ED Surgical Wounds

Question 1

Wound healing stages

Answer 1

Inflammatory: 0-3d
Epithelialization: 2-5d
Proliferative/Fibroplasia: 4-24d
Maturation: 24d-1y

Collagen remodels and scars revise for up to 1 year after injury*

Question 2

Primary Union

Answer 2

• closure of wound edges w/sutures, staples, or adhesives
• best if w/in 6hr of injury*
• longer delay acceptable if good vascular supply and wound not grossly contaminated

Question 3

Secondary Union (Secondary Intention)

Answer 3

• granulates from bottom to top

- used in older, contaminated or puncture wounds

Question 4

Delayed primary union

Answer 4

• delayed suture closure after 3-5d

- contaminated or old wound that may have cosmetic or functional importance

Question 5

Approach to wound care, general

Answer 5

Brief wound assessment

• control bleeding w/pressure and elevation prn
• protect wound w/sterile dressing until ready to eval

Xray if indicated
Tissue anesthesia
Wound cleansing
Full tissue eval 
Wound repair 
Adjuncts, discharge

Question 6

Wound Care PE

Answer 6

• measure size, depth of wound
• identify base of wound and probe for foreign bodies
• neurovascular status distal to wound: 2-point discrimination
• test tendon function and ROM if joint involved
• brief neurologic exam w/head lac

Question 7

Indications for wound radiography

Answer 7

• suspected foreign body
• intoxicated/AMS pt w/wounds of unknown origin/duration
• patients returning to ED w/infected wounds
• suspected underlying fracture

Question 8

Wound anesthesia types

Answer 8

1. local infiltration
   - lidocaine
   - bupivacaine
2. regional: nerve block
   - fingers most common, then toes
   - lidocaine or bupivacaine
3. topical
   - LAT

Question 9

Anesthesia additives

Answer 9

1. epinephrine
   - C.I. fingers, toes, ears, tip of nose, penis
   - effects: prolongs duration of anesthesia, increases pain, limits bleeding
2. sodium bicarbonate [mix 1mL to 10mL of lidocaine]
   - C.I. use only w/lidocaine, not bupivacaine
   - effects: diminishes pain

Question 10

Lidocaine

Answer 10

Max adult dose = 30cc (300mg) of 1% solution

Warn pt it will sting

Neuro sxs if toxic:

• circumoral or tongue numbness
• metallic taste
• lightheadedness
• disorientation
• drowsiness
• seizure
• CV or respiratory collapse

Methods to decrease pain of injection:

• slow infiltrate wound
• add bicarb

Infiltrate through wound margins, not through intact skin, unless grossly contaminated

Question 11

Digital block fingers - regional anesthesia

Answer 11

• 27G needle w/1-2mL Lidocaine or Bupivacaine dorsally on either side of finger just proximal to web space or palmar for fingers 2-4

Question 12

LAT Anesthesia

Answer 12

Lidocaine / adrenaline / tetracaine

Advantages: increased tolerance over injection

Indication: facial lac in children or developmentally disabled

Risk:

• incomplete anesthesia
• avoid getting into mucus membrane
• takes 20-30min

How:

• soak cotton ball/gauze w/LAT
• place over laceration w/occlusive dressing

Question 13

Wound tourniquetes

Answer 13

common:
- finger tourniquet
- BP cuff
- penrose drains

advantages:
- hemostasis
- dry field

risks:
- ischemia

Question 14

Absorbable (internal) sutures

Answer 14

degrade in tissue

vicryl*
chromic gut
cat gut
PDS

Question 15

Nonabsorbable (external)

Answer 15

do not degrade

nylon*
prolene*
silk

Question 16

Suture size

Answer 16

6. 0 - cosmetic face
7. 0 - face, extremity
8. 0/3.0 - thigh, back, scalp, nails
9. 0/1.0 - deep fascia

Question 17

Staple wound closure

Answer 17

Advantage:

• speed
• decreased risk of infection
• increased wound eversion

Indications:
- high tension areas of scalp and extremities (knee)

Risks/disadvantage

• cost
• decreased precision
• cosmesis

Question 18

Steri-strip wound closure

Answer 18

Can reinforce or be used alone

Indications:

• superficial, straight, low tension lac
• skin tears in elderly

Advantages:
- painless, easy application

Disadvantage:

