U6 O1 - Orthopaedic and Soft Tissue Injuries Flashcards
Emergency surgical procedures
1
Q
Define the term angioedema?
A
Rapid, oedematous swelling of the dermis, hypodermis, mucosa and submucosa. Similar to urticaria but extends deeper into dermis and subcutaneous area.
2
Q
Define the term Bullous lesions/bullae?
A
Intact skin blisters often associated with an immune mediated condition (> 0.5 cm diameter).
3
Q
Define the term comminuted fracture?
A
Fracture that has multiple fragments.
4
Q
Define the term complicated wound/fracture?
A
Damage to other organs has occurred as well as a
wound/fracture e.g. vertebral fracture with spinal cord
damage
5
Q
Define the term cellulitis?
A
Inflammation of connective tissue- may be localised or
diffuse. Septic cellulitis is a very serious, acute bacterial
disease where lesions disseminate along soft tissues
6
Q
Define the term Ecchymosis ?
A
Purple, non-elevated area of skin associated with
haemorrhage - ‘bruise’
7
Q
Define the term erosion / ulcer ?
A
Open area associated with tissue loss in skin or mucous membrane
8
Q
Define the term erythema?
A
Reddening of the skin associated with inflammation.
9
Q
Define the term Eschar?
A
A slough or piece of dead tissue such as may develop
over the site of a burn.
10
Q
Define the term panniculitis?
A
Deep inflammation that involves the fat underlying the
skin.
11
Q
Define the term papule?
A
A solid (not fluid) raised lesion up to ½ cm diameter
12
Q
Define the term pemphigus?
A
Group of immune - mediated conditions e.g. Pemphigus foliaceous. The immune system reacts against the molecules that hold epithelial cells together.
13
Q
Define the term pustule?
A
A raised lesion containing pus
14
Q
Define the term urticaria?
A
Multiple, fluid-filled plaque-like eruptions formed by
localised oedema in the upper dermis that often develop and disappear suddenly. Immunological and nonimmunological causes- type 1 hypersensitivity reaction e.g. bee sting, exposure to pollen or chemicals
15
Q
Define the term vesicle?
A
A raised lesion containing fluid other than pus- smaller than bullae (< 0.5 cm). Can be associated with viral or
immune-mediated conditions
16
Q
What is the golden period in wound management?
A
There is a ‘golden period’ six hour period for wound
management, beyond which wounds are considered to be infected. As infection is the most common cause of poor wound healing, all attempts should be
made to minimise this.
17
Q
What advice should be given to an owner to start effective wound management on their pet and why should this advice be given?
A
Effective wound management starts at the first point of contact with the owner -the importance of prompt attendance should be emphasised. If a wound is known to be present, the owner should be advised to cover it (and what with) to limit further contamination (Coe, 2012). There is a ‘golden period’ six hour period for wound management, beyond which wounds are considered to be infected (Coe, 2012). As infection is the most common cause of poor wound healing, all attempts should be made to minimise this
18
Q
What initial first aid advice should be given to owners that call because of an electrical burn and why?
A
The initial first aid management of burns/scalds is very important. If there is an electrical burn, the owner must be advised to first disconnect the patient from the electrical source. Burns or scalds should be cooled, with tepid, running water, for a period of time (at least five minutes) to limit further tissue damage before the patient is transported. In each case the affected area should be covered for transport to decrease the chances of infection and to limit fluid loss. It is
important that the owner is advised that the burn is covered with non-adherent material (guidance should be provided as to what is and what is NOT appropriate)
and cooling continued as the patient is transported, if possible.
19
Q
What initial first aid advice should be given to owners that call because of a chemical burn and why?
A
Burns or scalds should be cooled, with tepid, running water, for a period of time (at least five minutes) to limit further tissue damage before the patient is transported; chemical burns should also be flushed with cool water to dilute/remove chemicals prior to transport. In each case the affected area should be covered for transport to decrease the chances of infection and to limit fluid loss. It is important that the owner is advised that the burn is covered with non-adherent material (guidance should be provided as to what is and what is NOT appropriate) and cooling continued as the patient is transported, if possible.
20
Q
What should be carried out by the VN prior to thorough wound assessment?
A
A full, thorough assessment of most wounds involves examination under anaesthetic. As with all other emergency presentations, this may not be possible,
until life-threatening conditions (e.g. pneumothorax) are first stabilised. The dramatic appearance of many wounds (e.g. open fracture, degloving wound) should not cause the VN to divert from the standard patient assessment and triage- it is very important
that life-threatening, but less obvious conditions, are not over-looked. An initial assessment of the cardiovascular, respiratory and neurological systems should be performed before considering the wound. Initial, emergency management of the wound can be performed at this stage- with the full wound assessment, evaluation and planning delayed until the patient is stable.
21
Q
What is emergency management of wounds generally aimed at doing?
A
Emergency management of wounds is generally aimed at controlling haemorrhage, preventing further contamination and providing analgesia. A sterile
dressing should be placed over the wound as soon as is feasible
22
Q
Why is the initial management of wounds very important?
A
The initial management of wounds is very important as this can influence how well the wound ultimately heals.
‘….there is an important “window of opportunity” shortly after injury where diligent and thorough treatment can prevent progression from contamination to infection and the associated complication and delay of wound healing.’
23
Q
What does a thorough examination of a wound usually require?
A
Once the patient is stable, the wound should be thoroughly assessed and examined.
Thorough examination of the wound will, generally, require deep sedation or general
anaesthesia.
24
Q
What should be considered when determining the healing process of a wound?
A
The following points should be noted as these will all influence healing
1. Position and area affected (e.g. head, limb, surface area involved)
2. Tissues involved (e.g. mucosa, skin, eyes)
3. Degree of damage – superficial, deep, complicated (involving other structures
e.g. muscle, bone, nerves, body cavities etc.)
4. Wound type e.g. laceration, avulsion, puncture
5. Presence of devitalised and necrotic tissue
6. Presence of foreign bodies
7. Presence of potential or actual complications e.g. compartment syndrome.
Compartment syndrome is due to increased pressure in a compartment e.g. limb. It is usually associated with swelling in a limb between the fascial planes
which is then constrained by fibrous tissues. This pressure compresses blood vessels which results in reduced or absent tissue perfusion.
It is very important at this stage to identify anything that could potentially delay or
prevent healing.
25
What is compartment syndrome?
Presence of potential or actual complications e.g. compartment syndrome.
Compartment syndrome is due to increased pressure in a compartment e.g. limb. It is usually associated with swelling in a limb between the fascial planes which is then constrained by fibrous tissues. This pressure compresses blood vessels which results in reduced or absent tissue perfusion.
26
How and why are wounds classified?
