Basic Boo-Boo and Owie Repair Kalpesh Patel, MD Dept. of Pediatric Emergency Medicine July 26, 2006.
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Transcript of Basic Boo-Boo and Owie Repair Kalpesh Patel, MD Dept. of Pediatric Emergency Medicine July 26, 2006.
Basic Boo-Boo and Owie Repair
Kalpesh Patel, MD
Dept. of Pediatric Emergency Medicine
July 26, 2006
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Pathophysiology
Wounds regain 5% strength in 2 weeks
Collagen synthesis begins within 48 hours of injury and peaks at 1 week
30% strength in 1-2 months
Full tensile strength in 6-8 months
Remodeling can occur up to 12 months
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Pathophysiology
Normal skin is under constant tension produced by underlying joints and muscles.
Lacerations parallel to joints and skin folds heal more quickly and better
Tension widens scars
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Pathophysiology
All wounds leave scars, but shallow ones heal better Fibroblasts cause wound contraction – Evert edges!
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Wound Infections
Areas of high bacteria counts (>100,000/gm) are more prone to infection: • Axilla, perineum, hands, face and feet• Areas of high vascularity, resist infection despite
high bacteria counts: face and scalp Sharp wounds (i.e. knife wounds) rarely infected Blunt injury causes irregular wounds, flaps and
crushes underlying skin. More likely to be infected and cause unacceptable scarring
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Evaluation
History:• Mechanism of injury - Shearing, Tension (Blunt),
or Compression (Crush)• Age of wound• Possibility of foreign body• Location and damage to adjacent structures• Environment in which injury occurred• Patient’s health status: diabetes,
immunocompromised, cyanotic heart disease, chronic respiratory problems, renal insufficiency
• Medications – steroids• Allergies to latex, antibiotics or anesthetics• Tetanus status
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Evaluation
Physical:• Vascular damage – pressure for active bleeding
Brisk dark blood = vein, can be ligated; Brisk bright blood = artery Tourniquet if needed for up to 2 hours
• Nerve damage – when sensation is intact, motor function is usually intact
• Tendon injury check full ROM of nearby joints Inability to withdraw from noxious stimuli
implies injury
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Evaluation
Physical:• Foreign material
Glass and metal are radiopaque, so X-ray Ultrasound is useful for other foreign bodies Explore for foreign bodies after anesthesia
• Bones Palpate nearby bones for tenderness or
crepitance and X-ray if found Refer vascular, nerve or tendon injuries or deep,
extensive lacerations to the face• HAND: Ortho and Plastics alternate days• FACE: ENT, Plastics, and OMFS alternate
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Decision to Close
Infection rate for children is 2% for all sutured wounds.
“Golden period” is within 6 hours for primary closure Low risk wounds can be primarily closed 12-24
hours after injury
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Decision to Close
Face can be primarily closed up to 24 hours after injury with excellent cosmetic effect
Some contaminated wounds (animal or human bites, barnyard injuries) or immunocompromised host should not be sutured even if presenting immediately
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Decision to Close
Secondary intention healing (secondary closure) should be allowed for infected wounds, ulcers, many animal bites, small puncture wounds• Small wick of iodoform gauze placed inside
wound to keep edges open and removed in 2-3 days to allow subsequent granulation
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Decision to Close
Delayed primary closure (tertiary closure) considered for heavily contaminated wounds or extensive wounds• Considered after 3-5 days, once infection risk
decreases due to re-epithelialization (about 1mm/day)
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Decision to Close
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Management
Preparation:• Tell the patient and family what is going to
happen, unhurried and with confidence• Arrange distractions: Child life, TV, music, etc• Keep parents in the room, sitting and focusing on
the child• Consider pain medication and sedation/anxiolysis
prior to procedure • Prepare injections, use needles, and open your
kit away from child• Immobilization for young children – use staff to
hold the wounded body part and the family to hold the rest. Avoid papoose.
