2. contents
• INTRODUCTION
• WOUND EVALUATION
• WOUND PREPARATION
• WOUND CLOSURE
• SOME SPECIFIC WOUND
MANAGEMENT
• POST REPAIR WOUND CARE
• SUMMARY
• REFERENCES
3. INTRODUCTION
• Management of acute wounds begins with obtaining a careful
history of the events surrounding the injury, followed by a
meticulous examination of the wound.
• Examination of the wound may require irrigation and débridement
of the edges of the wound, and is facilitated by use of local
anesthesia.
• Antibiotic administration and tetanus prophylaxis may be needed,
• planning the type and timing of wound repair should take place.
MUST REMEMBER TO EXAMINE THE WHOLE PATIENT ACCORDING TO ACUTE
TRAUMA LIFE SUPPORT (ATLS) PRINCIPLES
5. WOUND EVALUATION : Principles
• Evaluation of the patient with a traumatic wound begins with
overall patient assessment (ABCDE)
• more serious life-threatening injuries need care before
directing attention to wound management
• Remove rings or other jewelry that encircle the injured body
part as soon as possible
• External bleeding can usually be controlled by direct pressure
over the bleeding site, When possible, replace skin flaps to
their original position before applying pressure
7. Wound Examination
• Thorough wound examination should be conducted when the
patient is calm and cooperative and positioned appropriately, with
optimal lighting conditions, and with little or no residual bleeding
• Wound characteristics ( type, length, breadth, depth, extent of
non-viable tissues )
• Location
• ?? Foreign body
• Assoc with BONY/ tendon/ muscle injury, assoc compartment
syndrome
• Distal Neurovascular deficit
8. Adjunctive Testing
•most lacerations will not require any diagnostic testing
•Imaging for bony injuries (FRACTURE/DISLOCATIONS etc)
is necessary (RADIOGRAPHS)
•Injury to tendon , joint space can be done by ultrasound
in ED
•wound imaging for detection of foreign bodies may be
necessary
10. • the SINGLE MOST IMPORTANT STEP in treating a traumatic
wound
• Proper ED wound management can help restore integrity
and function of injured tissue, minimize the risk of
infection, and assure the best possible cosmetic result
• The majority (80% to 90%) of wounds treated in EDs heal
with a good outcome
• careful preparation is particularly important when
underlying medical conditions affecting wound healing are
present
12. STERILE TECHNIQUE
• EXTENT OF ADOPTION OF ASEPTIC TECHNIQUE REQUIRED FOR ED
WOUND REPAIR REMAINS UNCLEAR
Full sterile technique, with the physician wearing hair cap and face mask in
addition to sterile gloves, does not reduce the incidence of postrepair infections
The benefits of hand antisepsis prior to wound repair in the ED is unproven
Clean, nonsterile gloves have similar postrepair infection rates when compared
to sterile gloves
• These findings suggest that aspects of the sterile technique may be
curbed, leading to time and cost savings per laceration by using
common-sense cleanlines
13. Anaesthesia and Analgesia
• In general, pain control should be provided before extensive
wound preparation
• administration of anesthesia and analgesia will enable better
preparation and treatment if patients are relaxed and able to
cooperate without undue anxiety and pain
• Prior to the administration of local or regional anesthetic, the
sensory, motor, and vascular examination should be performed
at, and distal to, the wound site
14. • Two additional assessments may be required before local or
regional anesthesia:
• (1) testing of two-point discrimination on the volar pads of the
thumb and fingers ( Two-point discrimination (<6 mm) checks
for possible injury to the digital nerve )
• (2) comparison of the systolic blood pressure in the injured
extremity with the noninjured one. (Systolic blood pressure
comparison (using a Doppler stethoscope and pneumatic cuff)
assesses for hemodynamically significant arterial obstruction.)
15. • Lidocaine (0.5 to 1%) or bupivacaine (0.25 to 0.5%) combined
with a 1:100,000 to 1:200,000 dilution of epinephrine.
