Wound Management


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

Published in: Health & Medicine

Wound Management

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