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Advanced Musculoskeletal Physiotherapy Selfdirected Learning Modules: Emergency Department 2014 Module 4: Traumatic Wounds Prepared by Alfred Health on behalf of the Victorian Department of Health 2014 1 Module 4: Wound Management Contents Module 4: Wound Management........................................................................................ 2 4.1 Traumatic Wounds ..................................................................................................... 3 Theme 1 History taking in open wounds ............................................................. 3 Theme 2 Focused clinical wound assessment.................................................... 4 Theme 3 Common Pathology of open wounds .................................................. 5 Theme 4 Common Investigations of Open Wounds ........................................ 8 Theme5 Common Pharmacology in Open Wounds ......................................... 9 Theme 6 Wound Management ................................................................................ 11 Module 4: Wound Management 2 4.1 Traumatic Wounds Theme 1 History taking in open wounds LEARNING OBJECTIVES: 1. To understand the key principles of history taking in open wounds 2. To understand the importance of mechanism of injury in open wounds KNOWLEDGE: HISTORY What key areas of past medical history is important in open wounds What key areas of social history are important in open wounds What key areas of patients current medications important in open wounds What information should be obtained regarding vaccination status What key areas of allergy history is important in open wounds MECHANISM OF INJURY When obtaining information regarding the mechanism of injury, discuss the key areas Discuss the implications of blast wounds Discuss the implications of penetrating trauma Discuss the implications of puncture trauma Discuss the implications of blunt trauma RECOMMENDED RESOURCES Purcel, D (2010) Minor Injuries A Clinical Guide. Churchill Livingstone, UK. Chapter 6, Minor Wounds and Burns, p173-199. Talley, NJ & O’Connor, S (2009) Clinical Examination: A systematic Guide to Physical Diagnosis. 6th Edition. Churchill Livingstone, Sydney. Chapter 1, The General Principles of history taking, p1-12; Chapter 2, Advanced history taking, p13-21. Troutt, A (2005) Wounds and Lacerations Emergency care and closure. 3rd Edition. Elsevier Mosby. Chapter 4, Surface Injury and Wound Healing: Mechanism of Injury, p19-22 Wardrope, J & Edhouse, J (2002) The Management of Wounds and Burns. 2nd Edition. Oxford University Press. Chapter 3, Legal aspects and wound care, p31-36. Barnard, A & Allison, K (2009) The classification and principles of management of wounds in trauma. Trauma. 11, 3, p163-176. Refer to your local organisations wound management guidelines/policies and resources Module 4.1: Traumatic Wounds 3 Theme 2 Focused clinical wound assessment LEARNING OBJECTIVES: 1. To understand the principles of wound assessment KNOWLEDGE How does age of the wound effect the management and outcome? Where on the body wound you be concerned regarding cosmetically features? How would you measure the size of a wound? How would you determine the depth of a wound? How would you describe the characteristics of the wound? What would concern you on the peri-wound areas? How would you identify the type of wound? o Simple v Complex o Clean v Contaminated o Acute v Chronic How would you assess the level of pain? How would you assess the nerve innervations distally to the wound? How would you assess the movements distally to the wound? How would you assess for bony tenderness? RECOMMENDED RESOURCES Purcel, D (2010) Minor Injuries A Clinical Guide. Churchill Livingstone, UK. Chapter 6, Minor Wounds and Burns, p173-199. Wardrope, J & Edhouse, J (2002) The Management of Wounds and Burns. 2nd Edition. Oxford University Press Chapter 1, Wound Assessment, p5-12 Lazerus, G, Cooper D, Knighton, D, Margolis, D, Pecoraro, R, Rodeheaver, G & Robson, M (1994) Definitions and guidelines for assessment of wounds and evaluation of healing. Archives of Dermatology. 