Wounds are classified according to the level of contamination that is present; as well as the type of wound and likely cause. This will determine the nursing care that will be required especially in relation to infection. Whilst each case will vary in how rapidly infection will develop, (based on patient health, degree of damage, intercurrent disease, location etc.)
27
What are the 4 classifications for wounds?
clean wounds
clean - contaminated wounds
contaminated wounds
dirty wounds
28
What would be classified as a clean wound?
Clean wounds. These are surgical wounds that are made under sterile conditions. Wounds to the respiratory or gastrointestinal cannot be considered
to be clean wounds as there will always be a degree of contamination here
29
What would be classified as a clean-contaminated wound?
Clean – contaminated wounds. Surgical wounds of the urinary, respiratory, alimentary/gastrointestinal or reproductive tracts would be considered at least
clean contaminated- as long as performed under aseptic conditions and with no significant contamination e.g. leakage of urine. Surgical wounds with a break in asepsis are also considered clean-contaminated.
30
What would be classified as a contaminated wound?
Contaminated wounds. There is a high risk of infection developing. Recent, traumatic wounds will be contaminated with bacteria present on the surface of
the wound. Once these bacteria have had an opportunity to colonise, the wound is considered infected or ‘dirty’. Spillage of e.g. gastro-intestinal contents during clean-contaminated surgery,
results in contamination of the wound.
31
What would be classified as a dirty wound?
Dirty wounds. Wounds that have large numbers of microbes and infection present; surgical or traumatic wounds where there is faecal contamination; any traumatic wound of more than 4-6 hours will be infected; any wound with purulent, foreign body, necrotic or devitalised tissue
32
What is it important to know about a wound to allow effective planning and management of the wound to optimise healing and avoid complication?
Understanding the type of wound; how it may have occurred (e.g. high velocity, shaking, friction); and potential, associated complications will allow for effective planning and management of the wound to optimise healing and avoid complications.
33
What are the 7 different types of wounds?
```
incision
degloving
laceration
puncture
avulsion
abrasion
Burn (thermal, radiation, chemical, electrical) and
scalds
```
34
What is an incision and what is it caused by?
This type of wound is created intentionally during many surgical procedures- it has sharp, clear edges. It can, however, also be created unintentionally by e.g. glass wounds etc. The wound edges will often gape due to the elasticity of the dermis leading to more possibility of contamination.
35
What is a puncture and what is it caused by?
An injury caused by a sharp object. Small but often deep wound; often little associated bleeding; potential for infection (including tetanus). The causative agent may also impact on wound healing e.g. high velocity gun-shot wounds can have additional tissue trauma e.g. fractures, soft-tissue damage.
36
What is a laceration and what is it caused by?
Tissue that has been torn. There is often a large area of tissue damage; the wound edges are often ragged. This type of wound is likely to be contaminated because of the way it was created
37
What is an abrasion and what is it caused by?
Damage caused by friction- often superficial involving the epidermis but could involve the dermis through to the hypodermis. Usually caused by friction e.g. RTA. Like a laceration it will often be contaminated. Due to the drag nature of the wound, bacteria and other contaminants are often very well embedded in the tissue
38
What is an avulsion and what is it caused by?
This is a wound that is caused by forcible separation (shearing) away from the underlying tissue e.g. dog bite, RTA
39
What is degloving and what is it caused by?
This is a type of avulsion wound where there is a large section of skin, and associated blood supply, lost from the underlying tissue. These wounds are often associated with RTAs and often found on the limbs
40
What is a burn and what is it caused by?
There are various causes of burns and scalds - it is useful to understand what effect they can have on tissue. They will cause immediate tissue damage but some e.g. chemical burns will continue to cause damage. The severity of the burn is dictated
by the causative agent, the surface area affected and the depth to which it extends.
Burns can be classified as first, second or third degree. First degree burns are superficial only involving the epidermis; second degree burns extend into the dermis; and third-degree burns extend beyond the dermis into the hypodermis/subcutaneous area. Contamination/infection is a main complication of burns as is fluid loss leading to hypovolaemia and hypoproteinaemia.
41
What are the 4 main types of haemostasis?
pressure
digital pressure
elevation
torniquet
42
What different ways can pressure be applied when aiding haemostasis of a wound?
Pressure
This can be direct pressure over the site of bleeding or by application of a clean or sterile dressing over the affected area. Minor bleeding e.g. capillary or small venous haemorrhage will often be managed adequately in this way. Bleeding may also be
controlled by application of a sterile dressing and bandage in many cases.
Digital pressure over the site of major arteries (pressure points) can also be used, for example pressure on the femoral artery can reduce blood pressure in the distal ipsilateral limb and so aid the control of bleeding. Other superficial arteries which may be used include the medial palmar artery just distal to the stopper pad (which supplies the forepaw); the coccygeal/caudal artery that supplies the tail (ventral surface); and the brachial artery which runs in the axilla and supplies the forelimb.
43
How can elevation aid haemostasis of a wound?
Elevation
Elevating a bleeding limb above the level of the heart may help to reduce bleeding from this area and encourage haemostasis. This is only really useful where the patient is either amenable; or is already sedated or anaesthetised.
44
How can a tourniquet aid haemostasis of a wound?
Traditional tourniquets may be applied proximal to a wound on a limb. If the tourniquet is narrow, then it may be tightened to stop blood flow for a maximum of
five minutes: after this it MUST be loosened to allow blood to flow to the area again, otherwise avascular necrosis can occur due to significant damage to ‘neurovascular structures’ (Aldridge and O’Dwyer, 2013). If the tourniquet is wider (5-10 cm bands),
then longer periods of pressure can be applied (up to 10-20 minutes) - this can, however, result in damage to motor neurons and so is not advised where
preservation of the distal limb is being attempted.
Alternatively, blood pressure cuffs, used for blood pressure monitoring, may be placed around the proximal limb and inflated to a pressure of around 20-30mmHg greater than the measured systolic blood pressure of the patient. These can be left in
place for up to six hours (Aldridge and O’Dwyer, 2013). Remember, however, that if a patient is fluid resuscitated the systolic pressure may rise above that initially recorded when the pressure cuff was applied.
45
How long can a tourniquet be left on a wound to aid haemostasis?
If the tourniquet is narrow, then it may be tightened to stop blood flow for a maximum of
five minutes: after this it MUST be loosened to allow blood to flow to the area again, otherwise avascular necrosis can occur due to significant damage to ‘neurovascular structures’
If the tourniquet is wider (5-10 cm bands),
then longer periods of pressure can be applied (up to 10-20 minutes) - this can, however, result in damage to motor neurons and so is not advised where
preservation of the distal limb is being attempted.