• poor eversion
• adhesion, wound approximation

Tips: Benzoin or Mastisol aids adhesion

Question 19

Dermabond wound closure

Answer 19

Cyanoacrylate or “super glue”

Indications:

• low tension area (face)
• avoid mouth, hair, eyes, mucus membrane

Benefits:

• quick, painless
• no suture/staple removal

How to:

• need dry field, won’t work in grossly bloody wound
• 2+ applications
• NO topical abx/lubricants afterward

Question 20

Scalp lacerations

Answer 20

Abundant blood supply = increased bleeding risk

Anesthesia: lidocaine, bupivacaine w/epinephrine

Suture ligate arterial bleeders prn

Question 21

General facial lacerations

Answer 21

Sutures close together to limit scarring

Use subcutaneous sutures prn to reduce tension

Remove sutures earlier (5d) than other areas

Avoid debridement

Align vermillion border very carefully*

Question 22

MC ED skin closure technique

Answer 22

Simple interrupted

Question 23

Vertical mattress suture

Answer 23

Excellent wound edge eversion for neck and thigh or as a holding suture

Question 24

Horizontal mattress suture

Answer 24

Good for gaping or high-tension areas with little SQ tissue, such as the shin

Question 25

Continuous running technique

Answer 25

Benefit: speed Indication: long linear extremity or trunk wounds Precautions: wounds with increased infection risk

Question 26

SQ Sutures - layered closure

Answer 26

Benefits - reduce wound tension - close dead space where fluid collections develop Avoid in grossly contaminated wounds Layer is placed in the dermis Avoid suturing other subcuticular tissues (fat/muscle) - won't hold stitches well - increased infection risk

Question 27

Wounds and abx

Answer 27

MC organism: 1. Staph aureus (uncomplicated) 2. Streptococcus Inpatient: Cefazolin IV/IM 1g in ED Outpatient: Cephalexin, Cefadroxil, or Dicloxacillin x 3-5d to prevent unless known MRSA

Question 28

Dressings

Answer 28

Function: protect, absorb Triple antibiotic is beneficial 3 layer = MC - nonabsorbent contact layer e.g. Telfa or petroleum gauze - absorbent layer - gauze - outer wrap - Kerlex

Question 29

Increased risk of tetanus

Answer 29

``` Wound > 6hr old Depth > 1cm MOA: missile, crush, burn or frostbite Devitalized tissue present Contaminants (dirt, saliva) present ``` Admin tetanus toxoid-containing vaccine for wound management when >5y have passed since last tetanus toxoid-containing dose If indicated for person >11y, Tdap is preferred for those whose history is unknown or have not prior received Tdap for pregnancy Nonpregnant w/previous Tdap - either Td or Tdap may be used

Question 30

Initial severe burn evaluation

Answer 30

Primary Survey 1. Airway and c-spine - recognize impending airway compromise - consider CO poisoning in structural fires 2. Breathing and ventilation - chest/lung inspection, palpation, percussion, auscultation - mask O2 liberally 3. Circulation - auscultate heart and assess perfusion - find appropriate peripheral or central vascular access 4. Disability - GCS 5. Exposure - remove clothing and keep warm Adjuncts: - chest radiograph and other Xray Labs: - ABG - carboxyhemoglobin - CBC, BMP - Urine myoglobin Begin fluid resuscitation

Question 31

ABA Burn Center Transfer Criteria

Answer 31

1. Partial thickness burn greater than 10% 2. Involving face, hands, feet, genitalia, perineum, or major joints 3. Third degree in any age group 4. Electrical burns, including lightning injury 5. Chemical burns 6. Inhalation injury 7. Burn injury in pt w/preexisting medical disorders that could complicate mgmt, prolong recovery, or affect mortality 8. Concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality 9. Burned child in hospital w/out qualified personnel or equipment for care of children 10. Pt requiring special social, emotional, or rehab intervention

Question 32

Minor burn treatment

Answer 32

1. Immediate cooling - decreases burn depth if applied within 1hr - use cool water, not ice 2. Analgesia - NSAIDs* - opioids if severe pain 3. Elevate extremity 4. Cleanse with mild soap and water - irrigate - leave blisters intact unless tense and large 5. Apply burn ointment - Silvadene** or triple antibiotic 6. Non-adherent dressing 7. Tetanus prophylaxis 8. Dressing change BID 9. Wound recheck 24-48hr - debride prn - low threshold for abx if suspicious at f/u