Hour Lecture-tz

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Wound ManagementDepartment of Emergency Medicine

Johns Hopkins University

Center for International EmergencyDisaster and Refugee Studies


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2Wound managementCenter for International Emergency

Disaster and Refugee Studies

Objective

Define critical management of wounds

Discuss wound classification

Discuss wound evaluationDiscuss wound preparation

Discuss closure techniques

Discuss use of antibiotics


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Introduction

The proper management of wounds in the fieldsetting is one of the most basic and important

practices, and yet is overlooked by many healthproviders

Terence J Ryan of the Department ofDermatology, Churchill Hospital, Oxford notesthat wounds in Tanzania are often due trafficaccidents, fire-arms and household domesticfires, and also wounds from being hit with amachete or animal bites or traps which areoverall exotic and hence rare.


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Presentation

The most important first

step in any injured patient is

to evaluate the ABCs

It is not unusual for a health

care worker to be distracted

by a severe extremity injury

and ignore the potentially

disastrous occurrence of

airway compromise orshock.


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Presentation

After stabilizing the patient, the critical actions

for wound management are to:

stop active bleeding

identify injuries

decide on type of repair needed

consider tetanus immunization

consider antibiotics, and provide instructions to

patient.


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Presentation

There are a variety of

wounds and they are

described below:

Abrasion Superficial laceration

Deep laceration

Complex laceration
http://images.google.com/imgres?imgurl=www.outbackmedic.com/outbackmedicabrasion1.jpg&imgrefurl=http://www.outbackmedic.com/picture_gravelAbrasion.htm&h=240&w=181&prev=/images%3Fq%3Dabrasion%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8


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Presentation

There are a variety of

wounds and they are

described below:

Skin avulsion Crush injury

Burns

Frostbite

Infected wound


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Presentation

A number of wound characteristics can predict

the incidence of wound infections, namely:

The age of the wound prior to irrigation and repair

The location of the wound Whether the wound is contaminated with other items

Wounds which have a blunt mechanism

The presence of large amounts of absorbable sutures

in the wound

High-velocity missile injuries

Puncture wounds and bite wounds


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Presentation

Most wounds do not needprophylactic antibiotics toprevent infection.

Only wounds having thecharacteristics noted abovebenefit from antibioticprophylaxis.

The single most importantfactor for preventinginfection is thoroughirrigation with plain water


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Presentation

It has been found that, whenirrigation was ignored, thatdespite the use of antibiotics,infection rates remained high.

Any wound which is too oldto be closed primarily can beirrigated, debrided, and

packed, with closure to bedone electively in 3-5 days.

This allows time for the tissueto granulate in, anddramatically reduces thelikelihood of a woundinfection.


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11Wound management Center for International EmergencyDisaster and Refugee Studies

Presentation

Tetanus immunization should be given to all

people who have not had a booster within 5

years (for major wounds) or 10 years (for more

minor wounds).If a person has never had the primary series of 3

tetanus shots in the past, they should receive

tetanus immune globulin (TIG; 250 units) as well

as tetanus toxoid (Td) for all major wounds,wounds contaminated with soil or feces, and for

all puncture wounds.


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Presentation

Rabies prevention requires the

adminstration of human rabies

immune globulin (HRIG; 20

U/kg IM, with injected around

the bite site, and given IM at aremote site).

Human rabies vaccine should

also be given 1 mL/dose IM on

days 0, 3, 7, 14, and 28 (1 doseper day).


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Clinical Findings

The steps in wound evaluation,

preparation and closure are:

Stop active bleeding

Adequately expose the wound area

Anesthetize the wound if indicated

Clean the wound and debride as necessary Close the wound if indicated


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Stop the bleeding:


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Exposure

Be sure to expose the entire wound so that you

can see all margins and injuries.

Consider removing hair to expose the field, but

usually this is not needed (the hair can just be

slicked down with water, Betadine or K-Y

jelly).

Shaving increases wound infection rates


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Diagnosis

Laboratory studies are those which are needed for

other traumatic injuries which may be present.

For isolated wound management, there are no

particular lab studies needed.X-rays are often indicated, both to rule out an

underlying fracture (which would then need to be

considered an open fracture), and to rule out any

occult foreign bodies.


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Diagnosis

Foreign bodies, when present,should always be removed, ifreasonably possible.

Metal and most glass show up

well on an x-ray; wood andorganic materials frequently donot.

Unfortunately, wood and organicmaterials have a much higher

likelihood of causing asubsequent wound infection


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Removing Foreign Bodies

Most foreign bodies may be removed by

simple extraction.

