Wound Management

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Wound Management
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Epidemiology

• 11 million wounds E.D. managed (1996)
• 1/3 between 19-35
• males gt females
• Location
• head or neck (50)
• upper extremity (35)
• Mechanism
• blunt force
• sharp objects
• mammalian bites

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Pitfalls

• Failure to diagnose foreign body
• Wound infections (lt5)
• Missed tendon and nerve injuries

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What is an Appropriate Wound Evaluation?
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Evaluation/Charting

• History
• mechanism of injury, location
• age of wound
• comorbidity
• health history, tetanus
• allergies
• Physical Exam
• wound description
• neurovascular exam
• range of motion
• exploration
• Procedure Note

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Risk of Infection

• Diabetes
• Obesity
• Malnutrition
• Chronic renal failure
• Advanced age
• Steroid use
• Cigarette smoking
• Connective tissue disorders (Marfans,
  Ehlers-Danlos)

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• Primary closure
• Secondary intention
• cleansed in standard fashion
• typically more inflammation, scarring,
  contracture
• Delayed primary closure
• usual wound preparation, packed with NS gauze and
  dressed. Change daily.
• close at 3-5 days if not infected

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What Type of Primary Closure Should You Choose?
9
What Type of Suture Material S
hould You Use?
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Local Anesthesia

• Allergic reactions are rare (methylparaben)
• Amide allergies dont cross react with ester
• Diphenhydramine can be used
• Less infection pain with
• small needles
• slow infusion rates
• through the wound edge
• pre-treatment with topical anesthetics

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Wound Exploration

• Optimal lighting
• Minimize bleeding
• Comfortable patient, assistant, physician
• Restraints
• Gloves

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Control Bleeding

• Direct pressure
• Clamp and suture
• Electrocautery
• not for toes/fingers
• careful use for hands and feet
• not for blood vessels gt 2mm
• Fibrin foam
• Tourniquets
• digital/penrose drain
• extremity/blood pressure cuff
• 30-60 min time limit

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Wound Preparation

• Wound cleansing
• mechanical scrubbing
• irrigation
• do not soak
• debridement
• clip dont shave hair

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Mechanical Scrubbing

• 10 povidone iodine solution
• Area surrounding wound
• Not for irrigation (except if diluted 10 to 1
  with NS)
• Scrub wound if embedded particulate matter cant
  be irrigated out (fine pore sponge)

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Irrigation

• NS
• Typically 100 to 300 cc (100cc/cm)
• Hand held syringe/18 gauge catheter (5-8 psi)
• Unnecessary for most scalp/face lacerations
• Splatter control

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Debridement

• Transform ragged linear laceration
• May increase skin tension, undermining edges
  helpful
• Not for eyebrows, lips, eyelids
• heal well
• maintain symmetry

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Foreign Bodies

• Explore - not digitally if sharp object suspected
• Xray/fluoroscopy
• aluminum doesnt show if lt 0.5m
• glass sometimes visualizes
• organic materials (wood, splinters) dont
• US
• 90 sensitivity/specificity
• less useful when many echogenic structures are
  present (hands)
• perform before exploration (air can obscure)

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Closures

• Mostly a single cutaneous layer is adequate
• Deep space closure
• sew fascia not muscle belly
• bury knots in the subcutaneous layer
• under mine edges if under tension
• Superficial layer
• equal depth and width of each suture
• evert edges

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Facial Wounds

• Less scarring in wounds that are parallel to
  natural skin lines
• Close subcutaneous layer to appropriate wound
  edges 2-3mm, parallel
• Sutures 2-3mm apart, 2-3mm from edge

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?

• 1 Do topical antibiotics prevent wound
  infections?
• ACAD EMERG MED 1995 24-10
• 2 Are the results of stapled scalp wounds
  comparable to sutured?
• INJURY 1989 20217-8
• 3 Does it matter to irrigate a scalp wound?
• ANNALS OF EM 31173-77

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• 4 Can you primarily close a mammalian bite?
• ACAD OF EM MED Vol 7 No 2 157-161
• 5 Is local anesthesia less painful when injected
  from within the laceration as compared to through
  intact skin?
• ACAD EMERG MED 1998 5100-104