Wound Management Flashcards
what are the dose limits for:
lidocaine
lidocaine w/ epi
bupivicaine
lidocaine- 4mg/kg
lidocaine w/ epi- 7mg/kg
bupivicaine- 2mg/kg
describe the innervation distribution of the face
- forehead- supraorbital nerve
- nose- supratrochlear nerve
- cheek and upper lip- infraorbital nerve
- chin- mental nerve
types of wound closures
primary intention
secondary intention
tertiary intention
what is tertiary intention wound closure
(delayed primary closure) surgical closure in 3-5 days after injury. Used in high velocity wounds, contaminated wounds, old wounds, stab wounds
how do you care for lip lacerations
- Look for intraoral / thru and thru lacerations
- Look for dental injury
- First throw is to approximate vermillion border if involved
- Otherwise, start on mucousal aspect
- Then repair orbicularis oris
- Consider Abx – PCN or clindamycin
when do absorbable sutures degrade?
- Vicryl: has 2-4 weeks of tensile strength, can take 2+ months to dissolve. Braided.
- Plain Gut: 7-10 days of tensile strength; up to 90 d. to absorb. Monofilament
- Fast Absorbing Gut: 5-7 days of strength, absorbs in 3-4 weeks. Monofilament
What is the recommended suture size for: face trunk extremities hands/toes scalp
face: 6-0
trunk: 3-0, 4-0
extremities: 4-0
hands/toes: 5-0
scalp: 4-0
when should dermabonds NOT be used
- should not be used deep
- Avoid on hands, feet, over joints or other areas of high dynamic forces
- Do not use in places requiring frequent washing
- Do not use topical antibiotics after wound closure
- Removes with bacitracin, mineral oil in accidental placement
how can you assess a FB?
- X-ray- 98% glass greater than 2mm will show up on film, metal, and gravel
- If the patient feels FB sensation it’s in there
*risk for infection
types of non-absorbable
ethilon/nylon (black), prolene (blue), silk
how much volume should you use w/ irrigation
- Min 250 cc
- Standard 1 liter
- Use 100 cc/cm of wound length
*Volume is EVERYTHING
what % of dog bites become infected compared to cat bites
dogs 5%
cats 80%
examples of ester local anesthetics
cocain, procaine, tetracaine
*more likely to cause allergic rxn than amides
what animals will most likely expose you to rabies?
8% from domestic animals
(1% dogs, 4% cats, horses, cow)
92% wildlife
(36% OF ALL rabies cases raccoons, 23% skunks, 23% bats, 7% foxes)
*internationally more than 90% are from stray dog bites
describe the irrigation step in infection prevention
- tap water has been shown to work just as well
- ontaminated wounds need High Pressure Irrigation (18g catheter) = more than 7 psi; otherwise, slow gentle wash
- ***use 100cc/cm of wound length
how do you perform a facial suture compared to other body parts
Facial sutures: 2-3 mm from wound edge, 3-5 mm apart
Other body parts: 3-4 mm from wound edge, 5-10 mm apart
*Start suturing at the point most distal to you, and suture towards you
never been a case of transmission to a human from one of these animals
small rodents such as
squirrels, chipmunks, rats, hamsters, gerbils, guinea pigs, mice, rabbits
describe tetanus prophylaxis
- Update if last Tetanus was more than 10 years ago
- If very dirty or high risk, consider updating if last dose 5-10 years ago
-Tdap if adult; DTaP if pediatric
when do you refer for eyelid lacerations?