Alternatively, blood pressure cuffs, used for blood pressure monitoring, may be placed around the proximal limb and inflated to a pressure of around 20-30mmHg greater than the measured systolic blood pressure of the patient. These can be left in
place for up to six hours
46
If a tourniquet is required for management of haemorrhage of a wound what is generally required?
Generally, if a tourniquet is required, surgical intervention with ligation/reanastomosis of the affected vessel will be required.
47
What should be done after haemostasis of a wound has been achieved?
Once haemostasis is achieved, the wound should be covered with a sterile dressing until such times as the patient is suitably stable for a full wound assessment/evaluation. If there is a lot of tissue loss/contamination, the wound may be packed with sterile, water-soluble gel e.g. K-Y Jelly ® before the dressing is applied. Even if the patient is not a suitable candidate for sedation/ anaesthesia for wound exploration and debridement, some initial careful wound management (clipping, lavage) can often be performed at this stage, as long as the patient has
appropriate analgesic cover
48
How do you prepare a wound prior to cleaning and lavage?
Initially, following packing, the hair should be clipped from around the edges to allow assessment of the extent of the wound. This may be performed with electrical clippers. Care should also be taken not to make the wound larger or cause clipper rash by over-zealous use of the clippers. The clipper blades must be sterile and sharp to prevent further trauma/ contamination.
Hair around the edge of traumatic wounds may be removed more effectively using sterile scissors, moistened with sterile 0.9% saline, to catch the hair as it is cut. Extreme care should be taken to clip hair away from open wounds - the wound should be packed with a sterile aqueous gel prior to clipping to prevent hair entering the wound; alternatively, sterile surgical swabs, moistened with 0.9% sodium chloride solution may be placed on or packed into the wound during clipping. These can subsequently be discarded, or the wound may be temporarily closed over them.
This helps to prevent excessive drying of the wound (desiccation), which will prolong the healing time- wounds heal best in moist environment
49
What type of wounds should not be lavaged and why?
Deep wounds, especially puncture wounds, should NOT be lavaged until the full extent of the wound is known, following wound exploration. Flushing may push dirt, debris and microbes deeper into the wound or into a body cavity.
50
What needs to be administered to the patient prior to flushing of a wound?
Following clipping, fluids are used to flush the wound of any debris - lavage. This should be performed in the sedated/ anaesthetised patient after appropriate
analgesia has been administered as flushing open wounds can be very painful.
51
What is the goal of wound lavage?
The goal of lavage is to mechanically remove/loosen contaminants, debris, microbes and necrotic tissue but without causing damage to the fibroblasts
associated with wound healing. It is the pressure that is used and the volume of fluid that is important
52
What should lavage solutions not contain?
Lavage solutions should not contain detergents, antibacterials, or anything else which may cause tissue damage and delay wound healing
53
What is the initial management of a heavily contaminated wound?
Contaminated wounds should be lavaged,
initially, with copious amounts of warm fluids- ‘the solution to pollution is dilution’. If the wound is heavily contaminated then tap water, delivered through a shower head, can be used at this stage
54
What properties should a sterile, wound lavage possess?
This should be followed by sterile, wound lavage- the fluid chosen should be isotonic, iso-osmolar, sterile and non-irritant
55
What 4 different types of fluids can be used for wound lavage?
Fluids that may be used for sterile wound lavage include:
1. Sterile saline (0.9%)/ lactated Ringer’s solution
2. Chlorhexidine (0.05%)
3. Povidone-iodine 0.1-0.2% (containing iodine at 0.01-0.02%)
4. Tap water (for heavily contaminated wounds)
There is much discussion about the best fluid to use for wound lavage- it is important that the fluid is not harmful (cytotoxic) to the cells required for wound healing fibroblasts
56
What fluids should not be used for wound lavage?
Fluids that should not be used to flush wounds include:
1. Hydrogen peroxide
2. Concentrations of chlorhexidine >0.05%
3. Concentrations of povidone-iodine >1%
The standard concentration of both chlorhexidine and povidone-iodine that would be used for sterile skin preparation prior to surgery would cause tissue
damage where a wound is present.
Commercially available iodine solutions are usually 10% concentrations providing 1% iodine. A povidone-iodine solution of 0.1-0.2 % will contain 0.01- 0.02
% iodine. It is essential that the correct dilution can be made.
Hydrogen peroxide and strong solutions of chlorhexidine and povidone-iodine can cause tissue damage- prolonging the inflammatory phase of wound healing and retarding the proliferative phase of wound healing.
57
What is the ideal pressure for wound lavage?
The ideal pressure for wound lavage has not been established (Murgia, 2016) but 7-8 PSI has traditionally been suggested. The pressure required for wound lavage should be enough to dislodge contaminants yet not so much that it causes tissue damage or forces debris further into the wound. Pressures of ~ 5-10 psi or 8-12 psi are also considered appropriate
58
In what ways can you deliver lavage fluid at the ideal pressure?
Ideally the fluid bag and extension set are placed inside a pressure cuff which is set to 300mmHg. This circumvents the need to refill the syringe and provides constant lavage at the required pressure.
Another option, although less ideal, is to deliver lavage fluid using a bag of isotonic fluids with a giving set and three-way tap; a 35ml syringe and an 18 or 19-gauge
needle are attached to the remaining ports on the three-way tap. This system allows the syringe to be filled repeatedly with fluid throughout the period of lavage.
Manually squeezing punctured bags of lavage fluid is inadequate for pressure irrigation of ~ 8-10 psi. Similarly irrigating the wound using bulb syringes will not deliver an adequate force. It is now recognised that the traditional technique using a 20-30 ml syringe with an 18 or 19 gauge needle is likely to deliver fluids at a far higher pressure than 7-8 psi and could cause tissue damage (Fossum and Read, n.d.). Low pressure irrigation may be used, however, if there is a risk of driving contaminants further into a wound
59
What volume of fluids should be used for wound lavage?
The volume or duration of lavage that should be used is somewhat subjective. 1 litre of fluids may be enough for small, minimally contaminated wounds; large or very
contaminated wounds may require 2-3 litres or more
60
When should a wound be swabbed and why would this be carried out?
It may be considered appropriate to swab a wound for cytology and possibly culture and sensitivity- especially if the wound is infected or the response to lavage and
debridement is poor. It is important, however, not to contaminate the wound further so the technique must be sterile. All contaminated wounds will, of course, have bacteria present. Slides can be made in-house to identify the presence of bacteria, following lavage, and their morphology (rods and cones); and the number and
presence of neutrophils etc.
61
What is wound debridement?
Debridement is the removal of devitalised, necrotic, infected tissue, fibrin, gross contaminants and/or foreign material from a wound. It can be performed in various ways, depending on the nature of the wound and associated patient factors.
