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Emergency Med > Wound Repair > Flashcards

Wound Repair Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Primary intention healing

A

Healing of wound edges in direct contact

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2
Q

Secondary intention healing

A

Non-closure of a wound

  • Very dirty or infected wounds
  • Animal bites to hands, feet
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3
Q

Tertiary intention healing

A

Closure of a wound after observation (~3-5 days)

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4
Q

What is more likely to get infected? What is less likely to get infected?

A

More likely: Hands, feet

Less likely: Face, scalp

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5
Q

In prepping the wound, what should you do?

A

Thorough irrigation before closure

Pulsing works best

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6
Q

Should you soak the wound?

A

Betadine is great to prep the skin with, but don’t ever soak a wound in it bc it kills the cells that are helping the wound to heal
Peroxide can be used, but only if you’re judicious with it

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7
Q

Irrigation

A

Should remove all visible debris and devitalized tissue
Wound not in delicate or friable tissue should be scrubbed
Inspect wound to base
-Look for foreign bodies, tendon and muscle injuries through the wound
Anesthetize before inspecting

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8
Q

What is the exception to the soaking rule?

A

Soak animal bites in soap and water to dislodge rabies

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9
Q

Saline and irrigation

A

Do not reuse open bottles of saline for wound irrigation!

Common route of cross-contamination between pts

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10
Q

Skin prep

A

Apply cleansing agent in circular motion
-Start next to wound and work your way out, rotate swab stick in fingers
-Most are toxic to tissue, so keep agent out of wound
On extremity wounds, place sterile drape on table below limb
Cover wound with fenestrated drape or several drapes around field
Wash cleansing agent way from wound with sterile water or saline

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11
Q

Drying principles on skin prep

A

Want chlorhexidine to completely dry

EtOH and betadine completely kill on contact- don’t need to wait before wiping off

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12
Q

Filament type of nylon

A

Mono

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13
Q

Time required for absorption for nylon

A

Non-absorbable

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14
Q

Color of nylon

A

Black

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15
Q

Common use of nylon

A

General

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16
Q

Advantages of nylon

A

More secure knots

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17
Q

Filament type of polypropylene

A

Mono

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18
Q

Time required for polypropylene absorption

A

Non-absorbable

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19
Q

Color of polypropylene

A

Blue

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20
Q

Common use of polypropylene

A

General

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21
Q

Advantages of polypropylene

A

Strength

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22
Q

Filament type of polyglactin

A

Multi

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23
Q

Time required for polyglactin absorption

A

60-90 days

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24
Q

Color of polyglactin

A

White

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25
Q

Common use of polyglactin

A

Buried

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26
Q

Advantages of polyglactin

A

Dissolves slowly
Use for lower layer in layered closure
Exception is where you don’t want to lose strength (i.e., cracking open chest- use wire)

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27
Q

Filament type of chronic gut

A

Mono

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28
Q

Time required for chronic gut absorption

A

15-60 days

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29
Q

Color of chronic gut

A

Tan

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30
Q

Common use of chronic gut

A

Tongue

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31
Q

Advantages of chronic gut

A

Dissolves more slowly

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32
Q

Suture characteristics-size

A

Suture size expressed in numbers of zeros in the diameter

Larger the number, the smaller the suture

33
Q

What sizes should you use for what parts of the body?

A

3-0 for trunk
4-0 for extremities
5-0 for digits
6-0 for face

34
Q

Taper needles

A

Has round cross-section

Good for really deep wounds

35
Q

Conventional needles

A

Triangular cross-section
Pushes knot upward
Further out of the hole leaves less of a scar
Great for face

36
Q

Reverse needles

A

Triangular cross section
Sits down in the whole
Leaves more of a scar, but more strength and protects the knot more

37
Q

How to determine radius of the needle

A

Use a small radius for layers

Use a larger radius for a wide cut

38
Q

Iris scissors

A

3-4” pair with both tips sharp

Use for cutting tissue, dissecting, and undermining

39
Q

When should a scalpel be used instead of scissors?

A

For top of skin

40
Q

Undermining

A

Moving lateral or parallel to the skin

41
Q

Using a needle driver

A

For holding suture needle

Needle should be held at the proximal 1/3 of the shaft, perpendicular to the driver

42
Q

(Kelly) curved hemostat

A

Used for clamping bleeders

Good for foreign body, retracting tissue to get to something deep

43
Q

Tissue forceps (Pick-ups)

A

For grasping tissue and suture needle
Have teeth to improve grip
Used to lift tissue from underneath
Should be held like a pencil

44
Q

General rules for suture placement

A

Introduce the suture needle into the skin at a 90 degree angle
Suture depth should be just above bottom of wound and should be at least as wide as it is deep
Enter dermis at the same level as where you exited the other side of the wound

45
Q

How to perform an instrument tie

A

Place driver between suture ends and, with non-dominant hand, wrap suture (needle end) over the instrument twice (first throw only)
Grasp short end of suture with driver and pull through
Repeat these steps in the opposite direction from the throw before, using only one loop around the driver
Each loop you make should be wrapped toward the wound

46
Q

How many throws should be made for the different sizes of sutures?

A

3-0, 4-0 monofilament: at least 4 throws
5-0, 6-0 monofilament: at least 6 throws
Braided suture requires fever throws to hold
Pull knot off to side

47
Q

What are the two different ways to do a simple interrupted stitch?

