Wounds/Lacerations

Question 1

What are the goals in laceration repair?

Answer 1

1. Preserve normal function.
2. Achieve best cosmetic outcome.
3. Least painful approach.
4. Avoid infection and complications.

Question 2

What is the infection risk with proper wound care?

Answer 2

1-12%.

Question 3

What is another name for skin tension lines?

Answer 3

Langer’s Lines or cleavage lines.

Question 4

What are Langer’s Lines?

Answer 4

They are lines of skin tension; they are topological lines drawn on a map of the human body. They correspond to the natural orientation of collagen fibers in the dermis, and are generally perpendicular to the orientation of the underlying muscle fibers.

Question 5

How does local anesthetic work?

Answer 5

It interferes with neural depolarization and transmission of impulses along axons.

Question 6

What is the difference between 1% and 2% plain lidocaine?

Answer 6

1% lido = feel the touch and pressure, but NO pain.

2% lido = ALL sensation eliminated.

*Pain receptors in the skin have a small diameter and no myelin sheath, whereas larger myelinated fibers control pressure and touch.

Question 7

What areas do we NOT use epinephrine?

Answer 7

Penis, nose, ears, fingers, toes.

Question 8

What are the complications of local anesthetic?

Answer 8

1. Possible increased infection from decreased blood flow and potential for bacteria overgrowth.
2. Hematoma.
3. Permanent nerve damage.
4. True allergic reaction (< 1%).

Question 9

What are most regional blocks used for?

Answer 9

Epidural for childbirth.

Question 10

What is important to remember about a nerve block?

Answer 10

Do NOT go into the nerve directly, go around it.

Question 11

What is the most important step to minimize potential for infection of a wound?

Answer 11

Irrigation!

Question 12

What is the ‘pearl’ of irrigation?

Answer 12

Irrigate with COPIOUS amounts of water; at least 500 cc sterile saline or tap water.

*Irrigation in the manner will remove small particulate matter without pushing fluid into fascial planes further increasing risk of infection.

Question 13

Do small, uncomplicated wounds or lacerations need antibiotics?

Answer 13

NO!

Question 14

When should we consider antibiotic treatment for wounds or lacerations?

Answer 14

1. Wounds greater than 8-12 hrs, esp. of hands & LEs.
2. Facial wounds after 24 hrs of injury.
3. Crushing (compression) MOI wounds with potential for devitalization of those requiring extensive revision.
4. Significantly contaminated wounds requiring extensive cleansing and debridement.
5. Violation of ear cartilage.
6. Involvement of joint spaces, tendon or bone.
7. Complex, extensive paronychia and felons.
8. Mammalian bites (human and cats).
9. Extensive or contaminated wounds in patients w/pre-existing valvular heart disease.
10. Conditions of immunosuppression or impaired host defenses (DM, HIV).

Question 15

What antibiotic is preferred if a wound or laceration is infected? MC organism?

Answer 15

Keflex (Cephalexin); if allergic use Erythromycin, 3-5 days.

MC organism = staph aureus.

Question 16

When do you recheck the wound if there is a high risk for infection?

Answer 16

48 hrs; if infection free at 3-5 days and will usually remain that way.

Question 17

What are the 4 phases of wound healing?

Answer 17

1. Hemostasis.
2. Inflammatory.
3. Proliferative.
4. Maturation or remodeling.

Question 18

Describe the first phase of wound healing.

Answer 18

Hemostasis…

• Begins at the onset of injury, where the body activates its emergency repair system – the blood CLOTTING SYSTEM.
• -PLATELETS come into contact with collagen, which results in PLT activation and aggregation; THROMBIN initiates the formation of FIBRIN MESH that strengthens the PLT clumps into a stable CLOT.

Question 19

Describe the inflammatory phase of wound healing.

Answer 19

The focus is to DESTROY BACTERIA and REMOVING DEBRIS – WBC/Neutrophils 24-48 hrs, then macrophages for several days.

-This stage prepares the wound bed for the growth of new tissue; often will last 4-6 days and is associated with EDEMA, ERYTHEMA, heat and pain.

Question 20

What is the focus of the Proliferative phase of wound healing?

Answer 20

To FILL and COVER the wound.

Question 21

What are the 3 distinct stages of the proliferative phase of wound healing?

Answer 21

1. Filling the wound.
2. Contraction of the wound margins.
3. Covering the wound – EPITHELIALIZATION.

Question 22

Describe the Maturation phase of wound healing?

Answer 22

• New tissue slowly gains strength and flexibility.
• COLLAGEN fibers reorganize, TISSUE REMODELS and matures.
• Increase in tensile strength.
• Lasts from 21 days, up to 2 yrs.

Question 23

Name some factors (5) that can affect the wound healing process?

Answer 23

1. Type of wound – linear or crush (won’t heal well).
2. Location (mechanical stress, high tension areas = longer to heal).
3. Extent of the wound (deep, involvement of other structures = nerve, vascular).
4. Level of contamination (infection potential).
   - -organic materials are living & have a higher infx potential (grass, wood, dirt, food, etc).
5. Estimated length of time before repair = time open to closure; more time if vascular area, such as the face.
6. Pt’s general health status (DM, smoking, chronic steroid use, age, nutrition, chemo or radiation).

Question 24

What is the best time for adequate closure of a wound?

Answer 24

Within 8 hrs.

Question 25

What are some other things to take into consideration when using local anesthetic?

