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Presenter-
Dr. SUBHANKAR PAUL
WOUND MANAGEMENT
In
EMERGENCY DEPARTMENT
contents
• INTRODUCTION
• WOUND EVALUATION
• WOUND PREPARATION
• WOUND CLOSURE
• SOME SPECIFIC WOUND
MANAGEMENT
• POST REPAIR WOUND CARE
• SUMMARY
• REFERENCES
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
SCHWARTZ 9th
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
HISTORY
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
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
Wound Preparation
• 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
Components of Wound Preparation
• Sterile Technique
• anaesthesia and analgesia
• Hemostasis
• Foreign-Body Removal
• Skin Disinfection
• Hair Removal
• Irrigation
• Debridement
• Prophylactic Antibiotics
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
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
• 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.)
• 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
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).
• 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
• 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
• 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
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
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
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
• 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
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
 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
• 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
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.
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
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
• 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
• 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.
• 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
Methods for Wound Closure
Emergency Wound Management
Wound Closure Methods : Overview
• Suture
• Staples
• Tissue adhesives
• Adhesive tapes
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
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
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.
• 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
Sutures
• 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
Types OF suture materials
Nonabsorbable sutures Absorbable sutures
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
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
Emergency Wound Management
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
Wound Closure Method
Simple Interrupted Percutaneous Sutures
Continuous (Running) Percutaneous Sutures
Vertical Mattress Sutures
Horizontal Half-Buried Mattress Sutures
Deep Dermal Sutures
Continuous Subcuticular Sutures
Selecting Closure Method Based on Wound Type
Emergency Wound Management
Other methods of skin closure
Staples
Adhesive Tapes
Cyanoacrylate Tissue Adhesives
Emergency Wound Management
Emergency Wound Management
WOUND MANAGEMENT
Some SPECIFIC CONSIDERATIONS
Open Fractures : Principles of Wound Management
AIMS :
• life preservation,
• limb preservation,
• infection avoidance,
• functional preservation
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
• 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
Lacerations to the Face and Scalp: Introduction
Emergency Wound Management
Emergency Wound Management
Mammalian Bites
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.
• 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
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
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
Approach to Post-Exposure Prophylaxis (PEP) for
RABIES
WORLD RABIES DAY , 28TH SEPTEMBER
Emergency Wound Management
Emergency Wound Management
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.
Emergency Wound Management
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.
• 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
Ring Tourniquet Syndrome
• 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.
ring-preservation methods OF ring removal
cutting the ring
Postrepair Wound Care
• Wound Dressings
• Patient Positioning after Wound Repair
• Prophylactic Antibiotics
• Tetanus Prophylaxis
• Wound Cleansing
• Pain Control
• Health Care Provider Follow-Up
• Patient Education About Long-Term Cosmetic Outcome
Wound Dressings
• nonadherent fabrics
• absorptive dressings
• occlusive dressings
• creams, ointments, and solutions
Characteristics of Ideal Dressing
Emergency Wound Management
Emergency Wound Management
Emergency Wound Management
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
Prophylactic Antibiotics
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
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
—
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
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.
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
• 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.
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
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
Technique for Removal of Sutures
Technique for Removal of Staples
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
summary
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
THANK
YOU

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Emergency Wound Management

  • 1. Presenter- Dr. SUBHANKAR PAUL WOUND MANAGEMENT In EMERGENCY DEPARTMENT
  • 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
  • 11. Components of Wound Preparation • Sterile Technique • anaesthesia and analgesia • Hemostasis • Foreign-Body Removal • Skin Disinfection • Hair Removal • Irrigation • Debridement • Prophylactic Antibiotics
  • 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
  • 33. Methods for Wound Closure
  • 35. Wound Closure Methods : Overview • Suture • Staples • Tissue adhesives • Adhesive tapes
  • 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
  • 54. Selecting Closure Method Based on Wound Type
  • 56. Other methods of skin closure
  • 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
  • 66. Lacerations to the Face and Scalp: Introduction
  • 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
  • 74. Approach to Post-Exposure Prophylaxis (PEP) for RABIES WORLD RABIES DAY , 28TH SEPTEMBER
  • 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.
  • 85. Postrepair Wound Care • Wound Dressings • Patient Positioning after Wound Repair • Prophylactic Antibiotics • Tetanus Prophylaxis • Wound Cleansing • Pain Control • Health Care Provider Follow-Up • Patient Education About Long-Term Cosmetic Outcome
  • 86. Wound Dressings • nonadherent fabrics • absorptive dressings • occlusive dressings • creams, ointments, and solutions
  • 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
  • 101. Technique for Removal of Sutures
  • 102. Technique for Removal of 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

Editor's Notes

  1. Proper wound management begins with a pertinent patient history
  2. 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
  3. Vasoconstriction : hemostasis Avascular plane Duration of analgesia prolonged Decreased systemic toxicity Disadv: more painful inj Htn, arrythmia Delayed wound healing Local tissue damage
  4. 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.
  5. 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.
  6. 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
  7. 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.
  8. excessive pressure should be avoided in all pressure dressings, especially in the extremities where they may compromise circulation