WOUND CARE AND SUTURING IN THE EMERGENCY DEPARTMENT Dr. Sinead Fitzpatrick, Dr. Termizi Hassan Antrim Area Hospital February 2016 Wound: Definition DEFINITION: A wound is a bodily injury caused by physical means, with disruption of the normal continuity of structures. This can be identified as an acute or a chronic wound. ACUTE: Heals in approximately 2 weeks to 6 months CHRONIC: Takes 6 months or more. Classification of the accidental wound based on the mechanism I. Mechanical 1. Abraded wound (vulnus abrasum) 2. Punctured wound (v. punctum) 3. Incised wound (v. scissum) 4. Cut wound (v. caesum) 5. Crush wound (v. contusum) 6. Torn wound (v. lacerum) 7. Bite wound (v. morsum) 8. Shot wound (v. sclopetarium) II. Chemical 1. Acid 2. Base III. Wound cause by radiation. IV. Wound caused by thermal forces 1. Burning 2. Freezing V. Special 3 1.) Abraded wound (v. abrasum) 1.) Abraded wound (v. abrasum) 2.) Punctured wound (v. punctum) 2.) Punctured wound (v. punctum) Superficial part of the epidermal layer Good wound healing Sharp-pointed object Seems negligible BUT Anaerobic infection Injury of big vessels and nerves Mechanical wound 4 3.) Incised wound (v. scissum) 3.) Incised wound (v. scissum) 4.) Cut wound (v. caesum) Sharp object Best healing Sharp object + blunt additional force Edges - uneven Mechanical wound 5 5.) Crush wound (v. contusum) 5.) Crush wound (v. contusum) 6. ) Torn wound (v. lacerum) 6. ) Torn wound (v. lacerum) Blunt force Pressure injury Edges uneven and torn Bleeding Great tearing or pulling Incomplete amputation Mechanical wound 6 (v. lacerocontusum) 7.) Shot wound (v. scolperatium) Close - burn injury Foreign materials Mechanical wound 7 uninjured tissue necrobiotic zone necrotic zone foreign bodies aperture slot tunel output 8.) Bite wound (v. morsum) Ragged wound Crushed tissue Torn Infection Bone fracture Prevention of rabies Tetanus profilaxis Mechanical wound 8 1.) Burning 2.) Freezing 1 st degree superficial injury (epidermis) 2 nd degree partial or deep partial thickness (epidermis+superficial or deep dermis) 3 rd degree full thickness (epidermis + entire dermis) 4 th degree (skin + subcutaneous tissue + muscle and bone) Treatment: o Cooling cold water and clean covering Wound caused by thermal forces 9 Metabolic change! - toxemia mild, moderate, severe (redness, bullas, necrosis) rewarm not only the frozen area but the whole body Wound classification: According to the bacterial contamination Clean wound Clean-contaminated wound Contaminated wound Heavily contaminated wound 10 Superficial Partial thickness Full thickness Deep wound Classification of the wound: Depending on the depth of injury + bone, opened cavities, organsetc. 11 Factors that impair wound healing 1.Age 2.Malnutrition 3.Obesity/Emaciation 4.Poor circulation and oxygenation 5.Immunosuppression 6.Smoking 7.Incontinence 8. Medications (steroid) 9. Co-morbidities ( Diabetes) 10.Wound Stress 11.Radiation Promotion of wound healing Dressings: keep wound covered & clean Wound bed moist / Surrounding skin dry Debridement when necessary Remove exudate: o Drains, o Wound VAC, o I rrigation Pack wounds loosely Nutritional interventions Wound infection Bacteria infection are likely- (treat with co- amixoclav) o Puncture wound- cat/human/dog o Hand wound o Wound > 24 hours o Wounds in Alcoholics, diabetic & immunocompromised Likely organism o Eikenella corrodens(human bites) o Pasteurella multicoda (cats) Tetanus prone wound o Heavily contaminated wound o Devitalized wound o Infection o Wound > 6 hours o Puncture wound o Animal bites Approach to wound management History: Key questions What caused the wound? (glass/knife can cause a deep injury) Was there a crush component? (considerable swelling may ensue) Where did it occur? (contaminated or clean environment) Was broken glass/china involved? (if so, obtain an x-ray) When did it occur? ( old wound may need delay closure and antibiotic) Who caused it? (is patient safe to go home) Is tetanus cover required? The ABCDE in the injured assessment The mnemonic ABCDE is used to remember the order of assessment with the purpose to treat first that kills first. A: Airway and C-spine stabilization B: Breathing C: Circulation D: Disability E: Environment and Exposure 17 Wound