Wound Care Flashcards
What are the initial steps in wound care?
●Initial steps:
•Patient comfort and safety
●Positioning: Patient should be supine to avoid fainting. Any observers should be seated as well
•Initial Hemostasis
●Should be established with simple direct pressure
●When you are ready (well lit area, repair tools available) you can use more invasive measures
•Remove all rings and other jewelry from the injured area (i.e. finger
Initial steps:
•Pain relief
●Begins with gentle and empathetic handling of the injury
●Continues with a specific pain management plan
•Wound care delay
●If there are going to be delays in your repair then please dress the wound with some moistened gauze
What is important in the history of someone with a wound
(MADAM has hx of a PIT wound)
Basic and key history should be collected:
•Mechanism of injury (what caused the injury)
•Age of the wound (time since injury)
•Allergies
•Tetanus immunization status
•Medical history
●Diabetes
●Immunosupression
●Peripheral vascular disease
What is important with the examination of wounds
How is the wound assessed
Screening examination
•Basic vital signs
●A forehead laceration with hypotension and tachycardia is a more concerning injury
•Wounds and lacerations are often the visual result of systemic issues
●The laceration from a fall should lead to a discussion of why the person fell
•General examination should be performed
●The only injury is the one you visualize
Wound assessment
•A complete evaluation of an injury must include documentation of the following elements
●Location
●Length
●Estimated depth (visible tissues)
●Shape of wound
●Proximal and distal nerve function
●Tendon function
Wound assessment continued:
•Examination elements cont:
●Vascular integrity (blood flow through area)- check pulses in the part of the body affected by the wound
●Evidence of foreign body or contamination
●Evidence of fracture
●Alterations in range of motion
How do you prepare a wound if you decide to repair it ?
●Once you have decided to repair the wound, the area must be prepared
●This process involves several components
•Peripheral area cleansing
•Provision of anesthesia
•Wound irrigation and cleansing
•Wound exploration and or debridement
How do you cleanse the peripheral area of a wound
Why do you need a aesthetic before wound irrigation
What a aesthetic agents do you give when suturing a wound?
What does lidocaine toxicity cause?
How is lidocaine given(dosage)
Peripheral cleansing:
•The area adjacent to the wound should be as free of dirt and contaminates as possible
•Goal is to remove dirt, dried blood and other debris
•It should be visibly clean to the eye
Provision of Anesthesia:
•In most cases the wound should be anesthetized prior to irrigation
•It is difficult and often ineffective to attempt to irrigate a painful wound
•Depending on the location and extent of the injury one can choose local wound infiltration, versus a regional nerve block
Ketamine and diazepam for suturing. Don’t give ketamine alone
Lidocaine toxicity can cause arrhythmias and cardiac arrest. 3mg/kg as a max dose of 1% lidocaine for normal lidocaine. So 1ml of 1%=10mg
If it’s lidocaine plus adrenaline and not lidocaine alone, the dosage is 7mg/kg as Mac dose. Also 1ml of 1%=10mg
How is wound irrigation done?
What’s the use of wound irrigation
What can be sued to clean the periphery of the wound
What syringe can be used to achieve irrigation
When do you stop irrigation?
What happens if after all your irrigation, it doesn’t work and there’s still contaminant on the wound?
As part of the irrigation process the wound should be explored to the base
●Searching for any foreign material that could be a focal point for infection
●Also directly inspect for function of relevant nerves, tendons, arteries and joints
●Irrigation without exploration is incomplete at best
True or false
Once good anesthesia has been achieved
●“The solution to pollution is dilution.”
●Irrigation is the most effective way to:
1.Remove debris and contaminates from a laceration
2.Reducing bacterial counts on wound surfaces.
●We know that higher pressure irrigation is superior to low pressure systems
●The Current practice is based on a study using a 35 ml syringe attached to a 19 gauge catheter (7-8 psi)
●Most clinicians use normal saline as irrigation fluid
●However there are other solutions
•10-20 parts saline with 1 part 10% povodine-iodine solution
●No proven advantage to this solution
●Moistened sponges can be used to cleanse the wound periphery
●Irrigation can be achieved with:
•20ml or 35ml syringe attached to either
●A 18-19gauge catheter
●Or a Zerowet splash guard
•One can fashion a similar device by piercing the base of plastic medicine cup and placing it over the syringe and needle or catheter
Irrigation should continue until there is no visible skin or wound contaminates
●The amount of irrigation varies depending on the size, location and amount of contamination
●Typically 200-500ml
●The clean wound should appear pink with viable issue, may have some mild bleeding
●Should there be any contaminate not removed by the irrigation
●Then a moist 4x4 gauze can be used for manual debridement
●If unsuccessful then sharp debridement can be pursued with tissue scissors or a surgical scalpel
State the types of sound closure
Which types of wounds are not usually closed ?
There are 3 types of wound closures and they can be achieved with several different options.
●These types are:
•Primary closure (Primary intention)
•Secondary closure (Secondary intention)
•Tertiary Closure (Delayed primary closure)
Puncture wounds and animal bites.
