Wound Management

1. Wound Management Andrew Stiell U of C Family Medicine R2 October 1st, 2009

2. Thanks • Dr Ian Rigby • Carole Rush

3. Objectives • Review a few basic topics • Interactive Game • Discuss your cases

4. Quiz:From when is the earliest evidence we have of a surgical technique being done?

5. Quiz:From when is the earliest evidence we have of a surgical technique being done ? • 1200’s • 500 • 500 BC • 1200 BC • 12 000 BC

6. Quiz:From when is the earliest evidence we have of a surgical technique being done ? • 1200’s • 500 • 500 BC • 1200 BC • 12 000 BC

7. Trapanation (burr hole) • 12 000 BC • Used tools to make hole into skull • Used to treat trauma, seizure, migraines, psychiatric disorder • 50% survival

8. Skin • Largest organ in our body • 16-21 square feet • 1-4mm thick

9. Skin • Largest organ in our body • 16-21 square feet • 1-4mm thick • Lots going on: (per square inch) • 650 sweat glands • 20 blood vessels • >1,000 nerve endings

10. Skin - Function • Barrier from pathogens

11. Skin - Function • Barrier from pathogens • Sensation

12. Skin - Function • Barrier from pathogens • Sensation • Heat regulation (radiation, convection, conduction)

13. Skin - Function • Barrier from pathogens • Sensation • Heat regulation (radiation, convection, conduction) • Barrier to fluid loss (evaporation)

14. Skin - Function • Barrier from pathogens • Sensation • Heat regulation (radiation, convection, conduction) • Barrier to fluid loss (evaporation) • Storage (water & lipids)

15. Skin - Function • Barrier from pathogens • Sensation • Heat regulation (radiation, convection, conduction) • Barrier to fluid loss (evaporation) • Storage (water & lipids) • Vitamin D production

16. Skin - Function • Barrier from pathogens • Sensation • Heat regulation (radiation, convection, conduction) • Barrier to fluid loss (evaporation) • Storage (water & lipids) • Vitamin D production • Communication (mood, physical status)

17. Skin - Anatomy

18. Skin - Anatomy

19. Skin- Healing

20. Healing terminology • Closed • Open • Delayed • Primary intention • Secondary intention • Third intention

21. Skin Healing- Open vs Closed Closed: • less inflammation • less contracture • less scar width • less future contamination Open: - less chance of infection

22. Skin Healing • Open or Delayed Closure: • Already infected (by soil, organic matter or feces) • Extensive tissue damage (high-velocity missile injuries, explosion injuries of hand or complex crush injuries) • Human Bite wounds • Animal Bites

23. Skin Healing- Delayed Closure

25. Some Rules: • In each section go in order starting with the lowest question available • Do not have to answer in the form of a question • Dr Rigby gets the final say on if answers are correct as he is giving out the prize

27. Ooh It Burns! $100 What is the most common age to suffer a burn? (decade)

28. Ooh It Burns! $100Answer Ages 0-10 and 20-29

29. Burns • Most common in ages 1-2 yo & 20-29yo • Males > Females • In small children almost all burns are scald burns. • Adults flame burns are most common • Most common contributing factor is EtOH

30. Burns

31. Burns • Don’t forget child abuse • Immersion scald burns • Stocking pattern • Back of hands & feet, buttock and legs • Accidental • Spill burns • Head, trunk, palmer surface of hands & feet

32. Ooh It Burns! $200 How do we classify burns?

33. Ooh It Burns! $200Answer 1st, 2nd, 3rd & 4th degree burns Partial vs Full thickness

34. Burns - severity • 1)Temperature • 2)Time of exposure • Capacity to hold heat • Viscosity • Clothing

35. Burns - depth • 1st Degree • 2nd Degree • Superficial Partial Thickness • Deep Partial Thickness • 3rd Degree • Full Thickness • 4th Degree • -Full Thickness