assessment 1.Look at the whole patient not just the hole. 2.Look the appearance of the wound: granulation tissues, eschar, slough, edema, sinus tract, color, tunneling etc 3.Drainage: serous, serosanguineous, sanguineous, purulent AND amount 4.Size & location on body 5.Presence of sutures or staples 6.Presence of drains or tubes 7.Wound edges 8.Other factors: mechanism of injury, need for tetanus booster or IVIG, onset of injury & previous treatment Next steps Probe the wound In some circumstances, exploration not app. In ED (neck) Try and correct the causes that may delay wound healing 1. Edema 2. Nutrition 3. Glycemic control 4. Treat infection 5. OT/physiotherapy consult Take a swab ( if indicated) Cleaning methods Different type of wound cleaning Contaminated wound would require o Brushing o Cutting devitalized skin/ tissue o irrigation Wound Cleaning: Irrigation Cleanses a wound using pressure Using sterile normal saline Normal Saline Avoids caustic agents such as peroxide, iodine etc Technique: Irrigate with 19G needle attached to ml syringe 5-15 PSI Devitalized or grossly contaminated wound edges usually need to be trimmed back Management of wound: Tissue unifying Skin: o Stiches o Clips o Steri-Strips o Tissue glues Fascia and subcutaneous layers: o Interrupted stiches 22 Wound closure: Principles Preparation is important: Comfortable patient & operator Consent Good light & instruments Good anesthesia- 1% vs 2% lidocaine, + adrenaline Assistance Correct needle & suture Post wound care including leaflet Local anesthetic agents Special cautions ( increased risk of toxicity) o Small children o Elderly or debilitated o Heart block o Low cardiac output o Epilepsy o Myasthenia gravis o Hepatic impairment o Porphyria o Anti-arryhthmic or beta blocker o Cimetidine therapy Lidocaine o Max dose 3mg/kg o Max dose in adult (70kg) is 200 mg (20ml of 1% lidocaine) o Duration of action: immediately to 60min Lidocaine with adrenaline o Max dose 7mg/kg o Max dose in adult 500 mg (50ml of 1% solution) o Duration: up to 90 min o Not suitable for area with end artery supply such as nose, toes & fingers Topical LA: LAT gel o Ideal in children Wound closure: 3 types Primary closure o Surgical closure soon after the injury o Wound not suitable for primary closure Stab wound to the trunk and neck Wound associated with tendon,joint & neurovascular involvement Wound with associated crush injury or significant devitalized tissue Heavily contaminated or infected wound Most wound > 12 hours old (except clean facial wound) Secondary closure o No intervention o Heal by granulation (secondary intention) Delayed primary closure o Surgical closure 3-5 days after injury Guide to suture gauges for common procedures Part of bodySuture and sizeTime to removal scalp2.0/ 3.0 non- absorbable/ glue/staple 7 days Trunk3.0 absorbable10 days Limb3.0/ 4.0 non-absorbable10 days Hands4.0/5.0 non-absorable10 days Face5.0/6.0 non-absorbable5 days Lip, tongue, mouthAbsorbable i.e. 6.0 vicryl/dexon 1 st step Suturing: How to hold the equipment 2nd step Suturing 3rd step4th step Suturing 5th step6 th step Steristrip Indication o Pretibial laceration o Superficial wound Inappropriate over joint Use tincture of benzoin to dry skin for better hold onto the skin Leave 3-5mm between steristrip Skin tissue glue Technique: o Skin edges opposed, glue is put on surface of wound o Hold the skin edges together for seconds Useful in children with superficial wound and scalp wound Staples Quick and easy to apply Particularly suited for scalp wound Different type of suture Wound closure: Tips Wound Care Products o Liquid barrier o Transparent films o Hydrocolloids o Gauze dressings o Hydrogels o Foam dressings o Absorptive dressings o Calcium alginate o Charcoal dressings o Silver coated dressings o Non adherent dressing o Debriding agents o antiseptic Summary Focused history and detailed assessment of the wound is vital Consider antibiotic in high risk patients Consider rabies infection (patient returning from abroad/ animal bites) Check tetanus status o Tetanus prone wound may need tetanus immunoglobulin Think of the possibility of FB ( X-ray/ US/ CT/ MRI) Post wound care is important o Leaflet o Informed patient of possible/risk of complication o Analgesia