50. Wound Management Principles Flashcards by Tegan Turner

What are risks for wound infection to consider

location
mechanism
Host factors
wound care

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Risk of infection clean vs dirty wound

less than 1%
dirty wound >20%

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Outermost layer of skin

epidermis

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Most important parts of the epidermis?

stratum corneum - outermost cell layer (cosmetic)
stratum germinativum (basal layer) - new cells originate

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What layer of skin is right below the epidermis?

dermis

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What is the dermis

thick CT layer, primarily responsible for ultimate wound healing

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Removing debris and devitalized tissue from the __ is key for optimal healing

dermis

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What lies below the dermis and encloses subcutaneous fat?

superficial fascia

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What is below the fat?

deep fascia - strong, off white sheath covers and protects muscle

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Normal wound healing - sequence of biologic events (5)

coagulation
inflamm
collagen metabolism
wound contraction
eipithelialization

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After tissue integrity is altered, process of coagulation starts - how does this work? How does inflamm process work?

pl release factor to enhance response
cap permeab incr to allow WBC migration into wound
Neutrophils and monocytes scavenge to rid debris and bacteria
stimulation of fibroblast replication, trigger neovasc

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Collagen stage of wound healing - what occurs?

synthesis, deposition then cross linking

synthesis and deposition by fibroblasts 48h post injury

immature collagen is highly disorg and gel like then fibrils interlink

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Entire process of collagen interlinking is based on …

tissue lactate and ascorbic acid
tissue arterial co2 partial presssure

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What 4 things are important for hydroxylated collagen?

vit c
prolyl
lysyl hydroxylase
o2

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Under normal conditions when does collagen synthesis peak?

d7 with coinciding of rapid incr in tensile strength

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The healing wound has greatest mass at _ weeks but remodels itseldf during next - months

3
6-12

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Contraction phase of wound healing - what is this?

movement towards centre of defect

retraction of edge at first
then next 3-4 days as edges move to centre, wound size shrinks

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Epithelialization - epithelial cells migrate across wound - what can impede this process?

eschar and edbris

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What medical conditions may signficantly effct wound care decisions?

sign PVD
immunocompromised
high riksk of retained FB
Structural defects like damaged/prosthetic heart valves

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RF for wound morbidity:

prolonged time since injury
crush mechanism
long >5cm and deep
patient age
high velocity missiles
location on LE
contamination with saliva, feces soil or other foreign material

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__ hours after acute trauma, bacteria can proliferate to a level that may result in infection

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For sutured wounds, __ has the strongest association with infection

location

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Face and scalp have a infection risk rate after lac repair of 4% - what is this compared to leg/thigh or torso and other extremities

low

> 20%
10%

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Rosen’s Box 50.1: Risk factors for wound infection (8)

location - leg and thigh > arms >feet > chest > back > face > scalp
contamin with devitalized tissue, fb, saliva or stool
blunt/crush injury
presence of subcu suture
type of repair : suture > staple > tape
anes with epi
high velocity missile injury
DB

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Although uncomfortable, how high can a blood pressure cuff be held up in order to get a good PE view?

2 hours

Will radiography detect all foreign material?

What is the best imaging test for ID foreign material (but expensive so not really done)

What is particularly helpful anesthesia for appropriate exam of a wound?

nerve block

Lidocaine onset of action following direct infiltration can take ?

seconds

Lidocaine length of action when direct infiltration?

20-60 mins

Lidocaine as a regional nerve block - onset of action? duration?

4-6 min duration: 75 min

A 1% lido solution is ?mg/ml

Safe non epi dose of lido mg/kg?

3-5

If epi is added to lido why does this increase the safe dose?

vasoconstriction prolongs the effect

What is a safe dose of lido with epi?

5-7mg/kg

When should lido with epi be avoided?

high risk of infection wounds tissue viability concern

Digital artery vasospasm can occur if local injection of epi given - how to successfully reverse?

0.5-2mg local injection of subcut phentolamine or application of topical NG

How does bupivicaine's action of onset compare to lidocaine?

slower onset lasts 4-8x longer

What is the preferred local anesthetic for care of most wounds?

bupivicaine due to lasting longer

Safe dose of bupivicaine without epi per kg?

