- 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

- 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

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

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

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

ED Surgical Wounds Flashcards by Ben Aleckson

Wound healing stages

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*

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Primary Union

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

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Secondary Union (Secondary Intention)

granulates from bottom to top

- used in older, contaminated or puncture wounds

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Delayed primary union

delayed suture closure after 3-5d

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

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Approach to wound care, general

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

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Wound Care PE

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

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Indications for wound radiography

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

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Wound anesthesia types

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

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Anesthesia additives

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

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Lidocaine

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

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Digital block fingers - regional anesthesia

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

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LAT Anesthesia

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

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Wound tourniquetes

common:
- finger tourniquet
- BP cuff
- penrose drains

advantages:
- hemostasis
- dry field

risks:
- ischemia

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Absorbable (internal) sutures

degrade in tissue

vicryl*
chromic gut
cat gut
PDS

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Nonabsorbable (external)

do not degrade

nylon*
prolene*
silk

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Suture size

0 - cosmetic face
0 - face, extremity
0/3.0 - thigh, back, scalp, nails
0/1.0 - deep fascia

Staple wound closure

Advantage:

speed
decreased risk of infection
increased wound eversion

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

Risks/disadvantage

cost
decreased precision
cosmesis

Steri-strip wound closure

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

Dermabond wound closure

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

Scalp lacerations

Abundant blood supply = increased bleeding risk

Anesthesia: lidocaine, bupivacaine w/epinephrine

Suture ligate arterial bleeders prn

General facial lacerations

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*

MC ED skin closure technique

Simple interrupted

Vertical mattress suture

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

Horizontal mattress suture

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

Continuous running technique

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

SQ Sutures - layered closure

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

Wounds and abx

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

Dressings

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

Increased risk of tetanus

``` 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

Initial severe burn evaluation

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

ABA Burn Center Transfer Criteria

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

Minor burn treatment

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