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Wound Management By Elspeth Frascatore October 2013.

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Presentation on theme: "Wound Management By Elspeth Frascatore October 2013."— Presentation transcript:

1 Wound Management By Elspeth Frascatore October 2013

2 Timing of Wound Closure <6hrs: primary closure OK 6-24hrs: primary closure OK unless high risk factor present Heavily contaminated Extensive intra-oral lacerations Foot wounds Stellate lacerations Devitalised wounds: crush injury, under XS tension PMH diabetes, ETOH dependence, PVD, immunosuppression (inc. long term steroids)

3 Wound Cleaning Tap water is just as good as normal saline Use high pressure irrigation Need 5-8psi Use 30-60ml syringe attached to 19 guage luer Use 50-100ml irrigant per cm of laceration

4 Tetanus Given at 2 / 4 / 6 / 18 months 5 / 15yrs every 10yrs thereafter Immune: if have had at least 3 doses and UTD

5 Tetanus HISTORY Of TETANUS COURSE AND/OR BOOSTER CATEGORY 1 <5 years (ie. Immune) 2 5 - 10 years 3 >10 years (ie. Full course but out of date) 4 Never / Partial Course / Unknown Clean wound (<6hrs, non- penetrating, negligible tissue damage) Nil Booster ADTADT course Dirty wound NilBooster ADT ADT course and TIG: 250iu routinely or 500iu if old, contaminated wound or burn injury

6 Suture Techniques Gaping / high tension wounds (eg. Over joints) Wounds on fragile skin as spreads tension To evert wound edges (eg. Posterior neck, concave skin surface)

7 Signs of Arterial Injury Large expanding haematoma Severe active / pulsatile bleeding Shock unresponsive to fluids Signs of cerebral infarction Bruit / thrill Decreased distal pulses Paraesthesia

8 How do you tie off an arterial bleeder?

9 Human Bites 10-15% infection risk Do not close hand wounds, puncture wounds, infected wounds, wounds >12hrs old Copious wound washout Avoid layered closure Use loose sutures to allow fluid drainage Antibiotic prophylaxis in all cases Although this may change in future Remember punch injuries

10 Dog / Cat Bites Can close if <6hrs and in low risk area / patient Antibiotic use Meta-analysis has revealed that antibiotics decrease incidence of wound infection in hand wounds only

11 Neck Lacerations If multiple, assess most important regions first rather than largest Look at the back early Wound size does not correlate with severity of injury

12 3 2 1

13 Structure to Consider Spinal cord – suggested if bilateral symptoms Phrenic nerve – hypoventilation; implies subclavian vein / artery injury Brachial plexus (C5-7) Recurrent laryngeal nerve Cranial nerves Glossopharyngeal nerve – dysphagia, altered gag Vagus nerve – hoarseness; implies common carotid / IJV injury Horners syndrome – ipsilateral miosis, enopthalmos, anhydrosis Carotid and vertebral arteries; vertebral, brachiocephalic and jugular veins Thoracic duct, oesophagus, pharynx etc… Thyoid, parathyoid, submandibular, parotid glands

14 Examination Wound exploration – keep minimal and only perform if stable Identify affected zone and triangle Identify direction tract takes Determine if platysma is penetrated If platysma not penetrated: can be cleared of significant injury If platysma penetrated: 50% risk of other significant injury, mandates OT

15 Investigation Always Xray Knives can break off under skin CT angiography All zone I Stable zone II Zone III with evidence of arterial injury

16 Intra-oral Lacerations

17 Eyelid Lacerations

18 Lip Lacerations

19 Tongue Lacerations

20 Nasal Lacerations

21 Facial Nerve Blocks


23 Ear Block

24 Hand Blocks

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