• Contraindications of Epinephrine : should not be used in
wounds of the fingers, toes, ears, nose, or penis due to the risk
of tissue necrosis secondary to terminal arteriole vasospasm in
these structures
• MAXIMUM dose
Anaesthetic agent without epinephrine With epinephrine toxicity
LIDOCAINE (0.5 to
1%)
4.5 mg/kg(300 mg) 7mg/kg(500mg) CNS (SEIZURE)>
CVS (ARRYTHMIA)
bupivacaine (0.25
to 0.5%)
2mg/kg 3mg/kg MOST
CARDIOTOXIC LA
16. Hemostasis
• necessary for control further blood-loss, & proper evaluation of a
wound
• Diffuse bleeding most often occurs from the SUBDERMAL PLEXUS and
SUPERFICIAL VEINS. Direct pressure with saline-soaked sponges or
gauze is usually effective in stopping this type of bleeding
• Bleeding from a MINOR EXPOSED LACERATED VESSEL of the
extremities is best controlled by direct pressure applied with a gloved
fingertip directly on the vessel. Once bleeding from a minor extremity
vessel is halted, more permanent control can be achieved by clamping
the involved vessel, isolating a short length, and ligating it with
absorbable synthetic suture (typically 5-0).
17. • Major arteries of an extremity should not be ligated, and
surgical consultation is needed for further hemorrhage control
• Exercise caution clamping vessels in facial wounds to avoid
damaging facial nerves
• Scalp lacerations can bleed extensively from the wound edges
due to the highly vascular subcutaneous layer. Scalp bleeding
can be controlled by the use of specially designed clips applied
along the wound edges
18. • For bleeding wounds where the involved vessel is not visible, a figure-
of-eight or horizontal mattress suture applied adjacent to the wound
edge near the site of bleeding will sometimes achieve control.
• Chemical means of hemostasis is typically done using epinephrine
mixed with local anesthetics in concentrations of 1:100,000 or
1:200,000 and injected into the wound area
• Physical means of applying pressure to bleeding include the use of
gelatin, cellulose, or collagen sponges placed directly into the wound
• Bipolar electrocautery can achieve hemostasis in blood vessels <2 mm
in diameter, Battery-powered, hand-held cautery units (Figure 44-3)
are more readily available but do not generate sufficient heat to
produce coagulation in vessels larger than capillaries
19. • Extremity wounds that are refractory to direct pressure, ligation,
or cautery may require an arterial tourniquet.
• Tourniquets may compress and damage underlying blood
vessels and nerves, reducing tissue viability.
• The simplest tourniquet to use in an ED is a blood pressure cuff
placed proximal to the wound and inflated above the patient's
systolic pressure.
• Elevating the extremity to reduce venous blood volume prior to
cuff inflation is useful.
• If an extremity tourniquet is needed to control bleeding, the
best course of action is exploration and repair in the operating
room
20. Foreign-Body Removal
• Obvious foreign debris should be carefully removed from the
wound, using forceps to avoid injury to the physician from
sharp edges or points
• Probing wounds with a gloved fingertip to detect foreign
bodies by palpation is discouraged
• Visual wound inspection, down to the full depth and along the
full course of the wound, is the most important method for
detecting foreign bodies
• Imaging modalities (plain radiographs, high-frequency US , CT
and MRI) may be utilized in selected patients
21. Skin Disinfection
• A common practice is to disinfect intact skin around the wound
with either a povidone-iodine–based or chlorhexidine-
containing agent
• Although these agents suppress bacterial growth on intact
skin, they impair host defenses and promote bacterial growth
in the wound itself.
• Skin disinfectants should be applied from the wound edges
outward and care taken to avoid spillage into the wound
22. Hair Removal
• hair can interfere with wound closure, becoming entangled in
sutures or staples, and/or act as a foreign body, potentially
increasing the risk of wound infection
• Shaving the area with a razor damages the hair follicle, allowing
bacterial invasion, and is associated with an increase in infection
rates when compared with clipping or a depilatory cream
• HAIR IS BEST REMOVED BY CLIPPING IT 1 TO 2 MM ABOVE THE
SKIN WITH SCISSORS
• An alternative method to clipping is to use ointment or saline to
allow hair to be parted away from wound edges
23. • wounds in well-perfused locations (i.e., scalp and face) may be closed
without prior hair removal and with no apparent increase in infection.
