Wound Management
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Wound Management



Wound Management

Wound Management
Emerg Med Clin N Am, 25 (August 2007) 873–899



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    Wound Management Wound Management Presentation Transcript

    • Wound Management Emerg Med Clin N Am, 25 (August 2007) 873–899
    • Goal of Wound Management
      • Providing painless, quick wound closure
      • Excellent cosmetic result
      • Avoiding infection
    • History
      • Contaminated wounds
        • mammalian bites, human bites,
        • wounds incurred in submerged bodies of water (eg, streams, lakes, ponds).
        • “ old” wounds, high level of bacteria 6 to 8 hours after wounding.
    • Golden Period for Wounds Repair
      • The accepted interval from injury to wound closure is up to 6 hours for wounds to the extremities and up to 24 hours for face and scalp wounds.
    • Tetanus-Prone Wounds
      • Age of wound greater than 6 hours
      • Stellate wound or avulsion
      • Depth of wound greater than 1 cm, mechanism of injury is a missile, crush, burn, or frostbite
      • Signs of infection are present
      • Devitalized tissue is present
      • Presence of contaminants (dirt, feces, soil, or saliva)
      • Presence of denervated or ischemic tissue
    • Physical Examination
      • Location
      • Length in centimeters
      • Neurovascular examination
      • Motor examination
      • Exploration for tendon or joint involvement
      • Presence of foreign body
    • Wound Preparation
      • High-pressure irrigation
        • Recommended irrigation pressure is 5 to 8 psi which can be achieved by using a 30 to 60 ml syringe and a 19 gauge needle or splash shield
        • Use 50 to 100 ml of irrigant per cm of laceration
      • If saline is not available for irrigation, tap water may be a good alternative
      • Detergents, hydrogen peroxide, and concentrated povidone-iodine should be avoided in wound irrigation
    • Types of Wound Closure
      • Primary closure is closure of the wound before formation of granulation tissue.
      • All “clean” wounds can be closed primarily except puncture wounds that cannot be irrigated adequately.
      • Contaminated wounds, noncosmetic animal bites, abscess cavities, and wounds presenting after a delay should be irrigated, hemorrhage controlled, and debrided.
      • Delayed primary closure can be performed after 3 to 5 days to allow the patient's defense system to decrease the bacterial load.
      • Secondary closure is healing by granulation tissue. This type of closure is suited for partial-thickness avulsions (ie, fingertip injuries), contaminated small wounds (ie, puncture wounds, stab wounds), and infected wounds.
    • Techniques of Wound Closure
      • When the goal is to obtain the best function, the laceration should be closed in a single layer with the least amount of sutures.
      • When cosmesis is most important, a multiple-layer closure should be used.
      • Stellate wounds are best closed with simple interrupted sutures.
      • For a wound under increased tension, such as over joints, horizontal mattress sutures can be used in a single-layer closure because they are naturally everting, hemostatic, and do not cut through skin edges if tension increases from movement or swelling.
    • Materials
      • Sutures
      • Staples
      • Tissue adhesives
      • Adhesive tapes
    • Staples
      • For closure of linear lacerations of the scalp, trunk, or extremities.
      • More rapid wound repair and lower rate of reactivity and infection.
    • Tissue Adhesives
      • Less painful and faster than closure with sutures.
      • Limited to linear lacerations less than 4 cm in length in wounds devoid of significant tension or repetitive movement.
    • Adhesive Tapes
      • Less risk of infection than either staples or sutures.
    • Scalp
      • A scalp wound requires palpation and exploration for the evaluation of a possible skull fracture.
      • Scalp lacerations 3 to 10 cm in length also can be closed using the patient's own hair.
    • Pinna
      • The wound needs to be inspected for any cartilaginous involvement.
      • If possible, avoid placing sutures through the cartilage.
    • Eyebrow
      • Eyebrows should never be removed.
      • The eyebrow provides a useful guide for approximation of wound edges.
    • Lip
      • Through-and-through lip lacerations require layered closure from the inside out . Suturing the oral mucosa first minimizes contamination of the wound from saliva.
      • Subsequently the muscle layer is closed with 4.0 or 5.0 absorbable suture.
      • In closing the outer aspect of the lip, priority is given to approximating the vermilion border with the first stitch or “stay” suture placed at this site.
    • Oral Cavity and Mucous Membranes
      • Lacerations of the buccal mucosa and gingiva generally heal without repair.
      • Wounds that are longer than 2 cm, gaping, or continuing to bleed should be closed tightly with absorbable 4.0 or 5.0 suture.
    • Face
      • With cheek lacerations, there is potential for injury to the parotid gland and to the seventh cranial nerve.
      • Discharge of clear fluid from the wound indicates parotid gland or Stensen's duct involvement.
    • Bites
    • Gunshot Wounds
      • Wounds caused by bullets should be debrided, irrigated, and left open to be repaired with delayed primary closure or by secondary closure.
    • Antibiotics in Wound Care
      • In general, antibiotics are recommended for contaminated wounds or wounds that cannot be adequately debrided or irrigated.
      • Also antibiotics need to be considered in patients who are more prone to infection including DM, bacterial endocarditis, orthopedic prosthesis and lymphedema.