Wound Management Flashcards
What investigations are required for certain wounds?
X-ray = glass and possible bony injury
Ultrasound = wood FB
Bacteriology = infected wounds
INR = pt is on warfarin and bleeding is a problem
Minor Injury and Minor Illness at a Glance
Describing wound types
what is an abrasion, contusion, laceration, cut and puncture wound?
Abrasion = injury caused by friction shearing skin away
Contusion or bruise = caused by blunt force may cause fractures/damage to organs
A laceration is caused by a blunt or crushing force. Skin has been burst open - more ragged and with more tissue damage
A cut = caused by sharp object - neat and easy to close, have higher risk of damage to tendons and nerves
Puncture wound = depth exceeds the width or length of wound
Minor Injury and Minor Illness at a Glance
What are the RED FLAGs in hand injuries?
- Damage to tendon or nerve
- fractures in crush injury
- Punch (human bite) injury to dorsum metacarpalpharangeal joint
- high pressure injection injury
Minor Injury and Minor Illness at a Glance
What are the RED FLAGs in face injuries?
- cosmetic issues e.g. wounds to eyelids and vermilion boarder lip
- damage to facial nerve and parotid duct
Minor Injury and Minor Illness at a Glance
What are the RED FLAGs in wound infection?
- Patients with systemic signs of infection (temp, riggers, tachy)
- patients with severe pain and signs of wound infections (necrosting fascitis)
- diabetic foot infections
Minor Injury and Minor Illness at a Glance
PITFALLS
Infection
- Dirty environment e.g. farm
- Bites - human bites need antibiotics
- Delayed heeling e.g. underlying pathology e.g. diabetes, smokers or not getting it seen immediately
Minor Injury and Minor Illness at a Glance
PITFALLS
Delayed Presentation
- Alcohol induced
- Age / dementia
- Stubbornness
- Domestic abuse
- Remove debridement if already started to heal
PITFALLS
Tendon Injury
- MOI
- Depth
- Location
- Partly severed tear - pain in proportionate to injury
PITFALLS
Vascular/neurovascular injury
- Penetrating wounds
- Blast Injuries
- Degloving
- Self- harm
PITFALLS
Joint Involvement
- Degloving
- Open wound - infection
- if its near a joint, may be deeper than what’s seen
PITFALLS
FB
- Could be tamponading blood flow
- Organic matter e.g wood can cause an infection
- soil and dirt
- abrasions from road slash - tar can cause tattooing
PITFALLS
Type of injury
- Crush - bone, compartment syndrome - ECG
(caused by pressure and reduced blood supply can cause underlying damage e.g. to muscle) = rhmodyalsis (can cause AKI) = increased potassium = arrhythmias - lacerations
- blast - energy travel through body, neumatic drills = air causing surgical emphysema
- de-gloving = loose tissue = loss vascular supply (ischaemia distally), increase evaporation (insensible volumes), area becomes dry and doesn’t heal properly
PITFALLS
Associated injuries
- Fractures e.g. facial fractures - MOI; mechanical? syncope? intoxication?
- thermal
- seizures, hypoglycaemia - fallen onto radiator
- superficial e.g. sunburn
- parial thickness - blistering
- full thickness - white and leathery
- bites
PITFALLS
Quality of skin/Associated diseases
- Ischaemia
- Diabetes (sugar toxic)
- Steroid medication - thins skin, reduces inflammatory response = delayed healing, increased risk of infection
- Aging = loss of collagen, loss fatty tissue
- Warfarin = bleeding
- Allergy = tetanus immunisation status?
Which wounds are best left open or referred to ED?
- Wounds more than 6-12h old (infection risk)
- Bites esp hand
- Infected wound
- heavily contaminated wounds
- Severe crush injury
- Evidence or damage to deeper structures
Minor Injury and Minor Illness at a Glance
Classification of wound healing….
Primary and secondary
Primary Intention
- edges clean and held together (aposed) with ligatures
- little gap to bridge healing
- quick healing
Second Intention
- when edges are separated
- extensive epithelial loss
- severe contamination
- e.g. abdo open surgery
- healing slower
- granulation - healing from bottom towards surface
- scaring
EMedicine
When would you use steri-strips - what are the advantages?
When to remove?
Used for..
- Pretibial lacerations (poor vascular supply, adhesive strips gives best result, suturing would put wound under to much tension)
- small face wounds
Advantages
- easy to apply
- don’t interfere with blood supply
- don’t need to use local anaesthetic
- don’t introduce another wound through needle
Not effective on bleeding wounds
Minor Injury and Minor Illness at a Glance
When to remove..
- 3–5 days for wounds on the head.
- 7–10 days for wounds at other sites.
NICE
When would you use glue - what are the advantages?
When to remove?
Used for…
- effective for facial wounds (NOT eyelid or lips)
Advantages
- doesn’t interfere with blood supply
- don’t need to use local anaesthetic
- don’t introduce another wound through needle
Disadvantages
- can’t be used on denuded skin only on wounded edges
Minor Injury and Minor Illness at a Glance
When to remove..
- It will slough off naturally after 7–10 days.
NICE
When would you suture - what are the advantages?
When to remove?
Advantages
- Good for control of bleeding
- Good for gaping wounds
- Good for wound across joints and hands
- Healing by secondary intention
- interrupted non-absorbable nylon sutures allow drainage and minimise tissue tension and ischaema
Adult Emergency Medicine at a Glance
Remove…
- 3–5 days for wounds on the head.
- 10–14 days for wounds over joints.
- 7–10 days for wounds at other sites.
NICE
Advice to patient regarding their wound?
1st few days
- walk as little as poss
- rest
- injured leg raised
- freq move toes - to prevent DVT
until healed
- keep wound dry
- eat healthy
- monitor blood glucose if diabetic
- stop smoking
signs of infection - increasing pain that doesn't settle with elevation redness spreading up leg - fever / flu like symptoms - pus or smelly fluid coming from wound
RCEM
What local anaesthetic used for suturing?
Lidocaine 1% + adrenaline
1:100000
Adult Emergency Medicine at a Glance
When is tetanus and antibiotics given?
Tetanus given if..
- Not up to date with it
- tetanus immunoglobulin given if heavily contaminated
Antibiotics given if..
- wound high risk of infection
- established infection
Adult Emergency Medicine at a Glance
What are the indications for referrals to burn specialists?
- superficial burns over more than 10% body surface area
- < 5 or >60
- sign burn to hand, face or perineum
- full thickness to feet
- circumferential burns
- inhalation injury
Minor Injury and Minor Illness at a Glance
What are the Signs of smoke inhalation?
- increased RR/dyspnoea
- Soot around nose & mouth
- Singing of facial/nasal hair
- Soot in mouth
- Burns in & around mouth & nose
Minor Injury and Minor Illness at a Glance
RED FLAGS in burns
- Airway problems develop quickly after inhalation injury
- Think about carbon monoxide poisoning (headache, drowsy)
- cyanide poisoning (shock)
- Large burns need referral
- Chemical burns often cause deep injury
- shock can be caused by; hypovolemia, cyanide, trauma and blast injury
- High voltage electrical burns cause deep tissue damage
- Think about non-accidental injury in vulnerable groups
Minor Injury and Minor Illness at a Glance
What are pt co-morbidities in burns?
- age >60
- diabetes
- heart failure
- lung disease
- immunosuppression
- pregnant
Adult Emergency Medicine at a Glance
What is the parkland formula for IV fluids in burns?
2-4 mls x (% burn) x (bodyweight in kg) over 24h
half given in first 8h, rest over 16h
Adult Emergency Medicine at a Glance
