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Clin Specialties - EMed > Lecture 2 - Wound Management > Flashcards

Lecture 2 - Wound Management Flashcards

1
Q

Puncture

A

deeper than it is wide

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2
Q

Avulsion

A

no bone

a chunk missing (like cutting off the tip of your finger)

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3
Q

Laceration

A

longer than it is deep

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4
Q

Amputation

A

bone is included

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5
Q

A pt comes in with a wound, before you suture, what neurovascular exam needs to be done?

A 
Vascular: 
cap refil 
distal pulses
temperature 
pulsatile flow 
edema

Nerve/Sensory:
perform BEFORE anesthesia
measure appropriate region distal to wound
compare sensation to uninjured side
measure 2 point tactile discrimination in digits (test along distal radial and ulnar aspects and distal to PIPJ only - normal range 2-8 mm, compare to unaffected digit)

Motor:
done AFTER anesthesia

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6
Q

2 point tactile discrimination in digits

A

test along distal radial and ulnar aspects and distal to PIPJ only - normal range 2-8 mm
give pt baseline reference in unaffected digit

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7
Q

What do you do for a pt who comes in complaining of feeling a foreign body in their palm or plantar?

A

STANDARD OF CARE:

X-ray:
80-90% FB detected on x-ray –if its radiopaque
look for changes in tissue density

US:
more sensitive for organic matter

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8
Q

Primary intention

A

wound is closed at or near time of injury

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9
Q

Secondary intention

A

wound is allowed to close by natural process

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10
Q

Tertiary Intention

A

(aka Delayed Primary Repair)

wound prepped in Er and brought back later for primary repair

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11
Q

What do you tell pts in regards to wound scarring?

A

yes it will scar

but we wont know the exact extent until about a year out

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12
Q

Explain wound healing from onset of injury to a year out

A

platelets aggregate on exposed wound surface –> clotting cascade –> hemostatic coagulum

inflammatory response

after wound repair –> initial epithelialization within 24-48 hours

peak collagen between 5-7 days
wound is at 5% tensile strength in 2 weeks and 35% in 1 month

wounds contiune to remodel over 3-12 months

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13
Q

What are the primary closure recommendations?

A

face up to 24 hours
UE up to 12 hours
LE up to 8 hours

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14
Q

When do we use staples to close wounds?

A

scalp in the ER only

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15
Q

What is the procedure of primary closure?

A

clean and debride devitalized tissue from wound
apply saline damp gauze and cover
after 72 -96h wound should be re-irrigated and closed
close follow up

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16
Q

When do we use running sutures?

A

in the OR

we use interrupted in the ER d/t risk of infection and possibilities of needing to open a portion of the wound back up

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17
Q

Why do wounds along Langer Lines scar less?

A

lower tension

wounds with an orientation >45 degree from the Langer line are under higher tension and more likely to have significant scaring

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18
Q

How do we close wounds under high tension?

A

like on the face

multi layered closure to help minimize tension on healing wound and promote cosmesis

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19
Q

What layers can NOT hold a suture?

A

muscle or fat

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20
Q

Galea

A

layer of tissue closure

decrease dead spread against bone of skull

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21
Q

Where on the hand are the only places on the hand where sutures other than percutaneous?

A

thenar and hypothenar

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22
Q

How do you apply local anesthesia before suture a wound?

A

inject within the wound edges using a 27g needle/3cc syringe
inject slowly to decrease pain of injection

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23
Q

When do nerve blocks get used?

A

wounds that wound otherwise require large volume of anesthesia
wounds in which tissue distortion needs to be avoided (lip, digit)
wounds where local infiltration is particularly painful (plantar foot)

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24
Q

Which is faster, lidocaine or bupivicaine?

A

lidocaine

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25
Q

How do you determine mg/ml from percentage for anesthetic agents?

A

move the decimal
1% –> 10mg/ml
0.25% –> 2.5 mg/ml

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26
Q

Which anesthesia is contraindicated in pregnancy?

A

Bupivacaine

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27
Q

Epi is often added with anesthetic agents, when is Epi contraindicated?

A

areas below the neck (classically the fingers, nose, toes, and genitalia)
areas with decreased blood flow or increased risk of infection
areas where blanching of tissue will interfere with alignment of anatomical borders
infected wounds
pts with significant cardiac or vascular disease
pts on propranolol

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28
Q

What 3 instruments are used for suturing?