2.5

Safe dose of bupivicaine wit epi per kg?

3-3.5

How often can bupivicaine dosing be given? Not going over ?mg in 24h

3hrs 400mg

___ will buffer lido and reduce pain at injection site

bicarb

What ratio of Na bicarb can be added to lidocaine to decrease the pain of injection without compromising injection anesthesia?

1:10 1 ml bicarb, 10 of lido

What ratio of Na bicarb can be added to bupivicaine to decrease the pain of injection without compromising injection anesthesia?

1:100 0.1ml bicarb, 10ml bupivicaine

When is toxicity of LET decreased?

<3ml not on mucous membranes

Cardiovascular adverse SE of LET

dysrh decreased myocardial contactility cardiac arrest

CNS adverse side effects of LET

headache irritiable restless blurry vision seizure

Small risk of associated with __ using tetracaine in neonates

methhemoglobinemia

EMLA cream can be put on __ wounds

intact

What is the active ingredient in EMLA gel?

lidocaine 2.5% prilocaine 2.5%

Allergy to amides vs ester family of "caines" - which is uncommon vs rare

amide - rare ester - uncommon

If allergic to amide, is there cross reactivity with an ester?

2 main ways to disinfect skin

povidone iodine chlorhexadine

Should povidone or chlorhexadine go on wound?

no, can be toxic to wound defenses to avoid inside

Povidone iodine is effective against which bugs?

gram +, neg, fungi and viruses

Chlorhexadine is less effective against which bugs than povidone?

gram neg unknown re viruses

Chlorhex can cause corneal ___

opacification

What is debridement?

removal of foreign material and devitalized tissue from wound

Based on wound healing, what is the most important step?

debridement

What is a possible negative outcome of debridement

larger wound/tissue defect

What is most useful for irrigation of a wound?

0.9% NS or tape water with high pressure syringe

What psi should wounds be irrigated with (haha for fun question)

7psi attach an 18g needle to a 30ml syringe for force of 7-8 psi

When to irrigate scalp wounds?

>5cm long or other high risk feat only

What wounds should not be closed in the ED?

1. large and highly contaminated 2. human and animal bites

Primary wound closure definition

closed in traditional fashion then

Delayed primary closure definition

closed in 4-5 days

Third option for closure of wound

left open to heal on its own

When decision is made to delay primary closure, what still needs to be done?

prepared debrided irrigated same as primary closure splint and dressed with care instructions noted

Techniques to decrease wound tension?

1. deep sutures subuctaneous tissue to bring together 2. avoid suturing adipose 3. minimal dermal sutures as can act as FB delay healing 4. can undermine at lacerated margin from deeper attachments

When should buried sutures not be used?

contaminated wound

What type of closure may be ideal for simple linear scalp lac?

staples

How to use hair apposition of scalp lacs?

bundle of hair on both sides of wound, then twisting hair bundles with hemostat small dab of cyanoacrylate glue to twisted hair to prevent unraveling

For peds, option for treating scalp lac?

chromic gut absorbable in children 3- or 4-0

In fragile skin like the elderly, what is preferred option for wound closure if feasible?

steri strips or topical skin adhesive like cyanoacrylate based derivatives

When to use a vertical suture?

improve wound eversion close gaping wounds and deep lacs that may ned more than simple to close deadspace areas of lax skin tension

When to use horizontal mattress sutures?

disperse skin tension and evert wound edges example: scalp, fragile skin, lacs with lost tissue from injury/debridement

What is the definition of an absorbable suture?

undergo rapid degradation/loss strength is <60d

Examples of absorbable sutures

nylon prolene collagen silk

What area is a suture most increase risk of infection?

subcutaneous

When to use tape to close a wound?

linear simple approximation

When should staples be removed from the skin?

1-3 days

When are tissue adhesives probably not as reasonable to use?

>4cm long high area of tension/rep movement keep dry

Abx prophylaxis for simple wounds?

When to consider abx even in simple wounds?

immunocomp pt - this includes obese, malnu, CKD, advanced age, chr steroid, prosth joint/endocarditis risk gross contaminated severe crush

Open fracture abx without sign soft tissue damage?

abx 24h

Severe comminuted fractures of sign tissue damage - abx how many hours?

