Wound Management UNC Emergency Medicine Medical Student Lecture Series.

Wound ManagementWound Management

UNC Emergency Medicine

Medical Student Lecture Series

2 Principles of Wound Management

Goals of Wound CareGoals of Wound Care

Facilitate hemostasis Decrease tissue loss Promote wound healing Minimize scar formation


Mechanism of InjuryMechanism of Injury

Wounds are caused by three different types of forces– Shear– Compressive– Tensile


Shear ForcesShear Forces

Result from sharp objects– Low energy– Minimal cell damage– Result in straight edges, little contamination– Heals with a good result


Compressive ForcesCompressive Forces

Result from blunt objects impacting the skin at a right angle– Results in stellate or complex laceration– Ragged or shredded edges– More prone to infection


Tensile ForcesTensile Forces

Result from blunt objects impacting the skin at an oblique angle– Results in triangular wound– Sometimes produces a flap– More prone to infection


Evaluation of WoundsEvaluation of Wounds

ABC’s first Always! Ensure hemostasis

– Saline gauze dressing– Compression

Remove obstructions– Rings, clothing, other jewelry

History


HistoryHistory

Symptoms Type of Force Contamination Event Potential for

foreign body Function Non-accidental

trauma

Tetanus status Allergies Medications Comorbidities Previous scar

formation


Wound ExaminationWound Examination

Location Size Shape Margins Depth Alignment with

skin lines Neuro function

Vascular function Tendon function Underlying

structures Wound

contamination Foreign bodies


Wound ConsultationWound Consultation

Tarsal plate or lacrimal duct Open fracture or joint space Extensive facial wounds Associated with amputation Associated with loss of function Involves tendons, nerves, or vessels Involves significant loss of epidermis Any wound that you are uncertain about


Wound Preparation - Wound Preparation - AnesthesiaAnesthesia 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


Wound Preparation - Wound Preparation - AnesthesiaAnesthesia

Drug Max Dose Onset Duration

Cocaine 6.6 mg/kg Rapid 1 hour

Procaine 10-15 mg/kg Rapid 30min-1hr

Tetracaine 1.5 mg/kg Moderate 2 hours

Lidocaine 5 mg/kg 5-30 min 2 hours

(with Epi) 7 mg/kg 5-30 min 2-3 hours

Bupivacaine 2 mg/kg 7-30 min > 6 hours


Minimize the Pain of Minimize the Pain of InjectionInjection

Use sodium bicarbonate mixed with the anesthetic (1 ml/10 ml solution)

Use smallest needle possible Inject slowly Insert needle through open wound

edge and skin that has already been anesthetized


Wound Preparation - Wound Preparation - HemostasisHemostasis

Physical vs. chemical– Direct pressure– Epinephrine– Gelfoam– Cautery

Refractory– Use a tourniquet


Wound Preparation – Foreign Wound Preparation – Foreign Body RemovalBody Removal

Visual inspection Imaging

– Glass, metal, gravel fragments >1mm should be visible on plain radiographs

– Organic substances and plastics are usually radiolucent

Always discuss and document possibility of retained foreign body


Wound Preparation – Wound Preparation – IrrigationIrrigation

Local anesthesia prior to irrigation Do not soak the wound Use normal saline Large syringe (60mL) with Zerowet

attachment Do not use iodine, chlorhexidine,

peroxide or detergents


Wound Preparation – Wound Preparation – DebridementDebridement

Removes foreign matter & devitalized tissue

Creates sharp wound edge Excision with elliptical shape Respect skin lines


Wound Preparation – Wound Preparation – AntibioticsAntibiotics

Infections occur in ~3-5% of traumatic wounds seen in the ED

Factors that increase risk– Heavily contaminated wound, especially with soil– Immunocompromised patients– Diabetics – Human bites > animal bites

Most important prevention adequate irrigation & debridement


Wound Preparation – Wound Preparation – AntibioticsAntibiotics

Dog & cat bites– Cover pasteurella– Augmentin

Human bites– Cover eikenella– Augmentin

Puncture wounds– Cover pseudomonas– Cipro, levaquin


Wound Preparation – Tetanus Wound Preparation – Tetanus ProphylaxisProphylaxis

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!


Wound ClosureWound Closure

Primary closure– Suture, staple, adhesive, or tape– Performed on recently sustained lacerations: <12

hours generally and <24 hours on face

Secondary closure– Secondary intent– Allowed to granulate

Tertiary closure– Delayed primary (observed for 4-5 days)


Suture MaterialSuture Material

Absorbable– Chromic gut– Vicryl– PDS II

Non-Absorbable– Silk– Prolene– Dermalon

Monofilament vs. braided


Staples, Adhesives & Staples, Adhesives & TapeTape Staples

– Quick, poor aesthetic result Adhesives

– Dermabond- painless, petroleum dissolves Tape

– Steri-strips


Wound ClosureWound Closure

Undermine the wound edges– Release tension


Suture TechniquesSuture Techniques

Deep layer approximation– Absorbable sutures– Buried knot– Serves two purposes

Closes potential spaces

Minimizes tension on the wound margins


Skin ClosureSkin Closure

Key – wound edge eversion “Approximate, don’t strangulate” Anticipate wound edema Choose appropriate size of suture for

location of laceration



Simple Interrupted– Used on majority of wounds– Each stitch is independent



Simple Continuous– Useful in pediatrics

Rapid Easy removal

– Provides effective hemostasis– Distributed tension evenly along length– Can also be locked with each stitch



Horizontal Mattress– Useful for single-layer closure of lacerations

under tension


Horizontal MattressHorizontal Mattress



Vertical Mattress– Useful for everting skin edges– “Far-far-near-near”


Vertical MattressVertical Mattress



Purse-string– Useful for stellate lacerations



Instrument tie


Wound CareWound 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!


Practice Time!Practice Time!

Wound Management UNC Emergency Medicine Medical Student Lecture Series.

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