Advanced Wound Care http://medstat.med.utah.edu/kw/derm/pages/ph11_2.htm.

Advanced Wound Care

Perform Advanced Wound Care
References Clinical Procedures for Physician Assistants Merck Manual CSDT C348 Minor Surgery A Text and Atlas

Outline Management of traumatic wounds Principles of wound closure Selected skin closures Discuss the complications of suturing Describe the suturing of traumatic wounds Describe cautery devices List the three main factors that promote wound infection Definitions of Infection Types Management of Infected Wounds

Management of Traumatic Wounds
Wound Closure most superficial wounds will heal without intervention a superficial laceration extending into the subcutaneous tissue should be considered for closure in order to avoid undesirable outcomes C288 Clinical Procedures for Physician Assistant’s chap 23 pg

Indications for suture, staple or adhesive tape closure are: to decrease the time required for the wound to heal to reduce the likelihood of infection to decrease the amount of scar tissue likely to form to repair the loss of structure or function, or both, of the tissue to improve cosmetic appearance C288 Clinical Procedures for Physician Assistant’s chap 23 pg

Contraindications wounds that have a high likelihood of contamination should not be closed with sutures wounds that require suturing to minimize infection and scar potential should be closed within 8 hours of the injury. Some wounds can be closed up to 24 hours after the injury if the anatomic location is highly vascular presence of foreign bodies in the underlying tissues extensive wounds involving tendons, nerves or arteries should be carefully considered before closure** C288 Clinical Procedures for Physician Assistant’s chap 23 pg Before any wound or laceration repair is initiated, a thorough evaluation of the patient must be carried out. Remember that all wounds, no matter how minor they appear, can be the result of serious injury to underlying structures. Contraindications to suture closure of wounds relate largely to the risk of infection and disruption of underlying and surrounding structures such as nerves, arteries and tendons. Contaminated wounds – suturing may mask a developing underlying infection. This delayed treatment may result in a spread of infection to underlying and surrounding structures, which has the potential to cause morbidity. Foreign bodies will remain a source of repeated infections if not thoroughly removed

Irrigation copious irrigation with saline solution enhances wound cleanliness using a 60ml syringe and a 21 gauge needle, repeatedly squirt saline into the site with short bursts to dislodge remaining particulate matter several litres may be necessary for large wounds that are heavily contaminated C288 Clinical Procedures for Physician Assistant’s chap 23 pg 312

Management of Injured Tissue
Debridement all traumatic wounds are potentially infected antibiotics are not enough for total protection debridement of dead, devitalized tissue and meticulous removal of foreign elements is the only way to assure infection protection lack of debridement and cleansing allows the possible formation of gangrene, tetanus and necrotizing fasciitis C21 CEDT

Skin first step in debridement is the development of complete exposure by extending the wound with an incision in the direction of the wrinkle lines conservative skin debridement, usually only a narrow edge of skin needs to be sacrificed from the edges of the wound purple, discolored, macerated and crushed skin is excised scissors better than a scalpel complete exposure (foreign body and damage assessment) Every nook and cranny of the wound must be visible and examined. The skin is usually well supplied with blood vessels and considerably resistant to infection.

Muscle must be debrided and sacrificed radically (in consultation only)*** discolored, bruised and non-contractile muscle must be totally excised remove all non metallic foreign bodies, dirt and clothing particles some metallic fragments (bullets, shrapnel) may be left in place if they are too deeply imbedded debridement of muscle is best done with forceps and scissors or scalpel ***in consultation with GDMO/surgeon

Bone save if possible all detached fragments should be removed and set aside under sterile conditions all attached fragments are gently cleansed with a currette and placed in their normal positions when possible the wound should then be thoroughly irrigated

Bone Cont’d while bone can occasionally be left exposed, a preferable approach is to cover it with soft tissue by approximating nearby muscle over it with several lightly tied absorbable sutures