72h

Gunshot wounds - low v need abx?

Gunshot wound - high velocity with fracture - abx for how long?

48-72 hours keflex +/- aminoglycoside +/- gent if severe contamination

Cat bite abx prophylaxis

esp on nhand yes

what bugs do you need to cover from a cat bite?

staph strep pasteurella multocidda dicloxacillin cephalexin clinda *amox clav is current recommendation 875mg x7d

dog bite prophylaxis?

lesss puncture wound so more help from I+D

What cases should have dog bite prophylaxis?

Hand injury deep puncture wounds bite in extremities with wounds with underlying venous or lymph compromise near prosth joint pt with diabetes wounds in older/immunocomp

What is recommended for a intraoral laceration?

prophyl with Pen VK 500mg BID x5d

Puncture wounds - bugs to worry about?

pseudomonas

Best drug for tx of puncture wound where pseudomonas is concerned?

levo cephalexin for diclox for stpah and strep unless MRSA then doxy or septra

Film dressing for what kind of injury?

low drainage left in place up to 7d not absorptive but water proof and transparent and adhesive

For wounds with moderate drainage what to use?

hydrocolloid dressing - absorptive left up to 7d may need to change every 3d

Box 50.2: Wound care intructions: key 6 parts

1. Pos: elevation/sling if appropriate 2. Cleansing 3. immob 4. signs of infection 5. when to get wound checked 6. suture removal

Suture removal for face

Suture removal for scalp and trunk

7-10d

Suture removal for arms and legs

10-14d

Suture removal for joints

14d

Incubation period for tetanus (days)

7-21

Dose of Dtap or tetanus toxid

0.5mgl IM

If pt inadequate immunization, give TIG what dose in addition to Tdap?

250 IU 7 and older <7: 4IU/kg IM up to 250

Fully immunized and less than 10 years since booster? dTap? TIG?

Fully immunized and greaterthan 10 years since booster? dTap? TIG?

dtap yes tig no

Incomplete tetanus series (<3) dTap? TIG?

both

Pregnancy - when to give tetanus shot and which one?

use DT in pregnancy immediately postpartum can given Tdap, including BF women

2. A 32-year-old man presents with 20 stab wounds to his arms and legs sustained in an assault. He weighs 80 kg. Which of the follow- ing is an appropriate dosage of wound anesthesia? a. 240 mg of 1% lidocaine b. 320 mg of 0.5% bupivacaine c. 400 mg of 0.5% bupivacaine with epinephrine d. 700 mg of 1% lidocaine with epinephrine

1. Which of the following is associated with an increased risk of infec- tion? a. Avoidance of epinephrine use in wound anesthesia b. High-pressure irrigation c. Use of clippers instead of razors for hair management near wound d. Use of silk suture material e. Use of tape over sutures for wound closure

3. A 23-year-old female presents with a laceration to her thigh. As you begin to apply anesthetic, she tells you that when she went to the dentist she had an allergic reaction to procaine. Which of the fol- lowing should you use? a. Benzocaine b. Benzocaine with epinephrine c. Bupivacaine d. Lidocaine from a multidose vial e. Tetracaine

. Which of the following factors is most likely to require no antibiotic prophylaxis? a. Catbite b. Diabetic with contaminated wound c. Dogbite d. Human bite e. Puncture wound through rubber sole

5. Antibiotic coverage of a cat bite must target which of the following pathogens? a. Bacteroidesspecies b. Clostridium perfringens c. Eikenella corrodens d. Pasteurella multocida e. Pseudomonas species

. A 74-year-old patient presents with a gaping wound from a dog bite, complaining of pain at the site. The dog belongs to a friend, has reportedly had “all his shots,” and is in custody. The patient is from Central America but has lived in the US for more than 50 years; he does not recall his immunization history. Besides copious irrigation and wound dressing, which of the following should be included in the treatment of this patient? a. Diphtheria, pertussis, tetanus toxoids (Tdap) and tetanus immu- noglobulin (TIG) b. Rabies immunization c. Tetanus toxoid d. Tetanus toxoid and immunoglobulin e. B and D