A

webster needle driver
adson forceps
iris scissors (cut at 45 degrees to avoid cutting out the knots)

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29
Q

What are the rules for hair removal near wound cultures?

A

do not remove the hair (no shaving)

you can trim it or slick it back with gel (abx ointment)

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30
Q

Why don’t we remove hair when doing wound closure?

A

hair follicles are a significant source of bacteria

eyebrows may not regrow

always maintain landmarks

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31
Q

Devitalized tissue

A

Weak or dead tissue can increase risk of infection and scaring
remove devitalized tissue and loose adipose in the wound

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32
Q

What should NEVER be used to clean out a wound?

A

alcohol
chlorhexidine
peroxide

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33
Q

When during the wound closure procedure is irrigation done?

A

AFTER anesthesia

use isotonic saline (normal saline)

34
Q

What pressure is used for wound irrigation?

A

5-8 PSI

provides adequate mechanical debridement without tissue destruction

35
Q

What hemostasis options are available during wound closure?

A

direct pressure

epinephrine (not idea, really not used below the neck)

digital tourniquet

  • use sterile wide tourniquet (penrose drain) or specifically designed digital tourniquet
  • apply for up to 30 minutes

ligation of bleeding vessel or suture SQ over vessel to tamponade vessel

BP cuff inflated over SBP or CAT type for up to 2 hours

36
Q

Absorbable vs non-absorbable suture material

A

absorbable:
synthetics: vicryl (polglactic acid), PDS (polydiaxnone)
non-synthetics: gut

non-absorbable:
synthetic: ethilon (nylon), prolene (polypropylene)
non-synthetic: silk

37
Q

Which increases the risk of infection, braided or monofilament suture material?

A

braided increases risk of infection
but is better at secure knotting

monofilatment has a lower risk of infection but less dependable knotting

38
Q

Which type of sutures should you avoid in contaminated wounds?

A

highly reactive sutures – silk and gut

39
Q

Ethilon suture material

A 
non-absorbable 
good knot security 
good tensile strength 
minimal issue reactivity 
good workability 
any anatomical site
40
Q

Of the absorbable types, which have the longest days of integrity?

A

PDS - 45-60 days

Vicryl - 30 days

41
Q

A pt comes in with a lac on their scalp, which absorbable sutures can you use?

A

vicryl rapide

chromic gut

42
Q

A pt comes in with a lac on their nailbed, which absorbable sutures can you use?

A

vicryl

chromic gut

43
Q

When do you use PDS suture?

A

this is an absorbable suture

used for fascia/galea/tendon

44
Q

When do you use chromic gut suture?

A

mucosa
tongue
nailbed
scalp

45
Q

When do you use vicryl suture?

A

intradermal

nailbed

46
Q

Which is a smaller suture, 7-o or 4-o?

A

7-o is the smallest

the most ‘o’ the smaller

47
Q

When do we use 6-o and 7-o sutures?

A

percutaneous closures on the FACE

48
Q

Which suture type do you use for high tension areas?

A

4-o

49
Q

The greater the curve of the needle the greater the….

A

depth

50
Q

Conventional cutting

A

third cutting edge TOWARD the wound edge

good for softer tissue

51
Q

Reverse cutting

A

third cutting edge is AWAY from wound edge
good for tougher tissue like fascia and skin
good for weaker wound edges

52
Q

When suturing, where on the body do you NOT want eversion to happen?

A

the face

you never want inverting, anywhere

53
Q

What is the MC suture done in the ER?

A

simple interrupted

single percutaneous stitches

individually knotted (keep all knots on one side of wound)

54
Q

What is the MC suture done in the OR?

A

subcuticular running

intradermal horizontal bites allows suture to remain for a longer period of time without development of crosshatch scarring
typically not used in acute wounds

55
Q

When do we not use intradermal sutures?

A 
adipose 
poorly vascular wounds
wounds with higher risk of infection 
hands (except thenar fascia), feet, cartilage 
areas where SQ tissue is minimal
56
Q

Vertical mattress

A

improves wound edge eversion
reduces “dead space”
help minimize tension

two-step stitch
far far, near near

57
Q

Horizontal mattress

A

improves wound edge eversion
high tension wounds
-palms and soles, elbow

two step suture

58
Q

How does the way you close the suture affect how you prep for it?

