4 – Early Wound Management

Question 1

What are some recommendations you can make remotely?

Answer 1

• Restrict movement
• Control hemorrhage
• Garden hose lavage
• Pressure bandage (non-stick telfa with kling gauze, vet wrap, etc.)
• Apply appropriate support
  o Reduce trauma and stress
  o Materials: fiberglass cast or commercial splint

Question 2

What is the golden period?

Answer 2

• Less than 8 hours
• Primary closure

Question 3

Visual examination

Answer 3

• Location of wound
• Extent of injury
• Age of wound
• Condition of wound

Question 4

Digital examination

Answer 4

• Sedate: local anesthesia
• Sterile lube in wound
• Clip and prep
• Explore wound
• Wear gloves: exam and sterile
• Palpation
• Range of motion
• Listen from crepitus with stethoscope
• Assess synovial structure: radiopaque material
  o Use a metal probe to help assess
  o Can pressurize synovial structures

Question 5

Joint evaluation

Answer 5

• Arthrocentesis: collect the sample

Question 6

Medicate synovial structure

Answer 6

• Intra-articular OR intra-thecal antibiotics
  o Aminoglycosides: *gentamicin, amikacin

Question 7

What are the goals of wound debridement?

Answer 7

• Remove contamination
• Remove devitalized tissue
• Eliminate infection

Question 8

What are some methods of debridement?

Answer 8

• Sharp
• Autolytic (leaving bandage on)
• Bandage: mechanical
• Enzymatic
• Biosurgical (ex. maggots)

Question 9

What are the goals of wound lavage?

Answer 9

• Remove debris
• Reduce bacterial numbers

Question 10

What are the mechanics of lavage?

Answer 10

• **Ideal pressure: 7psi
• Low pressure=ineffective
• *avoid high pressure (drive bacteria further into the tissues)

Question 11

What are some lavage methods?

Answer 11

• Garden house
• 1L bag with 300mmHg pressure cuff=7-8psi best method
• 35cc with 19g needel=18psi less than ideal
• Pulsavac

Question 12

What are some characteristics of ideal lavage solutions?

Answer 12

• Non-irritating
• Bactericidal
• Cheap

Question 13

Povidone iodine

Answer 13

• *ineffective
• At 0.1% bactericidal
• At >0.5% cytotoxic to fibroblasts
• Non-irritating
• Inhibits neutrophil migration
• 1% or 0.1% solution

Question 14

Chlorhexidine

Answer 14

• At >0.05% bactericidal
• 0.05% solution (1:40 dilution of 2% stock solution)
• Residual activity: 2 days
• Non-irritating
• Effective in wounds
• *trashes synovial structures

Question 15

Chlorhexidine in TRIS-EDTA

Answer 15

• 0.0005% chlorhexidine
• Bactericidal: increases permeability of gram –
• Non-irritating to tissue
• Non-irritating to synovial structures
• Efficacy NOT evaluated

Question 16

Antibiotic containing solutions

Answer 16

• 0.25% neomycin
• 0.1% gentocin
• *little evidence of efficacy

Question 17

Role of antibiotics: lavage solutions

Answer 17

• Prophylaxis: before contamination
• Therapeutic
  o Cellulitis
  o Open synovial structures
  o Severe muscle tissue