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Wound Management

Wound Management. Emergency Medicine Core Curriculum. Presentation/History. Clinical Features of Wounds Age of wound: > 6 hours < Configuration: Stellate vs. linear Depth: > 1 cm. < Mechanism of Injury: Missile, crush, burn frostbite Sharp surface

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Wound Management

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  1. Wound Management Emergency Medicine Core Curriculum

  2. Presentation/History • Clinical Features of Wounds • Age of wound: > 6 hours < • Configuration: Stellate vs. linear • Depth: > 1 cm. < • Mechanism of Injury: • Missile, crush, burn frostbite • Sharp surface • Location: face, ear, hand, cosmetically sensitive area • Signs of infection • Devitalized tissue • Contaminants (dirt, feces, soil, saliva) • Denervated and / or ischemic tissue Core Curriculum: Wound Management 2

  3. Vital Signs • Temperature: < 100 • > 101.5 systemic infection • Heart Rate: <100 • > 100 • Pain • Hypovolemia • Infection • RR: <18 • >18 • Pain • Chest wound - PTX • BP:90-149/60-90 • Decreased pulse pressure - early hypovolemia Core Curriculum: Wound Management 3

  4. Triage • Medications • Allergies: Antibiotics, tetanus • PMHx: Diabetes, immune compromised • PSHx: Wound healing, Keloid • Immunization: Tetanus Vaccine in past 5 years Core Curriculum: Wound Management 4

  5. Triage Orders • Td .5 mg • TIG 250 mg IM • Lidocaine • Wound care supplies Core Curriculum: Wound Management 5

  6. Physical Exam • GEN: WDWN white female in minimal distress, guarding right forearm • HEENT: NC/AT, Neck: soft, supple, NT • CHEST: CTA B, AT • ABD: soft, NT, Nml BS, AT • BACK: NT, AT • EXT: wound description • Location, length, depth, active bleeding • Exposed bone or tendon, step-off • Neuro vascular exam locally and distal to wound Core Curriculum: Wound Management 6

  7. Radiographs • Suspected Foreign Bodies/Fracture • Wounds < 1/2 cm in depth • Contaminated wounds • Assault trauma • Glass injuries Core Curriculum: Wound Management 7

  8. ED course • Complex wounds requiring/allowing a consultant: • Facial laceration: Face trauma call: OMFS, ENT, Plastic surg all rotate • Eye/Eyelid involvement: Opthomology • Amputation/degloving/neurovascular compromise/mechanical compromise (tendon/ligament laceration), hand wound, open fracture: Orthopaedics Core Curriculum: Wound Management 8

  9. Wound preparation Anesthesia first Alcohol swab away from wound margin Local infiltration Local block Soap and H2O scrub Betadine Surgical Scrub brush local pressure on bleeding Normal Saline high pressure irrigation 250-2 L Splash guard Wound closure Hemostasis 5-0/6-0 Dexon taper Deep closure 5-0/6-0 Dexon taper Skin closure Face: 6-0 Nylon/Prolene Extremity: Digit: 5-0 Nylon/Prolene Extremity: 4-0 Nylon/Prolene Abx ointment/dry dressing ED Course Core Curriculum: Wound Management 9

  10. ED Course • Delayed Primary Closure • Routine wound preparation • Wet to dry normal saline Kerlex/Guaze dressing • Train patient Core Curriculum: Wound Management 10

  11. Consultant repair D/C ED with consultants instructions /medications and follow-up ED repair D/C ED Primary Closure: Keep wound clean and dry for 48 hours Apply antibiotic ointment after 48 hours TID until healed Return to ED for suture removal in Face: 5 days Remainder: 7 days Return to ED for signs of wound infection Disposition Core Curriculum: Wound Management 11

  12. Delayed Primary Closure: Wet to dry dressing changes TID Return to ED in 48-96 hours for wound recheck and primary closure Return to ED for signs of infection No Antibiotics Antibiotics Allergies IV: Heavily contaminated wounds Open fractures PO: Hand/Foot Ear Nose Diabetes Disposition Core Curriculum: Wound Management 12

  13. Disposition • Pain Medications: • Allergies • Not to be overlooked • Tylox/Lortab/Darvoset/Lorcet • High dose Motrin • No drinking, driving, or operating machinery while taking prescribed narcotic Core Curriculum: Wound Management 13

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