Joints little resistance to infection and are rapidly destroyed by it if a joint capsule is open in the base of the wound it must be cleansed thoroughly remove any bone fragments and irrigate with copious amounts of normal saline the edges of the capsule are approximated with fine absorbable sutures** if possible, the capsule is then covered with viable tissue no drain is used

Tendon and Fascia heal slowly poor resistance to infection because of poor blood supply if they are frayed, badly contaminated or discolored they should be removed***(in consultation) the type of fascia will determine to a large extent the strength of closure use synthetic non-absorbable sutures as they keep their strength for a long time ***in consultation with GDMO/surgeon

Blood Vessels repair is for specialist arterial injuries usually more extensive than they appear check circulation frequently pallor, pain and pulselessness are late signs if there is any question of vascular injury or if the wound is near a major vessel the patient should be moved to a facility where and arteriogram can be done

Necrosis of the skin John L. Bezzant,M.D. The necrotic skin must be removed. Normally the dermis is red and bleeds easily, and the underlying fat is yellow. If the tissues are a different color than that, then they need to be surgically removed.

Removal of dead epidermis and dermis John L. Bezzant,M.D. This shows the removal of the dead epidermis and dermis with the exposure of the yellow fat.

Normal fat at the base of a debrided wound of the heel John L. Bezzant,M.D. This shows normal fat, but note is bleeding freely. I found when debriding a wound it is best to give an oral or injected analgesic before debridement, and when the patient is quite relaxed I then infuse the area to be debrided with a mixture of lidocaine and bupivacaine with epinephrine.

Hemostasis prior to wound closing absolute hemostasis must be established to prevent hematoma formation and further blood volume depletion this is accomplished by direct and indirect methods it is preferable to employ indirect methods first to carefully assess the wound, injury to important structures and allow time for replacement of significant blood loss C21 Current Emergency Diagnosis and Treatment Chap 24 pg Hemostasis – an arrest of bleeding or of circulation

Indirect Hemostasis elevation elevation of the injured part is least damaging to the tissues markedly diminishes capillary oozing pressure direct pressure over a bleeding wound is the most common method C21 Current Emergency Diagnosis and Treatment Chap 24 pg Elevation – caution is required in elderly patients with arterio-sclerotic vasculardisease,, since elevation of the lower extremity may induce tissue hypoxia.

Indirect Hemostasis cont’d pressure cont’d in extremity wounds, a proximally placed BP cuff is frequently used to minimize bleeding in distal wounds the use of tourniquets in extremity wounds should be reserved for isolated digital injuries or complex injuries associated with excessive blood loss or requiring special examination C21 Current Emergency Diagnosis and Treatment Chap 24 pg Pressure – BP cuff – pressure should not exceed 30mmHg and should not impair vascular flow to distal parts. For proximal extremity wounds, pressure should be applied in a graded fashion from the distal aspect of the extremity to avoid the tourniquet effect. This graded pressure is accomplished with bulky dressings and elastic bandages Tourniquets – is placed proximal to the wound and is inflated to a mm Hg above systolic pressure. Ischemia resulting from this maneuver can be tolerated by most patients for 15 to 20 minutes. However, the ischemia produces a reactive vasodilation upon release of the tourniquet and may result in oozing or hematoma formation.

Indirect Hemostasis cont’d application of vasoconstrictive agents epinephrine containing solutions*** are frequently used in acute wounds to control capillary oozing after infiltration a full 7 minutes is required for maximal vasoconstrictive effect Caution – epinephrine decreases local wound defense mechanisms and should not be used in contaminated wounds due to the increased risk of infection C21 Current Emergency Diagnosis and Treatment Chap 24 pg Epinephrine – although it will not affect the viability of acute random cutaneous flaps, epinephrine can induce vasospasm that may lead to necrosis of tissues supplied by an “end-arterial circulation”. For this reason epinephrine is contraindicated in the management of wounds of the penis, of any digit, the tip of the nose, or in any tissue with circulation compromised by the trauma