62
After wound debridement what should be noted?
After the wound has been thoroughly lavaged, it should be fully explored noting any damage, tissue loss or potential complicating factors. This allows for appropriate planning of subsequent management. Thereafter the wound should be debrided to
remove any materials that would support or encourage bacterial growth.
63
What are the most common techniques for wound debridement?
The most common techniques used are surgical and mechanical debridement- other options include osmotic e.g. honey or sugar dressings (Moores, 2009) and
enzymatic e.g. medical maggots
64
What debridement technique should wounds with significant debris and necrotic tissue be treated with first?
all wounds with significant debris and necrotic tissue are treated with surgical debridement first. Failure to remove such material will increase the likelihood
of infection and delayed/non-wound healing.
65
What is surgical debridement?
Conservative, sharp debridement involves the removal of necrotic tissue only. This may be done in a sedated patient. Surgical debridement involves the removal of both necrotic and healthy tissue (e.g. to remove ragged edges). For surgical debridement, the patient should be anaesthetised or the procedure performed under sedation with adequate local anaesthesia. the patient should be anaesthetised or the procedure performed under sedation with adequate local anaesthesia.
66
What is mechanical debridement?
Mechanical debridement involves the use of dressings e.g. wet to dry. As these are removed, so is necrotic tissue. As this is painful, the patient should be sedated/
anaesthetised and have appropriate analgesia. Appropriate use of autolytic hydrogel dressing can also be considered.
67
What is dehiscence?
wound breakdown ‘dehiscence’
68
What options can be considered if surgical closure of a wound is not an option?
If surgical closure is not an option, other options will be considered dependent on the situation. Ongoing open (non-surgical) wound management will be continued in
many cases with repeated lavage and debridement. The wound will be dressed and kept covered in between
69
What is required when a wound is surgically close but has a large volume fluid discharge?
If surgical closure of wounds with a large volume fluid discharge, a large area of dead-space or possible residual contamination is contemplated (e.g. bite wounds), it is likely some form of surgical drain will be required. Whether a passive or an active suction drain is used, it is essential that it is managed appropriately to avoid problems with wound healing.
70
What properties should suture material for wound closure possess and why?
All suture material could support bacterial colonisation of contaminated wounds. To minimise this possibility, the suture material used for wounds should be synthetic, monofilament and non-absorbable. This should prevent the bacterial wick associated with braided material; and the inflammatory reaction associated with absorbable sutures.
71
What are the 4 different types of wound closure?
primary closure
delayed primary closure
secondary closure
secondary intention healing
72
What is primary wound closure?
primary closure- the wound is surgically closed immediately after lavage/ debridement
73
What is delayed primary wound closure?
delayed primary closure- the wound is surgically closed after 3-5 days of wound management
74
What is secondary wound closure?
secondary closure- the wound is closed after the development of a granulation tissue bed
75
What is secondary intention healing?
secondary intention healing- the wound is managed conservatively and left to heal by granulation and re-epithelialisation.
76
When is it appropriate to surgically manage a wound?
The key to surgical management of wounds is only to attempt to close those that are considered clean or clean-contaminated; and where there is no tension on the wound edges once the wound is closed. Appropriate initial management of infected wounds aims to convert them to clean-contaminated wounds, thus decreasing the likelihood of breakdown
77
What does there need to be for a wound to heal?
For wounds to heal there needs to be a good blood supply and nerve supply to the area; no barriers to healing (e.g. infection, necrotic tissue etc.) and minimal
movement of the wound (stability).
78
What are the advantages of using dressings in wound management?
Dressings
Dressings should prevent further contamination of the wound; provide analgesia; and prevent damage due to physical trauma, maceration (from excess tissue fluid), or desiccation thus, providing the ideal environment for wound healing.
79
Why is a wound dressing beneficial when a primary closure is performed?
Even when primary closure is performed, a wound dressing is beneficial: allowing a fibrin seal to establish and limiting the chance of nosocomial infection.
80
What classifications can wound dressings be put into?
```
Dressings can be:
• Passive, interactive or bioactive
• Adherent or non-adherent
• Absorptive or non-absorptive
• Occlusive or non-occlusive
```
81
What does the selection of a correct dressing to apply to a wound depend on?
Selection of the correct dressing to apply to a wound depends on:
1. Whether further debridement of the wound is required
2. The amount of exudate that the wound is likely to generate
3. The degree of instability of the wound
4. The location
82
What is a wet to dry dressing and what type of wound is it typically used for?
If a wound is contaminated or infected a wet to dry dressing may be used initially i.e. sterile gauze swabs, moistened with sterile saline are placed on the wound.
Absorbent dressings are placed over the moist swabs which will adhere to the wound surface as they dry. When the dressing is removed (under sedation or
general anaesthesia for welfare reasons), the surface of the wound is mechanically debrided.
83
Why is a wet to dry dressing not appropriate in the later stages of wound healing?
This type of dressing will damage healthy granulation tissue so would not be appropriate at a later stage of healing.
84
Give some examples of autolytic debridement dressings?
Autolytic debridement can also be used in this situation. Honey dressings and hydrogels are often used to facilitate autolytic debridement although other dressings are also suitable
85
What type of dressing and secondary layer is appropriate for a wound with large volumes of exudate?
Wounds that are producing large volumes of exudate may be contaminated or infected. Non-adherent, absorptive dressings can be used to absorb excess fluid away from the wound surface, whilst maintaining enough humidity to encourage cellular repair. An example would be Allevyn® (Smith & Nephew) or other
polyurethane foam dressings.
After application of the primary dressing, a secondary layer is applied. This layer absorbs fluids and provides padding- providing both comfort and immobilisation of
the wound. This layer may be an absorbent cotton-wool material or orthopaedic padding e.g. Soffban™ or Ortho-band™.
86
What is the benefit of a tertiary layer when applying a bandage on a patient?
Conforming bandages and, sometimes, support dressings are used to create the tertiary layer. The tertiary secures the dressing and secondary layer and provides support and protection. The nature of the three layers will depend on the nature, age and site of the wound: e.g. more padding is required where the wound has less soft tissue covering and is more unstable.
After dressing the primary wound a bandage will frequently be required. This may need to be a support bandage e.g. a Robert Jones bandage or a bandage
incorporating a splint to minimise movement at the site.
87
How often should a wound dressing and bandage be changed?
Appropriate dressing and bandage management is vital for wound healing.
Dressings should be changed regularly to assess the wound- this will be more frequent in the initial stages of wound management. In all cases, they should be
changed before tissue fluid wicks to the surface of the bandage otherwise external bacterial access, through the dressing, to the wound is a risk – ‘strike-through’.
