WOUND AND WOUND CARE. Definition: A wound is a break in the continuity of the tissues of the body...
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WOUND AND WOUND CARE
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Definition:
A wound is a break in the continuity of the
tissues of the body either internal or external.
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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.
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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.
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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.
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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
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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
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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
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Causes of traumatic wounds:
Cause of wound No. of Patients %Blunt object 42Sharp object 34Glass 13Wood 4Bite 6Human 1Dog 3Others 5
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Distribution of traumatic wounds:
Location of Wound No. of Patients (%)
Head and Neck 51
Trunk 2
Upper Extremities 34
Lower Extremities 13
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Evaluation:
History:• Mechanism• Time• FB• Medical conditions• Allergies• Tetanus status
Exam:• Size• Location• Contaminants • Neurovascular• Tendons
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Universal Precautions:
Use of protective barriers:
eg. Gloves/ gowns/ masks/ eyewear
Will decrease exposure to infective material.
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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
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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
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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
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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
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Skin and Wound preparation:
1- Hair removal
2- Disinfecting the skin
3-Wound Cleansing and Irrigation
4-Soaking
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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)
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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:
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Wound Closure:
Time
Delayed primary closure
Options
Suturing method
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Time:
The Golden Period: the time interval from injury to
laceration closure and the risk of subsequent infection,
(is highly variable)
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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
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Options:Nonabsorbable sutureAbsorbable suture Tissue adhesive Adhesive tapes Staples
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Suturing methods:
Simple interrupted
Simple running
Horizontal mattress
Vertical mattress
Running subcuticular (intradermal)
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Simple Interrupted:
Most commonEasy to master Can adjust tension with each sutureStellate, multiple components, or directions wound
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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
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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
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Vertical Mattress:
High-tension wounds Prone to skin suture marks if left in too long
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Running Subcuticular (Intradermal):
Best for areas where cosmetic result is of utmost importance
Time-consumingDifficult to masterLow tension woundsAbsorbable suture
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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
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Prophylactic Antibiotics: Bite woundsContaminated or devitalized
woundsHigh risk sites eg. FootImmunocompromisedRisk for infective
endocarditisIntraoral through lacerationsDeep puncture woundsExtensive soft tissue injury
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Prophylactic Antibiotics:
Amoxicillin, ClavulinKeflex Erythromycinrecommended course is 3 to 5 days