A

Halves (start in the middle and go to one side first)

End to end

48
Q

Simple running (baseball) stitch

A

Similar to simple interrupted, except that only the first and last passes are tied

49
Q

Advantages and disadvantages of simple running stitch

A

Advantage: Faster
Disadvantages: Harder to get tight, comes unraveled if any loop breaks

50
Q

Locked running stitch

A

Variation of running stitch

Easier to keep tight

51
Q

Vertical mattress stitch

A

Provides layered closure with one stitch
Creates everted wound edges
Deep bite is made first, followed by a more superficial bite in the same plane, but in the opposite direction
They hold more tension, good for a wound over a joint

52
Q

Horizontal mattress stitch

A

Good for high tension wounds or wounds that need to hold most of the tension on one side
First bite is nl
Move down the wound and bite back in opposite direction

53
Q

Subcuticular stitch

A 
Can do interrupted or running
Avoid "train-track" scar appearance
Used for surgical or very clean wounds
Sutures are placed upside-down to bury knots
Final tail is hidden
54
Q

Special considerations

A

Splinting sometimes required
Shaving traumatizes skin and contaminates wound
NEVER shave an eyebrow
Take special care to align all natural (and unnatural) landmarks
If incision has to be made, try to make it along natural skin tension lines
Excessively dirty wounds need recheck

55
Q

Dog ear repair

A

Incision made at 45 degree angle to wound
Excess tissue undermined and flap pulled across wound
Excess tissue cut over original incision and sewn

56
Q

Staples

A 
Easy to use and very quick
Can often be placed without anesthesia
Don't require sterile technique
Automatically evert wound
Leave scars
-In ER, primarily used in scalp
57
Q

Using staples in children

A

Anesthetize first- still building a psyche
LET for 15-20 mins, then return to staple
Let them hear the sound of the staple before you start stapling

58
Q

Tissue adhesive

A

Very quick, no anesthesia or sterile technique required
Be very judicious about where and how you use it
-May pull off sooner in an area with a lot of tension
-Mostly just forehead and around the eyes, volar part of the arm
Wound must be clean/dry
NO ACTIVE BLEEDING
Put glue over the top of the skin

59
Q

Wound tape

A

Rarely used for primary wound closure
More effective for reinforcing
Sometimes used to re-approximate skin tears
Often used in conjunction with glue
Can be useful to reinforce thin skin when suturing

60
Q

Hair ties

A

Sometimes used in wilderness medicine and nursing homes

61
Q

Wound care instructions

A 
Keep dry and covered for 24 hrs
Dirty wounds need recheck in 48 hrs
No submersion for several more days
Elevate if applicable
Clean 2-3 x daily with soap and water
-Peroxide should only be used for face to keep scars from scabbing
-Minimal abx ointment bc wound needs to be dry
Watch for signs of infection
APAP or NSAIDs for pain
62
Q

High risk wounds

A

Wounds >12 hrs old at presentation- leave open
Tooth-related wounds
Crush wounds
Heavily contaminated wounds
Wounds of relatively avascular areas
Wounds involving joint spaces, tendons, or bones
Severe paronychia and felons (abscess in pulp of fingertip)
Wounds in pts with hx of valvular heart dz
Wounds in IC pts

63
Q

Tetanus prophylaxis

A

A non-tetanus prone wound in a pt who has not had a Td in the past 10 yrs
A tetanus prone wound in a pt who has not had a Td in the past 5 yrs
Any wound in an adult pt who has not had adequate immunization

64
Q

Tetanus prone wounds

A 
>6 hrs old
>1 cm deep
Stellate or avulsion configuration
Associated with devitalized tissue
Contaminated with soil, feces, or saliva
From a missile 
From a puncture or crush
Associated with burn or frostbite
65
Q

Days to removal for scalp stitches

A

6-8

66
Q

Days to removal for face stitches

A

3-5

67
Q

Days to removal for ear stitches

A

4-5

68
Q

Days to removal for chest/abdomen stitches

A

8-10

69
Q

Days to removal for back stitches

A

12-14

70
Q

Days to removal for extremity stitches

A

8-10

71
Q

Days to removal for hand stitches

A

8-10

72
Q

Days to removal for finger stitches

A

10-12

73
Q

Days to removal for foot stitches

A

12-14

74
Q

When to add 2-3 days to suture removal time

A 
Extensor surfaces
Age >65
Diabetics
Chronic steroid use
Smokers
75
Q

Suture removal technique

A

Prep area with alcohol or other skin cleanser
Cut the suture with iris scissors as close to the skin as possible
Tight sutures may need to be cut with a #11 blade
Cut farthest from the knot possible
Mattress suture needs two cuts

76
Q

Anesthesia for I and D

A

Organic material present in abscess makes it difficult to numb well
Field block safest way to anesthetize skin
-Alternative: make superficial narrow field over top of abscess
-Include area where pus seems most superficial
Often helps to inject V-shaped area of anesthetic under abscess if underlying structures permit

77
Q

Preparing the field for I and D

A

Apply cleansing agent in circular motion
Cover wound with fenestrated drape or several drapes around field
Wash cleansing agent away from field with sterile water or saline

78
Q

Old school I and D procedure

A

Using #11 blade, stab downward into area of maximal fluctuance
Allow most of pus to run out
Widen incision to approximately 2 cm
Probe wound using blunt dissection techniques to break up loculations
Obtain cultures if indicated
Irrigate with sterile saline
Use forceps to fill cavity with 1/4 inch packing gauze (iodoform or plain)

79
Q

After I and D procedure

A

If MRSA suspected, pt should be prescribed 10 days of abx
-Bactrim DS 2 twice daily OR
Clindamycin 300 mg 4x daily OR Doxycycline 100 mg twice daily
Pain meds appropriate
Pt should return in 48 hrs to have packing removed and wound checked
-If wound tries to close, needs to be repacked
Send pt home to irrigate
Bactrim is best choice

Emergency Med (11 decks)

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