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Wound Preparation
Do not shave hair• Secure with petroleum jelly or clip with scissors if
needed to keep hair from entering wound Clean the wound periphery with 10% povidone-
iodine• A 1% solution may also be used for dirty wounds
• Avoid chlorhexidine, H2O2, Alcohol, and surgical scrub in the wound
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Wound Preparation
Anesthetize locally or with a regional block
http://www.mainehealth.org/em_body.cfm?id=3235
Pressure irrigation to wound (7-8 PSI) with Saline 100 ml per 1cm of laceration
Do not soak wounds – causes skin maceration and edema
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Wound Preparation
Only scrub dirty wounds and consider non-ionic detergents
Remove embedded foreign material (road rash) to avoid tattooing of skin
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Wound Preparation
Trim irregular lacerations, debride necrotic skin• Subcutaneous fat
can be removed in small amounts or undermined
• Don’t remove facial fat as it may leave depressions
• Stellate or highly irregular lesions may need excision to minimize scar
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Wound Closure Equipment
Choose suture material that has adequate strength while producing little inflammatory reaction• Non-absorbable sutures for skin
Nylon or polypropylene Silk causes tissue reaction Use 4-5 throws per knot
• Absorbable for skin or deep sutures Monocryl, Vicryl, Dexon – synthetic Guts are natural and cause more reaction Fast Gut for face or scalp
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Wound Closure Equipment
• Size: 5-0 to 6-0 for face 4-0 for deep tissues with light tension 3-0 for tissues with strong tension (joints, sole
of foot or thick skin) 3-0 to 4-0 for oral mucosa 4-0 to 5-0 for everything else
• Needles 3/8 reverse cutting needle satisfies most
needs Round needles for oral mucosa High grade plastic for face (P or PS) Fine needle (P3) for fine cosmesis
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Wound Closure
2 goals:• Match the layers of
injured tissue Identify all skin
layers and appose each layer as closely as possible to original location
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Wound Closure
Evert the wound edges• Enter skin at 90 degrees
perpendicular and pronate wrist
• Use slight thumb pressure on the wound edge as needle enters the opposite side
• Take equal bites on both sides
• Do not pull the knot tightly. Causes puckering
• Minimize skin tension with deep sutures
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Suture Techniques
Deep sutures – to reduce skin tension and repair deep structures• Buried subcutaneous suture
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Suture Techniques
Simple interrupted• Loop knot allows
minimal tension and allows for edema
Running sutures – used to close large, straight wounds or multiple wounds• Horizontal dermal stitch
(subcuticular)
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Suture Techniques
Vertical mattress – for deep wounds, reduces tension, closes dead space
http://www.jpatrick.net/WND/woundcare.html
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Suture Techniqes
Horizontal mattress – relieves tension
http://www.jpatrick.net/WND/woundcare.html http://
www.bumc.bu.edu/Dept/Content.aspx?DepartmentID=69&PageID=5236
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Suture Techniques
Corner stitch (half-buried mattress stitch) – to close a flap
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Suture Alternatives - Tape
Leaves no marks, minimal tissue reaction
Can be placed between sutures to relieve tension
Can be used primarily for small lacerations
Can be used for loose approximation of dirty wounds
Use benzoin to adjacent skin (not wound)
Don’t pull tape or wound edges won’t approximate well, apply perpendicularly across wound
Do not bandage if possible to minimize moisture
Don’t tape in moist areas: palms or axillae
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Suture Alternatives - Staples
Staples• Best for scalp, trunk, and extremity
wounds• Use when saving time is important,
such as mass casulties• Does not allow for meticulous
cosmetic repair• Should not be used on face, neck,
hands or feet• Should not be used prior to MRI or
CT as they may interfere with imaging
• More painful to remove
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Suture Alternatives - Glue
Tissue Adhesives• Rapid and painless closure• Sloughs off in 7-10 days so no follow up
required• Antimicrobial effects against Gram positives• High viscosity adhesives are less likely to
migrate during repair• Clean and dry wound, achieve hemostasis• Hold edges together manually and apply.• Avoid getting into wound, it acts as a foreign
body• Dry for 30 seconds between layers• Don’t use over high tension areas
Suture Alternatives - Glue
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Dressings
Dressings protect the wound, absorb secretions and immobilze the part
For simple wounds a clean absorbent gauze is sufficient with bacitracin or polysporin (not neosporin)
A non-adherent gauze (Telfa or Xeroform) can be used underneath if desired
Tegaderm can be used for small wounds of the face and trunk
Scalp wound need no dressing
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Dressings
Dressings should remain in place for 24-48 hours or for active children, until sutures removed
Daily dressing changes should be done and wound inspected
Dressing changed sooner if soiled, wet or saturated If the wound overlies a joint, splint it for no more
than 72 hours
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Antibiotics
Antibiotics are not recommended for routine use Proper irrigation is more efficacious than antibiotics
to prevent wound infection Consider antibiotics for heavily contaminated
wounds, bites, crush injuries, or wounds > 12 hours old
Use antibiotics for • oral wounds• wounds of the hands, feet or perineum• open fractures or exposed cartilage, joints or
tendons 1st generation cephalosporin or Augmentin
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Tetanus
Document immunization status of patients with wounds
For minor or clean wounds, 3 previous doses of tetanus toxoid and a booster given > 10 years, then give tetanus (DTaP, or Tdap)
For a dirty wound, give tetanus toxoid if last tetanus was more than 5 years ago
If unknown status and a dirty wound, then give tetanus toxoid and tetanus immune globulin (TIG)
If massive tissue destruction and contamination have occurred, consider hospitalization
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Discharge and Follow-Up
Return for signs of infection: increasing pain, redness, edema, wound discharge or fever
Keep wound elevated Bathing allowed after 24-48 hours, but PAT dry and
recover Notify family that the wound was inspected for foreign
body, but retained foreign body or undetected injury cannot be excluded
All wounds leave a scar and scar appearance is not complete for 6-12 months
Minimize sun exposure and use sunscreen for 6 months to prevent hyperpigmentation
Massage frequently to soften scar after sutures removed
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Suture Removal
Follow up all but very simple wounds in 24-48 hours
Remove Sutures in:• Neck 3-4 days• Face, scalp 5 days• Upper extremities, trunk 7-10
days• Lower extremities 8-10 days• Joint surface 10-14 days
Remove sutures if well approximated
Remove sutures early if wound infected
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Questions?