Wound CareSuzana Tsao, DO

Why do we care?

Layers of the Skin

Closure at the dermal level

Subcutaneous adds little strength

Complex wounds in/below fascial layer need multi-layer closure

HealingInitially edges retract and tissue contracts

Platelet aggregation and clotting cascade activated

Initial epithelialization 24-48 h

Peak collagen synthesis 5-7d

Strength of wound5% at 2 weeks35% at one month

Initial EvaluationAlways start with the ABCD’s

Airway

Breathing

Circulation

Disability

Wound EvaluationLocation

Active bleeding

Exposed tissue/bone/organs

Check for peripheral pulses

History

WhereLocation, location, location

WhenGolden period

HowMechanism

Potential for foreign body

WhereAnatomic location

Special ConsiderationMouth

Ear

Joints

periorbital

When

Golden Hour of WoundsInfectious inoculum 105 per gram

Need 3-5 hours for proliferation of bacteria

Extremities 6 hours

Face and scalp 24 hours

But wait ….

When to close

Studies show can close as late as 19 hours on extremities

ACEP clinical policy supports 8-12 hours

Depends on the clinical scenario

Consider other types of closurePrimary closure

Delayed primary closure

Healing by secondary intention

HowMechanism

Assess concern for foreign body

Clean wound

Dirty wound

Contaminated wound

High Risk MechanismsOpen fracturesIntraoral woundsMamillian bitesCrush injuries/devascularized tissueHigh pressure injuriesJagged edges/stellate shape/deeper than subcutaneous layerForeign bodyVisible contamination

PMH/SocHx

Co-Morbid Conditions

Hand dominance

Occupation

Last tetanus booster

Tetanus

< 3 doses in primary series

Clean/minorTetanus toxoid

All otherToxoid and immunoglobulin

Primary 3 series completed

< 5 yearsNone needed

> 5 years but < 10 years

Clean minor

None needed

All others

Give toxoid

> 10 yearsGive toxoid

Pertussis

Give Tdap regardless of last Td to update pertussis if not updated as an adult

Replaces one of the 10 year Td booster doses

Boostrix when feasible for > 65 y/o

Tdap during each pregnancy b/w 27 and 36 weeks

CDC linkhttp://www.cdc.gov/vaccines/vpd-vac/pertussis/recs-summary.htm

Co-Morbid Conditions

Age (very young/very old)

Diabetes

Renal Failure

Malnutrition

Obesity

Immunocompromised

Physical ExamType of wound

Superficial/deep

Length/shape

Bleeding/revascularization

Associated injuries

Retained foreign body

Complete neurovascular exam2 point discrimination most accurate for sensory function in extremities

Active Bleeding

Direct pressure

BP cuff2 hours max

Figure of 8 stitch

Associated InjuriesAssess for tendon injuries

90% lacerated tendon can still maintain normal neuro function

Assess for joint involvementMay need to inject joint

Assess for underlying fractureX-ray if suspected before manipulating the area

Retained Foreign BodyDirect visualization

May need anesthesia to fully evaluate

X-ray80-90% can be detected

Does not visualize organic material

UltrasoundCT/MRI?

Indications for FB removal

Reactive materialsWood Vegetative material

Contaminated materialsClothes

Most fb in foot

Impingement on neurovascular structures

Impairment of function

Easy to remove

Indications for consultation

Nerve injury

Vascular injury

Tendon or joint involvement

Difficult to remove foreign body

High pressure injection injury

IrrigationDilution is the solution to the pollution

High pressure (5-8 psi)30-60 cc syringe with 19 gauge angiocath or splash shield

AmountMin 250ml50-100ml/cm of laceration

Type of fluidTap water just as good as normal saline

NEVER, EVER, NEVERBetadine or peroxide1% Betadine may be ok, but no increased benefit

Debridement

Remove necrotic tissue

May need to debride for better approximation and cosmetic results

Sterile Gloves

Several trials showed no difference if final outcome

Dealer’s choice

Anesthesia

Topical pretreatment

Consider procedural sedation

AllergiesMost are from preservative

Consider using cardiac lidocaine

1% Benadryl

Local vs. Regional Block

BlockLarge areas

When needed to avoid tissue distortion

Areas where infiltration is painfulPlantar surface of foot

Anesthesia

AmidesLidocaine

Max 4.5mg/kg Duration 1-2 h

Lidocaine with epinephrineMax 7mg/kgDuration 2-4 hNo epi in fingers/toes, ear, nose, penis

BupivacaineMax 2mg/kg 0.25%Duration 4-8 h

EstersProcaine

Max 7mg/kg

Duration 15-45 min

Types of Repair

Primary closureClosure of the wound at the time of the ED visit

Delayed primary closureClosure of wound 3-4 days after injury

Healing by secondary intentionAllow wound to heal without closure through scarring

Methods of Closure

TapeSuperficial, straight, under little tension

Skin AdhesivesDoes not involve deep layers

Little tension

StaplesLinear on trunk, extremities, scalp

Sutures

Types of Sutures

AbsorbableGut

PDS (polypropylene)

Maxon (polyglyconate)

Dexon (polyglycolic acid)

Coated Vicryl (polyglactin)

NonabsorbableDermalon or ethilon

Prolene or surgilene (polypropylene)

Silk

steel

Suture size by location

Face5-0 to 6-0

Scalp/Chest/Back/Abdomen3-0 to 5-0

Extremities4-0 to 5-0

Oral3-0 to 5-0 (absorbable)

Indications for antibiotics

Prosthetic device

Endocarditis prophylaxis

Open joints and/or fractures

Mamillian bites

Intraoral lesions

Immunocompromised patients

Heavily contaminated wounds

Discharge instructionsSigns and symptoms of infection

Fever, discharge, red lines from wound, erythema, swelling

Elevation +/- splinting

When to do wound checks at one or two days

Suture removal instructionsFace 3-5 daysScalp 5 daysExtremities 7-10 days, high tension 10-14 days

Washing - showering - avoid long baths, pools, ocean

Triple antibiotic ointment

Pearls

No such thing as absolute golden hour

Tap water is as good and normal saline

Do not soak in betadine

Nonsterile gloves ok

Hand wounds less than 2cm -> big, bulky dressing as good as sutures

PitfallsAlways remember ABC’s

Look for associated injuriesBone, vascular, nerve

Don’t dismiss high pressure injuries

Always assess for foreign body

Antibiotics vs. delayed primary closure for high risk wound and/or co-morbid conditions

Remember special locationsEar, nose, vermillion borderFight bites do not close