• Hair SHOULD NEVER BE REMOVED from the eyebrows or at the
hairline because of the potential for impaired or abnormal regrowth
Simple scalp wounds, without contamination
or active bleeding, may be closed via the
hair-apposition technique. Surrounding hair
(>3 cm long) on either side of the laceration
is brought together, twisted, and secured
with tissue adhesive, thereby closing the
wound
24. Irrigation
Low pressure irrigation
• 0.5 psi
• USED FOR
for uncontaminated wounds and
for loose tissues around the scrotum
or eyelids
• achieved with a slow, gentle, wash
with saline or water
high pressure irrigation
• 7 psi or greater
• USED FOR
wounds with high levels of
contamination
in areas of the body that are at higher
risk of infection such as the extremities
• achieved with any combination of
syringes and 18 gauge intravenous
catheters (COMMONLY USED 50-mL
syringe with a splash guard)
Effective irrigation decreases bacterial count and helps to remove debris
and foreign bodies, thereby reducing the risk of wound infection
25. volume of irrigant required : exact volume not known
• a common recommendation is to use 60 mL per cm of wound
length
• ANOTHER recommendation is to use at least 200 mL for wound
irrigation
Irrigant AGENT :
• 1. Sterile normal saline, most commonly used , lowest toxicity
• 2. tap water is easily obtained in large quantities
26. • there is no added benefit to the addition of an antiseptic such as
povidone-iodine or hydrogen peroxide
• Universal precautions should be observed while participating in
wound care
27. Debridement
• Debridement not only removes foreign matter, bacteria, and
devitalized tissue, but it also creates a clean wound edge that
is easier to repair.
TECHNIQUES of debridement
Autolytic debridement
mechanical debridement (irrigation and wet-to-dry dressings)
excisional debridement (to reestablish a margin of normal
tissue at wound edges)
• After debridement is completed, wounds should be re-
irrigated.
28. generally the skin should be
débrided until there is a
bleeding edge. This
débridement should not be
done under tourniquet
control because the viability
of the skin may not be known.
Muscle débridement should
remove all nonviable muscle
that is noncontractile or
grossly contaminated
29. Prophylactic Antibiotics
• Infections occur in approximately 3% to 5% of traumatic wounds
repaired in Eds
• The most important step in prevention of a wound infection is
adequate irrigation and debridement
• no clear evidence that antibiotic prophylaxis prevents wound
infections in most patients whose wounds are closed in the ED
• Antibiotics have an inconclusive role in intra-oral traumatic wounds
• Prophylactic antibiotics do not reduce the incidence of wound
infection after dog or cat bites on areas other than the hands
30. • For wounds contaminated by debris or feces or caused by
punctures or bites, wounds with tissue destruction or in avascular
areas, and neglected wounds, sufficient bacteria may be present
to cause infection, and prophylactic antibiotics are often
administered
• Prophylactic antibiotics are recommended for all human bites to
the hands and feet as well as to those overlying joints or cartilage
• Wounds contaminated by fresh water and plantar puncture
wounds through athletic shoes should include Pseudomonas
coverage
31. • Most nonbite wound infections are due to staphyloccci or
streptococci and despite the increase in methicillin-resistant
Staphylococcus aureus skin infections, prophylactic coverage
with a beta-lactam is still adequate
• For human bites in all locations and for mammalian bites on
the hands, amoxicillin-clavulanate should be used to cover
both Pasteurella and Eikenella. Prophylactic antibiotics do not
reduce the incidence of wound infection after dog or cat bites
on areas other than the hands.
32. • Principles of Antibiotic prophylaxis for traumatic wounds in ED
(1) initiated before significant tissue manipulation is done,
(2) performed with agents that are effective against predicted
pathogens, and
(3) administered by routes that rapidly achieve desired blood levels.
