WOUND EVALUATION WOUND EVALUATION & CARE& CARE
Rachel Steinhart, MD, MPHRachel Steinhart, MD, MPHEmergency MedicineEmergency Medicine
CCRMC Family Practice Resident ER Rotation - August 2009
General Wound EvaluationGeneral Wound Evaluation
History:History:• MechanismMechanism• TimeTime• Foreign BodyForeign Body• Medical ConditionsMedical Conditions• AllergiesAllergies• Tetanus StatusTetanus Status
Exam:Exam:• SizeSize• LocationLocation• Contaminants Contaminants • NeurovascularNeurovascular• Tendons & BonesTendons & Bones
TETANUS PRONE WOUND?TETANUS PRONE WOUND? Compound fractures Deep penetrating wounds Wounds containing foreign bodies (especially wood)
Wounds complicated by pyogenic infections Wounds with extensive tissue damage Burns Wounds contaminated with soil, dust or horse
manure Re-implantation of an avulsed tooth
Recommendations for tetanus prophylaxisRecommendations for tetanus prophylaxis
History of Tetanus Immunization
Td TIG Td TIG
Uncertain or <3 doses Yes No Yes Yes
Last dose within 5 y No No No No
Last dose 5-10 y No No Yes No
Last dose >10 y Yes No Yes No
Not Prone Prone
Be certain to clarify history of dT - patients confuse PPD with dTBe certain to clarify history of dT - patients confuse PPD with dTCAUTION with tetanus prone wounds in elderly & foreign bornCAUTION with tetanus prone wounds in elderly & foreign born => Seriously consider TIG=> Seriously consider TIG
Important Important wounds wounds to recognizeto recognize
High Pressure Injection InjuryHigh Pressure Injection Injury
Extent of injury easy to underestimateExtent of injury easy to underestimate
PATIENT WITH HIGH PRESSURE INJECTION WOUND NEEDS URGENT SURGICAL CONSULTATION FOR TIMELY DEBRIDEMENT TO AVOID LOSS OF LIMB
Knuckle Laceration = Fight BiteKnuckle Laceration = Fight Bite
Fight BiteFight Bite
Avoid closing any wound over a knuckle unless you have explained to the patient the risks of closing a wound that has had contact with saliva
PATIENT WITH INFECTED FIGHT BITE NEEDS URGENT SURGICAL CONSULTATION FOR TIMELY DEBRIDEMENT TO AVOID LOSS OF LIMB
Know Kanaval’s SignsKnow Kanaval’s Signsfor Flexor Tenosynovitisfor Flexor Tenosynovitis
Kanavel’s SignsKanavel’s Signs
Fusiform swelling Finger held in flexion Severe pain with passive extension Tenderness to palpation along proximal
tendon sheath
URGENT SURGICAL CONSULTATION REQUIRED FOR TIMELY DEBRIDEMENT TO AVOID LIMB LOSS
TASER INJURYTASER INJURY
Taser injury is a marker for Taser injury is a marker for “AGITATED DELIRIUM”“AGITATED DELIRIUM”
Pull dart
Basic puncture wound care
Verify tetanus
Assess for rhabdomyolysis - UA
Beware of chest pain complaint
Necrotizing FasciitisNecrotizing Fasciitis
Necrotizing FasciitisNecrotizing Fasciitis
Pain out of proportionPain out of proportion Toxic appearanceToxic appearance TachycardiaTachycardia HypotensionHypotension CrepitusCrepitus Dishwater drainageDishwater drainage Disrupted fasciaDisrupted fascia
IMMEDIATE SURGICAL CONSULTATION REQUIRED FOR EMERGENT DEBRIDEMENT TO AVOID LOSS OF LIFE OR LIMB
Wound ClosureWound Closure
Anesthesia
Wound preparation
Time to closure
Closure techniques
Post closure management
Properties of commonly used local anestheticsProperties of commonly used local anesthetics::
AgentAgent ClassClass Max. safe Max. safe dose mg/kgdose mg/kg
Onset Onset (min)(min)
Duration Duration (hrs)(hrs)
Procaine (Novocaine)
Ester 7 2-5 0.25-0.75
Procaine + Epi 9 0.5-1.5
Lidocaine Amide 5 2-5 1-2
Lidocaine + Epi 7 2-4
Bupivacaine
(Marcaine) Amide 2 2-5 4-8
Bupivacaine + Epi 3 8-16
Reducing pain of local anaesthetic Reducing pain of local anaesthetic infiltration:infiltration:
1-Small-bore needles 1-Small-bore needles 2-Buffered solutions2-Buffered solutions 3-Warmed solutions3-Warmed solutions 4-Slow rates of injection4-Slow rates of injection 5-Injection through wound edges5-Injection through wound edges 6-Subcutaneous rather than intradermal injection6-Subcutaneous rather than intradermal injection 7- Pretreatment with topical anesthetics7- Pretreatment with topical anesthetics
Consider regional nerve blockConsider regional nerve block
May save time Decrease possibility of systemic toxicity
with large wound area Less painful than local infiltration Avoid volume-related tissue distortion
Skin and Wound PreparationSkin and Wound Preparation
Remove hair? → NO
Disinfect skin? → NO (H2O2, iodine)
Debride wound? → YES
Irrigate wound? → YES (Tap=Bottled) Pressure & volume important
Sterile gloves? → NO (infection rate same)
Foreign BodiesForeign Bodies
Most glass, metal, and gravel are radiopaque
Wood and some aluminum are radiolucent
Glass is visualizable on 2-view radiographs if it is 2 mm, gravel if it is 1 mm
It is always wise to discuss risk of retained foreign body in spite of aggressive exploration and irrigation
Wound ClosureWound Closure
Time to closure Delayed primary closure Options
Glue Staples Sutures
Suturing method
TIME TO CLOSURETIME TO CLOSURE
Berk WA: Evaluation of the "golden period" for wound repair: 204 Cases from a third world ED. Ann Em Med 1988.
• <19 hours to repair 92% satisfactory healing• >19 hours to repair 77% satisfactory healing• Exception: head and face lacerations had 95.5% satisfactory healing, regardless of time
Morgan WJ: The delayed treatment of wounds of the hand and forearm under antibiotic cover. Br J Surg 1980.
300 hand and forearm lacerations closed < 4hr had infection rate 7% closed > 4hr had infection rate 21%
Delayed primary wound closureDelayed primary wound closure
High risk wounds that are contaminated or contain devitalized tissue
Wound is initially cleansed and debrided
Covered with gauze
Leave undisturbed for 4 to 5 days
If the wound is uninfected at the end of the waiting period, it is closed with sutures or skin tapes
TISSUE ADHESIVETISSUE ADHESIVE
S. Mizrahi: Use of Tissue Adhesives in the Repair of Lacerations in Children. Journal of Pediatric Surgery,April, 1988.
1500 pediatric patients with simple laceration glued in ED Infection 1.8% Dehiscence 0.6%
Which lacerationWhich laceration??
Short (< 6-8 cm)
Low tension (< 0.5 cm gap)
Clean edged
Straight to curvilinear wounds that do not cross joints or creases
Contraindications for glueContraindications for glue
Jagged or stellate lacerations
Bites, punctures or crush wounds
Contaminated wounds
Mucosal surfaces
Axillae & perineum (high-moisture areas)
Hands, feet & joints (unless kept dry and immobilized)
STAPLESSTAPLES
Consider staples for linear lacerations not Consider staples for linear lacerations not involving the face involving the face
Frequently used for scalp, trunk, extremitiesFrequently used for scalp, trunk, extremities
Optimally, two operators perform this Optimally, two operators perform this procedureprocedure
Cosmetic effect is equivalent to sutures/glueCosmetic effect is equivalent to sutures/glue
SUTURESSUTURESSimple interruptedSimple interrupted Most commonMost common Easy to masterEasy to master Can adjust tension with each sutureCan adjust tension with each suture Stellate, multiple components, or directions woundStellate, multiple components, or directions wound
Simple runningSimple running Minimize time of suture repairMinimize time of suture repair Even distribution of tension Even distribution of tension Low-tension, simple linear woundsLow-tension, simple linear wounds Removed within 7 days to avoid suture marksRemoved within 7 days to avoid suture marks Optimal suture material is non-absorbableOptimal suture material is non-absorbable
Prophylactic Antibiotics?Prophylactic Antibiotics?
