Transcript Wound Management - Improving care in ED

Wound Management
By Elspeth Frascatore
October 2013
Timing of Wound Closure
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<6hrs: primary closure OK
6-24hrs: primary closure OK unless high
risk factor present
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Heavily contaminated
Extensive intra-oral lacerations
Foot wounds
Stellate lacerations
Devitalised wounds: crush injury, under XS
tension
PMH diabetes, ETOH dependence, PVD,
immunosuppression (inc. long term steroids)
Wound Cleaning
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Tap water is just as good as normal
saline
Use high pressure irrigation
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Need 5-8psi
Use 30-60ml syringe attached to 19
guage luer
Use 50-100ml irrigant per cm of
laceration
Tetanus
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Given at 2 / 4 / 6 / 18 months  5
/ 15yrs  every 10yrs thereafter
Immune: if have had at least 3
doses and UTD
Tetanus
HISTORY Of TETANUS COURSE AND/OR BOOSTER
CATEGORY
Clean wound
(<6hrs, nonpenetrating,
negligible
tissue
damage)
1
2
3
4
<5 years
(ie. Immune)
5 - 10 years
>10 years
(ie. Full course
but out of
date)
Never /
Partial Course
/ Unknown
Nil
Nil
Booster ADT
ADT course
Dirty wound
ADT course
Nil
Booster ADT
Booster ADT
and
TIG: 250iu
routinely or
500iu if old,
contaminated
wound or burn
injury
Suture Techniques
Gaping / high
tension
wounds (eg.
Over joints)
Wounds on
fragile skin as
spreads
tension
To evert wound
edges (eg.
Posterior neck,
concave skin
surface)
Signs of Arterial Injury
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Large expanding haematoma
Severe active / pulsatile bleeding
Shock unresponsive to fluids
Signs of cerebral infarction
Bruit / thrill
Decreased distal pulses
Paraesthesia
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How do you tie off an arterial
bleeder?
Human Bites
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10-15% infection risk
Do not close hand wounds, puncture
wounds, infected wounds, wounds >12hrs
old
Copious wound washout
Avoid layered closure
Use loose sutures to allow fluid drainage
Antibiotic prophylaxis in all cases
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Although this may change in future
Remember punch injuries
Dog / Cat Bites
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Can close if <6hrs and in low risk
area / patient
Antibiotic use
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Meta-analysis has revealed that
antibiotics decrease incidence of wound
infection in hand wounds only
Neck Lacerations
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If multiple, assess most important
regions first rather than largest
Look at the back early
Wound size does not correlate with
severity of injury
3
2
1
Structure to Consider
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Spinal cord – suggested if bilateral symptoms
Phrenic nerve – hypoventilation; implies subclavian vein /
artery injury
Brachial plexus (C5-7)
Recurrent laryngeal nerve
Cranial nerves
Glossopharyngeal nerve – dysphagia, altered gag
Vagus nerve – hoarseness; implies common carotid / IJV
injury
Horner’s syndrome – ipsilateral miosis, enopthalmos,
anhydrosis
Carotid and vertebral arteries; vertebral, brachiocephalic and
jugular veins
Thoracic duct, oesophagus, pharynx etc…
Thyoid, parathyoid, submandibular, parotid glands
Examination
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Wound exploration – keep minimal
and only perform if stable
Identify affected zone and triangle
Identify direction tract takes
Determine if platysma is penetrated
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If platysma not penetrated: can be
cleared of significant injury
If platysma penetrated: 50% risk of
other significant injury, mandates OT
Investigation
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Always Xray
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Knives can break off under skin
CT angiography
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All zone I
Stable zone II
Zone III with evidence of arterial injury
Intra-oral Lacerations
Eyelid Lacerations
Lip Lacerations
Tongue Lacerations
Nasal Lacerations
Facial Nerve Blocks
Ear Block
Hand Blocks