Wound management

1. Wound Management in
the ED
James Pocock

2. Topics for this Session
 Assessment of Wounds in ED
 Types of Wound Closure
 Sutures
 Suture Techniques
 Staples
 Steristrips
 Adhesive Glue
 Wound Dressing

3. Lacerations and Wounds in the ED
 Common
 Most common in young men
 Sites
 Head & Neck- 50%
 Upper limbs- 35%
 1.1-12% risk of infection in all wounds presenting to ED

4. Lacerations and Wounds in the ED
 Concerns for Patient
 Functional outcome
 Cosmesis
 Least painful repair
 Avoiding infection

5. Initial Assessment of Wounds in ED
 Stabilisation
 History
 Host factors
 Allergies
 Tetanus
 Time since injury
 ‘Golden Period’
 Examination
 Distal neurovascular status
 Functional status of surrounding structures
 Foreign Bodies

7. ED Management
 Anaesthesia
 Local
 Topical
 Regional
 Irrigation
 ~100ml per 1cm
 Debridement

8. Wound Closure Methods

9. Staples
 Fast
 Low wound reactivity
 Low rates of infection
 Use on scalp, trunk
 Avoid in areas where cosmesis is important

10. Tissue Adhesive Glue
 Simple lacerations with minimal tension
 <3cm in length
 Fast
 Less painful than sutures
 Needs to be dry skin
 Hold wound for 30s
 Comparable to 5-0 suture

11. Steri-Strips
 Least reactive of all wound closure methods
 Need clean wound
 Oppose slightly separated wound edges
 Minimal tensile strength
 Placed perpendicularly across the wound
 2-4mm between each strip
 Must be kept dry and

12. Sutures
 Variety of materials, sizes available
 Absorbable leads to increased reactivity
 Natural fibres more reactive than synthetic
 Avoid silk in ED
 Monofilament vs multifilament
 Absorbable suture uses:
 Deep dermal- degrade in ~60 days
 Mucosal
 Unlikely to seek follow up
 Suture size should be smallest to resist the wound’s tension

14. Suture Sizes by Region

15. Suture Removal Times

16. Delayed Primary Closure
 Uses
 Heavily contaminated wounds
 Delayed presentation
 Concerns about infection
 Decreases infection rate by ~50%
 Technique
 Clean & Debride
 Fine mesh dressing
 Large gauze dressing
 Review in 3-4 days

17. Suture Types

19. Suture Types at SCGH
 Surgipro
 Synthetic
 Unbraided
 Sizes from 3-0 to 6-0
 Most commonly used suture at SCGH

20. Suture Types at SCGH
 Vicryl Rapide
 Synthetic
 Braided
 Sizes 4-0 & 5-0 in ED
 Uses:
 Mucosal injuries
 Deep dermal sutures
 If patient is unlikely to engage in follow up

21. Suture Types at SCGH
 Cat Gut
 6-0
 Absorbable, natural
 Used for nail bed lacerations
 Braided Silk
 Securing CVC, ICDs, etc
 Not used for wound closure

22. Suture Techniques

23. Suture Techniques
 Simple interrupted

24. Suture Techniques
 Deep Dermal Suture

25. Suture Techniques
 Vertical Mattress
 Useful in areas of high tension (e.g. shin)
 Can lead to ischaemia around wound edges

26. Dressings in ED

27. Dressings at SCGH
 Large number of dressings available in ED
 When working out what dressing, think about intention

28. Burns- simple!

29. Burns Management
 Acticoat
 Silver coated
 Prevent infection
 Uses:
 Burns
 Needs activation with sterile water

30. Wound Management
 Intrasite
 Hydrogel-impregnated
 Uses:
 Slow healing/ necrotic wounds
 Lifts aware slough, necrotic tissue and eschar
 Allows granulation tissue to form
 Burns

31. Active Bleeding
 Major bleeds
 Consider direct or indirect pressure
 ?Tourniquet
 Ligature of the vessel if collateral available
 Ongoing ooze
 Alginate or Kaltostat
 Seaweed based
 Promote haemostasis and form a gel
 Consider Jelonet as further barrier
 Compression gauze

32. Wound Management
 Mepilex/ Mepilex Border
 Silicone based
 Uses:
 Secondary closure
 E.g ulcers, pressure injuries
 Skin tears
 Thick abrasions
 Mepitel
 Tacky
 Useful in skin tears

33. References
 Jamie Bawden, SCGH ED ANP
 www.lacerationrepair.com
 https://lifeinthefastlane.com/own-the-wound/
 https://hqmeded.com/wound-care-ed/
 Wound Care: Modern Evidence in the Treatment of Man’s Age-Old Injuries;
Emergency Medicine Practice; March 2005; 7(3)
 https://www.rch.org.au/clinicalguide/guideline_index/Lacerations/
 https://coreem.net/core/suture-materials/