• There are no studies that compare the common practice of IV
administration of the initial dose of prophylactic antibiotics with
PO administration
• The duration for antibiotic prophylaxis is unknown; most
physicians use 3 to 5 days for nonbite wounds and 5 to 7 days for
bite wounds. Patients with established wound infections usually
require longer treatment
36. Technique
Advantages Disadvantages
Suture Time-honored Requires removal (if using
nonabsorbable material)Meticulous closure
Greatest tensile strength Requires anesthesia
Lowest dehiscence rate Risk of needle stick to physician
Greatest tissue reactivity
Highest cost
Slowest application
Staples Rapid application Less meticulous closure
Low tissue reactivity May interfere with some
imaging techniques (CT, MRI)Low cost
Low risk of needle stick
37. Technique Advantages Disadvantages
Tissue adhesives Rapid application Lower tensile strength than 5-0 or
larger sutures
Patient comfort
Resistant to bacterial growth Dehiscence over high-tension areas
(joints)
No need for removal
Low cost Not useful on hands
No risk of needle stick Cannot bathe or swim (can shower)
Microbial barrier
Occlusive dressing
Adhesive tapes Least reactive Frequently fall off
Lowest infection rates Lower tensile strength than sutures or
tissue adhesives
Rapid application
Patient comfort Highest rate of dehiscence
Low cost Often requires use of toxic adjuncts
No risk of needle stick Cannot be used in areas with hair
Cannot get wet
38. choosing a wound closure method
• Choice of the wound closure method and timing should take into account
both patient and wound characteristics
• One of the most important considerations when choosing a wound closure
method is the amount of tension on the wound, both static (at rest) and
dynamic (with motion).
• Linear lacerations subject to little tension : can usually be closed by any one
of the four closure methods. In this case, the practitioner should take into
consideration patient characteristics and preferences such as compliance,
the availability to return for follow-up and device removal, and overall level
of anxiety.
39. • low-tension irregular lacerations : sutures may be the best alternative,
allowing the greatest degree of precision with accurate wound edge
approximation.
• lacerations subject to high tension (static and/or dynamic) : it is vital to
relieve the amount of tension on the wound in order to avoid early
dehiscence or gradual widening of the scar. Relief of tension is best
achieved by careful undermining, placement of deep dermal sutures, and
wound immobilization (when appropriate).
• With patients at risk of keloid formation, it is best to relieve tension and
minimize the amount of foreign material introduced into the wound
41. • strongest of all the closure devices and allow the most
accurate approximation of the wound edges, regardless of
their shape or configuration
• most time consuming and operator dependent of all wound
closure methods
Types
Size
method
42. Types OF suture materials
Nonabsorbable sutures Absorbable sutures
43. Nonabsorbable Suture Characteristics
Suture Structure Raw Material Tensile Strength
Retention In Vivo
Tissue Reactivity Common ED Uses
Silk Braided Organic protein called
fibroin
Degradation of
fiber results in loss
of strength over
many months
Significant
inflammatory
reaction
Intraoral mucosal
surfaces for comfort
Nylon (Ethilon®,
Dermalon®)
Monofilament Polyamide polymer Hydrolysis results
in loss of strength
over years
Minimal Soft tissue and skin
reapproximation
Polypropylene
(Prolene®,
Surgipro®)
Monofilament Polypropylene polymer No degradation or
weakening
Least Soft tissue and skin
reapproximation
Polyester
(Mersilene®,
Ticron®)
Braided and
monofilament
Polyethylene
terephthalate
No degradation or
weakening
Minimal Tendon repair using