130, (4), p489-493. http://www.ncbi.nlm.nih.gov/pubmed/8166487 Local organisation’s wound care assessment and management policy – Nursing resources Module 4.1: Traumatic Wounds 4 Theme 3 Common Pathology of open wounds LEARNING OBJECTIVES 1. Identify high risk groups for delayed wound healing 2. Demonstrate an understanding of high risk wounds 3. Demonstrate ability to apply focused knowledge of high risk wounds regarding history, assessment, investigations, management and pharmacological agents 4. Demonstrates the ability to assess and manage nail injuries KNOWLEDGE WOUND HEALING List the high risk patient groups that are predisposed to wound healing impairment List medications that may affect wound healing and explain your reasons HIGH RISK GROUPS Discuss the special considerations that must be given for patients who sustained an animal bite with regards to history, assessment, investigations, management and pharmacological agents. Discuss the special considerations that must be given for patients who sustained a human bite with regards to history, assessment, investigations, management and pharmacological agents. Discuss the special considerations that must be given for patients who sustained a crush injury with regards to history, assessment, investigations, management and pharmacological agents. Discuss the special considerations that must be given for patients with suspected foreign body with regards to history, assessment, investigations, management and pharmacological agents Discuss the special considerations that must be given for patients who delay in presenting with wounds with regards to history, assessment, investigations, management and pharmacological agents. Discuss the special considerations that must be given for patients with suspected infected wound with regards to history, assessment, investigations, management and pharmacological agents Discuss the special considerations that must be given for Pediatric Patient with an open wound with regards to history, assessment, investigations, management and pharmacological agents. NAIL INJURIES Describe the anatomy of the nail What are the causes of a subungal haematoma Describe how and when you would trephine a subungal haematoma What further management is required for the patient post trephining What is paronychia What common organism is involved in paronychia What are the common causes of paronychia How would you treat a patient with a paronychia What follow up education would you provide the patient with a paronychia Module 4.1: Traumatic Wounds 5 RECOMMENDED RESOURCES Purcel, D (2010) Minor Injuries A Clinical Guide. Churchill Livingstone, UK. Chapter 6, Minor Wounds and Burns, p173-199. Troutt, A (2005) Wounds and Lacerations Emergency care and closure. 3rd Edition. Elsevier Mosby. Chapter 5, Wound Care and the Pediatric Patient, p35-47; Chapter 16, Common Wound Problem Foreign Bodies p.239-244 and Plantar puncture wounds, p244-247. Wardrope, J & Edhouse, J (2002) The Management of Wounds and Burns. 2nd Edition. Oxford University Press. Chapter 6, Wound Infection, p93-112; Chapter 7, Special types of wounds, p119-132; Chapter 8, Hand Wounds, p138-162; Chapter 9, Facial Wounds, p171-181. Abraham, M & Oh, J (2010) Recent advances in Wound Care. Trauma Reports. Evidence based medicine for the ED. 11, 14. http://xa.yimg.com/kq/groups/14639670/2016726332/name/Advances+in+Wound+Care+710.pdf Baranoski, S (2003) Skin tears: Staying on guard against the enemy of frail skin. Nursing 2003. 33, p.14. http://journals.lww.com/nursing/Fulltext/2003/10001/SKIN_TEARS__ Staying_on_guard_against_the_enemy_of.5.aspx Burton, F (2004) Benchmarking and wound care in A&E. Nursing Standard. 18, 45 p67-72. http://nursingstandard.rcnpublishing.co.uk/archive/article-benchmarking-and-wound-carein-a-e Conlon, S (2007) Human bites in Classroom: Incidence, treatment and complications. The Journal of School Nursing. 