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Wound Management
UNC Emergency MedicineMedical Student Lecture Series
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2 Principles of Wound Management
Goals of Wound Care
Facilitate hemostasisDecrease tissue loss
Promote wound healingMinimize scar formation
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3 Principles of Wound Management
Mechanism of Injury
Wounds are caused by threedifferent types of forces
Shear Compressive Tensile
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4 Principles of Wound Management
Shear Forces
Result from sharp objects Low energy
Minimal cell damage Result in straight edges, little contamination Heals with a good result
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5 Principles of Wound Management
Compressive Forces
Result from blunt objects impactingthe skin at a right angle
Results in stellate or complex laceration Ragged or shredded edges More prone to infection
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6 Principles of Wound Management
Tensile Forces
Result from blunt objects impactingthe skin at an oblique angle
Results in triangular wound Sometimes produces a flap More prone to infection
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7 Principles of Wound Management
Evaluation of Wounds
ABCs first Always!Ensure hemostasis
Saline gauze dressing Compression
Remove obstructions
Rings, clothing, other jewelryHistory
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8 Principles of Wound Management
History
SymptomsType of ForceContaminationEventPotential forforeign body
FunctionNon-accidentaltrauma
Tetanus statusAllergies
MedicationsComorbiditiesPrevious scarformation
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9 Principles of Wound Management
Wound Examination
LocationSize
ShapeMarginsDepthAlignment withskin linesNeuro function
Vascular functionTendon function
UnderlyingstructuresWoundcontamination
Foreign bodies
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10 Principles of Wound Management
Wound Consultation
Tarsal plate or lacrimal ductOpen fracture or joint space
Extensive facial woundsAssociated with amputationAssociated with loss of functionInvolves tendons, nerves, or vesselsInvolves significant loss of epidermisAny wound that you are uncertain about
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11 Principles of Wound Management
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
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13 Principles of Wound Management
Minimize the Pain of Injection
Use sodium bicarbonate mixed withthe anesthetic (1 ml/10 ml solution)
Use smallest needle possibleInject slowlyInsert needle through open wound
edge and skin that has already beenanesthetized
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14 Principles of Wound Management
Wound Preparation - Hemostasis
Physical vs. chemical Direct pressure
Epinephrine Gelfoam Cautery
Refractory Use a tourniquet
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15 Principles of Wound Management
Wound Preparation ForeignBody Removal
Visual inspectionImaging
Glass, metal, gravel fragments >1mm should be visible on plain radiographs
Organic substances and plastics are usuallyradiolucent
Always discuss and documentpossibility of retained foreign body
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16 Principles of Wound Management
Wound Preparation Irrigation
Local anesthesia prior to irrigationDo not soak the wound
Use normal salineLarge syringe (60mL) with Zerowetattachment
Do not use iodine, chlorhexidine,peroxide or detergents
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17 Principles of Wound Management
Wound Preparation Debridement
Removes foreign matter & devitalizedtissue
Creates sharp wound edgeExcision with elliptical shapeRespect skin lines
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18 Principles of Wound Management
Wound Preparation Antibiotics
Infections occur in ~3-5% of traumaticwounds seen in the EDFactors that increase risk Heavily contaminated wound, especially with soil Immunocompromised patients Diabetics Human bites > animal bites
Most important prevention adequateirrigation & debridement
l f d
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19 Principles of Wound Management
Wound Preparation Antibiotics
Dog & cat bites Cover pasteurella Augmentin
Human bites Cover eikenella Augmentin
Puncture wounds Cover pseudomonas Cipro, levaquin
20 i i l f d
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20 Principles of Wound Management
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!
21 P i i l f W d M
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21 Principles of Wound Management
Wound Closure
Primary closure Suture, staple, adhesive, or tape Performed on recently sustained lacerations:
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22 Principles of Wound Management
Suture Material
Absorbable Chromic gut Vicryl
PDS II Non-Absorbable Silk Prolene DermalonMonofilament vs. braided
23 P i i l f W d M t
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23 Principles of Wound Management
Staples, Adhesives & Tape
Staples Quick, poor aesthetic result
Adhesives Dermabond- painless, petroleum dissolves
Tape
Steri-strips
24 P i i l f W d M t
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24 Principles of Wound Management
Wound Closure
Undermine the wound edges Release tension
25 P i i l f W d M g t
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25 Principles of Wound Management
Suture Techniques
Deep layerapproximation Absorbable sutures Buried knot Serves two purposes
Closes potentialspaces
Minimizes tension onthe wound margins
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26 Principles of Wound Management
Skin Closure
Key wound edge eversionApproximate, dont strangulate
Anticipate wound edemaChoose appropriate size of suture forlocation of laceration
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27 Principles of Wound Management
Suture Techniques
Simple Interrupted Used on majority of wounds Each stitch is independent
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28 Principles of Wound Management
Suture Techniques
Simple Continuous Useful in pediatrics
RapidEasy removal
Provides effective hemostasis Distributed tension evenly along length Can also be locked with each stitch
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29 Principles of Wound Management
Suture Techniques
Horizontal Mattress Useful for single-layer closure of lacerations
under tension
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30 Principles of Wound Management
Horizontal Mattress
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31 Principles of Wound Management
Suture Techniques
Vertical Mattress Useful for everting skin edges Far
-far-near-near
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32 Principles of Wound Management
Vertical Mattress
33 Principles of Wound Management
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33 Principles of Wound Management
Suture Techniques
Purse-string Useful for stellate lacerations
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34 Principles of Wound Management
Suture Techniques
Instrument tie
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35 Principles of Wound Management
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!
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Practice Time!