wound management by elspeth frascatore october 2013
TRANSCRIPT
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Wound Management
By Elspeth FrascatoreOctober 2013
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Timing of Wound Closure
<6hrs: primary closure OK 6-24hrs: primary closure OK unless high
risk factor present Heavily contaminated Extensive intra-oral lacerations Foot wounds Stellate lacerations Devitalised wounds: crush injury, under XS
tension PMH diabetes, ETOH dependence, PVD,
immunosuppression (inc. long term steroids)
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Wound Cleaning
Tap water is just as good as normal saline
Use high pressure irrigation Need 5-8psi Use 30-60ml syringe attached to 19
guage luer Use 50-100ml irrigant per cm of
laceration
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Tetanus
Given at 2 / 4 / 6 / 18 months 5 / 15yrs every 10yrs thereafter
Immune: if have had at least 3 doses and UTD
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TetanusHISTORY Of TETANUS COURSE AND/OR BOOSTER
CATEGORY 1
<5 years(ie. Immune)
2
5 - 10 years
3
>10 years(ie. Full course but out of date)
4
Never / Partial Course / Unknown
Clean wound (<6hrs, non-penetrating, negligible tissue damage)
Nil Nil Booster ADT ADT course
Dirty wound
Nil Booster ADT Booster ADT
ADT course
and
TIG: 250iu routinely or 500iu if old, contaminated wound or burn injury
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Suture Techniques
Gaping / high tension wounds (eg. Over joints)
Wounds on fragile skin as spreads tension
To evert wound edges (eg. Posterior neck, concave skin surface)
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Signs of Arterial Injury
Large expanding haematoma Severe active / pulsatile bleeding Shock unresponsive to fluids Signs of cerebral infarction Bruit / thrill Decreased distal pulses Paraesthesia
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How do you tie off an arterial bleeder?
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Human Bites
10-15% infection risk Do not close hand wounds, puncture
wounds, infected wounds, wounds >12hrs old
Copious wound washout Avoid layered closure Use loose sutures to allow fluid drainage Antibiotic prophylaxis in all cases
Although this may change in future Remember punch injuries
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Dog / Cat Bites
Can close if <6hrs and in low risk area / patient
Antibiotic use Meta-analysis has revealed that
antibiotics decrease incidence of wound infection in hand wounds only
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Neck Lacerations
If multiple, assess most important regions first rather than largest
Look at the back early Wound size does not correlate with
severity of injury
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3
2
1
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Structure to Consider
Spinal cord – suggested if bilateral symptoms Phrenic nerve – hypoventilation; implies subclavian vein /
artery injury Brachial plexus (C5-7) Recurrent laryngeal nerve Cranial nerves Glossopharyngeal nerve – dysphagia, altered gag Vagus nerve – hoarseness; implies common carotid / IJV injury Horner’s syndrome – ipsilateral miosis, enopthalmos,
anhydrosis
Carotid and vertebral arteries; vertebral, brachiocephalic and jugular veins
Thoracic duct, oesophagus, pharynx etc… Thyoid, parathyoid, submandibular, parotid glands
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Examination
Wound exploration – keep minimal and only perform if stable
Identify affected zone and triangle Identify direction tract takes Determine if platysma is penetrated
If platysma not penetrated: can be cleared of significant injury
If platysma penetrated: 50% risk of other significant injury, mandates OT
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Investigation
Always Xray Knives can break off under skin
CT angiography All zone I Stable zone II Zone III with evidence of arterial injury
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Intra-oral Lacerations
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Eyelid Lacerations
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Lip Lacerations
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Tongue Lacerations
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Nasal Lacerations
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Facial Nerve Blocks
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Ear Block
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Hand Blocks