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Nicole Y. Ottens, DO Donald J. Sefcik, DO, MBA
A 22 year-old male presents with wounds involving his right hand. He was involved in an altercation at a bar. He grabbed a knife during an attempted stabbing. He has incisions on the palmar aspect of his index, long and ring fingers. – What do you need to consider?
Case Three A 9 year-old female presents with a wound above her left eye sustained during a bicycle accident. What do you need to consider? .
What do you need to consider? . He was bitten by the family pet.Case Four A 14 year-old male presents with a wound to the right thigh.
Types of Wounds • Abrasion – forcible avulsion of skin • Laceration – Simple .usually the result of shearing forces – Avulsion – usually the result of tension forces – Stellate – usually the result of compressive forces • Puncture – wound is deeper than it is wide – difficult to explore • Bite .
General Principles • Purposes of wound repair – Control bleeding – Promote healing – Decrease risk of infection – Minimize scarring .
General Principles • When to Repair – Low Risk wounds • Primary Closure can be done – Extremity wounds can be closed within 6 hours – Torso wounds can be closed within 12 hours – Facial wounds can be closed within 24 hours – High Risk wounds • Primary closure may not be indicated • Wound may need to be allowed to heal by secondary or tertiary intention (union) .
General Principles • When to Consult/Refer – Neurovascular compromise – Tendon or Ligament involvement – Wound characteristics • • • • • Wound size Severe wound contamination Open fractures Amputations Joint involvement – History of prior wound dehiscence – Cosmetic concerns • Skills of plastic surgeon required .
Wound Care Principles • • • • • Inspection Preparation Anesthesia Closure Follow-up .
Wound Inspection • Appropriate environment – Lighting – Hemostasis • Assess distal neurovascular and motor function • Visualization to wound apex (when possible) – Rule out soft tissue injuries • • • • Tendons Ligament Joint capsules Neurovascular structures – Rule out foreign bodies – Assess during range of motion testing .
Wound Inspection • Other considerations – Radiographs • Suspicion of osseous or joint involvement • Possible foreign body – Glass may be visualized up to 90% of the time – Tetanus Risk • Unknown last tetanus • Dirty wound .
Wound Preparation • Methods to minimize risk of infection – Cleansers • Poloxamer 188 (Shur-Clens) – Not antibacterial. necrotic tissue and nonviable tissue . may cause tissue damage – Irrigation (“The solution to pollution is dilution”) • Copious irrigation decreases infection risk • Sufficient pressure and volume are important • Various techniques have been described – Debridement • Remove foreign bodies. Not toxic to tissue • Povidone-Iodine (Betadine) – Should only be used on intact skin – Dissolves cell membranes.
Wound Anesthesia • Anesthetic Agents – Lidocaine (Xylocaine) – Bupivacaine (Marcaine) • Anesthetic Techniques – Topical – Local – Regional .
5% • Onset: 8 – 12 minutes • Duration: 4 – 8 hours • Maximum: 2 mg/Kg .5 mg/Kg – Bupivacaine 0.25 or 0.Wound Anesthesia • Agents – Lidocaine 1 or 2% • Onset: 2 – 5 minutes • Duration: 1 – 2 hours • Maximum: 4.
Wound Anesthesia • Agents – Addition of epinephrine to the solution • Causes vasoconstriction – – – – Prolongs duration of action of the anesthetic agent Reduces bleeding Increases risk of infection Delays wound healing • Do not use in areas with terminal arterioles – Digits – Nose – Penis .
Wound Anesthesia • Topical – Helpful with pediatric patients. and/or prior to injection of anesthetic agents • Infiltration – Local • Infiltration of agent around and into the wound – Regional • Infiltration at a site proximal to the wound • Advantage: Does not distort the wound . small wounds.
linear. Good with fragile skin – Most useful with small. linear. cosmetic results comparable to sutures • Sutures – Multiple decisions regarding suture type and size and suturing techniques need to be made . dry wounds under low tension – Topical antibacterial ointments can affect integrity • Wound Tape (Steri-Strips) – Easy to apply. dry wounds • Staples – Cause less tissue reactivity – On appropriately chosen wounds.Wound Closure • Chemical Adhesives – Useful on small. low tension.