Following severe trauma, dressings should be changed daily to allow inspection, lavage and debridement as required. Simple wounds, that are closed primarily, may
have dressings changed every 2-3 days as required. It is essential that an aseptic technique is used for all dressing and bandage changes.
88
Why is it important to manage stress in a patient with a healing wound?
Wound healing will be delayed by high circulating levels of cortisol – thus, it is essential to limit stress within the practice environment and provide appropriate analgesia
89
What is antibiosis dependent on in wound management? What should it aim to manage?
Antibiotic administration may also be required. As discussed by Williams and Moores (2009) ‘antibiotics are not a substitute for effective wound lavage or debridement’. The requirement for antibiosis in each case must be based on clinical judgement and awareness of antibiotic resistance- there is discussion and controversy over the correct protocol to follow. It is dependent on patient factors, nature or wound, location and age of the wound.
Antibiotic use should aim to manage established or developing infection, whilst avoiding resistance and nosocomial infections.
90
Are prophylactic antibiotics appropriate in wounds over 4 hours old? How would this be managed?
Prophylactic antibiotics are not appropriate in wounds that are > 4 hours old.
These wounds are infected so antibiotic choice should be based on culture
and sensitivity.
91
When are prophylactic antibiotics indicated in wound management?
Prophylactic antibiotic use on contaminated or clean-contaminated wounds that are < 4 hours old is advisable, using a bacteriocidal antibiotic that is
active against the likely pathogens.
92
When can antibiotics be stopped in wound management?
Antibiotics can be stopped once granulation develops
93
When are antibiotics not necessary in wound management?
If the wound is fresh (<4-6 hours old) when lavage and closure is performed; and primary closure of the wound is achieved, antibiotic therapy may not be necessary.
94
When are antibiotics necessary in wound management?
However, if the wound is to be left open, or is deep, or involves vital structures such as tendons, bone and ligaments, then antibiotics are necessary initially. Evidence suggests that if intravenous antibiotics are given early in the treatment plan (< 4 hours), then these will reach the site of contamination in tissue fluids before the area becomes protected by fibrin clots etc. If the wound is older than 4 hours, there is no benefit in prophylactic antibiosis so a deep swab should be obtained for culture and sensitivity, before lavage
95
When might topical antibiotics be indicated for wound management?
Some topical antibiotics may also be of use, particularly where extensive wounds are concerned e.g. with burns. In these cases, secondary contamination of the wounds
with environmental bacteria such as Pseudomonas spp. is common. Antibiotic preparations such as silver sulfadiazine (Flamazine® Smith & Nephew) are useful for their antibacterial effects; other topical antibiotics can, however, delay wound healing and promote resistance.
96
What is it important to consider with the location of a head wound?
Location
This is important to consider as some areas will inevitably involve delicate structures such as the eyes, ears and mouth. Depending on the depth of the lesion, vital structures may also be affected e.g. major nerves and arteries, particularly in the region of the cranial neck.
Other factors
With any head wound, an assessment of patient vital signs should be made early on particularly of the nervous system regarding the level of consciousness. Depression fractures of the skull, associated with head trauma, are common and may cause damage to the brain, brainstem and proximal spinal cord.
97
What iodine dilution rate is suitable for the periorbital skin?
Povidone-iodine antiseptic solution (1:50 (0.02%) dilution) can be used to clean the peri-orbital skin without causing injury to the cornea
98
What is the initial management of a head wound?
Initial cleaning and management should be as described in section 6.1.3. Care should be paid to any wounds involving the eyes and muco-cutaneous junctions as these can deteriorate quickly, resulting in permanent damage. When cleaning wounds around the eye, care should be taken to ensure that surgical scrub solutions containing chlorhexidine or iodine do not encounter the eye as they will damage the cornea. Povidone-iodine antiseptic solution (1:50 (0.02%) dilution) can be used to clean the peri-orbital skin without causing injury to the cornea. Alternatively, isotonic fluids could be used e.g. lactated ringers or 0.9% saline.
99
How would you dress a head wound?
Dressings used are as described in section 6.1.3. However, there are specific aspects of head wounds that make dressing these a challenge-notably the lack of any sites to anchor dressings to prevent them slipping/sliding off. There are two possible solutions- one is to bandage the whole head and neck of the patient; the other more sensible approach is to anchor the dressing around the ears. If the injury involves an ear, apply the dressing to the area and then bandage the affected ear (ideally flat to the head); use the opposite ear as an anchor around which to secure the dressing. Care should be taken to avoid compression of the neck especially if there is any concern regarding traumatic brain injury and raised intracranial pressure.
Additional protection can be provided for many head wounds by using Elizabethan collars, or similar soft collars, to stop animals from dislodging dressings/traumatising wounds. Where an ocular wound is known or suspected, an Elizabethan collar should be put on the patient immediately to prevent self-trauma. A doughnut type collar is NOT suitable for this purpose.
The patient should be kept in a quiet environment ideally in dimmed lighting.
100
How are wounds to the eye dressed?
Wounds to eyes should not be covered, of course, with standard dressings. Small wounds may not need dressings, but eye drops may be administered instead. Large or deep wounds may be managed using veterinary contact lenses; surgical options include conjunctival flaps/grafts or eyelid flap surgical techniques.
In addition, where eye damage is involved, frequent assessment of the patient demeanour and inspection of the wounds is essential to ensure prompt recognition of any deterioration.
101
What should the initial assessment of a chest wound focus on?
The initial assessment should focus on the respiratory system, to determine if there is any evidence of respiratory compromise from pulmonary contusions or pleural space disease e.g. pneumothorax. Regular, on-going assessments should be performed as the patient’s breathing may continue to deteriorate after the initial presentation. An assessment of respiration pattern and depth is required and the chest should be auscultated to assess for crackles and wheezes etc. In addition, mucous membrane colour and cardiovascular function should be assessed; where possible, blood gas analysis and pulse oximetry should also be performed to determine the impact of the chest injury on respiration. Respiratory signs may be secondary to pneumothorax, pleural effusion/haemorrhage, pulmonary contusions, atelectasis, lung lobe collapse or torsion.
102
What problems can occur with Penetrating wounds of the thorax?
Penetrating wounds of the thorax can accompany chest wall injuries. Some will be immediately obvious e.g. crush injury but others e.g. puncture wounds will not. As well as infection issues, an open pneumothorax will develop if there is a penetrating wound of the thorax which is not sealed. If air can be felt or heard being sucked into the thorax through a chest wound, it is important to occlude the hole securely, as
soon as possible, with a temporary, sterile dressing. This will convert an open pneumothorax to a closed pneumothorax and allow thoracocentesis to be performed if necessary. With a penetrating wound, an exploratory thoracotomy is likely to be indicated to allow appropriate wound management, lavage, visual inspection etc.