Indirect Hemostasis cont’d chemical promoters of clotting hemostatic agents such as Avitene, Gelfoam or Surgicel should be avoided in the emergency department setting, since they have been shown to increase the risk of infection in contaminated wounds C21 Current Emergency Diagnosis and Treatment Chap 24 pg

Direct hemostasis includes ligation and electrocauterization of the cut vessel ends direct hemostasis should only be employed for bleeding that cannot be controlled by indirect methods an exception to this rule is injury to major vascular tributaries (e.g. ulnar, femoral and brachial artery) C21 Current Emergency Diagnosis and Treatment Chap 24 pg Further injury to the cut vessel end resulting from attempts at direct hemostasis may preclude a successful repair. In these situations, it is wise to apply firm pressure to the wound and consult a vascular surgeon.

Direct hemostasis Ligation simple tying or suture ligation is indicated for most vessels more than 2mm in diameter…make sure to anchor the suture! to avoid excessive tissue trauma, precisely identify and clamp vessel end prior to ligation cut arteries usually only require simple tying C21 Current Emergency Diagnosis and Treatment Chap 24 pg Suture ligation is performed by passing the suture needle through a portion of the vessel wall and then circumferentially tying the vessel. This method prevents slippage. Absorbable sutures are preferred for tying and suture ligation in the acute wound. Synthetic absorbable sutures are advantageous because of their low reactivity and high friction coefficients. Chromic catgut is also satisfactory.

Direct hemostasis cont’d Ligation veins do not hold ligatures well and suture ligation is preferred Caution – arteries and veins should not be ligated en masse, since this may predispose to arteriovenous fistula formation

Tie Ligature Suture Ligature C58 Wound Closure Manual pg 25

Direct hemostasis cont’d Electrocautery effective in coagulating small vessel ends pinpoint coagulation is preferred, with the delivery of the least amount of current needed for vessel thrombosis Chemical cautery silver nitrate and other caustic agents achieve hemostasis through tissue coagulation but are not recommended for wound hemostasis because of the amount of tissue necrosis they produce C21 Current Emergency Diagnosis and Treatment Chap 24 pg C348 Minor Surgery A Text and Atlas Chap 15, 16 and 17

Tetanus Prophylaxis preventable endotoxin-mediated disease if possible determine last tetanus immunization classify wound as either tetanus prone or non tetanus prone Tetanus Prone greater than 6 hours old greater than 1 cm deep stellate or have an avulsion configuration associated with devitalized tissue C288 Clinical Procedures for Physician Assistants chap 23 pg

Tetanus Prone cont’d contaminated with soil, feces, or saliva from a missile (e.g. gunshot) from a puncture or crush associated with a burn or frostbite All other wounds can be considered non tetanus prone** C288 Clinical Procedures for Physician Assistants chap 23 pg ** common sense prevailing

Non Tetanus Prone Wounds up to date adult requires Td if more than ten years years since last booster adult patient with unknown status or inadequate immunization requires Td Tetanus Prone Wounds adult with up to date status but five or more years since last requires Td adults with inadequate immunization receive both Td and Tetanus immune globulin Clinical Procedures for Physician Assistants Ch 23 pg TIG is safe in pregnancy, Td Toxoid can be safely given in the second trimester and late in those that have high risk wounds

Tetanus Prophylaxis Td TIG Clean minor Wounds All other
History of Tetanus Immunization ( Doses ) Clean minor Wounds All other Td TIG Uncertain 0 - 1 2 3 or more Yes No No2 No3 No1 1. unless wound is more than 24 hours old 2. unless it has been more than 10 years since last dose 3. unless it has been more than 5 years since last dose Td: tetanus and diphtheria toxoids for adults ( > 7 y.o. ) DPT for children Tetanus Prophylaxis Table 24-3 page 394 of CEDT

