Wound Management

UNC Emergency Medicine

Medical Student Lecture Series
2 Principles of Wound Management

Goals of Wound Care

Facilitate hemostasis
Decrease tissue loss
Promote wound healing
Minimize scar formation
3 Principles of Wound Management

Mechanism of Injury

Wounds are caused by three

different types of forces
Shear
Compressive
Tensile
4 Principles of Wound Management

Shear Forces

Result from sharp objects

Low energy
Minimal cell damage
Result in straight edges, little contamination
Heals with a good result
5 Principles of Wound Management

Compressive Forces

Result from blunt objects impacting

the skin at a right angle
Results in stellate or complex laceration
Ragged or shredded edges
More prone to infection
6 Principles of Wound Management

Tensile Forces

Result from blunt objects impacting

the skin at an oblique angle
Results in triangular wound
Sometimes produces a flap
More prone to infection
7 Principles of Wound Management

Evaluation of Wounds

ABCs first Always!

Ensure hemostasis
Saline gauze dressing
Compression
Remove obstructions
Rings, clothing, other jewelry
History
8 Principles of Wound Management

History
Symptoms Tetanus status
Type of Force Allergies
Contamination Medications
Event Comorbidities
Potential for
foreign body Previous scar
formation
Function
Non-accidental
trauma
9 Principles of Wound Management

Wound Examination

Location Vascular function

Size Tendon function
Shape Underlying
Margins structures
Depth Wound
Alignment with contamination
skin lines Foreign bodies
Neuro function
10 Principles of Wound Management

Wound Consultation

Tarsal plate or lacrimal duct

Open fracture or joint space
Extensive facial wounds
Associated with amputation
Associated with loss of function
Involves tendons, nerves, or vessels
Involves significant loss of epidermis
Any wound that you are uncertain about
11 Principles of Wound Management

Wound Preparation - Anesthesia

Topical
Solution or paste
LET
EMLA
Local
Direct infiltration
1% lidocaine with or without epinephrine
Bupivicaine or sensorcaine for longer acting anesthesia
Regional Block
Local infiltration proximally in order to avoid tissue disruption
Smaller amount of anesthesia required
12 Principles of Wound Management

Wound Preparation - Anesthesia

Drug Max Dose Onset Duration

Cocaine 6.6 mg/kg Rapid 1 hour

Procaine 10-15 mg/kg Rapid 30min-1hr

Tetracaine 1.5 mg/kg Moderate 2 hours

Lidocaine 5 mg/kg 5-30 min 2 hours

(with Epi) 7 mg/kg 5-30 min 2-3 hours

Bupivacaine 2 mg/kg 7-30 min > 6 hours
13 Principles of Wound Management

Minimize the Pain of Injection

Use sodium bicarbonate mixed with

the anesthetic (1 ml/10 ml solution)
Use smallest needle possible
Inject slowly
Insert needle through open wound
edge and skin that has already been
anesthetized
14 Principles of Wound Management

Wound Preparation - Hemostasis

Physical vs. chemical

Direct pressure
Epinephrine
Gelfoam
Cautery
Refractory
Use a tourniquet
15 Principles of Wound Management
Wound Preparation Foreign
Body Removal
Visual inspection
Imaging
Glass, metal, gravel fragments >1mm should
be visible on plain radiographs
Organic substances and plastics are usually
radiolucent
Always discuss and document
possibility of retained foreign body
16 Principles of Wound Management

Wound Preparation Irrigation

Local anesthesia prior to irrigation

Do not soak the wound
Use normal saline
Large syringe (60mL) with Zerowet
attachment
Do not use iodine, chlorhexidine,
peroxide or detergents
17 Principles of Wound Management

Wound Preparation Debridement

Removes foreign matter & devitalized

tissue
Creates sharp wound edge
Excision with elliptical shape
Respect skin lines
18 Principles of Wound Management

Wound Preparation Antibiotics

Infections occur in ~3-5% of traumatic

wounds seen in the ED
Factors that increase risk
Heavily contaminated wound, especially with soil
Immunocompromised patients
Diabetics
Human bites > animal bites
Most important prevention adequate
irrigation & debridement
19 Principles of Wound Management

Wound Preparation Antibiotics

Dog & cat bites

Cover pasteurella
Augmentin
Human bites
Cover eikenella
Augmentin
Puncture wounds
Cover pseudomonas
Cipro, levaquin
20 Principles of Wound Management

Wound Preparation Tetanus Prophylaxis

Clean wounds
Incomplete immunization toxoid
>10 years, then give toxoid
Tetanus prone wound
Incomplete immunization
Toxoid & immune globulin
> 5 years, give toxoid
Remember to think about rabies!
21 Principles of Wound Management

Wound Closure

Primary closure
Suture, staple, adhesive, or tape
Performed on recently sustained lacerations: <12
hours generally and <24 hours on face
Secondary closure
Secondary intent
Allowed to granulate
Tertiary closure
Delayed primary (observed for 4-5 days)
22 Principles of Wound Management

Suture Material
Absorbable
Chromic gut
Vicryl
PDS II
Non-Absorbable
Silk
Prolene
Dermalon
Monofilament vs. braided
23 Principles of Wound Management

Staples, Adhesives & Tape

Staples
Quick, poor aesthetic result
Adhesives
Dermabond- painless, petroleum dissolves
Tape
Steri-strips
24 Principles of Wound Management

Wound Closure

Undermine the wound edges

Release tension
25 Principles of Wound Management

Suture Techniques

Deep layer
approximation
Absorbable sutures
Buried knot
Serves two purposes
Closes potential
spaces
Minimizes tension on
the wound margins
26 Principles of Wound Management

Skin Closure

Key wound edge eversion

Approximate, dont strangulate
Anticipate wound edema
Choose appropriate size of suture for
location of laceration
27 Principles of Wound Management

Suture Techniques

Simple Interrupted
Used on majority of wounds
Each stitch is independent
28 Principles of Wound Management

Suture Techniques

Simple Continuous
Useful in pediatrics
Rapid
Easy removal
Provides effective hemostasis
Distributed tension evenly along length
Can also be locked with each stitch
29 Principles of Wound Management

Suture Techniques

Horizontal Mattress
Useful for single-layer closure of lacerations
under tension
30 Principles of Wound Management

Horizontal Mattress
31 Principles of Wound Management

Suture Techniques

Vertical Mattress
Useful for everting skin edges
Far-far-near-near
32 Principles of Wound Management

Vertical Mattress
33 Principles of Wound Management

Suture Techniques

Purse-string
Useful for stellate lacerations
34 Principles of Wound Management

Suture Techniques

Instrument tie
35 Principles of Wound Management

Wound Care

Dressing
Maintain dry for 24-48 hours
Use antibiotic to maintain moist environment
If overlying a joint, splint in a position of
function
Sun protection to prevent scar
hyperpigmentation
Suture removal instructions!
36 Principles of Wound Management

Practice Time!