Kevin P. Kilgore, M.D., FACEP

The process of wound care involves

 evaluation  plan  action

Overview

Kevin P. Kilgore, M.D., FACEP

Objectives

   

Objectives

Discuss the process of wound evaluation Review the materials used for wound repair Discuss “simple” wound closure Discuss wound aftercare items Kevin P. Kilgore, M.D., FACEP

   When did this happen?

 time Where did this happen?

 location How did this happen?  mechanism Kevin P. Kilgore, M.D., FACEP

History

    allergies current medications pre-existent medical conditions immunization status for tetanus Kevin P. Kilgore, M.D., FACEP

History

The “golden period”

A misnomer with:    meticulous debridement copious irrigation antibiotic coverage Kevin P. Kilgore, M.D., FACEP

History

Mechanism

 shear  tension  compression  missile injuries a combination of shear, tensile, and compressive

History

Kevin P. Kilgore, M.D., FACEP

Shear

History

    Sharp tissue division Little energy required Lower infection rate Cosmetics acceptable Kevin P. Kilgore, M.D., FACEP

Tension

History

     Compression injury Less than 90 o Triangular flap Increased infection Poor result Kevin P. Kilgore, M.D., FACEP

Compression

History

    Crushing injury Significant injury Increased infection Poor results Kevin P. Kilgore, M.D., FACEP

Environment

 protective dressing  gloves, gowns, goggles  good lighting 

goal

- determine extent of injury

Examination

Kevin P. Kilgore, M.D., FACEP

Extent of injury

 amount of tissue loss  tissue viability  depth of the wound  presence of any associated injuries

Examination

Kevin P. Kilgore, M.D., FACEP

Depth of injury

Injury to underlying structures?  nerves  tendons  muscles  bone Kevin P. Kilgore, M.D., FACEP

Examination

Examination

Lacerations over bones

 probe with a gloved finger to determine whether or not there is a fracture.  If a wound overlies a fracture site an open fracture should be assumed present. Kevin P. Kilgore, M.D., FACEP

Examination

Deep structure

injury

 puncture wounds of the head, neck and torso must be managed on the premise that there has been penetration and damage to vital structures.

Kevin P. Kilgore, M.D., FACEP

Anesthesia

   Topical  TAC or XAP Local   1% buffered xylocaine bupivocaine Regional (nerve block)   1% buffered xylocaine bupivocaine Kevin P. Kilgore, M.D., FACEP

Techniques

Techniques

Irrigation & debridement

 The single most important element of basic wound care.

 Intent:  remove devitalized tissue  remove potential nidus for infection Kevin P. Kilgore, M.D., FACEP

Techniques

Preparation

 Generally, an iodophor solution (e.g., Betadine 10%)  Sterile draping is imperative Kevin P. Kilgore, M.D., FACEP

Instruments

 four basic instruments  needle-holder  forceps  scissors  towels Kevin P. Kilgore, M.D., FACEP

Techniques

Suture materials

 Absorbable Sutures   employed below the skin Polyglycolic acid (Dexon®)  Nonabsorbable Sutures  nylon (dermalon®, ethilon®)   surgelene® novifyl® Kevin P. Kilgore, M.D., FACEP

Techniques

Other closure materials

 Steri-Strips® and Shur-strips®  Surgical staples  Dermabond

Techniques

Kevin P. Kilgore, M.D., FACEP

Size Selection

 face, hands or feet - 5-0 and 6-0  trunk and extremity - 4-0 and 5-0

Techniques

Kevin P. Kilgore, M.D., FACEP

Techniques

Suture techniques

 Subcuticular Closure  Dexon® or Vicryl®, are used for this deep layer closure.

 Cuticular Closure Kevin P. Kilgore, M.D., FACEP

Subcuticular Closure

Techniques

Kevin P. Kilgore, M.D., FACEP

Techniques

Simple Suture

   easiest to learn safest & most effective more time needed Kevin P. Kilgore, M.D., FACEP

Wound Edge Eversion

Techniques

Kevin P. Kilgore, M.D., FACEP

Instrument Tie

Techniques

Kevin P. Kilgore, M.D., FACEP

 Dressings  Immobilization  Medications  Antibiotics  Tetanus Prophylaxis  Rabies Prophylaxis  Discharge Instructions Kevin P. Kilgore, M.D., FACEP

Completing Care

Suture Removal

        face ear scalp trunk arms legs hand feet 3 to 5 days 4 to 6 days 7 to 12 days 7 to 12 days 10 to 12 days 10-12 days 10 to 12 days 10 to 14 days Kevin P. Kilgore, M.D., FACEP

Completing Care

Objective Review

 Discuss the process of wound evaluation   Review the materials used for wound repair Discuss “simple” wound closure  Discuss wound aftercare items  Remember to remove your sharps from the tray Kevin P. Kilgore, M.D., FACEP

Now to the Lab