Wound Care Flashcards
layers of the skin
- epidermis
- dermis
- superficial fascia
- deep fascia
epidermis
cutaneous layer
few cell layers thick
undifferentiated from dermis
dermis
layer used to approximate for closure
easily ID
replaced by scar tissue
superficial fascia
subcutaneous layer
loose CT, fat, nerves
can be liberally debrided, susceptible to infection
deep fascia
thick, dense, fibrous off white sheath
supports and protects the muscle
requires closure
injury and tension line
laceration parallel to tension lines heal better than lacerations perpendicular
types of injury list
- shearing injury
- tension injury
- compression injury
shearing injury
sharp objects
little energy transfer
tension injury
higher energy transfer
potential devitalized tissue
higher risk of infection
compression injury
significant risk of devitalization
what to consider when deciding sedation or anesthesia
procedural complexity
duration
pt population
conscious sedation agents
ketamine
propofol
ketamine + propofol
considerations for LOCAL anesthetics
- location
- onset of action
- duration of action
location for local anesthetics
avoid lidocaine where?
in combination with epinephrine when
fingers, nose, lips, toes, anything that grows
when do you use bupivicaine 0.5%
nerve blocks
aka marcaine, sensorcaine
esters list
cocaine
benzocaine
tetracaine
Procaine (Novocaine)
Amides list
Bupivicaine (95% protein bound)
Mepivicaine (78% protein bound)
Lidocaine (64% protein bound0
lidocaine MOA
prevents sodium influx across nerve membrane = decreased polarization = inadequate formation of AP = no nerve impulse
lidocaine
immediate onset of action
MC used
epi extends duration of action
anesthetic buffering
mix 1 mL bicarb per 9 Ml 1% lidocaine
reduces time to onset and increases intensity
small needles
reduce the speed of injection
topical anesthesia combos
TAC (Tetracaine, epinephrine, cocaine)
LAT (lidocaine, epinephrine, tetracaine)
pediatric pts
direct wound infiltration
inject plane just below dermis at jxn with superficial fascia
MC approach
list of nerve blocks (5)
- supraorbital n.
- infraorbital n.
- mental n.
- digital n.
- auricular block
should all be done with Marcaine
supraorbital block
forehead block
parallel margin infiltration in continuous track at brow level
infraorbital
intra or extra orally
intraoral is less painful (insert needle from maxillary banana to infraorbital foramen)
1-3 cc
mental block
insert needle at gingival buccal margin inferior to second bicuspid
extend to mental nerve foramen midway between up and low margin of mandible
Digital nerve block and epi
DO NOT use vasoconstrictors bc it can cause tissue extravasation (ischemia and scarring)
if you do - Phentolamine
digital nerve
all 4 digits
go in and numb right around bone
best strategy for repairing wound to external ear
auricular n. block
parallel margin, 2-3 mL of anesthesia
do not use lidocaine + epi
inject below dermis at subQ jxn
components of wound prep
personal precautions anesthesia foreign material wound soaking wound periphery cleansing irrigation
foreign material
all should be considered harmful
MC reason for malpractice suit
irrigation
irrigate until no visible contaminate around wound
NS is MC used
3 categories of wound closure
primary closure
secondary closure
tertiary closure
primary intention
clean wounds
must be repaired within 6-8 hrs of injury ( < 24 hrs on face)
secondary intention
wounds >8 hrs old (>24 hrs on face)
abscess, punctures, bites
NOT closed with suture but allowed to heal gradually by granulation of re-epithelialization
tertiary intention
clean, debrided, observe wound 4-5 days then come back and close again
grossly contaminated wound with vital tissue
wound exploration
should be done whenever there is minor possibility of FB
XR before explore if glass, gravel, metallic FB suspected
I.e. tooth fracture - XR to see fragment
how to get hemostasis
direct pressure (most effective) vasoconstrictor gelfoam direct clamping cautery tourniquets
** NO BLIND CLAMPING
active bleeding and wound care
hemostasis prior to closure is idea bc active bleeding limits exportation and visualization
can cause hematoma formation
tourniquets time
can only be on 30 min max in large extremities (20 min max in digit)
common instruments in suture kit
needle holder forceps/skin hooks scissors hemostats scalpel/blade
needle driver
hold like a pencil
rings are designed to be used for closing and release
forceps
used to grasp fascia
incorrect use may cause crushing injury to dermis and epidermis
can be used as skin hook
functions of hemostat
- clamp small blood vessels for hemorrhage control
- grasp and secure undermining and deriding wound
- expose, explore, visualize deeper area of wound
scapel sizes
numer 11 blade
number 10 blade
number 15 blade
numer 11 blade
I and D of superficial abscess
removing small sutures
number 10 blade
used for cutting skin
helpful for extending wounds during revision
number 15 blade
versatile
precise depribement and wound revision
simple excision
wound edge revision
minimal excision of macerated and devitalized tissue
full wound excision
involved more extensive excision of devitalized and contaminated epidermal, dermal, subQ tissues
must score the epidermis, dermis
reserved for wounds when skin is not viable but must have tissue redundancy
lenticular (length:width = 3:1)
considerations in selecting suture material
tensile strength
knot security
pliability
ability to resist infection
classes of suture material
- non absorbable (primary surface skin closure)
2. absorbable (dead space in lg wound, reduce closure tension)
non absorbable suture material (monofilament)
nylon, polypropylene (ethylene, proline)
MC suture material for percutaneous dermal layer closure
less tissue reactive, strong, able to resist infection
greater material memory = knot loosen if not secure
common absorbable suture material
vicryl
chromic gut
monocole
vicyrl
MC used absorbable
buried subQ suture, oral mucosa, perennial area
braided threat
chromic gut used where
MC oral, perennial and scrotal tissue
mucosal closure
monocle
new
reduced hypertrophic scar formation
monofillamnet
location and suture size scalp
4-0 ethilon or proline
location and suture size face
6-0 proline ethilon
trunk location and suture size
4-0 ethilon
extremities location and suture size
4-0 ethilon
digits location and suture size
5-0 proline, ethylene
sutures last
7-10 days then removed
5 days if in face
types of needles
- reverse cutting
2. tapered
reverse cutting needles
wound and laceration repair
more sharp
less traumatic
code P designation
tapered needle
less expensive
less sharp
code C or FS
undermining
used to reduce tension in wound
releases dermis and superficial fascia from deeper attachment
can be done by hemostats or scissors
distance should be = to gap of wound
where MC undermining use
where skin is under great deal of natural tension
scalp, forehead, lower legs