Outline Management of traumatic wounds Principles of wound closure Selected skin closures Discuss the complications of suturing Describe the suturing of traumatic wounds Describe cautery devices List the three main factors that promote wound infection Definitions of Infection Types Management of Wound Infections

Principles of Wound Closure
Wound Handling wounds treated gently and closed precisely will heal with minimal scarring in contrast rough treatment of wounds with crushing of tissues, failure to achieve hemostasis, incomplete cleansing and tight, strangulating sutures will lead to infection, breakdown and unsightly painful scars for optimal healing the wound should have fresh edges and be clean Surgical incisions and simple lacerations can usually be closed directly, but many traumatic wounds require debridement. In most old wounds excision of a thin margin of scar and granulation is indicated to afford mobility and to provide fresh healing surfaces.

Wound Handling cont’d prior to closure, all loose fat, clot and other debris should be removed from the wound copious irrigation with saline solution enhances wound cleanliness the well prepared wound is red, clean, odorless and remarkably painfree even badly contaminated wounds will heal nicely with minimal scarring if these basic principles are followed

Primary Closure immediate repair with suture to heal by primary intention used on tissues that are clean and free of infection all layers are closed best chance for minimal scaring C288 Clinical Procedures for PAs Usually performed in clean and clean contaminated wounds

Secondary closure the deep layers are closed whereas superficial layers are left open to granulate on their own from the inside out often leaves a wide scar and requires frequent wound care consisting of irrigation and assorted types of packing and dressings is a prolonged process reasons for use include excessive tissue loss and infection C288 Clinical Procedures for PAs Wounds allowed to granulate through contamination, neglect or other causes are said to undergo healing by secondary intention. Wounds closed by second intention often require re-excision and even grafting to produce sound cosmetic and functional results.

Delayed Closure the deep layers are closed primarily whereas the superficial layers are left open until reassessment on the forth or fifth day after initial closure where wound is checked for infection if it looks clean and granulation has begun the wound is irrigated and closed if infected it is left open to heal by secondary intention these wounds often arise from contaminated wounds C288 Clinical Procedures for PAs

HMCS MONTREAL Sick bay EMERGENCY REPORT Actual Hx: This evening around 20h50 local, LS was working in the After Eng. Room and hit his Rt knee on the Fly wheel on the Propulsion Diesel Eng. The Fly wheel was rotating at that moment. He was able to made his way to Sick bay ambulatory with the help of Eng. Pers. O/E: Wound about 7 cm X 2 cm over Rt patella, deep, able to view Patella, Patella was swindled by the Fly wheel, living a groove about 2 X 1 cm on the bone itself. Surrounding tissue was blackened. Prepatellar bursal damage.

HMCS MONTREAL Sick bay EMERGENCY REPORT Wound care: Sterile procedure used & irrigated with copious amounts of NS Wound debrided of all blackened skin with No 11 blade

HMCS MONTREAL Sick bay EMERGENCY REPORT Wound repair Anesthetised with Lidocaine 2% with, 11cc used. Continuous subcuticular suture done with 4-0 Gut followed by simple interrupted X 10 sutures 3-0 Ethilon. Dressing: Polytopic oint, Telfa and Kling. Antibiotic: Ancef 2g IV bolus given over 6 minutes and Keflex 500mg QID X 10 days. TD up to date 1.Are you sure that there was no penetration into the joint from your wound exploration. If no joint penetration, fine. If there is, then you should watch him very closely for signs of septic joint. If no problems within first 2-3 weeks, further problem unlikely. If joint penetration noted at time of initial debridement, scope/lavage is ideal, but sterile saline lavage with 3-9 litres throughout joint would be reasonable. In such a case close joint capsule acutely but leave remainder of wound open for hrs after debridement then delayed closure after 2nd look and any further debridement as long as infection not present. 2. No concerns with a bit of a groove in the patella (non-articular, of course) as long as it was curetted as part of the debridement. Bone will really grab on to foreign material so it has to be curetted/scraped well to insure it is clean and then thoroughly irrigated. If gouge is deep (>5mm say) then there is a chance it could precipitate a patellar fracture with stress such as heavy lift or jumping activity, or with repetitive high impact loading (E.g. running), so best to avoid these for about 6 weeks. If not so deep, no problem. Either way it will gradually heal in. 3. Closure of wound after debridement. A judgement call depending on size, degree of contamination and how good you think your debridement is. You will never be faulted for leaving a wound open for hours and then doing delayed closure once absence of infection is confirmed. Saline soaked gauze packing changed 1-2X daily in interim will usually suffice. Coverage over tendons, nerves or vessels should always be done at time of initial debridement and joint capsule should also be closed at first debridement. 4. Antibiotics. Your method is fine. You could also probably be okay with IV dose initially and then for 3 more doses after debridement. There is a theoretical concern re: resistant bacteria if full 7-10 day course IV/PO given in absence of confirmed infection. S.Taylor, MD, FRCSC Commander

