Wounds Flashcards
What is the best solution for cleaning a wound?
Tap water or normal saline are adequate/ good for simple wounds.
Severely contaminated:
- Chlorhex 0.1%
- Iodine 1% (most antimicrobial: bacteria/virus/fungal/spores)
Optimal pressure for wound irrigation?
At least 8 psi (55 kPA)
>20 psi = damage.
When should primary closure of a wound be done?
Primary closure gives better cosmesis, and more rapid healing. BUT, infection increased
-
Within 6 hours
and after inital clean/ debride, is: - Clean
- Viable
When should delayed primary closure be done?
When there is risk of infection- want to ensure there isn’t, before closing it in
-
>6 hours
Remains: - Contaminated
- Non-viable tissue present
Close after 2-3 days, if no infection
When is healing by secondary intention suitable?
- Bites
- Badly contaminated
- Infection
- Significant tissue loss (uncloseable)
Tetanus cover:
Risk:
- Soil/ animal faeces
- Retained organic foreign body
To be ‘covered’, must have had:
- 3 or more doses
- Last one within 5-10 years
All ‘uncovered’ patients should get ADT, regardless of wound.
‘Covered’ patients get ADT if >5 years, AND dirty wound
If ‘uncovered’ AND dirty wound, give immunoglobulin
When are the following suture techniques useful?
Simple
Vertical mattress
Horizontal mattress
Subcuticular
Simple
- Small, low-tension wounds
- Can release one at a time PRN
Vertical mattress
- Edge eversion
- Depth
Horizontal mattress
- Edge eversion
- Distributes tension- good first sutures
Subcutic
- Rapid in long, linear wounds
- Good tension distribution
- Tricky
- Reliant on one knot
Classes of wound:
Surgical classification
Class 1- Clean
Class 2- Clean-contaminated
Class 3- Contaminated
Class 4- Dirty-infected
Approach to puncture wounds:
Hx:
? <6 hours, > 6 hours
? Depth/ direction
? Risk of retained FB
Tetanus status
Immuno status
OE
….. Look for retained FB!
USS: must be at least 2.5mm to be seen
Mx:
- Don’t explore
- Soak in warm water/saline 30mins
- Refer if complex:
–>deep structure, FB in situ, grossly contaminated
Antibiotic prophylaxis only if particular risk (Augmentin)
If through sole of shoe: Cipro (pseudomonas)
Management of clenched fist injury:
ie. human bite over MCPJ
Risk ++ if infection to deep structures and dysfunction
–> Polymicrobial: staph, strep, Eikenella, anaerobes
ALL for IV antis and debridement!!
IV:
Ceftriaxone + metronidazole
PO:
Augmentin
Management of animal bite:
Dog: capnocytophaga carnimorsus. more tissue damage
Cat: Pasteurella, More infection
Bat: Lissavirus
Wild: Rabies
- Check for FB (tooth)
- Irrigate
- Debride
- Ideally, leave open
- Antibiotic prophylaxis for all deep, cat or clenched fist
IV:
Tazocin
OR
Ceftriaxone + metro
PO:
Augmentin
What is a closed degloving injury:
Dermis seperates from underlying fascia, but skin surface intact.
- **Boggy swelling
- Hypermobile skin** (morel-lavalee lesion)
- Ecchymosis
- Sensory change (loss of 2-point discrim)
Most commonly outer thigh
–> Drainage/ aspiration
–> Compression
–> +/- debridement
Management of a traumatically amputated digit:
Amputated part:
- Gently wash with saline
- Wrap lightly in saline-soaked gauze
- Plastic bag
- Ice-water slurry
–> 4 degr ideal
Viability best within 6 hours of ‘warm’ time.
–> 1 hour warm = 6 hours cold
Stump:
- Irrigate with saline
- Control bleeding
–> Tourniquet, clamps, pressure..
- Dress in saline-soaked gauze
General:
- Xray the stump AND the part
- ADT +/-
- Cephazolin 2g
- Plastics
Repair of ear laceration:
Considerations:
- Cartilage infection/ healing
- Perichrondral haematoma
- Cosmetics and acoustics
- Auricular block
- If doesn’t approximate, wedge excision
- +/- layered closure
- Compression dressing
Repair of lip and oral lacerations:
Lip:
- Upper: Infraorbital block
- Lower: Mental block
- Non-absorbable (dehiscence, cosmetic implications)
- 1st suture to approximate vermillion border
