1. Wound Care
Suzana Tsao, DO

2. Why do we care?

3. Layers of the Skin Closure at the dermal level
Subcutaneous adds little strength
Complex wounds  in/below fascial layer need multi-layer closure

4. Healing Initially edges retract and tissue contracts
Platelet aggregation and clotting cascade activated
Initial epithelialization h
Peak collagen synthesis 5-7d
Strength of wound
5% at 2 weeks
35% at one month

5. Initial Evaluation Always start with the ABCD’s Airway Breathing
Circulation
Disability

6. Wound Evaluation Location Active bleeding Exposed tissue/bone/organs
Check for peripheral pulses

7. History Where When How Location, location, location Golden period
Mechanism
Potential for foreign body

8. Where Anatomic location Special Consideration Mouth Ear Joints
periorbital
Head injuries bleed less chance of infection
Hand and feet more prone to infection

9. When Golden Hour of Wounds Infectious inoculum 105 per gram
Need 3-5 hours for proliferation of bacteria
Extremities  6 hours
Face and scalp  24 hours
But wait ….

10. When to close
Studies show can close as late as 19 hours on extremities
ACEP clinical policy supports 8-12 hours
Depends on the clinical scenario
Consider other types of closure
Primary closure
Delayed primary closure
Healing by secondary intention

11. How Mechanism Assess concern for foreign body Clean wound Dirty wound
Contaminated wound

12. High Risk Mechanisms Open fractures Intraoral wounds Mamillian bites
Crush injuries/devascularized tissue
High pressure injuries
Jagged edges/stellate shape/deeper than subcutaneous layer
Foreign body
Visible contamination
Mamillian bites have 6% risk of infection

13. PMH/SocHx Co-Morbid Conditions Hand dominance Occupation
Last tetanus booster

14. Tetanus < 3 doses in primary series Primary 3 series completed
Clean/minor
Tetanus toxoid
All other
Toxoid and immunoglobulin
Primary 3 series completed
< 5 years
None needed
> 5 years but < 10 years
Clean minor
All others
Give toxoid
> 10 years

15. Pertussis
Give Tdap regardless of last Td to update pertussis if not updated as an adult
Replaces one of the 10 year Td booster doses
Boostrix when feasible for > 65 y/o
Tdap during each pregnancy b/w 27 and 36 weeks
CDC link
summary.htm

16. Co-Morbid Conditions Age (very young/very old) Diabetes Renal Failure
Malnutrition
Obesity
Immunocompromised

17. Physical Exam Type of wound Superficial/deep Length/shape
Bleeding/revascularization
Associated injuries
Retained foreign body
Complete neurovascular exam
2 point discrimination most accurate for sensory function in extremities

18. Active Bleeding
Direct pressure
BP cuff
2 hours max
Figure of 8 stitch

19. Associated Injuries Assess for tendon injuries
90% lacerated tendon can still maintain normal neuro function
Assess for joint involvement
May need to inject joint
Assess for underlying fracture
X-ray if suspected before manipulating the area

20. Retained Foreign Body Direct visualization X-ray Ultrasound CT/MRI?
May need anesthesia to fully evaluate
X-ray
80-90% can be detected
Does not visualize organic material
Ultrasound
CT/MRI?
RFB 5th leading cause of malpractice claims against em physicians

21. Indications for FB removal
Reactive materials
Wood
Vegetative material
Contaminated materials
Clothes
Most fb in foot
Impingement on neurovascular structures
Impairment of function
Easy to remove

22. Indications for consultation
Nerve injury
Vascular injury
Tendon or joint involvement
Difficult to remove foreign body
High pressure injection injury

23. Irrigation Dilution is the solution to the pollution Amount
High pressure (5-8 psi)
30-60 cc syringe with 19 gauge angiocath or splash shield
Amount
Min 250ml
50-100ml/cm of laceration
Type of fluid
Tap water just as good as normal saline
NEVER, EVER, NEVER
Betadine or peroxide
1% Betadine may be ok, but no increased benefit

25. Debridement Remove necrotic tissue
May need to debride for better approximation and cosmetic results

26. Sterile Gloves Several trials showed no difference if final outcome
Dealer’s choice

27. Anesthesia Topical pretreatment Consider procedural sedation Allergies
Most are from preservative
Consider using cardiac lidocaine
1% Benadryl

28. Local vs. Regional Block
Large areas
When needed to avoid tissue distortion
Areas where infiltration is painful
Plantar surface of foot

29. Anesthesia Amides Esters Lidocaine Procaine Lidocaine with epinephrine
Max 4.5mg/kg
Duration 1-2 h
Lidocaine with epinephrine
Max 7mg/kg
Duration 2-4 h
No epi in fingers/toes, ear, nose, penis
Bupivacaine
Max 2mg/kg 0.25%
Duration 4-8 h
Esters
Procaine
Max 7mg/kg
Duration min

30. Types of Repair Primary closure Delayed primary closure
Closure of the wound at the time of the ED visit
Delayed primary closure
Closure of wound 3-4 days after injury
Healing by secondary intention
Allow wound to heal without closure through scarring

31. Methods of Closure Tape Skin Adhesives Staples Sutures
Superficial, straight, under little tension
Skin Adhesives
Does not involve deep layers
Little tension
Staples
Linear on trunk, extremities, scalp
Sutures

35. Types of Sutures Absorbable Nonabsorbable Gut PDS (polypropylene)
Maxon (polyglyconate)
Dexon (polyglycolic acid)
Coated Vicryl (polyglactin)
Nonabsorbable
Dermalon or ethilon
Prolene or surgilene (polypropylene)
Silk
steel

37. Suture size by location
Face
5-0 to 6-0
Scalp/Chest/Back/Abdomen
3-0 to 5-0
Extremities
4-0 to 5-0
Oral
3-0 to 5-0 (absorbable)

38. Indications for antibiotics
Prosthetic device
Endocarditis prophylaxis
Open joints and/or fractures
Mamillian bites
Intraoral lesions
Immunocompromised patients
Heavily contaminated wounds

39. Discharge instructions
Signs and symptoms of infection
Fever, discharge, red lines from wound, erythema, swelling
Elevation +/- splinting
When to do wound checks at one or two days
Suture removal instructions
Face 3-5 days
Scalp 5 days
Extremities 7-10 days, high tension days
Washing - showering - avoid long baths, pools, ocean
Triple antibiotic ointment

40. Pearls No such thing as absolute golden hour
Tap water is as good and normal saline
Do not soak in betadine
Nonsterile gloves ok
Hand wounds less than 2cm -> big, bulky dressing as good as sutures

41. Pitfalls Always remember ABC’s Look for associated injuries
Bone, vascular, nerve
Don’t dismiss high pressure injuries
Always assess for foreign body
Antibiotics vs. delayed primary closure for high risk wound and/or co-morbid conditions
Remember special locations
Ear, nose, vermillion border
Fight bites  do not close