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Wound ManagementDepartment of Emergency Medicine
Johns Hopkins University
Center for International EmergencyDisaster and Refugee Studies
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2Wound managementCenter for International Emergency
Disaster and Refugee Studies
Objective
Define critical management of wounds
Discuss wound classification
Discuss wound evaluationDiscuss wound preparation
Discuss closure techniques
Discuss use of antibiotics
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Introduction
The proper management of wounds in the fieldsetting is one of the most basic and important
practices, and yet is overlooked by many healthproviders
Terence J Ryan of the Department ofDermatology, Churchill Hospital, Oxford notesthat wounds in Tanzania are often due trafficaccidents, fire-arms and household domesticfires, and also wounds from being hit with amachete or animal bites or traps which areoverall exotic and hence rare.
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Presentation
The most important first
step in any injured patient is
to evaluate the ABCs
It is not unusual for a health
care worker to be distracted
by a severe extremity injury
and ignore the potentially
disastrous occurrence of
airway compromise orshock.
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Presentation
After stabilizing the patient, the critical actions
for wound management are to:
stop active bleeding
identify injuries
decide on type of repair needed
consider tetanus immunization
consider antibiotics, and provide instructions to
patient.
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Presentation
There are a variety of
wounds and they are
described below:
Abrasion Superficial laceration
Deep laceration
Complex laceration
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Presentation
There are a variety of
wounds and they are
described below:
Skin avulsion Crush injury
Burns
Frostbite
Infected wound
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Presentation
A number of wound characteristics can predict
the incidence of wound infections, namely:
The age of the wound prior to irrigation and repair
The location of the wound Whether the wound is contaminated with other items
Wounds which have a blunt mechanism
The presence of large amounts of absorbable sutures
in the wound
High-velocity missile injuries
Puncture wounds and bite wounds
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Presentation
Most wounds do not needprophylactic antibiotics toprevent infection.
Only wounds having thecharacteristics noted abovebenefit from antibioticprophylaxis.
The single most importantfactor for preventinginfection is thoroughirrigation with plain water
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Presentation
It has been found that, whenirrigation was ignored, thatdespite the use of antibiotics,infection rates remained high.
Any wound which is too oldto be closed primarily can beirrigated, debrided, and
packed, with closure to bedone electively in 3-5 days.
This allows time for the tissueto granulate in, anddramatically reduces thelikelihood of a woundinfection.
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Presentation
Tetanus immunization should be given to all
people who have not had a booster within 5
years (for major wounds) or 10 years (for more
minor wounds).If a person has never had the primary series of 3
tetanus shots in the past, they should receive
tetanus immune globulin (TIG; 250 units) as well
as tetanus toxoid (Td) for all major wounds,wounds contaminated with soil or feces, and for
all puncture wounds.
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Presentation
Rabies prevention requires the
adminstration of human rabies
immune globulin (HRIG; 20
U/kg IM, with injected around
the bite site, and given IM at aremote site).
Human rabies vaccine should
also be given 1 mL/dose IM on
days 0, 3, 7, 14, and 28 (1 doseper day).
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Clinical Findings
The steps in wound evaluation,
preparation and closure are:
Stop active bleeding
Adequately expose the wound area
Anesthetize the wound if indicated
Clean the wound and debride as necessary Close the wound if indicated
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Stop the bleeding:
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Exposure
Be sure to expose the entire wound so that you
can see all margins and injuries.
Consider removing hair to expose the field, but
usually this is not needed (the hair can just be
slicked down with water, Betadine or K-Y
jelly).
Shaving increases wound infection rates
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Diagnosis
Laboratory studies are those which are needed for
other traumatic injuries which may be present.
For isolated wound management, there are no
particular lab studies needed.X-rays are often indicated, both to rule out an
underlying fracture (which would then need to be
considered an open fracture), and to rule out any
occult foreign bodies.
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Diagnosis
Foreign bodies, when present,should always be removed, ifreasonably possible.
Metal and most glass show up
well on an x-ray; wood andorganic materials frequently donot.
Unfortunately, wood and organicmaterials have a much higher
likelihood of causing asubsequent wound infection
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Removing Foreign Bodies
Most foreign bodies may be removed by
simple extraction.
Occasionally, extension of the wound is
necessary for greater exposure.
Often a small foreign body such as a splinter
or a piece of metal is too deeply imbedded and
is best left in the tissue.