A

it doesnt
regardless of how you close the wound, the WAY you prep is the same
anesthetize, explore, clean

59
Q

What is a “lose” closure?

A

you close it but you spread the sutures out further

60
Q

When do we use staples?

A

scalp

equivalent cosmesis
does not pull on hair

fast - emergency hemostasis

anesthesia still required

check that the edges are not overlapping after staple is placed

61
Q

Steri strips

A

sterile adhesive tapes

low tensile strength
weaken and fall off when wet
high dehiscence rate

frequently used with subcuticular sutures

used following staple and suture removal

62
Q

When is tissue adhesive appropriate to use?

A

cyanoacrylate and formaldehyde

simple linear low tension, self approximating wounds on the face

proper wound prep is still essential
don’t let glue enter between the wound edges

63
Q

How long should non-facial wounds be covered?

A

24-48 hours to allow enough epithelialization to reduce risk of wound contamination

64
Q

What should you do for a 1cm lab on the hand?

A

splint

it does NOT need to be sutured as long as the hand is immobilized

65
Q

Which wounds should we be splinting?

A

splint post repair to minimize movement:
wounds with risk of edema
open fx/joints
tendon lacerations
lacs over joints (splint in position of function)
wounds with risk of infection (ex. dog bit on hand)

66
Q

Which wounds absolutely need PO ABX?

A

open bone, cartilage or joint
tendon lacerations
through and through lip lacerations
cat bites

consider: 
highly contaminated wounds
high risk pts 
food puncture wounds (psudeomonas coverage) 
pre-tibial lacerations
dog/human bites
67
Q

What is something to keep in mind when using neomycin or bacitracin topical ABX?

A

8-11% contact allergen in US

68
Q

When do you vaccinate for tetanus in a pt coming in with a wound?

A

if >7 years have elapsed since last vaccine

give booster Tdap rather than Td in those >19 years old who have not received Tdap previously

69
Q

How long after applying a face suture should it be removed?

A

3-5 days (5 days is more ideal i think)

70
Q

How long after sutures were placed on the scalp should they be removed?

A

7 days

71
Q

How long after sutures were placed on torso or UE should they be removed?

A

7-10 days

72
Q

How long after sutures were placed on LE should they be removed?

A

8-12 days

73
Q

Sutures on joints can be removed after how long?

A

may stay in for up to 14 days

74
Q

What do you do after removing sutures?

A

apply steri strips in cosmetic and high tension wounds

send pt home with directions to apply topical (bacitracin, mederma, vitamin E, aquaphor, or vaseline) and sunscreen/avoiding the sun

75
Q

What percentage of dog and cat bites become infected?

A

dog bits: 3-18%

cat bites: 20-80% (MUST start on ABX)

76
Q

A pt comes in with a cat bite, what are your next steps?

A

you MUST get an XRAY for possible retained teeth
copious irrigation
consider loose closure of extremity wounds presenting within 8 hours that are amenable to effective irrigation
and then you MUST start them on ABX

77
Q

Which ABX prophylaxis is used for bite wounds?

A

3-5 days of:
augmentin
if PCN allergy:
flouroquinolone + clinamycin

monkey bites –> valacyclovir/acyclovir for 14 days

78
Q

Who gets rabies prophylaxis?

A

high risk bites and animal escapes

if animal is captures: send animal’s head to state health lab for path exam treat only if lab confirms rabid animal (brain sections show Negri bodies)

low risk animal + animal captured:
observe animal for 1 week

79
Q

How can you tell if an animal is rabid?

A

State health lab will do a path exam and the brain will show Negri bodies

80
Q

For non-immunized, what is the post exposure prophylaxis in regards to rabies?

A

begin with soap and water
then irrigate with povidine -iodine
RIG - infiltrated around the areas of the wound
if you cant give the full dose of RIG at the site of the wound, change syringe and give IM to a site distant from vaccine administration

Vaccine HDCV or PCECV 1.0mL, IM (deltoid area) given on days 0,3,7 and 14 (if immunocompromised give 5th dose on day 28)

81
Q

For post exposure, when are people given HDCV or PCECV?

A

day 0, 3, 7, and 14

if immunocompromised they get a 5th dose at day 28

Clin Specialties - EMed (11 decks)

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