103
What is a flail chest?
Another potentially life-threatening chest wound is one associated with flail chest i.e. where a segment of ribcage is detached from its vertebral and sternal anchor and so is functioning separately and oppositely to the rest of the chest wall. Because of
having multiple, adjacent, segmental rib fractures, the flail segment will move in an opposite direction to the rest of the thorax during respiration causing marked pain to the patient and possibly causing further damage.
104
What is the initial management of an open chest wound?
In the case of open chest wounds, after occluding the wound with a sterile dressing, it is likely that the patient will need to be prepared for thoracocentesis. The decision to perform thoracocentesis will be based on the veterinary surgeon’s assessment of the patient - it is good practice to anticipate and prepare for this procedure. As with any patient with respiratory injury, it is crucial to assess the patient’s breathing and
ensure no interventions cause the patient’s condition to deteriorate further. The patient may require additional oxygen. If a pneumothorax is a possibility, aseptic preparation of an area of the thorax, dorsally, around the 8th intercostal space should be performed. If there is a large volume pneumothorax, thoracocentesis may not be enough to maintain lung inflation- therefore a chest drain may need to be placed.
Please refer to Unit 3 Outcome 2 for further details on thoracocentesis, chest drains and oxygen therapy
Care should be taken NOT to flush wounds of the thoracic wall until an assessment has been made to ensure that the wound does not enter the thorax.
105
How do you dress a chest wound?
With large wounds, a sterile dressing should be placed over the wound. The primary dressing should be held in place with conforming bandages wrapped around the chest. These should be sufficiently tight to keep the dressing in place, but not so tight as to restrict chest movement.
106
What ongoing wound management may be needed for a chest wound?
All penetrating thoracic wounds must be surgically explored, lavaged, debrided and reconstructed. Flail chests may need wiring to the adjacent stable, non-fractured ribs- although frequently they can be managed conservatively. Soft tissue deficits
may be managed by local advancement of skin or skin flaps. Surgical management will be delayed until the patient is stabilised if any chest wall deficit can be covered with dressings adequately to allow re-inflation of the lung by thoracocentesis or chest drain. In any case where chest penetration has occurred, and a subsequent pyothorax is suspected or already present, a chest drain is essential.
Excellent analgesia is required with thoracic injuries to ensure the patient’s respiration is not further compromised. Regular pain assessment is required using a validated system
107
How do you carry out an assessment of abdominal wounds?
As with any trauma case, initial triage assessment should be focused on initial evaluation of the cardiovascular, respiratory and neurological system. Abdominal trauma may result in haemorrhage from various locations: the spleen, liver, renal arteries or other major blood vessels. In addition, there may be damage (and leakage of contents) from the urinary bladder, gall bladder, or gastrointestinal tract.
The clinical signs may not necessarily be present on presentation and only become apparent as time elapses e.g. signs relating to bladder rupture will not be obvious initially. Ongoing close assessment of the patient’s general condition is therefore essential.
Puncture wounds e.g. dog bites, gunshot wounds or foreign bodies can penetrate the peritoneal cavity and result in peritonitis which may lead to sepsis. As with all puncture wounds these small wounds may not necessarily be obvious on initial presentation. It is very important to note any specific deterioration in the patient’s condition which could suggest an abdominal problem e.g. abdominal distension or guarding. Regular and thorough patient assessment should allow for early identification of clinical signs that may be associated with abdominal injuries e.g. signs of hypovolaemia (e.g. pallor of the mucous membranes, prolonged CRT, tachycardia and weak/ absent peripheral pulses) secondary to haemorrhage or
clinical signs suggestive of sepsis (e.g. pyrexia, brick red mucous membranes, tachycardia, bounding pulses etc.) if peritonitis is present.
108
What is the initial management of an abdominal wound?
As with chest wounds, if there is suggestion / evidence of a full thickness perforation of the abdominal wall, the wound should not be flushed at this stage. This prevents further introduction of debris and bacteria into the abdomen and, hopefully, decreases the risk of peritonitis developing. Full thickness wounds must be fully explored- this necessitates performing an exploratory coeliotomy and opening into the abdomen under general anaesthesia. These patients are anaesthetic challengesthey should be stabilised as much as possible prior to anaesthesia but the basic
rules of wound management apply. The sooner the wound can be lavaged the better to limit infection. Large volumes of warmed, sterile, isotonic fluids will be required (minimum 200ml/kg) (Aldridge and O’Dwyer, 2013). Even with abdominal evisceration, a patient may have a favourable outcome with prompt and appropriate management (Gower et al. 2009). In this situation, it is important not to attempt to return the contents to the abdomen. Ideally, they should be carefully lavaged with sterile, isotonic fluids before being covered with saline-soaked, non-adherent
dressings and bandaged loosely to the abdominal wall. An Elizabethan collar should be applied and the patient observed constantly for evidence of self-mutilation.
109
What diagnostic procedures will aid
| the diagnosis of abdominal haemorrhage, bladder rupture or peritonitis?
Ultrasound examination of the abdomen (FAST/POCUS techniques), radiography, abdominocentesis and fluid cytology/ biochemistry (see previous outcomes) will aid
the diagnosis of abdominal haemorrhage, bladder rupture or peritonitis.
Pneumoperitoneum (free gas in the abdomen) may be noted if there is a puncture into the abdominal cavity or there is rupture of a GI viscus. Positive contrast radiographic studies of the urinary tract will aid in the diagnosis of urinary bladder rupture as contrast media will leak into the abdominal cavity.
110
What should be considered when applying an abdominal dressing?
Dressings should be chosen as per the guidelines outlined in section 6.1.3. Pressure bandages may be applied for short periods of time should internal bleeding be present but care should be taken to assess wounds to the chest and diaphragm, before these are applied, as they may compromise movement of the diaphragm.
111
Wat ongoing wound management may be required for an abdominal wound?
Surgery is required where abdominal wall penetration has occurred- this allows the depth of the wound and the nature of the injury to be assessed; and the wound to be fully explored. Concurrent damage to other internal organs can be assessed and managed e.g. puncture, laceration of intestine etc. Splenic injuries may necessitate splenectomy as a means of controlling haemorrhage. The need for blood transfusion/ auto-transfusion should be anticipated, in cases of abdominal haemorrhage, as the volumes of blood that may be lost can be significant.
112
What is a fracture?
A fracture is a complete or incomplete break in the bone cortex which is associated with trauma.
113
How do you assess an open fracture?
