Wound Management
Graham Jay
Introduction
Mechanism of injury predicts healing and outcome
Shear injuries have a better outcome
Poorer outcomes found in blunt injuries over a large area
Factors affecting healing include diabetes, obesity, nutritional status, and steroids
Children have lower infection rates than adults
History and Examination
History: time of injury, crush component, location, mechanism, tetanus status
Examination: location, size, depth, shape of wound, contamination
Perfusion of distal limb, neurological status, position of limb, and local tendon function
Consider taking photographs
Definitions
Laceration: secondary to blunt injury; skin is torn with irregular edges and adjacent skin usually crushed
Incised wound (or cut): caused by a sharp object; wound has clean-cut edges
Abrasions (or grazes): superficial blunt injury in which force has been applied tangentially
Puncture wound: often caused by a sharp object but may be secondary to a blunt object if sufficient force; often small diameter but may be deep
Investigations
X-ray may detect radio-opaque structures > 1-2 mm and any associated fractures
Wood and aluminum do not show up on X-ray (ultrasound may be useful)
Bloodwork often not required unless in the setting of more major trauma
Management
Anesthesia
Only a gentle cleanse before administering local anesthetic
Topical: LET = Lidocaine, Epinephrine, Tetracaine
Soak cottonball with 3 mL of LET and apply to wound with moderate pressure for 20-30 minutes
Do not repeat
Works well for facial lacerations
Injectable lidocaine 1%
Lidocaine with epinephrine is ideal for many wounds especially mouth and facial lacerations
Plain lidocaine (without epinephrine) to be used with lacerations of tips of digits, ears, nose (i.e., end organs)
Onset of action: approximately 3 min
• Dosage
5 mg/kg of a 1% lidocaine solution
7 mg/kg of a 1% lidocaine with epinephrine solution
Addition of epinephrine in low concentrations (1:200,000 to 1:100,000) extends the effect of lidocaine to 3 hrs
Bupivacaine: if more prolonged anesthesia required, maximum dose is 2 mg/kg of 1% solution
Wound Preparation
Detergent-containing antiseptics may be harmful to tissue
Most important step is decontamination with pressure irrigation
Irrigation of normal saline through an 18G angiocath will generate sufficient pressure; for each 1 cm of wound, irrigate with at least 10 mL
Keep hair away from edges of wounds with Vaseline, clipping is not recommended
Do not shave eyebrows: regrowth may be unpredictable
Debride obviously nonviable tissue from wound edges
Remove foreign material from abrasions to prevent tattooing
Do not close wound if suspect retained foreign body
Hemostasis
Fingertip: tourniquet around proximal finger is helpful but avoid prolonged use (longer than 30 minutes)
Direct pressure if nonpulsatile: closure of wound will usually cause hemostasis
If visible bleeding vessels, ligation may be beneficial but use extreme cautionRelated posts:
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