- inner surface of lid
- Lid Margins
- LACRIMAL DUCT involvement
- Ptosis- drooping or falling of the upper eyelid
- Tarsal plate involvement
ways to limit pain on injection
- Sodium bicarbonate 1:10 (shelf life 1 week)
- Warming the solution
- Size of the needle
- Injecting SLOWLY
- Use of a topical anesthetic
- Ice on wound (especially helpful in kids)
how do you assess hand injuries
- Test Motor and Sensory function distally
- Perfusion/Cap Refill
- Tendon lacs get referred
what microorganism infect human flight bites and what is the tx
- Eikenella corrodens
- Augmentin
how do you care for puncture wounds
- Do not close these; heal by secondary intention
- Plantar Wounds – cover for Pseudomonas with Cipro, especially if went through a shoe
- Remove FB if present
- Soak, don’t suture
11 pitfalls to avoid in regards to wound care management
- Failure to irrigate with proper technique
- Failure to consider delayed primary closure
- Using dermabond on high tension areas
- Using improper aftercare instructions
- Using abx to make-up for poor wound cleaning
- Failure to use clinical judgment when considering golden periods for wound closure
- Failure to find a foreign body
- Using betadine to irrigate
- Failure to warn patients of potential infection risk and scarring
- Failure to align the vermillion border
- Failure to examine in a bloodless field
how do you inspect/exam a wound
- Need good hemostasis to visualize complete depth of injury, through complete ROM
- Look for tendon injury, fb, joint involvement
- Document 2 point discrimination before anesthesia
how do you irrigate a wound
- Deliver under moderate pressure - especially dirty wounds
- 18 gauge IV catheter attached to a 30-60 cc syringe will achieve this
- 7-8 psi to remove material and bacteria
- If clean or loose tissue, use low pressure
*Washing for a few minutes under simple tap water has been shown to be just as effective as other hospital based irrigations
classes of local anethesia
- Amides -Most commonly used class (Lidocaine, Bupivicaine)-Allergy extremely rare
- Esters- cocaine, procaine, tetracaine (more likely to cause allergic rxn)
what does an inferior alveolar nerve block block
-Blocks all lower teeth and gums to the midline as well as anterior labial and lingual
epinephrine is commonly added to local anesthetics for many reasons including:
- provides hemostasis
- a longer duration of action
- slows systemic absorption thus decreasing potential toxicity
- allows a greater volume to be injected
what are the layers in dressing
*Antibiotic Ointment bid for 3-5 d
- Nonadherent layer
- Gauze sponges
- Gauze wrap
- Tape
- Pressure stocking
what do you do if you suspect a true allergy to a local anesthetic?
- use a preservative free agent from the other class
* true allergic rxns are rare and are usually due to preservatives
what local anesthetic is typically used if one has an allergy to amide anesthetics
procaine
what is a shear mechanism of injury
simple dividing of tissue, ie sharp glass, knife. Low energy force. Should heal with good result
when would you use a buried/deep dermal stitch?
Gaping wounds
*Do not place thru adipose tissue – doesn’t hold and increases risk for infection
what drugs affect wound healing
steroids, NSAIDS, anti-coagulants, anti-neoplastics,
what wound care instructions should you give your patient
- Apply bacitracin/antibiotic ointment after lac repair
- Wound dressing should be left on for 24 hours; after that can be removed and left open to air
- Apply topical abx crème bid for 3-5 d
When should epinephrine NEVER be used in local anesthetics
on fingers, toes, penis, ears, or nose
how do you care for an abscess
Fluctuance
Incision and drainage
Packing/Catheters
?Antibiotics
digital nerves
- Two palmar digital nerves innervate the palmar aspect,
- two dorsal digital nerves innervate the dorsal aspect
what is primary intention wound closure
surgical repair with initial reapproximation of tissue layers
What is the max dose of 2% lidocaine with epinephrine in a 70 kg patient?
lidocaine w/ epi 7mg/kg max dose
70kg x 7 mg/ml = 490 mg
2% lido with epi = 20 mg/ml
490mg /20mg/ml = 24.5 ml
where do you inject for supraorbital, infraorbital, and mental nerve blocks?
along an imaginary line through the pupil in appropriate zone
key principles of suturing
- start suturing away from yourself and go towards yourself
- symmetry
- eversion of edges (max approximation)
- minimize tension
- The number of ties you place is approximately equivalent to the caliber of the suture material
grossly contaminated wounds
- Wounds with saliva, feces, vaginal secretions
- Moist areas: oral or vaginal mucosa
- Contaminated wounds with soil and organic materials like wood
*consider delay primary closure after 4 days
what should a practitioner do with an injury involving the midcheek
an attempt should be made to milk the parotid gland and observe the flow of saliva from the Stensen duct in order to ensure duct patency.
why does pain occur w/ injections
acidic pH of anesthetics
complications of regional blocks
- Bleeding
- Infection
- Parethesias-in large nerves ok, in smaller nerves, can’t absorb as much and may damage the nerve
- Intravascular injection
where do you inject for a infraorbital nerve block and what does it numb?
- inject mucosa just superior to the first maxillary pre molar and canine
- blocks lower lid, medial cheek, side of nose and upper lip
what are patient expectations around wound management
- Good cosmetic outcome
- Preservation of normal function
- Least painful repair
- Avoidance of infection
- Cost
- Length of stay
- Missed work
- Set reasonable expectations about scarring
what are risks for poor outcomes w/ wounds?
- Retained FB/ FB sensation?