undyed (white) color
Polybutester
(Novafil®)
Monofilament Poly (butylene) and poly
(tetramethylene ether)
No degradation or
weakening
Minimal Soft tissue
approximation
44. absorbable Suture Characteristics
Suture Types Material Tensile Strength
Retention In Vivo
Absorption Rate Tissue Reactivity Common ED Uses
Surgical gut Plain Collagen derived from
bovine intestine
Retains 50%
tensile strength
for 5–7 d
Absorbed by
proteolytic
processes in
weeks
Moderate
reactivity
Rarely, for
intraoral wounds
Chromic gut Chromium
coating
Collagen derived from
bovine intestine
Retains 50%
tensile strength
for 10–14 d
Absorbed by
proteolytic
processes in
weeks
Moderate
reactivity
Rarely, for
subcutaneous
closures and
intraoral wounds
Polyglycolic acid
(Dexon®)
Braided Polymer of glycolic acid Retains 65%
tensile strength at
2 wk, 35% at 3 wk
Completely
absorbed by slow
hydrolysis by 60–
90 d
Minimal Approximation of
deep soft tissue
structures (i.e.,
dermis) and
ligation of vessels
Polyglactin 910
(Vicryl®)
Braided Copolymer of lactide
and glycolide coated
with polyglactin 370
and calcium stearate
Retains 65%
tensile strength at
2 wk, 40% at 3 wk
Completely
absorbed by slow
hydrolysis by 56–
70 d
Minimal Approximation of
deep soft tissue
structures, (i.e.,
dermis) and
ligation of vessels
Tintinalli, 7th
46. Recommended Suture Size Based on Laceration
Location
Location Suture Size
Scalp 4-0 Nylon or polypropylene
Face 6-0 Polypropylene or nylon
Trunk 4-0 Nylon
Extremities 4-0 Nylon
Digits 5-0 Polypropylene or nylon
63. Open Fractures : Principles of Wound Management
AIMS :
• life preservation,
• limb preservation,
• infection avoidance,
• functional preservation
64. MANAGEMENT PRINCIPLES :
1. Treat open fractures as emergencies,
2. Perform a thorough initial evaluation ABCDE approach, to diagnose life-
threatening and limb-threatening injuries.
• Then musculoskeletal and neurological evaluation protocols are crucial in
determining the type and extent of injury. Radiographs should be obtained to
show the extent and type of bony injury
• Emergency measures are necessary to combat pain, hemorrhage, and shock.
• Hemorrhage should be controlled with pressure. Tourniquets are rarely
recommended. The blind use of a hemostat in a wound also is not
recommended
• From the time of injury until the patient is ready for the wound preparation
for surgery, the wound should be protected by a sterile dressing, and the
extremity should be splinted to prevent additional soft-tissue injury from
movement of the sharp bone fragments
65. • Vascular injury or compartment syndrome should be treated promptly to
avoid tissue ischemia, which, if present for 6 hours or more, can cause
irreversible muscle and nerve damage. a difference between tissue
pressure and diastolic pressure of 10 to 20 mm Hg is an indication for
immediate fasciotomy.
3. Begin appropriate antibiotic therapy in the ED or at least in the operating
room, and continue treatment for 2 to 3 days only.
4. Immediately débride the wound of contaminated and devitalized tissue,
copiously irrigate, and repeat débridement within 24 to 72 hours.
5. Stabilize the fracture with the method determined at initial evaluation
6. Leave the wound open (controversial).
7. Perform early autogenous cancellous bone grafting.
8. Rehabilitate the involved extremity aggressively
70. General Principles of Bite Wound Management
CARE of
• injury inflicted by the bite,
• prevention or treatment of local bacterial infection,
• and prevention, recognition, and management of subsequent
systemic illness.
71. • In the initial assessment of the injured patient, attention should be
paid to the potential for a life-threatening injury
• Meticulous examination and cleansing measures, including
aggressive irrigation and debridement of devitalized tissue, are
important.