23, 4, p197-201. http://jsn.sagepub.com/content/23/4/197.abstract Department of Health Victoria (2013) Children at risk learning portal http://www.vfpms.org.au/childrenatrisk/vuln.htm Therapeatuic guidelines limited (2011) eTG complete http://www.tg.org.au/index.php?sectionid=71 Up to date Baddour, L (2013) Soft tissue infections due to human bites http://www.uptodate.com/contents/soft-tissue-infections-due-to-human-bites Baddour, L (2013) Soft tissue infections due to dog and cat bites http://www.uptodate.com/contents/soft-tissue-infections-due-to-dog-and-cat-bites Baddour, L (2010) Soft tissue infections following water exposure http://www.uptodate.com/contents/soft-tissue-infections-following-water-exposure Module 4.1: Traumatic Wounds 6 Endom, E (2012) Initial management of animal and human bites http://www.uptodate.com/contents/initial-management-of-animal-and-human-bites Berlowitz, D (2013) Pressure ulcers: Epidemiology, pathogenesis, clinical manifestations and staging http://www.uptodate.com/contents/pressure-ulcers-epidemiology-pathogenesis-clinicalmanifestations-and-staging Bothner, J & Fastle, R (2012) Subungal hematoma http://www.uptodate.com/contents/subungual-hematoma Calderwood, S (1997) Clinical Microbiology review: Wound, skin and soft tissue infections http://www.uptodate.com/contents/clinical-microbiology-review-wound-skin-and-softtissue-infections de Asla, R & McCulloch, D (2013) Management of diabetic foot lesions http://www.uptodate.com/contents/management-of-diabetic-foot-lesions McCulloch, D (2012) Evaluation of diabetic foot http://www.uptodate.com/contents/evaluation-of-the-diabetic-foot Sexton, D & Weintrob, A (2012) Clinical manifestations, diagnosis and management of diabetic infections of the lower extremities http://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-management-ofdiabetic-infections-of-the-lower-extremities Up to date doctors and editors (2013) Patient information: Paronychia (the basics) http://www.uptodate.com/contents/paronychia-the-basics Module 4.1: Traumatic Wounds 7 Theme 4 Common Investigations of Open Wounds LEARNING OBJECTIVES 1. Identify clinical indications for radiology imaging for open wounds 2. Identify clinical indications for ultrasonic imaging for open wounds 3. Identify laboratory tests required for a patient presenting with a human bite KNOWLEDGE RADIOLOGY When would you consider performing an x-ray and why? What foreign bodies are radio-opaque? What foreign bodies are non-radiopaque? What precautions must be taken prior to radiology interventions for women and why? ULTRASOUND When would you consider performing an ultrasound in an open wound and why? PATHOLOGY What are the infectious risks to patients presenting with a human bite? What blood tests are required? What would the follow-up procedure be for patients who received a human bite? RECOMMENDED RESOURCES Raby, N, de Lacey, G & Berman, L (2005) Accident and Emergency Radiology A survival guide. 2nd Edition. Elsevier Saunders,UK. Troutt, A. (2005) Wounds and Lacerations Emergency care and closure. 3rd Edition. Elsevier Mosby. Chapter 15, Bite Wounds, p223-238; Chapter 16, Common Wound Problem: Foreign Bodies, p239-244. The Royal Australian and New Zealand College of Radiologists (2013) Inside radiology www.insideradiology.com.au Refer to Radiology and Pathology Module Module 4.1: Traumatic Wounds 8 Theme5 Common Pharmacology in Open Wounds LEARNING OBJECTIVES 1. Have a basic understanding of antibiotic choice for common skin infections 2. Have a basic understanding of antibiotic choice for human and animal bites 3. Understand the underlying principles for vaccinations and immunoglobulin’s KNOWLEDGE ANTIBIOTICS What is the most common antibiotic for a local skin wound infection and why? What is the choice of antibiotic for a human bite and why? What is the choice of antibiotic for an animal bite and why? VACCINATIONS What are the national guidelines for immunization for tetanus-prone wounds? What are the indications for Tetanus immunoglobulin? Where and how would you access tetanus immunoglobulin? Regarding tetanus vaccine discuss the following o Indications o Precautions o Adverse Effects o Dosage What are the indications for