- Heavy contamination
- Delayed presentation (more than 24 hours for head/ face, more than18 hrs for other)
- Deep wound with tissue trauma
- Crush injuries
what are 3 mechanism of injury
- shear
- tensile
- compression
what is a transthecal block and modified transthecal block?
Transthecal: inject at distal palmar crease
Modified transthecal block: inject at palmar digital crease
*apply pressure proximally to encourage anesthetic to travel distally
what are alternatives to sutures
staple
steri strips
dermabond
When you are doing blocks or any sort of anesthesia, it is very important to use ___
sterile technique
*swab area w/ alcohol and prep the area before injecting
Regional Blocks, Advantages Over Infiltration
- No tissue distortion**
- Avoids infiltrating highly sensitive areas (palm)
- Longer duration of anesthesia**
- Smaller amount of anesthetic needed
what microorganism infect cat bites and what is the tx
- Pasteurella multicida
- penicillin or Augmentin 3-5 d.
- Elevate and splint if necessary
When would you use antibiotics with a wound?
- Location (mouth, genitals, feet)
- Mechanism–crush injury more likely to cause wound infection
- Immunosuppression – DM, steroids
- Bites
- Cartilage or joints (bc poor blood supply)
- Valvular heart disease
*healthy people don not require prophylactic Abx
what is the anatomy of skin
Epidermis Dermis Subcutaneous tissue (hypodermis) Superficial fascia Muscle layer Deep fascia
what are the effects of having rolled in edges when suturing
rolled in edges promote infection and have inferior scar appearance
what suture should you do if a kid is not sitting still and you need to suture quickly
running suture
how should you perform a simple interrupted suture
- Gather more tissue at the base than at the surface
- eversion is key
- enter at 90 degrees
- the number of ties you place is approximately equivalent to the caliber of the suture material
a long acting topical anesthetic
tetracaine
what microorganism infect dog bites and what is the tx
polymicrobial
Augmentin 3-5 days
*almost NEVER close a dog bite on the extremity
what instructions should you give the patient before leaving regarding their wound?
- cleaning
- signs of infection
- timing of removal
- sun exposure (for first 6 months)
recommended suture removal for the following locations:
- Face:
- Scalp:
- Hands:
- Feet:
- Extremities:
- Trunk:
- Face: 3-5 days
- Scalp: 7-10 days
- Hands: 7-10 days
- Feet: 7-10 days
- Extremities: 7-14 days (joints)
- Trunk: 7-10 days
when would you use secondary intention closure?
-Used in ulcerations, abscess cavities, avulsions, punctures
what type of organic material are likely to cause an infection if a FB in wound
soil
wood
clay
ex. branch in leg w/ skiing accident
how do you care for hand lacerations
- Must examine in position of injury, and through full range of motion, in a bloodless field
- Consider a fight bite – antibiotics
- Xray for foreign body
what are some digital blocks
- transthecal
- modified transthecal
- web space block
- 3-sided digital block
- ring block (for thumb)
when would you refer with a wound?
Patient request Foreign bodies Deep Structure involvement Time constraints Eye lid considerations Level of comfort
principles of wound care
- Inspect and examine
- Prep and Anesthesia
- Wash/Irrigate/Debride
- Hemostasis
- Exploration
- Closure - type, material used
- Dressing
- Care instructions
how do you do a hematoma nerve block
- ID fracture site. Introduce needle to to bone, aspirate
- Inject lidocaine or bupivicaine (W/o epi)
*Great for reducing fractures, especially distal radius
what kind of suture would you do over an area of increased tension such as in the fascia and over joints
horizontal mattress
what abx would you concider a lip lac
penicillin or clindaymycin
when would you perform a vertical mattress suture
-When excess/lax skin
where do you inject for a mental nerve block
- Inject into the mucosal fold at the canine/ first premolar.
- Innervates labial mucosa, gingiva and lower lip adjacent to the incisors and canines
____ needles are used on soft tissue, such as bowel and subcutaneous tissue, or when the smallest diameter hole is desired
Tapered
what is the undermining suturing technique?
- useful for high tension laceration repairs
- using sterile scissors to bluntly dissect the dermal layer away from the underlying connective tissue. Through the use of this technique, you can take away some of the connective tissue adhesions which anchor the skin in place and remove static tension on the wound
what is secondary intention wound closure
epithelialization and growth from base.
factors that affect wound healing
- technical
- anatomic
- drugs
- associated illness
_____ needle is made in such a way that the outer edge is sharp so as to allow for smooth and atraumatic penetration of tough skin and fascia.
Reverse cutting
Pros of using dermabonds
- Cosmetic result similar to sutures
- Faster application
- Possible needleless wound repair
- Best used on LOW TENSION wounds
how do you care for a nailbed repair
- May not need to remove nail if less than 50% subungual hematoma
- Trephination is an option
- Repair nailbed
- Replace nail plate under nail fold
*Subungual hematoma decompression
what is involved with hair removal/debridement?
- Clip, Don’t shave
- Never clip eyebrows or lashes
- Debridement improves vascularity, reduces infection
- All devitalized or necrotic tissue should be removed
- Dead tissue becomes a FB and will become infected
what are special concerns regarding these areas: -Lip oral hand lacerations eyelid lacerations nose ear punctured wounds hand lacs cheek lac
Lip - vermillion border Oral - thru and thru Hand lacerations – FB, joint/tendon Eyelid lacerations – lacrimal system Nose – septal hematoma Ear – dressing is key Puncture wounds - pseudomonas Hand Lacs – fight bite Cheek laceration - facial nerve, parotid gland/duct injury
how do you care for ear lacerations
- Use 6-0 nylon to close skin
- Cartilage needs only to be approximated, via skin closure
- A well formed dressing is key
what is the pathophysiology for wound healing
- Immediate response
- Inflammatory phase
- Epithilialization
- Neovascularization
- Collagen Synthesis
- Wound Contraction
what are steps in infection prevention
- irrigation
- debridement- remove dead/devitalized tissue
- blood supply
- prep
What are:
Adaptic
Tagaderm
telfa
nonadherent layers used in dressing
what are important things to assess when taking a history of a wound?
- allergies
- tetanus status
- meds
- fever
- r/ o other injuries
- co-morbidities- DM, steroids, obesity, PVD, CRI
what is a compression mechanism of injury
- Crushes skin against bone
- ex baseball bat, windshield
How long out can your close wound?
up to 8 hours typically if on extremity
- Facial wounds may be closed primarily up to 24 hours following the injury, and in select cases up to 48 to 72 hours if there are no signs of infection, the patient has no risk factors for infection, and the wound edges can be approximated easily
what are cleaning instructions to give your pt before leaving regarding wound care.
- Dressing in place at LEAST 24 hours
- 50-50% solution of h2O2 around wound edges; or just baby shampoo and water
- Topical abx ointment
- No soaking (hot-tubbing, swimming)
when do you use absorbable sutures and when do you use non-absorbable
absorbable- subcutaneous, mucus membranes
non-absorbable- colored, used on skin, don’t use deep
describe the prep step in infection prevention
usually NS or tap water is all this needed; can use baby soap, butfull strength Iodine , full strength H2o2 can devitalize healthy tissue as well
what is the duration of action for lidocaine and bupivicaine
lidocaine 1-2 hrs
bupivicaine 4-6 hrs (long acting)
what is a tension mechanism of injury
- Flap type laceration
- High energy forces with surround devitalized tissue and more prone to infection
when considering if there will be a wound infection, consider these…
- Microbiology
- Technical
- Patient Condition
- Infection Prevention
- Irrigation
- Debridement
- Blood Supply
- Prep
what associated illness affect wound healing
increased age, Etoh, uremia, diabetes, PVD, anemia (hct less than 14), malnutrition, Ehlers-Danlos
how do you care for nasal lac/trauma
- Look for, and drain, a septal hematoma
- Align the skin surrounding nasal canals
- Mucousal involvement, close with absorbable
where do you inject for a supraorbital and supratrocheal nerve block and what does it numb?
- Inject into the SQ space just superior to the eyebrow in line with pupil to medial brow
- blocks entire forehead
how can you control the bleeding from a wound
direct pressure- clamp, tie, cautery of vessels, tourniquet
*if reported pulsatile, need to explore arterial injury
Common Topical Anesthetic Agents
- Tetracaine/Proparacaine- ophthalmology
- Benzocaine- oral and ENT procedures
- LET (lidocaine, epinephrine, tetracaine)- must be kept in place 20 minutes, should not be used on mucus membranes or any where epinephrine is contraindicated
- EMLA- nonsterile mixture of lidocaine and prilocaine. use on intact skin. analgesia after 1 hr
- Hurricaine spray- used w/ abscess drainage in oropharynx
types of absorbable sutures
vicryl, chromic, gut*
What are: Povodine-iodine Chlorohexidine Hydrogen peroxide Baby soap and saline
common prep solutions
when should a pt. check for signs of infection
- Recheck wounds 48 hours if high risk
- Cat bites 24 hours