• Determine the extent of underlying tissue damage, with special
attention to the potential for penetration into joint spaces and
tendon sheaths
• Some bite lacerations can safely undergo primary repair , Delayed
primary closure is applicable for the management of contaminated
bite injuries, especially in areas other than the face
72. Indications for Primary Closure of Mammalian Bite Wounds
Location: face or scalp
Timing: within 6 h of injury (time dependent upon individual judgment)
Wound characteristics: simple and appropriate for single-layer closure, no devitalized tissue
Lack of underlying injury: no underlying fracture
Host: no systemic immunocompromising conditions
Bite Wounds at High Risk of Infection
Cat or human
Livestock
Monkey bites
Deep puncture wounds
Hand or foot wounds
Bites in immunosuppressed patients
73. Common Bites and First-Line Treatment
Animal Organism First-Line Antibiotic
Cat Pasteurella multocida Amoxicillin-clavulanate
Bartonella henselae (cat-scratch fever) Azithromycin
Dog Pasteurella, streptococci, staphylococci,
Capnocytophaga canimorsus
Amoxicillin-clavulanate
Human Eikenella, staphylococci, streptococci Amoxicillin-clavulanate
Herpes simplex (herpetic whitlow) Acyclovir or valacyclovir
Rats, mice, squirrels, gerbils Streptobacillus moniliformis (North America) or
Spirillum minus/minor (Asia)
Amoxicillin-clavulanate
Livestock, large game animals Multiple organisms Amoxicillin-clavulanate or specific agent
for diseaseBrucella, Leptospira, Francisella tularensis
Bats, monkeys, dogs, skunks,
raccoons, foxes (all carnivores
and omnivores)
Rabies Rabies immune globulin, rabies vaccine
Monkeys Herpes B virus (Cercopithecine herpesvirus) Acyclovir or valacyclovir
Freshwater fish Aeromonas, staphylococci, streptococci Fluoroquinolone or trimethoprim-
sulfamethoxazole
Saltwater fish Vibrio, staphylococci, streptococci Fluoroquinolone
77. Post exposure prophylaxis
Anti-Rabies Vaccine
• Regimen
• Essen Schedule: Five dose intramuscular regimen -
The course for post-exposure prophylaxis should
consist of intramuscular administration of five
injections on days 0, 3, 7, 14 and 28. The sixth
injection (D90) should be considered as optional
and should be given to those individuals who are
immunologically deficient, are at the extremes of
age and on steroid therapy. Day 0 indicates date of
first injection.
• Site of inoculation: The deltoid region is ideal for
the inoculation of these vaccines. Gluteal region is
not recommended because the fat present in this
region retards the absorption of antigen and hence
impairs the generation of optimal immune
response. In case of infants and young children
antero-lateral part of the thigh is the preferred site.
Anti rabies immunoglobulin
• Dose of rabies immunoglobulins: The
dose of equine rabies immunoglobulins
• is 40 IU per kg body weight of patient and
is given after testing for sensitivity, upto a
maximum of 3000 IU. The ERIG produced
in India contains 300 IU per ml.
• The dose of the human rabies
immunoglobulins (HRIG) is 20 IU per kg
body weight (maximum 1500 IU). HRIG
does not require any prior sensitivity
testing. HRIG preparation is available in
concentration of 150 IU per ml.
79. Human Bites
• Human bites tend to be more serious than bites from domestic
animals
• All human bites should be treated as contaminated wounds
• Most human bite wounds should not undergo primary closure with
the possible exception of wounds to the face, where primary
closure is associated with a postrepair wound infection rate of
approximately 10%
• Human bite wound infections are polymicrobial, and the most
common organisms are staphylococcal and streptococcal species,
& ALSO gram-negative rod Eikenella corrodens.
80. • Amoxicillin-clavulanate is recommended for treatment and
prophylaxis after all but the most trivial human bites.
• For established infections, parenteral agents of choice include
ampicillin-sulbactam, cefoxitin, or piperacillin-tazobactam
Herpes simplex virus can cause local infection after a human
bite or contact with infected saliva,
The resultant herpetic whitlow is a painful coalescence of
vesicles, typically on the distal phalanx
Vesicles usually resolve in 3 to 4 weeks. Treatment with oral
acyclovir for 7 to 10 days or topical acyclovir ointment for 7 to
14 days may shorten the duration of the symptom
82. • A tight ring encircling the proximal phalanx may become
entrapped as a result of distal swelling
• As the digit expands, venous outflow is restricted by the tight
ring, producing more swelling. This vicious cycle may lead to
nerve damage, ischemia, and digital gangrene
• The presence of impaired sensation (diminished static two-
point discrimination) or diminished perfusion (delayed
capillary refill) indicates significant constriction.
