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