Wound care 2 Flashcards
wound approximation
layer matching wound edge eversion wound tension dead spcae spacing and style
layer matching
match ea. layer of wound edge to counter part
best achieved one side at a time
failure here = improper healing and increased scarring
wound eversion
needle penetrates skin at 90 degree angle to surface
technique for reduction in wound tension
placing adequate amount of suture to reduce tension and preserve capillary blood flow
should not be secure too tight so they dont strangulate tissue
dead space wound approx
use subQ sutures (deep/buried sutures)
wound undermining to eliminate empty space
spacing and style of stitch
number needed varies but distance between suture should equal to the bite distance from wound edge
knots on same side and not overlying wound
simple interrupted suture
MC used in simple wounds
instrument ties knot – double fist throw which offers good knot security, followed by 3-4 alternating single throws
spacing = should be equal to bite distance from wound edge
vertical mattress suture
repair large, gaping wounds in area of high tension
useful over extensor joints (elbows and knees)
deep AND superficial closure
1st bite = 1.5 cm from wound edge, crossing they to = distance on opposite side of wound
needle = reversed and returned with smaller bite 2-3 mm form wound edge
horizontal mattress suture use
approximate point of greatest tension of large wound
starting anchor suture in large complex wound
fragile skin, distributes tension along side
mechanism horizontal mattress suture
normal introduction to skin, then second bite is taken along opposite side 0.5 cm from exit site
continuous running suture use + con
long wounds, low tension, cosmetic
CON: one site of damage req. restart of entire process, purse string effect
continuous running suture technique
normal suture placed but NOT CUT
suture is continued to opposite side (like normal sowing)
SubQ suture
used to close gaping wounds (lots of dead space where hematoma formation risk is high)
increase strength of wound closure and eliminate dead space
deep suture placement
drive needle from deep to superficial then start superficially and go deep
knot is then tied deep and away from wound surface
bevel wound flap management
must use unequal bites from wound space
larger pit used on “flap” portion
subcuticular technique
cosmetic, monofilament used
limited to straight lacerations <4-6 cm
may prevent keloid formation
pass parallel thru wound (S formation) secured with tape/buried
v technique
wound is in a V shape
use to avoid devitalization of apex of laceration
flap portion of suture passes horizontally thru dermis
decried subQ fat )remove subQ fat in dermal superficial fascia plane)
V to.Y technique
break down non-viable edges
after debridement if flap is not large enough to fill defect, corner stitch used to close wound as a Y
y technique use
Y is used to close flaps w.o. viable edges
devitalized flap
extend the wound to an eclipse and close primarily
length of eclipse should > 3:1 of owund
dog ear deformity tx
extend wound at 45 degree angle on side of redundancy
excise redundant tissue and close
skin avulsions on distal finger tip
will heal completely with secondary closure
use gauze
contaminated hand wound
leave open and heal with secondary closure
subQ suture in hand or foot
NEVER place subQ suture in hand and fit due to increased infection risk
neurovasular exam
should always check NV status and document
capillary refill, distal pulses, 2 point differentiation
tendon injury
check ROM of extremities and digit
explore for FB
identify which one is injured and grade it (25% increments)
ear laceration
coverage of all exposed cartilage with skin
uncomplicated = close with interrupted 6-0 nonabsorbable suture
drain all perichondria hematomas, excise <5cm of cartilage and pull skin over
DO NOT SUTURE CARTILAGE
vermillion border laceration transects obicularis oris
approximate muscle and fix with 6-0 vicryl absorbable subQ suture
then approximate vermillion border and close with 6-0 nylon or proline suture
then close wound
vermillion border laceration DOESN’t transect obicularis oris
approximate vermillion border with 6-0 nylon or proline suture then close wound
thru and thru lip laceration
2 layer closer (epidermal side and mucosal side)
give prophylatic ABX for augmenting and clindamycin
what tongue lacerations require suture
ABSORBABLE
large (>1cm)
large, gapping wounds
those that need stitch for hemostats
anterior split tongue laceration
what tongue lacerations DO NOT require suture
<1 cm
non gaping
nail bed laceration Transverse lacerations
remove the distal nail and suture
repair nail bed with absorbable suture + digit block anesthesia
longitudinal lacerations
complete removal of nail
The original nail or Adaptec packing can be used to separate the eponychium from the germinal matrix
Complete avulsions to the tip of the finger
anesthesia, exploration, possibly x-ray and hemostasis with a Surgicele, tube gauze dressing
heal well without intervention
if > 1/3 XR for fracture
a partial avulsion of the finger tip
attempt to re-approximate the tissue with 1-3 sutures to provide a layer of protection while the wound is healing.