91. Patient Positioning after Wound Repair
• For wounds with associated soft tissue contusion, the injury site
should be elevated above the patient's heart to limit the
accumulation of fluid in the wound interstitial spaces
• splints are quite useful for extremity injuries, especially over
joints, as they will decrease movement of the injured part,
decrease pain associated with the soft tissue injury, reduce
edema accumulation, and increase the attention paid to the
injured body part
• Pressure dressings can be used to minimize the accumulation of
intercellular fluid in the subcutaneous space. Pressure dressings
are most useful for ear and scalp lacerations
93. Clinical Situation First-Line Agent Alternative Therapy Comment
Uncomplicated patient and
wound
First-generation cephalosporin
or antistaphylococcal penicillin
Macrolide Methicillin-resistant
Staphylococcus aureus coverage
not necessary at this time
Patient with underlying
immunodeficiency
Amoxicillin-clavulanate or
second-generation
cephalosporin
Clindamycin plus a
fluoroquinolone
—
Patient with prosthetic heart
valve or orthopedic implant
Consider adding vancomycin to
standard regimen
— Give prophylaxis before
manipulating grossly
contaminated wound or incising
into an abscess
Barnyard injuries, fecal
contamination
Amoxicillin-clavulanate or
second-generation
cephalosporin
Fluoroquinolone plus either
clindamycin or metronidazole
—
Saltwater exposure Third-generation cephalosporin
± doxycycline
Fluoroquinolone Vibrio may cause hemorrhagic,
bullous lesions
Freshwater exposure Antipseudomonal
aminoglycoside or
antipseudomonal penicillin
Fluoroquinolone Aeromonas or Pseudomonas
may be involved
94. Clinical Situation First-Line Agent Alternative Therapy Comment
Abscesses and infections
associated with injection drug
use
Amoxicillin-clavulanate or
second-generation
cephalosporin
Clindamycin Antibiotics usually not
necessary, incision and
drainage essential
Necrotizing fasciitis Imipenem or meropenem Oxacillin plus gentamicin plus
clindamycin
—
Bite wounds Amoxicillin-clavulanate or
cefoxitin/cefotetan
Clindamycin plus either a
fluoroquinolone or
trimethoprim-
sulfamethoxazole
—
Open fracture First-generation cephalosporin
or antistaphylococcal
penicillin, plus aminoglycoside
Vancomycin —
Plantar puncture wound Ciprofloxacin First-generation cephalosporin
or antistaphylococcal penicillin
plus ceftazidime
—
95. Tetanus Prophylaxis
Clean Minor Wounds All Other Wounds*
History of Tetanus
Immunization
Administer Tetanus
Toxoid
Administer TIG‡ Administer Tetanus
Toxoid
Administer TIG
<3 or uncertain doses Yes No Yes Yes
3 doses
Last dose within 5 y No No No No
Last dose within 5–10
y
No No Yes No
Last dose >10 y Yes No Yes No
Tetanus immune globulin: adult dose, 250–500 IU administered into deltoid opposite the tetanus-diphtheria
toxoid immunization site
Tetanus toxoid: Tdap if adult and no prior record of administration, otherwise tetanus-diphtheria toxoid if >7 years
and diphtheria-tetanus toxoid if <7 years, preferably administered into the deltoid
96. Wound Cleansing
• Sutured or stapled wounds can be gently washed and cleansed as
early as 8 hours after closure without an increase in infection rate
• use of soap and tap water to cleanse lacerations is not associated
with an increased infection rate
• Gentle blotting should be used to dry the area; aggressive wiping
could result in wound dehiscence
• For routine wounds, patients should be instructed to remove their
dressings after 24 hours, cleanse the wound, and examine it for
signs of infections. In certain special situations, the dressing should
remain undisturbed for 4 to 5 days until the patient is reevaluated
by the physician.
97. Wound Drains
• (1) to drain interstitial fluid or blood and prevent accumulation into
a seroma or hematoma, respectively;
• (2) to maintain a tract so pus can drain from an infected area
• (3) to allow for drainage from a contaminated location and prevent
an abscess from forming
• categorized as
(1) gauze packing to maintain open drainage and collect the exudate
(2) open systems using soft rubber (e.g., Penrose drain) or silicone
tubing to direct drainage onto external gauze dressings,
(3) closed systems using silicone tubing and attached fluid collection
reservoirs
98. • The most common type of wound drain placed in the ED is 1/4- to 1-
in. (0.6- to 2.5-cm) ribbon gauze used to pack an abscess cavity
after incision and drainage.
