Download POEMS Woundcare and suturing

WOUND CARE AND
SUTURING IN THE
EMERGENCY DEPARTMENT
Dr. Sinead Fitzpatrick, Dr. Termizi Hassan
Antrim Area Hospital
February 2016
Wound: Definition
• DEFINITION: A wound is a bodily injury caused by
physical means, with disruption of the normal
continuity of structures.
• This can be identified as an acute or a chronic
wound.
• ACUTE: Heals in approximately 2 weeks to 6
months
• CHRONIC: Takes 6 months or more.
Classification of the accidental wound
based on the mechanism
 I. Mechanical
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1. Abraded wound (vulnus abrasum)
2. Punctured wound (v. punctum)
3. Incised wound (v. scissum)
4. Cut wound (v. caesum)
5. Crush wound (v. contusum)
6. Torn wound (v. lacerum)
7. Bite wound (v. morsum)
8. Shot wound (v. sclopetarium)
 II. Chemical
 1. Acid
 2. Base
 III. Wound cause by radiation.
 IV. Wound caused by thermal forces
 1. Burning
 2. Freezing
 V. Special
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Mechanical wound
1.) Abraded wound
(v. abrasum)
 Superficial part of the
epidermal layer
 Good wound healing
2.) Punctured wound
(v. punctum)
 Sharp-pointed object
 Seems negligible
BUT
 Anaerobic infection
 Injury of big vessels and
nerves
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Mechanical wound
3.) Incised wound
(v. scissum)
• Sharp object
• Best healing
4.) Cut wound (v. caesum)
• Sharp object + blunt additional
force
• Edges - uneven
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Mechanical wound
5.) Crush wound
(v. contusum)
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•
•
•
Blunt force
Pressure injury
Edges – uneven and torn
Bleeding
6.) Torn wound
(v. lacerum)
• Great tearing or pulling
• Incomplete amputation
(v. lacerocontusum)
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Mechanical wound
7.) Shot wound (v. scolperatium)
• Close - burn injury
• Foreign materials
aperture
output
slot tunel
uninjured tissue
necrobiotic zone
necrotic zone
foreign bodies
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Mechanical wound
8.) Bite wound (v. morsum)
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•
•
•
•
Ragged wound
Crushed tissue
Torn
Infection
Bone fracture
• Prevention of rabies
• Tetanus profilaxis
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Wound caused by thermal
forces
1.) Burning
Metabolic change! - toxemia
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•
1st
degree – superficial injury
(epidermis)
2nd degree –partial or deep partial
thickness (epidermis+superficial or
deep dermis)
3rd degree – full thickness
(epidermis + entire dermis)
4th degree – (skin + subcutaneous
tissue + muscle and bone)
2.) Freezing
 mild, moderate, severe (redness,
bullas, necrosis)
 rewarm – not only the frozen area
but the whole body
Treatment:
o Cooling – cold water and clean
covering
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Wound classification: According
to the bacterial contamination
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•
Clean wound
Clean-contaminated wound
Contaminated wound
Heavily contaminated wound
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Classification of the wound:
Depending on the depth of injury
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Superficial
Partial thickness
Full thickness
Deep wound
+ bone, opened cavities, organs…etc.
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Factors that impair wound healing
1. Age
2. Malnutrition
3. Obesity/Emaciation
4. Poor circulation and oxygenation
5. Immunosuppression
6. Smoking
7. Incontinence
8. Medications (steroid)
9. Co-morbidities ( Diabetes)
10.Wound Stress
11.Radiation
Promotion of wound healing
Dressings: keep wound covered & clean
Wound bed moist / Surrounding skin dry
Debridement when necessary
Remove exudate:
o Drains,
o Wound VAC,
o Irrigation
• Pack wounds loosely
• Nutritional interventions
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•
•
•
Wound infection
• Tetanus prone wound
o Heavily contaminated
wound
o Devitalized wound
o Infection
o Wound > 6 hours
o Puncture wound
o Animal bites
• Bacteria infection are
likely- (treat with coamixoclav)
o Puncture woundcat/human/dog
o Hand wound
o Wound > 24 hours
o Wounds in Alcoholics,
diabetic &
immunocompromised
• Likely organism
o Eikenella corrodens(human
bites)
o Pasteurella multicoda (cats)
Approach to wound
management
History: Key questions
• What caused the wound? (glass/knife can cause a
deep injury)
• Was there a crush component? (considerable
swelling may ensue)
• Where did it occur? (contaminated or clean
environment)
• Was broken glass/china involved? (if so, obtain an
x-ray)
• When did it occur? ( old wound may need delay
closure and antibiotic)
• Who caused it? (is patient safe to go home)
• Is tetanus cover required?
The ABCDE in the injured
assessment
The mnemonic ABCDE is used to remember the order of
assessment with the purpose to treat first that kills first.
