Wound History, Assessment, Management Flashcards
Immediate management of any wound before history taking
Life threatening wounds => ATLS
Severe hemorrhage => pressure, elevation, torniquet, arterial clamp/suture
History
-key questions to ask
Key details
-name, DOB, handedness, occupation/hobbies
What -objects used -blood loss -speed, angle -additional hazards, retained foreign bodies When - date and time => affects management Where - circumstances and location -clean/dirty environment Why - for prevention
PMHx
-DM, IC, vascular disease, AI, chronic disease
-tetanus status
DHx
-CS, AC/AP use
SHx
-smoking, alcohol => impairs wound healing
Examination
- wound
- surrounding skin
- neurovascular examination
- tendon function
Wound - try to classify wound
- site, size, shape
- direction, depth
- edges - granulated, macerated, clean, rolled
- flaps
- foreign body
- blood loss - ooze => venous pulsing => arterial
Surrounding skin
-bruising, abrasions, erythema, discharge
REPEAT BEFORE AND AFTER ANY INTERVENTION
Neurovascular exam - document everything you’ve assessed!
-sensation, motor, pulses, CRT
Tendon function - document everything you’ve assessed!
-active and passive movement
Investigations to consider
-when would you consider each examination
Xray - possibility of fracture, foreign bodies
USS - possibility of radiolucent FB
Wound culture - possibility for infection
Immediate management of wounds
-generally
Analgesia and fluids
Stop factors that may impair recovery if possible
-stop CS, NSAIDs
-INR measurement - VitK for warfarin
Tetanus booster - not had all 5 vaccines
Tetanus IgG - high risk contamination or if not fully vaccinated + wound high risk for tetanus
ABx - until culture returns, G+-ve anerobes
Blisters - leave them
-debride if open/contaminated
Follow up advice on wounds
Wound advice Predicted course -1ary closure - 5-10days -2ndary intention - 2-3wks Elevate limb to reduce swelling
Red flags - worsening pain, redness, pus
Shower - in 48hrs and redress wound
-don’t let pressured water to touch wound, scrub, immerse until sutures removes or wound fully healed
Follow up arranged for
- delayed primary closure
- DM, IC review of healing
- burns to check for infection
- suture removal and redressing
If fractures, advise that although unlikely, surgery may be needed to support healing
Cleaning, anaesthetising, inspecting and debriding wounds
-methods of cleaning and exploring
Carry out in sterile field
-lidocaine SC
Debridement - remove debris, FB, dead tissue with saline swabs, forceps and scalpel
-Under GA if extensive damage
Pressure irrigation - clean wound
Deep inspection - assess deeper structures and ROM
Urgent surgical exploration - possibility of nerve, vessel, tendon, organ damage
-if on hand, zigzag incisions so contractures don’t form on joint lines
Methods of wound closure
-when to use what
Primary closure
- negligible skin loss
- clean wound without FB
- clean edges that come together without tension
- U12hrs
Delayed primary closure - cleaned, dressed, left open for 2 days. Only closed when no infection, swelling, bleeding and can be closed without tension
- contaminated, bruised, infected
- 12hrs+
Secondary intention - closure by granulation
- tissue loss => edge approximation not possible
- chronic ulcers
- partial thickness burn
Skin grafts
-significant skin loss, full thickness burns
Burns
- types
- characteristics
- management
Superficial
-red, dry, blanches => moisturise, aloe vera, sunblock for 1year
Partial thickness
- red, wet, blisters, no blanching => systemic analgesia, clean and rinse, dress with gauze and dressing
- review in 48hrs for infection
- redress every 2 days
Full thickness
-white/grey/scalded, solid, dry => skin graft
Immediate first aid for burns
- thermal
- electrical
- chemical
Thermal
- extinguish flames => drop and roll, smother with blanket
- remove nonadherent clothing, restrictive jewelry
- irrigate with cool water for 20mins but keep patient warm if damage extensive
- cover burn with clingfilm in layers
- elevate, simple analgesia
Electrical => A&E
- low voltage => switch off power, remove person from source with wooden stick
- high voltage => DO NOT APPROACH
Chemical => A&E
- determine cause
- remove affected clothing
- brush off powder OR irrigate with water for 1hr
History taking for burns
Name, age, DOB, hobbies/occupation, handedness
PC - timing, type, MOI
-predisposing factors that led to burn
Risks of additional injuries
- inhalation injury - singed eyebrows, hairs, sore throat, hoarse voice, stridor/wheeze, soot
- non accidental injury
PMHx - affect wound healing, complications -cardiac, resp, hepatic disease -DM, IC, pregnancy -poor nutrition, cognitive impairment Tetanus status DHx - AC/AP, CS use
SHx - smoking and alcohol impairs healing
How would you assess the extent of the burn
How would this affect fluid replacement
Rule of 9s
- head - 9
- arm - 9
- leg - 18
- ant trunk - 18
- post trunk - 18
4 x kg x TBSA = L
- 1/2 of fluid in first 8hrs
- rest given in 16hrs
When to refer to a burns unit
Full thickness burn => skin graft needed TBSA 10%+ => risk of sig fluid loss Infants/children Hands, face, joints, groin Chemical, electrical
Bites
- dogs
- cats
- humans
Dog - shallow puncture and tear tissues
Cat - deep puncture and penetrate bones/joint/tendons
Human - biting clenched fists => tendon, nerve injury
Bite assessment
- history
- assessment
- management
Wound history
- who was bitten and by whom
- when
- where - may affect rate of healing
- skin broken? blood?
- deliberate bite? clenched fist punch?
- risk of contamination
PMHx - assess for conditions that delay wound healing
-DM, IC, AI, chronic conditions, HepBC HIV status
-tetanus status
DHx - AP/AC, CS use
Examination
Neurovascular function - pulses and sensation
Range of movement
Foreign bodies, signs of infection
Analgesia
Debride, irrigate, remove FB
ABx prophylaxis empirically if skin broken - coamox
Tetanus prophylaxis
HIV prophylaxis, HepBC management if needed
