Wound Management

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Wound Management

• Emergency Medicine
• Core Curriculum

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Presentation/History

• Clinical Features of Wounds
• Age of wound gt 6 hours lt
• Configuration Stellate vs. linear
• Depth gt 1 cm. lt
• Mechanism of Injury
• Missile, crush, burn frostbite
• Sharp surface
• Location face, ear, hand, cosmetically sensitive
  area
• Signs of infection
• Devitalized tissue
• Contaminants (dirt, feces, soil, saliva)
• Denervated and / or ischemic tissue

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Core Curriculum Wound Management
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Vital Signs

• Temperature lt 100
• gt 101.5 systemic infection
• Heart Rate lt100
• gt 100
• Pain
• Hypovolemia
• Infection
• RR lt18
• gt18
• Pain
• Chest wound - PTX
• BP90-149/60-90
• Decreased pulse pressure - early hypovolemia

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Core Curriculum Wound Management
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Triage

• Medications
• Allergies Antibiotics, tetanus
• PMHx Diabetes, immune compromised
• PSHx Wound healing, Keloid
• Immunization Tetanus Vaccine in past 5 years

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Core Curriculum Wound Management
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Triage Orders

• Td .5 mg
• TIG 250 mg IM
• Lidocaine
• Wound care supplies

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Core Curriculum Wound Management
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Physical Exam

• GEN WDWN white female in minimal distress,
  guarding right forearm
• HEENT NC/AT, Neck soft, supple, NT
• CHEST CTA B, AT
• ABD soft, NT, Nml BS, AT
• BACK NT, AT
• EXT wound description
• Location, length, depth, active bleeding
• Exposed bone or tendon, step-off
• Neuro vascular exam locally and distal to wound

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Core Curriculum Wound Management
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Radiographs

• Suspected Foreign Bodies/Fracture
• Wounds lt 1/2 cm in depth
• Contaminated wounds
• Assault trauma
• Glass injuries

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Core Curriculum Wound Management
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ED course

• Complex wounds requiring/allowing a consultant
• Facial laceration Face trauma call OMFS, ENT,
  Plastic surg all rotate
• Eye/Eyelid involvement Opthomology
• Amputation/degloving/neurovascular
  compromise/mechanical compromise (tendon/ligament
  laceration), hand wound, open fracture
  Orthopaedics

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Core Curriculum Wound Management
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ED Course

• Wound preparation
• Anesthesia first
• Alcohol swab away from wound margin
• Local infiltration
• Local block
• Soap and H2O scrub
• Betadine Surgical Scrub brush
• local pressure on bleeding
• Normal Saline high pressure irrigation
• 250-2 L
• Splash guard

• Wound closure
• Hemostasis
• 5-0/6-0 Dexon taper
• Deep closure
• 5-0/6-0 Dexon taper
• Skin closure
• Face 6-0 Nylon/Prolene
• Extremity
• Digit 5-0 Nylon/Prolene
• Extremity 4-0 Nylon/Prolene
• Abx ointment/dry dressing

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Core Curriculum Wound Management
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ED Course

• Delayed Primary Closure
• Routine wound preparation
• Wet to dry normal saline Kerlex/Guaze dressing
• Train patient

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Core Curriculum Wound Management
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Disposition

• Consultant repair
• D/C ED with consultants instructions /medications
  and follow-up

• ED repair
• D/C ED
• