Wound Management Flashcards
What to include in assessment
Who - age, job, hobbies, hand dominance
What - happened, exact mechanism, force
When/Where/Why - it happened
Thorough wound exam after cleaning looking for deep structure damage
Assess for contamination
Check tendon function
Check neuromuscular status distally
Check tetanus vaccination status
X-ray if risk of fracture or foreign body
Steps of cleaning and debriding a wound
- Clean wound and area using sterile gauze soaked in sterile saline
- Anaesthetise - 1% lidocaine s/c
- Mechanical cleansing (debridement) - remove any debris/contamination/foreign bodies/dead tissue - use sterile gauze soaked in sterile saline to scrub and forceps and scalpel to excise tissue if required
- Pressure irrigation - squirt sterile saline into wound using pressure (from syringe via green needle or from pressure infusion bag via orange cannula)
- Deep Inspection - thoroughly re-inspect the wound looking for deep structures and ask patient to attempt full ROM to check for tendon damage
- Perform further cleansing or irrigation if required
- Wound debridement under GA - if large, extensive debris, lots of necrotic skin, dead muscle, contamination, underlying fracture or neuromuscular compromise
- Urgent surgical exploration if any possibility of nerve/vessel/tenden/organ damage
What are the closure options for a wound
Immediate Primary Closure
- Immediate closure with sutures/clips/steri-strips/glue
- only if negligible skin loss, no foreign bodies, <12h old (<24h for face) and edges come together without tension
Delayed Primary Closure
- Wound cleaned thoroughly, then dressed and left open for 48 hours
- Wound then reviewed for signs of infection, swelling and bleeding - if absent and wound edges close without tension it is sutured closed.
- used for contaminated/contused/bruised/infected/>12h old wounds
- antimicrobial dressings and prophylactic abx should be used for contaminated or infected wounds
Secondary Intention
- Allow wound to close by itself, i.e. by granulation, epithelialisation and scarring
- for wounds with tissue loss preventing edge approximation, chronic ulcers and partial-thickness burns
Skin Grafts
- For significant skin loss i.e. most full thickness burns
What types of wounds would you offer follow up for
- Wounds for delayed primary closure (to close)
- Diabetic or immunocompromised patients (to. review healing)
- Burns - to look for infection
When would you remove sutures
Head and Face - 5 days
Upper Limb / Trunk / Abdomen - 7 days
Lower Limb / Diabetic / Immunocompromised - 10 days
What to do in the initial assessment of a burn
- Test sensation and blanching
- Check tetanus status
- Determine % body surface area using:
- Rule of 9’s (head 9%, arm 9%, trunk front 18%, trunk back 18%, leg 18%)
- Palmar surface (patients palm and fingers = 0.8%)
- Lund and Browder chart (more accurate, esp paeds) - Classify burn by assessing depth
How do you classify the depths of burns and their management
Superficial
- Red and dry, blanches with pressure (like sunburn)
Partial Thickness (superficial / deep)
- Red and moist, with blisters, does not blanch
- Need re-epithelialisation and granulation to heal
Full Thickness
- White / grey / scalded, insensate, solid, dry
What is the management of a superficial burn
Simple moisturiser / Aloe vera gel
What is the management of a partial thickness burn
- Use systemic (never topical) analgesia
- Cleanse with soap and water
- Thoroughly rinse
- Scrub off any necrotic tissue
- Dress a simple, low-exudate burn with multiple layers of low-adherent impregnanted tulle gauze
- Cover this with a sterile non-adherent absorbent pad dressing and secure with bandages
- Review in 48 hours to look for signs of infection
- Re-dress every 2 days
Blisters - leave intact unless they are:
- open/contaminated - fully debride
- large/prevent dressing - sterile aspiration
What is the management of a full thickness burn
Skin graft
What burns require a specialist opinion or admission
- Full thickness burns - need skin graft
- > 10-15% body surface area
- Elderly / significant comorbidities (risk of significant fluid loss)
- Hands (put in paraffin bag and keep moving)
- Face (use vaseline)
- Genitalia / perineum - admit as difficult to dress
- Burns over major joints
- Chemical (needs repeated irrigation)
- Electrical - spare skin
- Inhalation injuries - airway risk
- Circumferential burns - risk of compartment syndrome
How to tailor ABCDE approach to burns
A - call anaesthetist and intubate ASAP if airway burn
B - give all patients 100% O2 via humidified non-rebreathe mask and nebulisers for smoke inhalation
C - 2 large bore cannulas and IV fluid resuscitation
- Parkland Formula: 4x TBSA (%) x weight (kg)
- 50% given in first 8 hours, 50% given over next 16 hours
- Children also given maintenance fluids
D - check responsiveness and strong analgesia
E - examine entire skin looking for other injuries
- large area burns - cover with sterile sheets or cling film until specialist review
- minor burns - immerse in cool water for 30 mins or cover with cool sterile saline soaked towels
What specific management do puncture wounds require
X-ray if any possibility of foreign body
If deep and contaminated then wide debridement in theatre
If not simple debridement and irrigation
Follow-up required
What specific management do bites require
Aggressive surgical management
Delayed primary closure or healing by secondary intention
Abx for 5 days - high risk of tendon injury and contamination leading to septic arthritis
When can crush tissue injuries be closed
After 7-10 days of elevation to reduce swelling prior to closure as risk of compartment syndrome