Empiric antibiotics
indicated for all complex/high risk wounds to prevent infection
The most commonly prescribed empiric antibiotic:
Cephalexin Keflex 500 mg tid x 5 days
strict return precautions:
Increased pain, bleeding, discharge, fevers, redness, swelling or red streaks moving away from the wound
Cat & Human bites
Treat with:
Amoxicillin-Clavulanic Acid (Augmentin) 875 BID x 10 days (first dose provided in the ED)
12-24 hour follow up wound check
management Wounds caused by broken glass:
X-ray all wounds you suspect any kind of retained foreign body, especially a glass foreign body.
CT scan is more sensitive
Through and through lip lacerations
ABX
high risk of infection and scarring
Consider x-ray to evaluate for retained tooth fragments
Empirically treat with empiric antibiotics
Pen-Vee K 500 mg qid x 5-7 days
Augmentin 875 mg bid 5-7 days
Clindamycin 300 mg tid x 5-7 days
Indications for Dermabond wound adhesive:
Used for simple lacerations that ~ 1-2 cm and easily approximated with gentle pressure
Avoid using Dermabond on: (6)
- Laceration > 2 cm
- Finger lacerations
- Lacerations over joints
- Laceration involving the eye brow or in proximity to the eyes
- Gapping wounds
- Wounds under tension i.e.: chin, joints, knees, elbows
Dermabond
when the adhesive dries they may feel a brief burning sensation
usually requires 3-4 layers of adhesive (new layer/minute)
has an antibiotic component to it, will go away in 7 days
puncture wound management
extend wound for irrigation with a 15 blade
Use a hemostat for exploration.
Do not suture closed give Empiric antibiotics
Keflex 500 mg tid x 5 days
Tetnus?
Definitive treatment of soft tissue abscesses
Incision and drainage
Results in marked improvement of symptoms and rapid resolution of the infection
Induration I and D
early stage of a skin abscess
I&D prior to localization of pus will not be curative
incision and drainage work up
U/S
CT
I and D Ultrasound use
localize the most fluctuant area within an abscess
determine the depth and proximity to vasculature (axilla, anticubital fossa or inguinal crease)
Large, deep abscess in proximity to major neurovascular structures
I and D CT scan use
determine the extent of abscess in the perineal area
Fournier’s gangrene vs. scrotal wall abscess
Large pilonidal cyst vs. perirectal abscess
Large perineal abscesses and abscesses that involve the rectum and deep abscesses that req. sx
Incision & Drainage Procedure
- Prep the area with antiseptic skin scrub (betadine, Chlorahexidine)
- Local anesthesia may only be partially effective due to the low pH of the infected tissue and local anesthesia will cause more distention and pain (IV opioids or benzo)
- 11 blade scalpel to nick the skin over the fluctuant area + linear incision along total size of cavity
- Hemostat probe to determine depth (most painful, but don’t skip)
- Wound irrigation
- loose packing of gauze (prevents closing and encourage draining)
- gauze on top and return in 2 days
paronychia
Inflammation iof lateral and proximal fingernail folds
paronychia Predisposing factors
Overzealous manicuring
Nail biting
Thumb sucking
Diabetes Mellitus
paronychia tx
Warm compresses
Oral antibiotic therapy
Incision/Drainage
paronychia I and D
Ethyl chloride or Digital Block prior to procedure
Prep skin with Betadine or Chlorahexidine
Sterile drape
Insertion of an 11 blade scalpel under the affected cuticle margin and extension of the incision along the lateral nail bed.
felon
Infection of the distal pulp
severe pain, swelling and erythema of finger PAD
Predisposing factors include: untreated paronychia or puncture wound
Treatment of a felon
is an emergency situation, requiring I/D
can lead to osteomyelitis, flexor tenosynovitis, permanent nail deformities and ischemic necrosis of the fingertip.
HERPETIC WHITLOW
viral infection of 1 finger
acute onset of vesicles, vesicopustuels, edema, erythema and pain
caused by HSV (tzanck staining +)
herpetic whitlow Clinical presentation
tingling, burning finger/hand pain disproportionate to clinical findings, fevers and lymphadenopathy
Mild ingrown toe nail
tx
Warm soaks 20mins. 3x per day
place a cotton wedge or dental floss underneath the lateral nail plate to separate the nail from the nail fold to relieve pressure.
70% of patient’s respond to this therapy.
Moderate to severe ingrown toenail
digital block + hemostat to separate nail
use scissors to remove portion of ingrown nail, silver nitrate cauterization
Apply bacitracin or mupirocin ointment 2-3 x per day.
