Wounds and Wound Care

1
Wounds and Wound Care
2
Types Of Wound

• Not all wounds are lacerations
• Accurate description is important
• Medico-legal implications
• Lacerations Vs Incised Wounds

3
Types Of Wound

• Related to causation
• Shear force
• Abrasion
• Flap
• Sharp object
• Incised wound
• Stab wound
• Blunt Object
• Laceration
• Burst wound

4
Lacerations

• Caused by blunt trauma
• Skin bursts open
• Ragged, irregular edges
• Edges contused
• Tends to bleed less

5
(No Transcript)
6
(No Transcript)
7
Incised Wounds

• Caused by sharp object
• Clean, straight edge
• Bleeds profusely
• Less tissue damage

8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
Other Wounds

• Bites
• Stab wound
• Abrasions

12
Evaluation

• Good light essential
• Remove all foreign material, blood clot etc
• Shave hair if necessary (NOT EYEBROWS)
• Local anaesthetic may be necessary
• Incised wounds in hands- what was the position at
  the time of injury ?

13
Evaluation

• Always check and document distal neurovascular
  function
• Always X-Ray for glass
• Ask about Tetanus status

14
Increased Risk of Infection

• Deep wounds
• Contused edges
• Dead or devitalised tissue
• Obvious contamination
• Clean
• Contaminated
• Dirty
• Bites
• Body regions with poor blood supply
• Patient factors

15
Goals of Treatment

• Achieve haemostasis
• Close dead space
• Remove foreign material and contamination
• Minimise scaring
• Rapid return to normal activity

16
Closure

• Primary Closure
• Delayed primary closure
• Healing by secondary intention

17
(No Transcript)
18
Facial Wounds

• Cosmetic result most important
• Primary closure
• No removal of tissue
• Haemostasis can be difficult
• Vermillion border

19
Hand Wounds

• Thorough examination essential
• Severed nerves can present with altered sensation
  not just NO sensation
• Do not tie off bleeding vessels in hand nerves
  and vessels run together

20
Finger Tips

• Generally crush injuries
• Bony damage irrelevant soft tissue problem
• Suspected nail bed damage should be explored and
  repaired
• Often good cleaning under LA and steri/dressing
  will give a good result
• Do not over suture

21
(No Transcript)
22
Pre- Tibial Lacerations

• Never suture even in a young person
• Patients with apparent skin loss often do nt and
  it can be unrolled and steried back
• Distally based, narrow thin flaps do badly
• Steri, dress and review in 5 7 days

23
(No Transcript)
24
Bites

• Do NOT suture except face
• Human worst
• Augmentin/Flagyl and review
• Fight bites to ortho
• Cats next
• Pasturella common organism
• Dogs
• Give antibiotics if adverse factors
• Squirrels, hampsters

25
Delayed Presentations

• In general do not suture wounds after 6 hours
• Clean and dress
• Review 48 72 hours
• Possible delayed primary closure
• Exception is the face

26
CLOSING WOUNDS

• TISSUE ADHESIVE
• STAPLES
• SKIN TAPE
• SUTURES

27
TISSUE ADHESIVE

• Available since 1959, a sterile topical adhesive
  composed of synthetic material cyanoacrylate
• Consist of liquid monomers that polymerize into
  solid material on contact with tissue
• Adhesive sloughs off in 7-10 days
• Always apply topically not between wound edges as
  prevents epithelisation (Sadovsky 1999, Tritle et
  al 2001).
• Ongoing research investigating internal use

28
INDICATIONS

• Wounds 6cm or less with clean edges
• Wounds not located over joints or creases
• Hands and feet minor lacerations only generally
  not recommended

29
ADVANTAGES and CONTRAINDICATIONS

• Rapid, painless application
• Dries quickly (1 min)
• Needle free
• No need for suture removal as cyanocrylate will
  slough off

• Infected wounds
• Mucosal surfaces
• Tension or repetitive movement areas
• Hypersensitivity to cyanoacrylate or formaldehyde
• Renal disease, uncontrolled diabetes or other
  conditions that delay wound healing

30
STAPLES

• Devised in 1908
• Often used for closure scalp wounds in AE
• Devices now disposable and clearly identified for
  either external or internal use
• Possibility of rotary staple migration

31
INDICATIONS

• Scalp wounds
• Wounds not located over joints or creases

32
ADVANTAGES and CONTRAINDICATIONS

• Rapid and efficient application
• Easy to use
• Reduced risk of infection

• Infected wounds
• Tension or repetitive movement areas
• Do not use when not possible to maintain at least
  5mm distance from stapled skin to underlying
  structures

33
SKIN TAPE

• Widely used in AE
• Advocated on broad range of wounds
• ? Exhibit the greatest resistance to infection
  (Thomas 1990)

34
INDICATIONS

• Superficial wounds
• Wounds not located over joints or creases

35
ADVANTAGES and CONTRAINDICATIONS

• Non-invasive, painless application
• Ease of application
• Needle free
• Cost effective, saving both time and material
  costs

• Uncontrolled haemorrhage
• Repetitive movement areas
• Severe oedema, wet skin
• Severe tension required

36
SUTURES

• Earliest sutures made of vegetable fibres or
  animal tendon
• Ideal suture for all purposes not yet developed
• Nylon sutures optimal standard for cosmetic
  result (Tritle et al 2001)
• Non-absorbable sutures left in place for
  different durations depending on site and degree
  of tension wound is under

37
ABSORBABLE SUTURES

• SYNTHETIC
• Vicryl
• Dexon
• PDS
• Maxon

• NATURAL
• Catgut (plain or chromic)

38
NON-ABSORBABLE SUTURES

• SYNTHETIC
• Nylon
• Prolene
• Gortex

• NATURAL
• Silk
• Linen
• Cotton

39
ADVANTAGES and CONTRAINDICATIONS

• Able to oppose skin edges with tension
• Allows movement of joint
• Able to oppose ragged skin edges

• Infected wounds
• Wounds gt 12 hours old

40
SUTURE REMOVAL AND NEEDLE GUIDE