Wounds and post operative management Flashcards
When can a wound be closed by primary closure?
When it ha been cleaned and there is negligible skin loss, it must be less than 12 hours old and the edges come together without tension?
When is delayed primary closure used for wounds?
When wounds are contminated, infected or more than 12 hours
They are cleaned and dressed and left open for 24 hours, then closed if no signs of infection
What will a wound be left to heal by secondary intention?
This is when there is tissue loss preventing edge approximation e.g. ulcers or partial thickness burns
The wound heals by granulation, epitheliasation and scarring
When should tetanus vaccination be considered?
In high risk wounds that are contaminated tetanus booster and immunoglobulin should be given
In patients with moderately contaminated wounds it depends on vaccination history
If vaccines (5 injections) more than 10 years give booster
If vaccination status unknown give booster regardless of wound severity
When roughly should sutures be removed?
Head and face - 5 days
Upper body and arms - 7 days
Lower limbs 10 days
How can the percentage surface body area for burns be calculated?
Estimated using rule of 9s (head 9%, Arm 9%, Leg 18%, trunk front 18%, trunk back 18%)
A lund and Browder chart is more accurate
How are burns classified?
By superficial, partial-thickness or full-thickness (1st, 2nd or 3rd degree)
Superficial is red and blanches with pressure
Partial-thickness is red and moist with blisters and does not blanch
Full-thickness is white/grey Whatand dry
What is the management of superficial burns?
Should rinse under tepid water for 10-30mins
Clean with soap and water
Small blisters can be left and larger ones are burst using aseptic technique
Use a non adhesive dressing
what is the management of an infected burn?
Should swab the wound and provide empirical treatment with 7 days of flucloxacillin
Inspection and dressing change daily
What is the initial management of burns?
Should use the A-E approach
A - airway burns suggested by burnt face/singed nostrils/stridor/soot in sputum require anesthetic intervention for intubation
B - all patients need 15L non-rebreathe as can have CO poisoning
C - Site 2 large bore cannulas and IV fluid resuscitation should be given according to the Parkland formula:
Fluid requirement (ml) = 4 x total body surface area (%) x body weight (kg)
-50% of this should be given in the first 8 hours and 50% in the next 16 hours
-Children should be given maintenace fluids in addition to this
-Disability - check responsiveness, give strong analgesia
-Exposure - examine entire skin and look for other injuries
What are the main immedaite complications that occur posst operatively?
Anesthetic complications (arrhythmias, allergy, breathing problems) Haemorrhage - monitor drains, observations, FBC/haematocrit
What are the 5 Ws of post-operative fever?
Wind - <2 days - Atelectasis, pneumonia
Water - 2-4 days - UTI
Wound - 5-7 days - Wound infection, infected post operative collections
Walking - 8-10 days - Venous thromboembolism
Wonder drugs - any time - Transfusion/drug reactions (serotonin syndrome)
What are the causes of post operative hypotension?
Decreased intravascular volume e.g. haemorrhage or 3rd space losses
Pump failure - cardiogenic shock, surgery increases risk of MI and worsens heart failure
Sepsis and anaphylaxis
Sympathetic shock - high epidurals can causes loss of sympathetic outflow causing vasodilation
What are the causes of low urine output post operatively?
Pre renal AKI - most common due to volume depletion
Renal - May be secondary to nephrotoxic drugs (metformin, aminoglyosides)
Post-renal - may be due to postatic hypertrophy