Fractures, in general, result in instability, haemorrhage, inflammation and varying degrees of disruption to the blood and nerve supply. Most fractures cause the patient significant pain, especially if there is any movement at the fracture site. Fractures can be complicated i.e. there may be damage to other organs/ structures e.g. brain injury following a skull fracture. A clinical assessment should first include an examination for other more immediate and life-threatening clinical signs such as those associated with chest trauma, internal bleeding, pneumothorax, and ruptured bladder etc. The cardio-vascular, respiratory and neurological status should be assessed and monitored regularly. The pain associated with a fracture may affect a patient’s mentation. Open wounds, especially, can have a very dramatic appearance but it is crucial not to be distracted by their presence.
Significant haemorrhage can occur secondary to a fracture (e.g. femoral or pelvic fractures) and the patient should be assessed and resuscitated accordingly.
114
When first assessing an open fracture what is the initial aim?
Initially the aim is to control any life-threatening injuries e.g. haemorrhage, as alluded to above. Other considerations are managing fracture complications; limiting further contamination of open wounds; pain management and fracture immobilisation. N.B.
Full stabilisation and fracture repair require general anaesthesia which is not likely to be an option on initial presentation.
115
How do you avoid further contamination of an open fracture?
If there is an open fracture, further contamination should be avoided by careful application of a sterile, non-adherent dressing.
N.B. Once the patient is suitably stable to undergo sedation/anaesthesia any wounds should be managed as discussed previously with thorough lavage,
exploration and debridement; followed by appropriate dressing and support.
116
how can you limit further trauma and provide pain relief to a fracture when it initially presents?
One main aim of emergency fracture management is immobilisation of the affected area to limit further trauma to soft tissues from the unstable bone fragments- thereby reducing swelling, limiting internal bleeding and trauma to nerves and blood vessels;
reducing patient pain and improving comfort. In the emergency patient, it takes relatively little time to temporarily immobilise a fractured limb in a conscious patient this should be performed as soon as possible after the patient has been treated for any other life-threatening issues. It is essential, however, not to increase the patient’s pain by trying to immobilise.
A very effective way of temporarily stabilising the fracture is to limit movement, by placing the patient in a confined area with deep bedding, especially for fractures of the upper limbs e.g. femur, humerus. If there is any suspicion of a spinal fracture, it is essential to prevent patient movement.
Fractures distal to the elbow or stifle can be managed temporarily by applying a support bandage e.g. modified/Robert Jones bandage or a splint if the patient tolerates this; if not the patient should be cage-rested as described above until definitive fracture support or repair can be performed
117
What is a dislocation/luxation?
This is when there is displacement of the bones at the joint
118
What is the initial first aid treatment for a patient with a luxation?
Luxations are often closed wounds, unless the extremities are affected. Significant pain can be
associated with luxation especially if there is any movement of the affected bones.
Other life-threatening conditions should be assessed and prioritised initially.
Thereafter, the initial first aid of a luxation is to limit patient movement by putting it into a well-padded, confined area- N.B. no attempt should be made to reduce the luxation in a conscious patient. Early appropriate analgesia from a veterinary surgeon is essential to control patient discomfort.
Diagnostic radiography should not be performed until the patient can tolerate general anaesthesia.
119
What type of sling is used for hip luxation?
The Ehmer sling may be used for a hip luxation where the dislocation is craniodorsal (most common type). This is a figure of eight sling which starts on the lateral aspect of the thigh and extends to the metatarsal region- it internally rotates the hip and lifts
the foot off the ground.
120
What is the ongoing treatment of luxation following limiting movement and pain relief?
Once the patient can be anaesthetised, the affected area should be X-rayed to confirm the presence of a luxation and to identify any other abnormalities e.g. chip
fractures. If there any wounds, these should be managed as previously discussedexplored, lavaged, debrided and dressed. Following reduction, various bandaging techniques may be used to decrease the likelihood of repeated luxation
121
What sling is used for shoulder dislocation?
The Velpeau sling is used in a similar manner to the Ehmer sling- it is designed for medial dislocations of the shoulder. This bandage wraps around the metacarpal area, then over the shoulder and around the body to both flex the limb and rotate it slightly outwards. Medial, congenital shoulder dislocations are relatively common in small dogs. If larger dogs dislocate their shoulder, it is usually traumatic and in a lateral direction. A Velpeau sling is not appropriate for this luxation- a Spica splint should be used instead.
A simple carpal flexion bandage may be used to prevent the patient from using the forelimb but allowing free movement of the upper limb and shoulder. It should therefore not be used with upper limb fractures
122
Why must Ehmer slings be applied with extreme care?
Ehmer sling dressings must be applied and managed with extreme care as avascular necrosis of the distal limb can arise when they are not applied correctly.
Where the hip dislocation is ventral, the hind limbs can be hobbled together- this is performed by placing a rigid support between the two hind legs at the level of the mid tibia. This can be done by using thermosetting cast material and then bandaging this in place. Care must be taken to keep both legs parallel to each other, by careful measurement of the length of the hobble.
123
In what situations would you not apply a bandage?
Cats can be a particular problem as they often will not tolerate dressings required for luxation management- therefore, with closed injuries it may be preferable to cage rest them and ensure adequate analgesia is provided.
Fractures of the pelvis, femur, scapula and humerus should not be bandaged as the large muscle bulk around these bones will stop the dressing or splint from providing adequate support and may cause complications- the surrounding musculature
should provide support.
Additionally, spinal fractures are generally not amenable to dressings and bandages attempting to apply them could cause dangerous patient movement. The exception to this is when there is a suspected fracture of the cranial cervical area e.g. the
atlanto-axial joint. In this case stabilising the cervical vertebrae is essential to prevent further spinal cord damage. A padded dressing may be carefully applied around the neck and then splinted to the ramus of the mandible and scapula, using a long splint
of light wood or thermosetting cast material on either side of the body. This will effectively lock the neck in one position. There is a risk with this technique of
applying excessive pressure over the trachea which could cause hypoxia or asphyxiation. Consequently, constant monitoring of these patients is essential.
124
Why is surgical repair of most fractures necessary?
Surgical repair of most fractures is necessary. Articular fractures need rapid, accurate fixation to optimise the likelihood of return to normal joint function otherwise a reduction in joint function and development of degenerative joint disease, post treatment, is likely.
125
are antibiotics required for an open fracture? if so how is the type of anbiotics determined?