Occasionally, extension of the wound is

necessary for greater exposure.

Often a small foreign body such as a splinter

or a piece of metal is too deeply imbedded and

is best left in the tissue.


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Such is the case with bullet

wounds, which usually heal

well if there is no nerve or

artery injury.Leave deeply imbedded

objects in place for removal

in the operating room if

you suspect nerve or arterydamage.


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Wound Cleansing

Clean the wound thoroughly, cleaning dirt and debrisaway with saline or sterile water

then irrigate the wound.

For irrigation, use an 18 or 19 gauge needle and 20 to30 cc syringe give best irrigation pressure.

The best cleaning agent is sterile saline, as it is cheapand isotonic; however, it is not bacteriacidal.

Normal saline with 3 ppm iodine (2 to 3 drops ofiodine per liter) is perhaps the best choice. It is

bacteriacidal but not tissue toxic.


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Wound Cleansing


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Debridement


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Wound Prep


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Local anesthetic agents


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26Wound management

Center for International Emergency


Use of TAC

TAC = tetracaine (0.5%), adrenalin (1:2000),

and cocaine (11.8%) is an excellent topical

anesthetic for open wounds.

It should not be used for wounds on or nearmucosal surfaces (due to rapid absorption of

cocaine), areas of body served by end arteries

(digits, penis, ear lobes, tip of nose), pregnancy

or history of high blood pressure.

It is most useful for scalp or face lacerations in

children.


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Choice of sutures


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Nonabsorbable Sutures

Comparison of nonabsorbable sutures

Nylon (Dermalon)

Polypropylene (Prolene)

Braided nylon (Surgilon)

Silk

Wire (stainless steel)


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Absorbable Sutures

Comparison of absorbable sutures

Plain gut

Chromic gut

Polyglycolic acid / polyglactin (Vicryl, Dexon)

Polydioxanone (PDS)


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Suture size guidelines

Suture size guidelines

Wound location Recommended suture size

Scalp 3-0, 4-0

Face 6-0, 5-0

Chin 6-0, 5-0 (2 layer)Trunk 4-0

Arm 4-0

Hand 5-0

Leg 4-0

Foot 4-0, 3-0

General rule: 6-0 on face, 5-0 on hand, and 4-0 elsewhere on body


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Basic suturing techniques


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Suturing pearls

Use the smallest suture needed to approximate theedges of the wound.

Use small sutures placed closer together rather than

larger sutures places further apart.Edema occurs after closure of a wound, so onlyapproximate the edges, do not strangulate the tissue

Use forceps as little as possible during woundclosure, use skin hooks where available, when onelearns to handle skin hooks well they offer the bestmeans of handling a wound edge


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Alternative techniques for wound closure


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Main suturing techniques


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Choices for wound dressings

Dry gauze is suitable for most wounds or if steri-strips are used.

Nonadherent dressings are preferred for abrasions,nailbed injuries, skin flaps, or the thin skinnedelderly, i.e.,

Vaseline gauze, Xeroform gauze, adaptic gauze (mostexpensive), and Telfa (not really nonadherent).

Antibiotic ointments may be helpful to apply afterclosing the wound, but not usually necessary.


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Incision and Drainage of Simple

Abscess


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Wound Packing


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Skin Grafts


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Disposition/Referral

Most isolated wounds, not associated with multiple

trauma, can be safely evaluated and treated in the

hospital, and discharged home.

As mentioned earlier, antibiotics should beconsidered for bite wounds, contaminated wounds,

hand or foot wounds, or if there is a delayed

presentation (>4-6 hours for limb or trunk; >24 hours

for head wounds)


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Disposition/Referral

In addition to the above listed wound characteristics,

host risk factors for infection include diabetes,

malnutrition, vascular disease, and age >70.

If antibiotics are used, those most commonly used arefirst generation cephalosporins, or

amoxicillin/clavunulate (for dog, cat and human

bites).

Patients with a high risk for infection should be seen

back in the hospital for a wound check in 48-72

hours.


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Suture removal guidelines

Wound Location Suture removal (days)

Scalp 7

Face 3-5

Chin 7Trunk 7-10

Arm 7-10

Hand 10-14

Leg 10-14

Sole of foot 14-21


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Case 1


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Case 2


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Case 3


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Case 4


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Case 5
http://www.eatonhand.com/JPG/1353107.JPG


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Case 6


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Case 7

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3.13 - Wound Mngmnt - 2 Hour Lecture-tz

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