Hepatitis B immunoglobulin? Regarding Hepatitis B discuss the following o Indications o Precautions o Adverse Effects o Dosage What are the indications for Rabies vaccination and Immunoglobulin? Regarding Rabies vaccine discuss the following o Indications o Precautions o Adverse Effects o Dosage How would you determine the immunity status of the patient? Have an overall understanding of the recommended vaccinations required for children and adults in Australia List the common presentations to ED that are notifiable diseases RECOMMENDED RESOURCES Byrant, B & Knights, K (2007) Pharmacology for health professionals. 2nd Edition. Mosby. Neal, M (2009) Pharmacology at a glance. 2nd Edition. Wiley-Blackwell. European Wound Management Association (2004) Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document, London: MEP Ltd. www.ewma.org Module 4.1: Traumatic Wounds 9 Australian Government Department of Health and Ageing (2013)The Australian Immunisation Handbook. 10th edition. http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10home Australian Medicines Handbook (2010) https://shop.amh.net.au/ Australian Red Cross Blood Service (2013) Immunoglobulins www.transfusion.com.au/Immunoglobulins.aspx CSL Limited (2013) Product information Normal Immunoglobulin - VF http://www.csl.com.au/docs/526/662/7.00_2,0.pdf Up to date Hibberd, P (2013) Tetanus-diphtheria toxoid vaccination in adults http://www.uptodate.com/contents/tetanus-diphtheria-toxoid-vaccination-in-adults Sexton, D (2012) Tetanus http://www.uptodate.com/contents/tetanus Refer to Pharmacology Module Module 4.1: Traumatic Wounds 10 Theme 6 Wound Management LEARNING OBJECTIVES 1. Understand hemorrhage control 2. Understand basic wound management 3. Understand wound care dressing products KNOWLEDGE What measures would you take to control wound hemorrhaging? When would you refer to Plastics Unit regarding wound debridement? When would you consider using steri-strips method for wounds? What are the advantages and disadvantages for using the steri-strip method? How would you apply steri-strips to the open wound? When would you consider using sutures for wound closure? What are the advantages and disadvantages for using sutures? When is sutures not indicated? When is it appropriate to refer to a specialist unit regarding wound closure? Describe the functions of the following dressings o Hydrocolloid o Hydrogel o Calcium Alignate o Hydrofibres o Foam o Hypertonic dressings o Parafin gauze o Topical Antimicrobials RECOMMENDED RESOURCES Mc Cann, J (2003) Wound Care made incredibly easy. Lippincott Williams & Wilkins. Chapter 3, Basic Wound care Procedures-wound irrigation and debridement, p59-65. Troutt, A (2005) Wounds and Lacerations Emergency care and closure. 3rd Edition. Elsevier Mosby. Chapter 4, Decisions before closure: Timing, Debridement and Consultation, p107-118; Chapter 14, Tissue Adhesives and Alternative Wound Closure, p209-222; Chapter 20, Common Dressing and Bandaging Techniques, p227-310. The Australian Wound Management Association (2010) Standards For Wound Management. West Leederville WA, Cambridge Publishing. http://www.awma.com.au/publications/2011_standards_for_wound_management_v2.pdf Caton-Richards, M (2011) Closure of minor wounds with tissue adhesive. Emergency Nurse. 18, (9), p18-21. http://www.ncbi.nlm.nih.gov/pubmed/21384781 Module 4.1: Traumatic Wounds 11 Up to date Brancato, J (2012) Minor wound preparation and irrigation http://www.uptodate.com/contents/minor-wound-preparation-and-irrigation Armstrong, D & Meyr, A (2012) Basic principles of wound management http://www.uptodate.com/contents/basic-principles-of-wound-management Kronfol, R (2013) Closure of minor skin wounds with staples http://www.uptodate.com/contents/closure-of-minor-skin-wounds-with-staples deLemos, D (2012) Closure of skin wounds with sutures http://www.uptodate.com/contents/closure-of-skin-wounds-with-sutures Kronfol, R (2013) Superficial wound repair with tissue adhesives http://www.uptodate.com/contents/superficial-wound-repair-with-tissue-adhesives Module 4.1: Traumatic Wounds 12
