Wound Management

Department of Emergency Medicine Johns Hopkins University Center for International Emergency Disaster and Refugee Studies

Objective
Define critical management of wounds Discuss wound classification Discuss wound evaluation Discuss wound preparation Discuss closure techniques Discuss use of antibiotics

Wound management

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Introduction
The proper management of wounds in the field setting is one of the most basic and important practices, and yet is overlooked by many health providers Terence J Ryan of the Department of Dermatology, Churchill Hospital, Oxford notes that wounds in Tanzania are often due traffic accidents, fire-arms and household domestic fires, and also wounds from being hit with a machete or animal bites or traps which are overall exotic and hence rare.
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Presentation
The most important first step in any injured patient is to evaluate the ABCs It is not unusual for a health care worker to be distracted by a severe extremity injury and ignore the potentially disastrous occurrence of airway compromise or shock.

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Presentation
After stabilizing the patient, the critical actions for wound management are to:

stop active bleeding identify injuries decide on type of repair needed consider tetanus immunization consider antibiotics, and provide instructions to patient.
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Presentation
There are a variety of wounds and they are described below:

Abrasion Superficial laceration Deep laceration Complex laceration

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Presentation
There are a variety of wounds and they are described below:

Skin avulsion Crush injury Burns Frostbite Infected wound

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Presentation
A number of wound characteristics can predict the incidence of wound infections, namely:

The age of the wound prior to irrigation and repair The location of the wound Whether the wound is contaminated with other items Wounds which have a blunt mechanism The presence of large amounts of absorbable sutures in the wound High-velocity missile injuries Puncture wounds and bite wounds
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Wound management

Presentation
Most wounds do not need prophylactic antibiotics to prevent infection. Only wounds having the characteristics noted above benefit from antibiotic prophylaxis. The single most important factor for preventing infection is thorough irrigation with plain water
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Presentation
It has been found that, when irrigation was ignored, that despite the use of antibiotics, infection rates remained high. Any wound which is too old to be closed primarily can be irrigated, debrided, and packed, with closure to be done electively in 3-5 days. This allows time for the tissue to granulate in, and dramatically reduces the likelihood of a wound infection.
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Presentation
Tetanus immunization should be given to all people who have not had a booster within 5 years (for major wounds) or 10 years (for more minor wounds). If a person has never had the primary series of 3 tetanus shots in the past, they should receive tetanus immune globulin (TIG; 250 units) as well as tetanus toxoid (Td) for all major wounds, wounds contaminated with soil or feces, and for all puncture wounds.
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Presentation
Rabies prevention requires the adminstration of human rabies immune globulin (HRIG; 20 U/kg IM, with injected around the bite site, and given IM at a remote site). Human rabies vaccine should also be given 1 mL/dose IM on days 0, 3, 7, 14, and 28 (1 dose per day).

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Clinical Findings
The steps in wound evaluation, preparation and closure are:

Stop active bleeding Adequately expose the wound area Anesthetize the wound if indicated Clean the wound and debride as necessary Close the wound if indicated
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Stop the bleeding:

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Exposure
Be sure to expose the entire wound so that you can see all margins and injuries. Consider removing hair to expose the field, but usually this is not needed (the hair can just be slicked down with water, Betadine or K-Y jelly). Shaving increases wound infection rates

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Diagnosis
Laboratory studies are those which are needed for other traumatic injuries which may be present. For isolated wound management, there are no particular lab studies needed. X-rays are often indicated, both to rule out an underlying fracture (which would then need to be considered an open fracture), and to rule out any occult foreign bodies.

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Diagnosis
Foreign bodies, when present, should always be removed, if reasonably possible. Metal and most glass show up well on an x-ray; wood and organic materials frequently do not. Unfortunately, wood and organic materials have a much higher likelihood of causing a subsequent wound infection

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Removing Foreign Bodies

Most foreign bodies may be removed by simple extraction. Occasionally, extension of the wound is necessary for greater exposure. Often a small foreign body such as a splinter or a piece of metal is too deeply imbedded and is best left in the tissue.

