Wound Repair Flashcards
List common causes of superficial wounds.
- lacerations
- bites
- small burns
- puncture wounds
- abrasions
3 Goals of Wound Care
- eliminate complications
- restore function (check tendon and nerve status)
- reduce scarring as much as possible
Steps in Good Wound Care
- cleansing
- hemostasis
- anesthesia
- wound irrigation and exploration
- removal of devitalized tissue
- tissue preservation
- closure tension, deep sutures if necessary
- tissue handling during closure
- dressing
- F/U
3 Stages of Wound Healing
- inflammatory phase
- proliferative phase: epithelialization, neovascularization, collagen synthesis
- remodeling: wound contraction and remodeling, scar management
Inflammatory Phase
- usually 1-5 days
- begins with hemostasis
- granulocytes released to wound followed by lymphocytes and immunoglobulins
- function is to control bacterial growth and suppress infection
- often resembles purulence/pus
Proliferative Phase I: Epithelialization
- inflammatory response ongoing
- w/in 24 hours, intact cells at wound edge replicate
- forms pseudopod like structures that facilitate cell migration and res-establish normal epidermis layers
- most evident days 5-14
Proliferative Phase II: Neovascularization
- new vessel formation crucial to wound repair and healing by replacing old, injured network and O2/nutrient delivery to healing wound
- evident by day 3, most active day 7
- gives erythematous appearance to wound
- new vessels = loops of capillaries –> granulation
Proliferative Phase III: Collagen Synthesis
- rapid mitosis of fibroblasts due to establishment of vascular supply and macrophage stimulation results in new collagen fibril production
- begins day 2, peaks day 5-7
- greatest collagen mass by 3 weeks
- random amorphous gel –> little tensile strength
- final tensile strength takes several months
Remodeling Phase I: Wound Contraction and Remodeling
- wounds continue remodeling over several months
- some degree of contraction occurs where normal surrounding skin is pulled over the defect
- scar changes in appearance with remodeling
- final appearance may take 6-12 months
Remodeling Phase II: Scar Management and Revision
- if final scar is unacceptable, multiple options for revision: cryotherapy, pressure dressings, dermabrasion, radiation, intralesional corticosteroids
- important to identify pts with hx of keloids/hypertrophic and refer to skilled specialists after initial repair
What chronic medical conditions might interfere with healing?
- advanced age
- EtOHism
- acute uremia
- severe anemia
- malnutrition
- diabetes
- peripheral vascular disease
What technical factors might interfere with healing?
- inadequate wound prep
- excessive suture tension
- reactive suture materials
- local anesthetics
What anatomic factors might interfere with healing?
- skin tension
- pigmented skin
- oily skin
- location of wound
What drugs/meds might interfere with healing?
- corticosteroids
- NSAIDs
- penicillin
- beta blockers (coumadin, plavix)
- anticoagulants
- colchicines
- antineoplastic agents
- tobacco
General Management of a Wound
- ABCs
- control hemorrhage
- pain relief
- abx/Tdap vaccine if necessary
- wound evaluation
- wound management
- consultation
What are some important pieces of information to gather in H&P for a patient with a wound?
- MOI: what happened, presence of foreign body, possibility of tendon injury
- age of wound: imp when deciding how to treat (6 hour suture?)
- underlying disorders
- prior healing
- allergies
- last tetanus
- interval for suture removal (depends on body region and other factors)
Why is it important to not put betadine in a wound?
causes tissue necrosis
What variables affect choice of anesthesia?
- type of wound
- location of wound
- estimated repair time
What reactions can occur with local anesthetic?
- cardiovascular reactions
- excitatory CNS effects
- vasovagal syncope secondary to pain/anxiety (common, esp with kids)
3 Most Commonly Used Anesthetics for Local Infiltration and Nerve Blocks
- lidocaine/xylocaine
- mepivacaine
- bupivicaine
Lidocaine
- most commonly used
- rapid onset 4-10 minutes
- good tissue preserving properties
- duration for nerve block: 60-120 minutes
- lidocaine w/ epi increases duration and reduces bleeding
When is use of epi with lidocaine contraindicated?