Suture Technique most important to achieve optimal results protect tissues from dying and contamination clean sharp dissection minimal and skillful use of cautery, ligatures and sutures good handling of tissues (no crushing, use toothed forceps) C288 Clinical Procedures for Physicians Assistants pg 315 C68 CSDT Chap 44 pg 1140 Suture technique is important in primary closure however, will not compensate for poorly planned flaps, excessive tension across the incision, traumatized skin edges, bleeding or other problems. Sometimes even a skillfully executed closure may result in an unsightly scar because of healing problems beyond the control of the surgeon.

Suture Technique cont’d prevent excessive tension and strangulation use least amount of sutures as possible proper material selection anatomical approximation of layers subcuticular sutures at base of dermis help prevent tension from forming in the upper dermis and also causes the surface planes to be even C288 Clinical Procedures for Physicians Assistants pg 315 C68 CSDT Chap 44 pg 1140 The goal of closure is level apposition of dermal and epithelial edges with minimal or no tension across the incision and no strangulation of tissue. This is usually accomplished by placement of a layer of interrupted or running absorbable sutures in the subcuticular level at the base of the dermis. A running monofilament permanent suture can also be used and pulled out after healing has started. Wound layering - mucosa to mucosa, muscle to muscle, and skin to skin. Muscle should be sutured in a single layer only if the muscle is thin. If the muscle is thick, the sutures should be confined to the investing fascial layers because muscle by itself does not hold sutures and will merely necrose.

Suture Technique cont’d epithelial edges can then be sutured with interrupted or running monofilament sutures which can be removed within a week so that suture tracts can be avoided steri-strips placed across the incision will also prevent surface marks and can be used primarily or after surface sutures have been removed sutures should be removed as soon as possible given the location of the wound…consider splinting certain wound areas and certain patient types!! C288 Clinical Procedures for Physicians Assistants pg 315

Suture Material Properties Wound type and the location dictates the selection of the material Size Permanent or absorbable Type of suture technique Subcuticular Interrupted vs continuous Mattress Time of removal Covered in detail in Perform Minor surgery

Special Considerations hair can be shaved for better wound exploration, irrigation and closure but it is no longer a necessity** cutting suture tails or using different colored sutures especially on the scalp is useful never shave an eyebrow, as the hair may not grow back or will grow back irregularly and it is critical to line up hair and skin borders to avoid misalignment C288 Clinical Procedures for PA’s pg 325 Often just trimming surrounding hair is sufficient. If an eyebrow has been shaved it is difficult to know where these borders are and therefore, the possibility of even slight misalignment of the hair to the skin border can occur. Infection rates do not seem to be significantly decreased by hair removal and in fact may be elevated due to the trauma of shaving.

Special Considerations also critical to align the vermilion border of the lips by placing the first stitch at the border of the skin and mucosal areas if an incision must be made, it is important to recognize and follow the natural skin tension lines. Scar visibility is minimized when it runs parallel to these lines C288 Clinical Procedures for PA’s pg

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