What is primary closure
When is primary closure usually performed?
How do you do a primary closure?
●Primary Closure:
•Is mainly carried out on a laceration that is relatively clean, maybe minimally contaminated
•The wound is without devitalized tissues.
•Can be achieved by the use of sutures, wound adhesive, wound tapes or staples
•Is often performed during the “Golden Period.”
●The golden period refers to the first 6-8hrs following the time of the laceration or wound
●In clinical practice this period can extend up to 24hrs after the actual injury.
●There are no rigid guidelines but typically any injury that can be converted to a fresh appearing wound, after usual wound preparation can be primarily closed
Which wounds are closed using secondary closure?
What is secondary closure?
What is tertiary closure?
What kind of wounds are for tertiary closure?
When is tertiary closure done
Why do you delay a closure
Secondary Closure:
•Refers to wounds that are not closed by sutures but are allowed to heal by the formation of granulation tissue
•Is best for ulcerations, skin infections, abscess cavities, puncture wounds, partial thickness dermal burns and abrasions
Tertiary Closure:
•Applies to wounds that on initial presentation were not good candidates for primary closure
•Wounds that were contaminated by feces, saliva, vaginal secretions, or significant soil.
•Usually undertaken 4-5days after the initial cleansing , debridement and observation.
•Theoretically you delay closure to avoid the high risk of closing a contaminated wound
State three methods of wound closure
Sutures
Wound taping
Wound stapling
State two types of sutures and give examples of each type
Which parts of the body are the types of sutures used
Sutures:
•There are several different types of sutures, which are then further divided based on the size of the needle
•Can be broken down into two groups
1.Absorbable:
•Gut, chromic gut, Polyglyolic-acid(PGA), Polyglactin 910(vicryl), Polydioxanone(PDS)
Used inside the mouth Ideal wound candidates for absorbable sutures include the following: Facial lacerations, where skin heals quickly and prolonged intact sutures may lead to a suboptimal cosmetic result. Percutaneous closure of lacerations under casts or splints. Closure of lacerations of the tongue or oral mucosa.
2.Non-absorbable:
•Silk, Nylon(ethilon, Dermalon), Proypropylene (Prolene), Dacron(Mersilene)
You use non absorbable sutures for the skin,for a permanent wound, fascia, tendons, abdominal wall surgeries, or vascular anastomosis
One example of non absorbable suture. Prolene has a blue color making it easier to see in areas where hair is involved.
Suture sizing is just like the sizing for IV’s and injection needles- the smaller the suture, the larger the number.
The suture material smaller than the USP size 1, is 1-0 which is pronounced as ‘ought’ and smaller yet is 2-0, meaning 00 (pronounced ‘two ought’ or ‘two zero’). The more zeros, the smaller the material, so 6-0 is actually size 000000, and is pronounced ‘six ought’ or ‘six zero’.
Small suture sizes are represented by a number followed by zero. For example, a 3-0 suture is smaller than a 2-0 suture. An extremely small suture, such as one with a 10-0 size, might be used to repair an eye incision. As sutures get smaller, they lose tensile strength.
Sutures are numbered by their size relative to their diameter. Thick suture numbering is from 0-10, with #10 being the largest diameter.
So an 0-5 is larger than an 0-6suture
When is wound taping used
Which parts of the body can wound taping not be used
●Wound Taping
•Can be considered and used with:
●Straight laceration with little tension
•Forehead, chin, thorax, non joint areas of the extremities
●Laceration that have a high potential for infection
●A Laceration in a patient with thin fragile skin
•Elderly, those on chronic steroids
●Support of a sutured wound
•Cannot be used on the scalp, over the joint surfaces, or in a bleeding wound
When are wound staples used
Which parts of the body should wound staples be avoided
Wound Stapling
•Can be used in the following situations:
●Linear lacerations of the scalp, trunk and extremities
●As temporary rapid way to close an extensive laceration in acutely ill patients exampke Skin Staples used to close Cesarean section surgical laceration
•Should be avoided in areas that you are going to CT.
•They may also move during the process of obtaining an MRI
State four things you’ll need to suture a wound
What type of suture technique is used in the face
Suture Tools and Technique
●To repair the wound you will need:
•Suture Materials
•Needle driver(holds needles) or hemostat(clamps vessels(
•Scissors
•Forceps
A running (“baseball”) suture (Figure 1B) is used for long, low-tension wounds, whereas a subcuticular suture technique running suture is ideal for closing small lacerations in low skin-tension areas where cosmesis is important, such as on the face.
Why won’t you shave an area before doing a suture?
How many days does it take to remove sutures from the face,scalp,neck,upper and lower extremities,trunk
Cuz doing that causes a break in the skin and puts patient at risk of infection
Face:3-5 days
Scalp:7-9days
Neck:5-8days
Upper extremities:8-14days
Lower extremities:14-21days
Trunk:10-14days
These are generalizations. Your patient’s time will depend on several factors, general co-morbidities, wound tension, level of wound contamination.