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A: Airway and C-spine stabilization
B: Breathing
C: Circulation
D: Disability
E: Environment and Exposure
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Wound assessment
1. Look at the whole patient not just the hole.
2. Look the appearance of the wound: granulation tissues,
eschar, slough, edema, sinus tract, color, tunneling etc
3. Drainage: serous, serosanguineous, sanguineous,
purulent AND amount
4. Size & location on body
5. Presence of sutures or staples
6. Presence of drains or tubes
7. Wound edges
8. Other factors: mechanism of injury, need for tetanus
booster or IVIG, onset of injury & previous treatment
Next steps
• Probe the wound
•
In some circumstances,
exploration not app. In ED (neck)
• Try and correct the
causes that may delay
wound healing
1.
2.
3.
4.
5.
•
Edema
Nutrition
Glycemic control
Treat infection
OT/physiotherapy
consult
Take a swab ( if
indicated)
Cleaning methods
• Different type of wound
cleaning
• Contaminated wound
would require
o Brushing
o Cutting devitalized skin/ tissue
o irrigation
Wound Cleaning: Irrigation
Cleanses a wound using pressure
Using sterile normal saline Normal Saline
Avoids caustic agents such as peroxide, iodine etc
Technique:
• Irrigate with 19G needle attached to 20-30 ml
syringe
• 5-15 PSI
• Devitalized or grossly contaminated wound edges
usually need to be trimmed back
•
•
•
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Management of wound:
Tissue unifying
Skin:
o Stiches
o Clips
o Steri-Strips
o Tissue glues
Fascia and subcutaneous layers:
o Interrupted stiches
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Wound closure: Principles
Preparation is important:
• Comfortable patient &
operator
• Consent
• Good light & instruments
• Good anesthesia- 1% vs
2% lidocaine, +
adrenaline
• Assistance
• Correct needle & suture
• Post wound care
including leaflet
Local anesthetic agents
• Lidocaine
o Max dose 3mg/kg
o Max dose in adult (70kg) is 200
mg (20ml of 1% lidocaine)
o Duration of action:
immediately to 60min
• Lidocaine with
adrenaline
o Max dose 7mg/kg
o Max dose in adult 500 mg (50ml
of 1% solution)
o Duration: up to 90 min
o Not suitable for area with end
artery supply such as nose, toes
& fingers
• Topical LA: LAT gel
o Ideal in children
• Special cautions ( increased
risk of toxicity)
o
o
o
o
o
o
o
o
o
o
Small children
Elderly or debilitated
Heart block
Low cardiac output
Epilepsy
Myasthenia gravis
Hepatic impairment
Porphyria
Anti-arryhthmic or beta blocker
Cimetidine therapy
Wound closure: 3 types
• Primary closure
o Surgical closure soon after the
injury
o Wound not suitable for primary
closure
• Stab wound to the trunk
and neck
• Wound associated with
tendon,joint &
neurovascular
involvement
• Wound with associated
crush injury or significant
devitalized tissue
• Heavily contaminated or
infected wound
• Most wound > 12 hours old
(except clean facial
wound)
• Secondary closure
o No intervention
o Heal by granulation
(secondary intention)
• Delayed primary
closure
o Surgical closure 3-5 days
after injury
Guide to suture gauges
for common procedures
Part of body
Suture and size
Time to removal
scalp
2.0/ 3.0 nonabsorbable/ glue/staple
7 days
Trunk
3.0 absorbable
10 days
Limb
3.0/ 4.0 non-absorbable
10 days
Hands
4.0/5.0 non-absorable
10 days
Face
5.0/6.0 non-absorbable
5 days
Lip, tongue, mouth
Absorbable i.e. 6.0
vicryl/dexon
1st step
2nd step
Suturing: How
to hold the
equipment
Suturing
3rd step
4th step
Suturing
5th step
6th step
Steristrip
• Indication
o Pretibial laceration
o Superficial wound
• Inappropriate over joint
• Use tincture of benzoin
to dry skin for better
hold onto the skin
• Leave 3-5mm
between steristrip
Skin tissue glue
• Technique:
o Skin edges opposed, glue
is put on surface of wound
o Hold the skin edges
together for 30-60 seconds
• Useful in children with
superficial wound and
scalp wound
Staples
• Quick and easy to
apply
• Particularly suited for
scalp wound
Different type of suture
Wound closure: Tips
Wound Care Products
o
o
o
o
o
o
o
o
o
o
o
o
o
Liquid barrier
Transparent films
Hydrocolloids
Gauze dressings
Hydrogels
Foam dressings
Absorptive dressings
Calcium alginate
Charcoal dressings
Silver coated dressings
Non adherent dressing
Debriding agents
antiseptic
Summary
• Focused history and detailed assessment of the
wound is vital
• Consider antibiotic in high risk patients
• Consider rabies infection (patient returning from
abroad/ animal bites)
• Check tetanus status
o Tetanus prone wound may need tetanus immunoglobulin
• Think of the possibility of FB (X-ray/ US/ CT/ MRI)
• Post wound care is important
o Leaflet
o Informed patient of possible/risk of complication
o Analgesia