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Removing Foreign Bodies

Such is the case with bullet wounds, which usually heal well if there is no nerve or artery injury. Leave deeply imbedded objects in place for removal in the operating room if you suspect nerve or artery damage.
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Removing Foreign Bodies

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Wound Cleansing
Clean the wound thoroughly, cleaning dirt and debris away with saline or sterile water then irrigate the wound. For irrigation, use an 18 or 19 gauge needle and 20 to 30 cc syringe give best irrigation pressure. The best cleaning agent is sterile saline, as it is cheap and isotonic; however, it is not bacteriacidal. Normal saline with 3 ppm iodine (2 to 3 drops of iodine per liter) is perhaps the best choice. It is bacteriacidal but not tissue toxic.
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Wound Cleansing

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Debridement

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Wound Prep

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Local anesthetic agents

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Use of TAC
TAC = tetracaine (0.5%), adrenalin (1:2000), and cocaine (11.8%) is an excellent topical anesthetic for open wounds. It should not be used for wounds on or near mucosal surfaces (due to rapid absorption of cocaine), areas of body served by end arteries (digits, penis, ear lobes, tip of nose), pregnancy or history of high blood pressure. It is most useful for scalp or face lacerations in children.
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Choice of sutures

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Nonabsorbable Sutures
Comparison of nonabsorbable sutures

Nylon (Dermalon) Polypropylene (Prolene) Braided nylon (Surgilon) Silk Wire (stainless steel)

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Absorbable Sutures
Comparison of absorbable sutures

Plain gut Chromic gut Polyglycolic acid / polyglactin (Vicryl, Dexon) Polydioxanone (PDS)

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Suture size guidelines

Wound location Scalp Face Chin Trunk Arm Hand Leg Foot
Suture size guidelines Recommended suture size 3-0, 4-0 6-0, 5-0 6-0, 5-0 (2 layer) 4-0 4-0 5-0 4-0 4-0, 3-0

General rule: 6-0 on face, 5-0 on hand, and 4-0 elsewhere on body
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Basic suturing techniques

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Basic suturing techniques

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Suturing pearls
Use the smallest suture needed to approximate the edges of the wound. Use small sutures placed closer together rather than larger sutures places further apart. Edema occurs after closure of a wound, so only approximate the edges, do not strangulate the tissue Use forceps as little as possible during wound closure, use skin hooks where available, when one learns to handle skin hooks well they offer the best means of handling a wound edge

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Alternative techniques for wound closure

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Main suturing techniques

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Main suturing techniques

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Main suturing techniques

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Main suturing techniques

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Choices for wound dressings

Dry gauze is suitable for most wounds or if steristrips are used. Nonadherent dressings are preferred for abrasions, nailbed injuries, skin flaps, or the thin skinned elderly, i.e., Vaseline gauze, Xeroform gauze, adaptic gauze (most expensive), and Telfa (not really nonadherent). Antibiotic ointments may be helpful to apply after closing the wound, but not usually necessary.

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Incision and Drainage of Simple Abscess

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Wound Packing

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Skin Grafts

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Disposition/Referral
Most isolated wounds, not associated with multiple trauma, can be safely evaluated and treated in the hospital, and discharged home. As mentioned earlier, antibiotics should be considered for bite wounds, contaminated wounds, hand or foot wounds, or if there is a delayed presentation (>4-6 hours for limb or trunk; >24 hours for head wounds)

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Disposition/Referral
In addition to the above listed wound characteristics, host risk factors for infection include diabetes, malnutrition, vascular disease, and age >70. If antibiotics are used, those most commonly used are first generation cephalosporins, or amoxicillin/clavunulate (for dog, cat and human bites). Patients with a high risk for infection should be seen back in the hospital for a wound check in 48-72 hours.
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Suture removal guidelines

Wound Location Scalp Face Chin Trunk Arm Hand Leg Sole of foot
Wound management

Suture removal (days) 7 3-5 7 7-10 7-10 10-14 10-14 14-21

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Case 1

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Case 2

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Case 3

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Case 4

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Case 5

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Case 6

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Case 7

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