• Dressings over draining abscesses may initially require frequent
changes.
• The internal packing should be replaced daily as long as the
wound continues to produce exudate.
• Once the purulence stops, internal packing is no longer required,
and daily cleaning with external dressing changes should continue
until enough granulation tissue forms and the wound becomes
dry.
• Maintaining a moist, clean environment promotes wound healing.
99. Pain Control
• Patients should be educated
• Splints can be used to reduce swelling and pain for extremity
lacerations
• Appropriate analgesic medications and anti-inflammatory
agents
• after the initial 48 hours opioid analgesics are rarely necessary
as pain from lacerations generally decreases
100. Location Number of Days
Face 3–5
Scalp 10
Chest 8–10
Back 10–14
Forearm 10–14
Fingers 8–10
Hand 8–10
Lower extremity 8–12
Foot 10–12
Removal of Sutures or Staples
103. Patient Education About Long-Term Cosmetic
Outcome
• Patients should be told that all traumatic lacerations result in
some scarring.
• short-term cosmetic appearance is not highly predictive of the
ultimate cosmetic outcome
• Injured skin should be protected with a sun-blocking agent for
6 to 12 months after injury
105. REFERENCES
• TINTINALLI’s EMERGENCY MEDICINE , 7TH & 8TH ED
• Sabiston Textbook of Surgery, 19th ed.
• Schwartz's Principles of Surgery 9th
• Bailey & Love’s SHORT PRACTICE of SURGERY 25th
• Washington Manual of Surgery,The, 5th Edition
• REDDY , essentials of FORENSIC MEDICINE & TOXICOLOGY,26th
• SRB’s MANUAL of SURGERY, 5th
• National Guidelines for Rabies Prophylaxis and 19 Intra-dermal
Administration of Cell Culture Rabies Vaccines,2007
Proper wound management begins with a pertinent patient history
Although adoption of aseptic technique represented a major advance in medical care, the extent required for ED wound repair remains unclear. Full sterile technique, with the physician wearing hair cap and face mask in addition to sterile gloves, does not reduce the incidence of postrepair infections.4,5 The benefits of hand antisepsis prior to wound repair in the ED is unproven.6 Clean, nonsterile gloves have similar postrepair infection rates when compared to sterile gloves.7–9 These findings suggest that aspects of the sterile technique may be curbed, leading to time and cost savings per laceration by using common-sense cleanliness
Vasoconstriction : hemostasis
Avascular plane
Duration of analgesia prolonged
Decreased systemic toxicity
Disadv: more painful inj
Htn, arrythmia
Delayed wound healing
Local tissue damage
ANYHING WHICH IRRITATES CONJUNCTIVA SHOULD NOT BE USED
Wound soaking is not effective in cleansing contaminated wounds and may actually increase wound bacterial counts.23 Routine scrubbing of traumatic wounds with a sponge is also ineffective, inflicting trauma and impairing resistance to infection.
Wet-to-dry dressings are useful mainly in the setting of necrotic, exudative wounds. Wet gauze is allowed to dry within the wound bed and then removed, thus taking viable and nonviable tissue nonselectively from the wound.26 This method may require the use of analgesia
the most effective type of debridement is excision, because it converts a contaminated wound into a clean surgical wound (Figure 44-7). A standard surgical blade is recommended. Tissue that has a narrow base or lacks capillary refill will require excision. The goal of debridement is to reestablish a margin of normal tissue at wound edges. The easiest technique for excisional debridement is to mark an elliptical area around the sides of the wound, and then use a surgical blade to cut only through the epidermis. Skin lines should be respected, and extensive excision should be avoided.
Lacerations may be closed by one of four commonly available methods or devices: sutures, staples, adhesive tapes, or tissue adhesives. Each method has advantages and disadvantages (Table 45-1). Choice of the wound closure method and timing should take into account both patient and wound characteristics
Tourniquets are rarely recommended because of the potential for further nerve and limb damage. The blind use of a hemostat in a wound also is not recommended because of the risk of damage to peripheral nerves lying near the vessels.
excessive pressure should be avoided in all pressure dressings, especially in the extremities where they may compromise circulation