Answer 25

- Onset of action (immediate vs delayed). - Duration (shorter vs longer-acting). - Toxicity. - Depends on vascularity of site; adjunctive epinephrine. - Type and amount of anesthetic. - Concentration (1 or 2%). - Technique and accuracy.

Question 26

What is important to know about epinephrine?

Answer 26

It has vasoconstrictive properties that prolongs the duration of anesthetic, decreases the bleeding, but MAY increase the infection potential.

Question 27

What are some different types of anesthetics?

Answer 27

Lidocaine (Xylocaine), Mepivicaine (Carbocaine), Bupivicaine (Marcaine), TAC.

Question 28

What is the most common type of anesthetic?

Answer 28

Lidocaine (Xylocaine)

Question 29

What are the features of Lidocaine?

Answer 29

1. Rapid onset, 60-120 minutes duration. 2. Lido + Epi = better hemostasis & increases duration, BUT may have a higher potential for infection. 3. HINT: INJECT SLOW or consider use of 1 mL NaBicarbonate (1 MEQ/mL solution) to 10 cc of a 1% concentration of Lido may decrease burn/sting associated from Lido, which is acidic (pH 6.49), throw away vial as shelf life decreased to 24 hrs. 4. Needles = 25 (MC), 27, 30G. 5. Syringe = 3 (MC), 6, or 10cc.

Question 30

Name the different methods of placing anesthetic?

Answer 30

Direct infiltration, field block, digital block, hematoma block, regional block, nerve block.

Question 31

What is the most common method of anesthetic delivery used in minimally contaminated lacerations in anatomically uncomplicated areas?

Answer 31

Direct Infiltration - Inject a small bolus thru wound margin into the SUBQ tissue, remove needle and reinject in previous injection anesthetic distribution, repeat. - Less painful as needle NOT thru intact sensory active skin, below dermis at junction of SUBQ tissue.

Question 32

What anesthetic delivery method is used to minimize pain in a heavily contaminated wound?

Answer 32

Parallel Margin Field Block

Question 33

What are the advantages and method of completing a field block?

Answer 33

Advantages: fewer needle sticks, useful in GROSSLY CONTAMINATED WOUNDS. METHOD: same as direct but thru intact skin: bury needle to hub, aspirate, inject as you withdraw; repeat in edge of anesthetic distribution.

Question 34

What areas do we use a digital block? What is the most important part of completing a digital block?

Answer 34

Fingers or toes. EX: paronychia, nail repair or removal, laceration. METHOD: 3 cc of 1% plain LIDO w/o EPI, alcohol pad to site, needle enters at 90 degrees at digital crease until bone is met, aspiration then injection of 0.5cc, needle is withdrawn BUT NOT ALL THE WAY out of skin, then re-direct at 45 degrees VOLAR, aspiration, then 0.5cc injected, again withdraw and re-direct at 45 degrees DORSAL with aspiration, then injection of 0.5 cc; the entire process can be repeated with a new needle on the other side of the digit for a complete block. *WAIT at least 5 mins.

Question 35

What is a hematoma block used for?

Answer 35

Useful in fracture reduction, EX: Boxer's Fx.

Question 36

What is the KEY point of a hematoma block?

Answer 36

Wait 10-15 minutes after injection.

Question 37

What is tissue toxic and can be made from Betadine (1%) by diluting it? What is important to know about it?

Answer 37

Povidone Iodine Solution (10%). Makine Betadine 1% from it is controversial and you want to avoid getting it into the wound but can be used around the wound.

Question 38

What is LET/TAC/TEC?

Answer 38

A topical anesthetic. LET = 1-3cc gel or solution of Lido 4% + Epi 1% with Tetracaine 0.5% or cocaine.

Question 39

What are the rare complications of TAC?

Answer 39

Seizures, Arrhythmias, Cardiac Arrest.

Question 40

Pearls to know about LET/TAC/TEC?

Answer 40

For pediatric patients; NO ear, tip of nose or penis, mucous membranes as highly permeable.

Question 41

What are some Tetanus Prone Wounds?

Answer 41

1. Wound greater than 6 hrs old. 2. Wound depth greater than 1 cm. 3. Stellate (star-like), Avulsion configuration. 4. Devitalized tissue 5. Contaminates. 6. Missile, Crush, Burns, Frostbite. Devitalized tissue is unviable for the healing process; it favors bacterial growth and the infectious process in the wound bed. It is also called sloughed or necrotic tissue

Question 42

When should a patient return after discharge of wound care?

Answer 42

If increased pain, erythema beyond wound margin, edema, pus or fever.

Question 43

What are some common analgesics for small, uncomplicated wounds?

Answer 43

Acetaminophen, NSAIDs.

Question 44

What are the instructions necessary to tell your patient upon discharge of wound care?

Answer 44

1. Frequent dressing changes often, as needed. 2. Bathing -- no immersion or soaking of wound, shower once per day after first 12-24 hrs. - Carefully dry, apply thin film of Abx ointment. 3. Possible activity restriction, depending on location. 4. Consider elevation, immobilization, cool compresses for 24-48 hrs.

Question 45

What are the necessary things to note when filling out the WOUND CLOSURE NOTE?

Answer 45

Date of procedure, Consent, Time wound open, MOI, Anatomic location/associated injuries, Length/Depth, Wound classification (clean/dirty), Cleansing method/Irrigation volume/type, Anesthesia and Method, Suture size/type, Closure method/technique, Dressing method, Pt responses or complications, Disposition/Follow-up, Pt Education Instructions, Signature.