36. Burns - depth • 1st Degree • Minor epithelial damage • Red, tenderness & pain • No blistering • Heals over several days • Eg. sunburns

37. Burns - depth • 2nd Degree Superficial Partial Thickness • Epidermis and superficial papillary dermis • Fluid-filled blisters • Pink, moist, soft and very tender • Heal in 2-3wks w/o scarring Deep Partial Thickness • Deeper into dermis • Red & blanched white • Thick walled blisters • Decreased 2pt discrimination • Heal in 3-6 wks • Increased risk of scar

38. Burns - depth • 3rd Degree Full Thickness • Destroy Epidermis and Dermis • Capillary network destroyed • White or leathery • Numb • Requires skin grafting • Eg. Immersion scalds,flames, chemical electrical

39. Burns - depth • 4th Degree Full Thickness + destruction of subcutaneous tissue • Involves fascia, muscle & bone • Require extensive debridement and reconstruction • Eg. Prolonged exposure to immersion scalds, burns, chemical and electrical

40. Burn Zones?

41. Burns - Zones • 1) Coagulation / Necrosis • Contact with source • Dead/Dying cells b/c loss of blood flow • White or charred • 2) Stasis / Ischemia • Red and may blanch initially • @ 24hrs no circulation, petechial hemorrhages • Becomes white as it is necrotic • 3) Hyperemia • Blanches, has circulation • Becomes deep red • Starts healing at 1 week

42. What should you do if you are out camping, many hours from help, and your friend suffers a burn?

43. What should you do if you are out camping many hours from help and your friend suffers a burn? • A) Do not remove burned clothing • B) Immerse in cool water x30min • C) Immerse in cool water x1hr • D) Cover with dry dressing • E) A & C • F) B & D

44. What should you do if you are out camping many hours from help and your friend suffers a burn? • A) Do not remove burned clothing • B) Immerse in cool water x30min • C) Immerse in cool water x1hr • D) Cover with dry dressing • E) A & C • F) B & D

45. Burns-Dressing • In the field prior to transport • Remove burned clothing • Skin washed with cool water • Immerse in cold water x30min if cannot be transported • >30 min only cool 9% of TBSA to prevent hypothermia • Do not use ice as it can cause frostbite injury • Cover with dry dressing

46. Burns-Dressing (in the ED) • Minor Burns(Outpatients) • Cleansed with sterile saline • Blisters?? To pop or not to pop? • Clean and debride If follow up is later (1week) • Synthetic dressings (Aquacel Ag dressing): maintain moist environment If follow up is next day • Strips of sterile fine-mesh gauze soaked in saline which are covered by fluffed 4x4 coarse gauze • Flamazine cream (Antibacterial ointment is often not used because require frequent changes needed) • F/u at wound clinic 1-3 days for dressing change

47. Burns-Dressing (in the ED) • Major Burns (Inpatients) • Cleanse with sterile saline • Maintain sterile environment If waiting for hydrotherapy - Cover with clean sheet or towel If too unstable for hydrotherapy - Plastics will apply Flamazine and gauze • Debridement of blisters (except palms and soles) • Aggressive debridement usually deferred unless involving joints • Silver stains the face, therefore polysporin is used

48. Burns - fluids Why do we have such big fluid losses? 1) Increased evaporation b/c loss semi-impermiable barrier 2) Systemic inflammatory causing vessels to have increased permeability -Fluid gets pushed in to burned tissues 3)Tissue destruction causes capillary permeability • Fluid gets goes in to adjacent tissue to the burn wound

49. Ooh It Burns! $300 Name 2 criteria for burn referral/transfer?

50. Ooh It Burns! $300Answer Transfer Guidelines for Patients with Severe Burns Any burn >10% of BSA in pts <10 or >50 Burns involving >20% of total BSA in any patient Full-thickness burns involving >5% of total BSA Significant burns of hands, face, feet, genitalia, perineum, or major joints Significant electrical injury Significant chemical injury Significant inhalation injury, trauma, co morbidities