As infection is a major cause of delayed or non-unions, antibiosis is indicated in the management of open fractures (Cross and Swiontkowski, 2008). As discussed in the management of open wounds, the age of the wound should dictate the antibiotic protocol. If the fracture is < 4 hours old, broad-spectrum antibiotics, effective against streptococcal, staphylococcal and Gram-negative bacteria, are likely to be administered prophylactically (Williams, 2009). Ongoing antibiosis is likely to be required with the length, type of antibiotic and route of administration being influenced by the nature of the fracture and infection. As with other wounds, choice of
antibiotic should be based on culture and sensitivity. Prophylactic antibiosis, ideally in accordance with WSAVA guidance (2014), is generally used prior to and during surgical repair of fractures to limit the risk of
surgical site infections (SSI). Ongoing antibiosis is ideally based on culture and sensitivity from swabs taken at the time of surgery.
It is also essential that a very strict aseptic protocol is adhered to and strict theatre infection control is practiced
126
how do you monitor for tissue ischaemia on a bandaged limb?
Care should be taken to monitor perfusion of the limb/area bandaged to ensure ischaemia does not occur. Where possible, the nails of the third and fourth digits should be left out of the bandage. Should swelling occur, the nails will start to splay outwards from each other. Other signs include lack of sensation and warmth in the exposed digits and signs of irritation and pain- the patient is likely to be chewing the dressing, often frantically.
127
If there is a skin wound over a fracture how often should the bandage/dressing be checked/changed?
If there is a skin wound, then the dressings should be
changed daily, initially, until the wound is clean and starting to granulate. After this, performing wound checks every 2-3 days is acceptable until wound closure occurs or surgical closure is undertaken.
128
If there is no skin wound over a fracture how often should the bandage be checked/changed?
If there is no skin wound, then reassessing the bandage (not removing it) after 24 hours is advisable. After that the bandage should be checked every 3-4 days. It should be changed if there are any signs of movement, undue soiling or other potential complications.
129
What is compartment syndrome?
Compartment syndrome
This is where, due to tissue oedema or haemorrhage, the pressure within a section or ‘compartment’ of soft tissue reaches sufficient levels to occlude the blood supply resulting in ischaemia and necrosis (Clinician’s Brief, 2012). It generally occurs in cats and dogs, as with humans, in areas where bone and muscle fascial sheets meet (ossofascial compartments)- therefore it is most often seen in the limbs, particularly the tibial area, the thigh and the antebrachium. This syndrome can be made worse by the application of an overtight bandage. Wherever there is severe swelling of a
limb, this condition should be considered. Checking of distal arteries, such as the medial metatarsal and median arteries, should be performed to ensure blood flow is still occurring to the distal limb. If compartment syndrome is suspected then the veterinary surgeon should be alerted- pressure will need to be relieved as soon as possible to minimise tissue damage.
130
What should you do or not if a patient has a penetrating foreign body?
Penetrating Foreign Bodies
There are many possible penetrating foreign bodies which may affect veterinary patients. On initial presentation, it is important to assess the patient’s general condition, the type of penetrating foreign body and the location. It is vital to remember that no attempt should be made to remove a penetrating foreign body at this stage. Removal under the wrong circumstances could lead to a rapid decline in the patient’s condition e.g. sudden, rapidly fatal pneumothorax if thoracic foreign body; sudden rapid, serious haemorrhage if blood vessel affected; or loss of ocular contents if corneal foreign body. It is essential that the patient is constantly monitored to prevent of interference and self-trauma.
131
How do you assess a patient with a stick injury?
These are common in dogs and are often witnessed by the owner, allowing for a prompt diagnosis in many cases. Stick injuries often involve the oropharynx
(Charlesworth, 2013). Depending on when the wound occurred, patients may present with salivation; oral pain signified by agitation and pawing at the mouth;
facial, retro-pharyngeal or cervical swelling; cellulitis and discharging, sinus tracts.
The patient may be pyrexic, reluctant to eat and lethargic. Patients with oesophageal rupture will be systemically unwell. Radiography is often unhelpful in confirming a diagnosis as the stick fragments have the same radiopacity as soft tissue- although thoracic radiographs may show signs associated with oesophageal perforation e.g. pneumomediastinum or, in chronic cases, mediastinitis. Ultrasound examination may be of benefit in detecting the presence of non-radio-opaque foreign bodies.
Examination of the oesophagus using a flexible endoscope may be indicated to rule
out oesophageal penetration. Tracheoscopy may be indicated to rule out injury to the trachea. If a sinus is present, a radiopaque iodine-based dye may be injected into the sinus to highlight the affected area.
132
What is the initial management in a patient with a stick injury?
Care should be taken not to pull stick fragments, which are projecting from the oral cavity, until the patient can be anaesthetised- not only because of the discomfort
involved, but also because of the danger of leaving fragments of foreign material in the wound. A complete assessment of the injury cannot be accomplished in a
conscious/sedated patient.
The patient’s general status (cardiovascular, respiratory ad neurological) must be assessed and monitored, especially if there is any concern about perforation.
Wounds tend to be either around the base of the tongue or in the pharyngeal area considerable surgical exploration may be required to find all the fragments. If the wound extends into the cervical region a ventral midline surgical approach may be required to thoroughly explore the penetration tract. Wounds that are several days old may not have any obvious stick fragments left but may have started to develop
an abscess or discharging sinuses.
133
Are dressings required with stick injuries?
Dressings are not usually indicated as the lesions tend to be intraoral, other than any
discharging sinuses. It may be necessary to place drains following surgical
exploration of the cervical lesions, to promote drainage of any abscess that have
formed.
134
What ongoing management is required for stick injuries following initial treatment?
All stick fragments that are found on exploration of the wound should be removed at the time of surgery.
Where surgery is performed on cervical lesions, primary closure is usually performed with corresponding placement of a surgical drain e.g. Penrose or closed suction drain. The drain should be covered with a sterile dressing and bandaged- this should be changed at least daily, or more frequently if strike-through occurs. The exit site for the drain needs to be cleaned carefully, in an aseptic manner, at each dressing change to prevent scalding. Barnes (2012) discusses drain management. Systemic antibiotics are essential to manage infection associated with stick injuries broad spectrum antibiotics are likely to be used initially, with ongoing choice based on culture and sensitivity. Appropriate analgesia is also important.
135
how do you assess a patient for shot gun or bullet wounds?
Assessment
The tissue damage caused following gunshot wounds depends not only on the area of the body affected but also on the velocity of the bullet. Air rifle and gunshot
wounds are low velocity wounds whereas rifles cause high velocity wounds. Any area of the body may be involved. If the bullet has passed through the abdomen or thorax, extensive organ damage may be present- bowel injury/perforation occurs quite frequently. If bones lie in the path of the bullet, then these will often fracture.
Exit wounds for high velocity bullets are usually larger and more ragged than the entry wounds. Even if no vital organs have been affected, bullets are not sterile- they drag skin and hair into the wound at the entry point, causing contamination and making infection a likelihood.