Polyglycolic acid (Dexon) • Non-absorbable Maintain tensile strength for longer than 60 days – Silk • good tensile strength • increased infection rate and tissue reactivity – Nylon (Ethilon. Polypropylene (Prolene. Surgilene) • good tensile strength • less reactivity and infection • require more knots to secure . Dermalon).Suture Types • Absorbable Maintain tensile strength for less than 60 days – Polyglactin (Vicryl).
Suture Size • Guidelines (the larger the number the smaller the diameter) – Face: 5-0 or 6-0 – Scalp: 4-0 or 5-0 – Hands: 4-0 or 5-0 – Trunk: 3-0 or 4-0 – Feet: 3-0 or 4-0 – High tension areas: 3-0 or 4-0 • example: near joints .
Suturing Techniques • Overview – Goal is to align tissues vertically • EVERT tissue margins • Minimize tension • If you don’t like a stitch. take it out – Learn how to appropriately do instrument ties • First tie (throw) is a double loop • Second tie (throw) completes the first square knot .
Suturing Techniques • Subcutaneous layer closure (with absorbable suture material) – The goal is to approximate the wound deeply – Work from the bottom to top – Suture knots should be at the bottom of the wound .
Suturing Techniques • Skin Closure – Simple Interrupted • Most common • Each stitch placed individually • Place equal distance apart – Distance varies by body part (2-3mm on face. 5 mm to 10 mm on torso) • Close wound by bisecting – Continuous (Running) • Begin at one end of wound and rather than cutting the suture after the knot is made. even tension distribution • Disadvantage: if suture breaks. continue to loop through wound • Advantage: Fewer knots (weak points of stitches). entire run may unravel – Mattress • Variations of Interrupted stitches • Examples include: Vertical Mattress and Horizontal Mattress .
Wound Follow-up • Prophylactic Antibiotics – Literature is controversial • If initiated – the sooner the better • Guidelines include: – – – – – Grossly contaminated wounds Open fractures Human and Animal bite wounds Immunocompromised patients Patients with prosthesis .
Suture Removal • • • • Scalp: 7 – 10 days Face: 3 – 5 days Trunk: 7 – 14 days Extremities: 7 – 14 days Near Joints • Flexor aspect: 7 – 10 days • Extensor aspect: 10 – 14 days * With immunocompromised patients consider delaying suture removal .
Wound Follow-up • Nonadherent dressing and gauze wrap – Consider wound immobilization • Information regarding follow-up – Discuss when wound should be examined next – Discuss signs and symptoms of infection – Discuss wound care • Avoid wound immersion • Application of topical agents • Wound dressings – Advise when sutures/staples need to be removed – Remind the patient about scarring potential • Don’t forget Tetanus and Rabies considerations .
Thank You Any Questions? .
ISBN: 0-7216-7611-1 Hamilton. JR. ISBN: 0-07-064879-4 Roberts. GC. ISBN: 0-7216-9278-8 Tintanelli. Presenting Signs and Symptoms in the Emergency Department Williams and Wilkins. GC. ISBN: 0-683-03869-9 .References Hamilton. Emergency Medicine: A Comprehensive Study Guide McGraw Hill. Emergency Medicine: An Approach to Clinical Problem-Solving Saunders. Clinical Procedures in Emergency Medicine Saunders. JE.
uiuc.com/knot-tying/index.novartis.bumc.Websites • http://www.bu.html • • • .shtml http://www.edu/sxclub/ethicon_knots.edu/Dept/Content.cvm.ussdg.ethicon.aspx?DepartmentID=69&Pag eID=5913 http://www.us/overview/en/knot_tips.pdf http://www.
What do you need to consider? . While carrying a letteropener.Case Two A 42 year-old female presents with a wound on her left forearm. she was running to answer a telephone at work and tripped. She stabbed herself.
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