wound care suzana tsao, do. why do we care? layers of the skin closure at the dermal level...
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Wound CareSuzana Tsao, DO
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Why do we care?
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Layers of the Skin
Closure at the dermal level
Subcutaneous adds little strength
Complex wounds in/below fascial layer need multi-layer closure
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HealingInitially edges retract and tissue contracts
Platelet aggregation and clotting cascade activated
Initial epithelialization 24-48 h
Peak collagen synthesis 5-7d
Strength of wound5% at 2 weeks35% at one month
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Initial EvaluationAlways start with the ABCD’s
Airway
Breathing
Circulation
Disability
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Wound EvaluationLocation
Active bleeding
Exposed tissue/bone/organs
Check for peripheral pulses
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History
WhereLocation, location, location
WhenGolden period
HowMechanism
Potential for foreign body
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WhereAnatomic location
Special ConsiderationMouth
Ear
Joints
periorbital
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When
Golden Hour of WoundsInfectious inoculum 105 per gram
Need 3-5 hours for proliferation of bacteria
Extremities 6 hours
Face and scalp 24 hours
But wait ….
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When to close
Studies show can close as late as 19 hours on extremities
ACEP clinical policy supports 8-12 hours
Depends on the clinical scenario
Consider other types of closurePrimary closure
Delayed primary closure
Healing by secondary intention
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HowMechanism
Assess concern for foreign body
Clean wound
Dirty wound
Contaminated wound
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High Risk MechanismsOpen fracturesIntraoral woundsMamillian bitesCrush injuries/devascularized tissueHigh pressure injuriesJagged edges/stellate shape/deeper than subcutaneous layerForeign bodyVisible contamination
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PMH/SocHx
Co-Morbid Conditions
Hand dominance
Occupation
Last tetanus booster
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Tetanus
< 3 doses in primary series
Clean/minorTetanus toxoid
All otherToxoid and immunoglobulin
Primary 3 series completed
< 5 yearsNone needed
> 5 years but < 10 years
Clean minor
None needed
All others
Give toxoid
> 10 yearsGive toxoid
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Pertussis
Give Tdap regardless of last Td to update pertussis if not updated as an adult
Replaces one of the 10 year Td booster doses
Boostrix when feasible for > 65 y/o
Tdap during each pregnancy b/w 27 and 36 weeks
CDC linkhttp://www.cdc.gov/vaccines/vpd-vac/pertussis/recs-summary.htm
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Co-Morbid Conditions
Age (very young/very old)
Diabetes
Renal Failure
Malnutrition
Obesity
Immunocompromised
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Physical ExamType of wound
Superficial/deep
Length/shape
Bleeding/revascularization
Associated injuries
Retained foreign body
Complete neurovascular exam2 point discrimination most accurate for sensory function in extremities
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Active Bleeding
Direct pressure
BP cuff2 hours max
Figure of 8 stitch
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Associated InjuriesAssess for tendon injuries
90% lacerated tendon can still maintain normal neuro function
Assess for joint involvementMay need to inject joint
Assess for underlying fractureX-ray if suspected before manipulating the area
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Retained Foreign BodyDirect visualization
May need anesthesia to fully evaluate
X-ray80-90% can be detected
Does not visualize organic material
UltrasoundCT/MRI?
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Indications for FB removal
Reactive materialsWood Vegetative material
Contaminated materialsClothes
Most fb in foot
Impingement on neurovascular structures
Impairment of function
Easy to remove
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Indications for consultation
Nerve injury
Vascular injury
Tendon or joint involvement
Difficult to remove foreign body
High pressure injection injury
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IrrigationDilution is the solution to the pollution
High pressure (5-8 psi)30-60 cc syringe with 19 gauge angiocath or splash shield
AmountMin 250ml50-100ml/cm of laceration
Type of fluidTap water just as good as normal saline
NEVER, EVER, NEVERBetadine or peroxide1% Betadine may be ok, but no increased benefit
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Debridement
Remove necrotic tissue
May need to debride for better approximation and cosmetic results
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Sterile Gloves
Several trials showed no difference if final outcome
Dealer’s choice
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Anesthesia
Topical pretreatment
Consider procedural sedation
AllergiesMost are from preservative
Consider using cardiac lidocaine
1% Benadryl
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Local vs. Regional Block
BlockLarge areas
When needed to avoid tissue distortion
Areas where infiltration is painfulPlantar surface of foot
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Anesthesia
AmidesLidocaine
Max 4.5mg/kg Duration 1-2 h
Lidocaine with epinephrineMax 7mg/kgDuration 2-4 hNo epi in fingers/toes, ear, nose, penis
BupivacaineMax 2mg/kg 0.25%Duration 4-8 h
EstersProcaine
Max 7mg/kg
Duration 15-45 min
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Types of Repair
Primary closureClosure of the wound at the time of the ED visit
Delayed primary closureClosure of wound 3-4 days after injury
Healing by secondary intentionAllow wound to heal without closure through scarring
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Methods of Closure
TapeSuperficial, straight, under little tension
Skin AdhesivesDoes not involve deep layers
Little tension
StaplesLinear on trunk, extremities, scalp
Sutures
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Types of Sutures
AbsorbableGut
PDS (polypropylene)
Maxon (polyglyconate)
Dexon (polyglycolic acid)
Coated Vicryl (polyglactin)
NonabsorbableDermalon or ethilon
Prolene or surgilene (polypropylene)
Silk
steel
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Suture size by location
Face5-0 to 6-0
Scalp/Chest/Back/Abdomen3-0 to 5-0
Extremities4-0 to 5-0
Oral3-0 to 5-0 (absorbable)
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Indications for antibiotics
Prosthetic device
Endocarditis prophylaxis
Open joints and/or fractures
Mamillian bites
Intraoral lesions
Immunocompromised patients
Heavily contaminated wounds
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Discharge instructionsSigns and symptoms of infection
Fever, discharge, red lines from wound, erythema, swelling
Elevation +/- splinting
When to do wound checks at one or two days
Suture removal instructionsFace 3-5 daysScalp 5 daysExtremities 7-10 days, high tension 10-14 days
Washing - showering - avoid long baths, pools, ocean
Triple antibiotic ointment
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Pearls
No such thing as absolute golden hour
Tap water is as good and normal saline
Do not soak in betadine
Nonsterile gloves ok
Hand wounds less than 2cm -> big, bulky dressing as good as sutures
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PitfallsAlways remember ABC’s
Look for associated injuriesBone, vascular, nerve
Don’t dismiss high pressure injuries
Always assess for foreign body
Antibiotics vs. delayed primary closure for high risk wound and/or co-morbid conditions
Remember special locationsEar, nose, vermillion borderFight bites do not close