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Removing Foreign Bodies
Such is the case with bullet
wounds, which usually heal
well if there is no nerve or
artery injury.Leave deeply imbedded
objects in place for removal
in the operating room if
you suspect nerve or arterydamage.
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Removing Foreign Bodies
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Wound Cleansing
Clean the wound thoroughly, cleaning dirt and debrisaway with saline or sterile water
then irrigate the wound.
For irrigation, use an 18 or 19 gauge needle and 20 to30 cc syringe give best irrigation pressure.
The best cleaning agent is sterile saline, as it is cheapand isotonic; however, it is not bacteriacidal.
Normal saline with 3 ppm iodine (2 to 3 drops ofiodine per liter) is perhaps the best choice. It is
bacteriacidal but not tissue toxic.
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Wound Cleansing
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Debridement
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Wound Prep
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Local anesthetic agents
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Use of TAC
TAC = tetracaine (0.5%), adrenalin (1:2000),
and cocaine (11.8%) is an excellent topical
anesthetic for open wounds.
It should not be used for wounds on or nearmucosal surfaces (due to rapid absorption of
cocaine), areas of body served by end arteries
(digits, penis, ear lobes, tip of nose), pregnancy
or history of high blood pressure.
It is most useful for scalp or face lacerations in
children.
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Choice of sutures
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Nonabsorbable Sutures
Comparison of nonabsorbable sutures
Nylon (Dermalon)
Polypropylene (Prolene)
Braided nylon (Surgilon)
Silk
Wire (stainless steel)
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Absorbable Sutures
Comparison of absorbable sutures
Plain gut
Chromic gut
Polyglycolic acid / polyglactin (Vicryl, Dexon)
Polydioxanone (PDS)
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Suture size guidelines
Suture size guidelines
Wound location Recommended suture size
Scalp 3-0, 4-0
Face 6-0, 5-0
Chin 6-0, 5-0 (2 layer)Trunk 4-0
Arm 4-0
Hand 5-0
Leg 4-0
Foot 4-0, 3-0
General rule: 6-0 on face, 5-0 on hand, and 4-0 elsewhere on body
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Basic suturing techniques
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Suturing pearls
Use the smallest suture needed to approximate theedges of the wound.
Use small sutures placed closer together rather than
larger sutures places further apart.Edema occurs after closure of a wound, so onlyapproximate the edges, do not strangulate the tissue
Use forceps as little as possible during woundclosure, use skin hooks where available, when onelearns to handle skin hooks well they offer the bestmeans of handling a wound edge
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Alternative techniques for wound closure
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Main suturing techniques
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Main suturing techniques
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Main suturing techniques
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Main suturing techniques
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Choices for wound dressings
Dry gauze is suitable for most wounds or if steri-strips are used.
Nonadherent dressings are preferred for abrasions,nailbed injuries, skin flaps, or the thin skinnedelderly, i.e.,
Vaseline gauze, Xeroform gauze, adaptic gauze (mostexpensive), and Telfa (not really nonadherent).
Antibiotic ointments may be helpful to apply afterclosing the wound, but not usually necessary.
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Incision and Drainage of Simple
Abscess
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Wound Packing
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Skin Grafts
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Disposition/Referral
Most isolated wounds, not associated with multiple
trauma, can be safely evaluated and treated in the
hospital, and discharged home.
As mentioned earlier, antibiotics should beconsidered for bite wounds, contaminated wounds,
hand or foot wounds, or if there is a delayed
presentation (>4-6 hours for limb or trunk; >24 hours
for head wounds)
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Disposition/Referral
In addition to the above listed wound characteristics,
host risk factors for infection include diabetes,
malnutrition, vascular disease, and age >70.
If antibiotics are used, those most commonly used arefirst generation cephalosporins, or
amoxicillin/clavunulate (for dog, cat and human
bites).
Patients with a high risk for infection should be seen
back in the hospital for a wound check in 48-72
hours.
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Suture removal guidelines
Wound Location Suture removal (days)
Scalp 7
Face 3-5
Chin 7Trunk 7-10
Arm 7-10
Hand 10-14
Leg 10-14
Sole of foot 14-21
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Center for International Emergency
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Case 1
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Case 2
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Case 3
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Case 4
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Case 5
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Case 6
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Center for International Emergency
Case 7