Trauma Flashcards
For wound management, what questions in a history are important to ask? (8)
- Mechanism of injury
- Possibility of infection?
- Non-accidental injury?
- When did the injury occur?
- Do they have other injuries?
- PMHx - any conditions that might delay healing or make them more prone to infection?
- DHx and allergies
- Tetanus??
What aspects of examination are important to cover for someone with a wound that needs managing? (5)
- Dirt and debris? - foreign bodies - is an X-ray required?
- Damage? - size of wound - is local anaesthetic required?
- Bleeding?
- Function? - damage to nerves etc.
- Evidence of infection?
What foreign bodies will show up on an X-ray? (4)
- Glass
- Metal
- Teeth
- Fragments of lead based paint
In what situations should wounds also be referred for specialist closure? (9)
- Open fracture
- Neurovascular compromise
- Tendon damage
- Vermillion border
- Near the eye
- Cosmetically sensitive wounds
- Penetrating wound where unable to assess damage
- Deep dirty wounds
- Infected wounds
If the wound is a clean laceration, how can it be cleaned? and what if the wound is contaminated?
By a low pressure irrigation using a syringe only - if the wound is contaminated then high pressure irrigation is required and this can be achieved by attaching a green needle
Why should you never used adrenaline with local anaesthetic on a digit?
You risk causing ischaemia
How many mm deep does a laceration need to be to require deep dermal sutures to close the dead space?
5mm
For wound closure, when are sutures preferred? (3)
- For any laceration longer than 5cm
- When deep dermal sutures are needed to close the dead space
- The wound is over an area subject to excessive movement eg. a joint
Which type of suture - absorbable or non-absorbable is preferred for skin?
Non-absorbable
What size suture is normally used on the face/neck and what size on hands/limbs?
5-6 on face/neck
4-5 on hands/limbs
When are staples useful for closing a wound?
Frequently used on the scalp and useful with aggressive patients where needle stick injury may be at risk
When can skin glue be used on an open wound?
When the wound is less than 5cm long and where there is no risk of infection and the wound edges can be easily apposed.
It can also be used in combination with steristrips, or sutures in larger wounds
When is skin glue not suitable even if the wound is less than 5cm?
Over areas of movement or if the area is exposed to excessive sweating/wetting e.g. the mouth, groin and axilla
When are adhesive strips (steristrips) used?
Small minor wounds less than 5cm long, always use for pre-tibial flaps
When are adhesive strips for wound closure not suitable? (6)
If the wound is:
- Bleeding
- Infected
- Exudate is present
- Over joints
- Wet or sweaty
- Hairy
What % of dog bites typically become infected?
30%
What % of cat bites become infected?
50%
If a wound is showing signs of infection, what should you do? (4)
- Take a swab for culture and debride slough and non-viable tissue
- Clean the wound and pack with non-adherent dressing to prevent wound edges apposing
- Do not close the wound, apply a suitable dressing
- Treat with broad spectrum ABX - NICE = co-amoxiclav (if penicillin allergy = erythromycin + metronidazole)
How should you manage a pre-tibial laceration? (5)
These are very common in older people as a result of a fall or blunt injury.
- Cover with moist saline soaked dressing whilst awaiting closure to prevent drying out and shrinkage of the flap
- Irrigate with sterile saline, and debride as necessary
- Use steristrips without tension to close flap
- Cover with supportive dressing
- Review regularly
Which patients are at risk of developing an infection with a wound? (5)
- Diabetic patients
- Elderly
3 Immunocompromised - Delayed presentation
- Extensive/deep injury
What should be considered if a patient is deemed high risk of infection e.g. has diabetes, but has a clean laceration?
Treat using flucloxacillin or erythromycin
When using staples to close wounds, how far apart should they be placed and when should they be removed?
Placed 5-7mm apart and removed after 5-14 days
If closing a wound using glue, how many layers are appropriate?
3-4 layers of glue, it will dissolve after 10 days
What documentation needs to be recorded after wound closure/care? (11)
- Time and date
- Mode of injury
- Depth/length of injury
- Sensation
- Pulses
- Immunisation status
- Cleaned with?
- Anaesthetic used
- No. of sutures/staples
- Removal date of sutures
- Date to review
What advice just be offered to patients after wound care? (5)
- Take OTC analgesia if necessary
- Advise to rest
- Keep wound and dressing clean and dry
- Observe for signs of infections - redness, swelling, fever, malaise, discharge
- Practice nurse for suture removal (head and neck = 3-4 days, over joints = 10-14 days)
How do you review a post-operative surgical wound for infection? (4)
- Observe vital signs of patient looking for evidence of infection
- Observe the wound for erythema, pain, heat, viscous or purulent discharge, leaking, abnormal smell
- Try to avoid removing dressings unnecessarily
- Palpate gently as the wound is likely to be tender, but feel for hard collections below the incision
What is the most common cause of wound dehiscence?
Infection
What patient factors might contribute to a bust abdomen? (7)
- Age
- Male
- Co-morbidities - diabetes
- Steroids
- Smoking
- Obesity
- Malnutrition
What post-op factors might contribute to wound dehiscence and a bust abdomen? (5)
- Prolonged ventilation
- Post-op blood transfusion
- Poor tissue perfusion
- Excessive coughing
- Radiotherapy
When does wound dehiscence most typically occur post-operatively? (which day?)
Day 6 post-op
What is the management for wound dehiscence? (5)
- Take swabs for culture
- Take bloods - FBC, CRP, blood cultures
- Either surgical closure or conservative closure
- Debridement of necrotic tissue
- If full bust abdomen - start analgesia, IV fluids, IV ABX, ASAP.