DO NOT USE ANESTHETICS WITH EPI IN ANATOMICAL AREAS WITH TERMINAL CIRCULATION (aka fingers, toes, ears, penis, nose)
Mepivicaine
- widely used in ED
- 6-10 min onset
- duration 30-60 min for simple blocks, 90-180 mins for nerve blocks
- less vasoconstricting effect than lidocaine so does not require addition of epi
Bupivicaine/Marcaine
- becoming more popular
- effective but slower onset 8-12 min
- LOOOONG duration 240-480 mins (4-8hrs)
- can be combined with lidocaine
Technique: Direct Wound Infiltration
- used for most minimally contaminated lacerations
- plane of injection: beneath dermis at junction of superficial fascia
- may use 25, 27, 30G needles
- simple lac 3-4 cm requires 3-5 mL (length of wound typically amount of lidocaine needed)
- can buffer with bicarb to decrease burning
Technique: Parallel Margin Infiltration (Field Block)
- alternative to direct infiltration
- advantage of fewer needle sticks
- preferred for grossly contaminated wounds so debris does not seed uncontaminated tissue
- approach is through intact skin
Technique: Digital Nerve Blocks
- most common nerve block in minor wound care
- usually need 6 mL
- recommended for lacerations distal to the level of the mid proximal phalanx of finger/toe
- preferred for nail removal, repair of digital lacs
What influences timing of wound closure? What is a rough guideline on when a wound should be closed?
- mechanism of injury, anatomic location, level of contamination
- rough guideline: 6-8 hours from time of injury is considered safe
Primary Closure
- used for relatively clean and uncontaminated lacs with minimal tissue loss
- repair w/in 6-8 bours of injury
- very important to aggressively clean, irrigate and debride wound prior to closure
Secondary Closure
- for skin infections, ulcerations, abscesses, punctures, small cosmetically unimportant animal bites, partial thickness abrasions, second degree burns
- wound care consists of thorough cleansing, irrigation and debridement
- wounds heal gradually through granulation formation and eventual re-epithelialization
Tertiary Closure
- include bite wounds and lacs beyond the golden period
- high bacteria count (abx may be helpful)
- delayed wounds may be converted to fresh wounds by I&D and closure
How can the provider decrease tension and improve healing/reduce scar formation?
- follow Langer’s lines –> go with flow of skin
- undermine when necessary: creates “free” tissue under wound edges
- use layered closure techniques when possible
Monofilament thread is named in the following manner: 6-0, 2-0, etc. What type of thread would be used on the eyelid or other facial structure? What would be used on the foot?
- face: 7-0, 6-0, 5-0
- foot/sole: 4-0, 3-0
Steri-strips: Indications
- superficial, straight lacs under little tension
- flaps in which sutures may compromise vascular supply
- lacs with greater than usual potential for infection
- lacs in elderly or steroid dependent pt (thin fragile skin)
- support for lacs after suture removal
Steri-strips: Advantages
- easy application
- even distribution of tension
- no suture marks
- no need to remove sutures
- application by non-providers
Steri-strips: Disadvantages
-don’t work well on oily surface, hair, joints, shin lacs, gaping wounds, wounds under tension, young or uncooperative pts
Stapling Indications
- linear, sharp lacs of scalp, forehead, neck, trunk, butt, extremities
- temporary, rapid closure of extensive superficial lacs in patients requiring immediate surgery for life threatening trauma
Stapling Advantages
- quick
- tolerated well once placed
When should staples not be used?
-if pt needs CT or MRI
Tissue Adhesives: Indications
- fresh lac within golden period
- lacs under low tension which are easy to approximate
- edges of wound are clean and even, closing without gaps
- dry wounds with little bleeding
- DO NOT USE NEAR EYES
Tissue Adhesives: Advantages
- flexible
- bacterial barrier
- high breaking strength
- may be used on many wounds/lacs
- esp good for face
- don’t need anesthesia
- can shower normally
- works well on aged/thin/steroid affected skin
- peels off spontaneously 5-10 days
3 Key Principles of Wound Aftercare
- protection
- elevation
- cleanliness
What is involved in wound aftercare for the patient?
- schedule for suture removal
- aftercare instructions
- info on what to expect as wound heals (manage pt expectations, do not promise no scar)
- provide written instructions and verbal explanation
Suture Removal
- technique is to cut under knot, close to skin surface
- this means previously exposed/contaminated portion won’t travel through the wound
- consider betadine cleansing prior to suture removal
Signs of Wound Infection
- most appear w/in 4-5 days
- excessive discomfort
- mucopurulent discharge
- erythema (>5 mm beyond wound margins)
- lymphangitic steaks
- fever