Bite woundsBite wounds Contaminated or devitalized Contaminated or devitalized
woundswounds High risk sites eg. FootHigh risk sites eg. Foot ImmunocompromisedImmunocompromised Risk for infective Risk for infective
endocarditisendocarditis Intraoral through and Intraoral through and
through lacerationsthrough lacerations
PVDPVD DMDM LymphedemaLymphedema Indwelling prosthetic deviceIndwelling prosthetic device Extensive soft tissue injuryExtensive soft tissue injury Deep puncture woundsDeep puncture wounds
Prophylactic Antibiotics?Prophylactic Antibiotics?
3-5 Days3-5 Days AugmentinAugmentin Keflex Keflex ErythromycinErythromycin
Alternate Suturing Alternate Suturing TechniquesTechniques
SIMPLE RUNNINGSIMPLE RUNNING
Horizontal MattressHorizontal Mattress
Cause wound edges eversion Single layer closure with significant tension Decrease repair time, less knots required Need delayed suture removal, so risk of suture marks
Vertical MattressVertical Mattress
High-tension wounds Prone to skin suture marks if left in too long
COMPLEX WOUND CLOSURECOMPLEX WOUND CLOSURE
COSMETIC ISSUESCOSMETIC ISSUES
HIGH RISK COMPLEX HIGH RISK COMPLEX LACERATIONSLACERATIONS
- Do NOT - Do NOT suture suture cartilagecartilage
- Give - Give antibioticsantibiotics
Possible Possible lacrimal lacrimal duct duct lacerationlaceration
- Consult - Consult opthooptho
QuickTime™ and a decompressor
are needed to see this picture.
Possible Possible parotid parotid duct duct lacerationlaceration
- Consult - Consult ENT/HNSENT/HNS
Suggested Suture Removal TimeSuggested Suture Removal Time
AreaArea Removal time (days)Removal time (days)FaceFace 3 to 53 to 5NeckNeck 5 to 85 to 8ScalpScalp 7 to 97 to 9Upper extremityUpper extremity 8 to 148 to 14TrunkTrunk 10 to 1410 to 14Extensor surface Extensor surface
HandsHands 1414Lower extremityLower extremity 14 to 2814 to 28
DISCHARGEDISCHARGE
Keep initial dressing clean, dry, and in Keep initial dressing clean, dry, and in place for first 24 hoursplace for first 24 hours
After 24 hours okay to wash but not soakAfter 24 hours okay to wash but not soak Apply antibiotic ointment 2 times daily - Apply antibiotic ointment 2 times daily -
primarily to facilitate suture removalprimarily to facilitate suture removal If extremity splinted to avoid dehiscence, If extremity splinted to avoid dehiscence,
keep splint in place at all timeskeep splint in place at all times Return for progressive redness, swelling, Return for progressive redness, swelling,
pus or painpus or pain
Procedure NoteProcedure Note
Size location and shape of woundSize location and shape of wound Thorough sensory-motor & vascular examThorough sensory-motor & vascular exam Wound explored in bloodless field, no FBWound explored in bloodless field, no FB Amount and type of anesthesiaAmount and type of anesthesia Amount, type and method of irrigationAmount, type and method of irrigation Number & type of stitches & suture usedNumber & type of stitches & suture used Dressing appliedDressing applied Instructions to patientInstructions to patient Tetanus & AntibioticsTetanus & Antibiotics