Wound Management

1. Wound Management UNC Emergency Medicine Medical Student Lecture Series

2. Goals of Wound Care • Facilitate hemostasis • Decrease tissue loss • Promote wound healing • Minimize scar formation

3. Mechanism of Injury • Wounds are caused by three different types of forces • Shear • Compressive • Tensile

4. Shear Forces • Result from sharp objects • Low energy • Minimal cell damage • Result in straight edges, little contamination • Heals with a good result

5. Compressive 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

6. Tensile Forces • Result from blunt objects impacting the skin at an oblique angle • Results in triangular wound • Sometimes produces a flap • More prone to infection

7. Evaluation of Wounds • ABC’s first  Always! • Ensure hemostasis • Saline gauze dressing • Compression • Remove obstructions • Rings, clothing, other jewelry • History

8. Symptoms Type of Force Contamination Event Potential for foreign body Function Non-accidental trauma Tetanus status Allergies Medications Comorbidities Previous scar formation History

9. Location Size Shape Margins Depth Alignment with skin lines Neuro function Vascular function Tendon function Underlying structures Wound contamination Foreign bodies Wound Examination

10. Wound 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

11. Wound Preparation - Anesthesia • 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

12. Wound Preparation - Anesthesia

13. Minimize the Pain of Injection • 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

14. Wound Preparation - Hemostasis • Physical vs. chemical • Direct pressure • Epinephrine • Gelfoam • Cautery • Refractory • Use a tourniquet

15. Wound Preparation – Foreign Body 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

16. Wound Preparation – Irrigation • 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

17. Wound Preparation – Debridement • Removes foreign matter & devitalized tissue • Creates sharp wound edge • Excision with elliptical shape • Respect skin lines

18. Wound Preparation – Antibiotics • 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

19. Wound Preparation – Antibiotics • Dog & cat bites • Cover pasteurella • Augmentin • Human bites • Cover eikenella • Augmentin • Puncture wounds • Cover pseudomonas • Cipro, levaquin

20. Wound Preparation – Tetanus Prophylaxis • 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!

21. Wound 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)

22. Suture Material • Absorbable • Chromic gut • Vicryl • PDS II • Non-Absorbable • Silk • Prolene • Dermalon • Monofilament vs. braided

23. Staples, Adhesives & Tape • Staples • Quick, poor aesthetic result • Adhesives • Dermabond- painless, petroleum dissolves • Tape • Steri-strips

24. Wound Closure • Undermine the wound edges • Release tension

25. Suture Techniques • Deep layer approximation • Absorbable sutures • Buried knot • Serves two purposes • Closes potential spaces • Minimizes tension on the wound margins

26. Skin Closure • Key – wound edge eversion • “Approximate, don’t strangulate” • Anticipate wound edema • Choose appropriate size of suture for location of laceration

27. Suture Techniques • Simple Interrupted • Used on majority of wounds • Each stitch is independent

28. Suture Techniques • Simple Continuous • Useful in pediatrics • Rapid • Easy removal • Provides effective hemostasis • Distributed tension evenly along length • Can also be locked with each stitch

29. Suture Techniques • Horizontal Mattress • Useful for single-layer closure of lacerations under tension

30. Horizontal Mattress

31. Suture Techniques • Vertical Mattress • Useful for everting skin edges • “Far-far-near-near”

32. Vertical Mattress

33. Suture Techniques • Purse-string • Useful for stellate lacerations

34. Suture Techniques • Instrument tie

35. Wound 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!

36. Practice Time!