Simple Wounds

Dr Phillip Kay
May 06
Key points
 No wound is too small to become infected.
 Small wounds may have major cosmetic
or functional problems. (hands)
 Reputation can depend on quality of scar!
 Most problems come from assessment
and aftercare not the operation.
 Assessment
 Time since injury. At 3hrs infection rate starts to rise and very high
at 12 hrs
 Type of force
 Type of wound
 Incised
 Contused
 Penetrating
 Bites
 Friction
 Contaminated
 Degloving
 Incised.
 Unlikely to cause problems but if >6/24 excise
edges.
 Contused

ALWAYS poor skin healing.

Excise and debride
 Attempt to refashion
 100 times the infection rate of clean incised.
 If only 100 bacteria from soil >infection
 Penetrating

Do not close
 Decide whether needs to be explored.
 Bites

ALWAYS contaminated
 Avoid suture
 Secondary closure after day 3
 Frictional
 Entrapment
rollers and machines
motor bikes re bitumen tattoo.
 Haemostasis
 Direct pressure
 Pack
 Cautery
 Large suture !!!
 No clipping.
 Torniquet Biers block.
 Closure
 Primary
 Secondary
 >12hrs
 Dirty

Bites
 Crush/contusion
 penetrating
 Grafting.
 Closure:preparation
 Explain

Infection
 Cosmetic
 Consent (verbal)
 Soaking
 Degreasing
 Scrubbing
 Closure: preparation
 Premed oral/IV
 Sedation midazolam / fentanyl

 Nitrous
 Local anaesthetic

Clean & debride sometimes two stages.
 Local anaesthetic
 Pain of injection

Tissue tension (use blocks if possible)
 Needle size 26G
 pH
 Speed of injection (minimum 10 secs Dentists)
 Acidic pH of local is for shelf life not
effectiveness.
 Can buffer. 1 to 10 with HCO3
 Blocks
 Advantages of blocks Field or nerve

Wider coverage
 Less painful
 NO wound swelling

NO pressure contamination
 Face; ear; scalp; axilla; elbow; wrist; ankle
foot
 Irrigation
 All forcefull wounds should be irrigated!
 High pressure irrigation of >7psi
 Squeeze of bottle is 0.5 psi useless
 20cc syringe and 19g with saline effective.
 Suturing Tips
 Not tight
 Halving
 Close skin with inverted fat stitch (knot buried)
 Needle at 90 deg NOT oblique.
 Unequal bites produce scars and dead
space.
 Too shallow and tight gives scar++
 Continuous sutures not in ED
 Suturing Tips
 Reshape wound if you can.
 Excise wound if you can.
 Two stage suture if tension problem.
 Long and thin better than short and thick.
 Suture removal
 Suture hole scars occur on day 4.
 Remove all face at day 3 and strap.
 If unsure whether ready remove
alternates.
 If infected remove all FB’s.
 Removal.
 Scalp 5-8
 Face 2-4
 Chest 7-10
 Back 7-14
 Abdomen 5-8
 Arm 5-8
 Prox Leg 7-10
 Distal leg 10-14
 Strapping
 Width of scar depends on magnitude of
perpendicular skin forces. Beware if
wound is >5mm gape.
 Strapping will reduce scar size.
 Used to oppose static tension lines.
 Steristrips/iodine and elastoplast.
 Antibiotics
 Limited use especially if wound cleaned
and debrided properly.
 Consider for feet and pretibial.
 If used give IV before the suture!!!
 Cephalosporin and gentamycin.
 Special sites
 Scalp haemostasis issue.
 Pre-tibial do not suture.
 Face early removal strapping.
 Hands splint &elevate!!!!!
 Dressing
 Try to keep sealed for at least 72hrs as
wound will be ‘sealed’ by then.
 Remember splints and slings!!!!!!
Infections depend on place

 Staph 50%
Mixed Gram Neg 25%

Strep 25%

If you are getting more than 2% infection rate

then something is wrong.
•Human bites
•John Wayne injury

•Bites to hand /ear

•Bitumen tattoo  BEWARE

•Penetrating
• what did it hit?
• NAT
•What is in it? Glass.
•If not healing ?FB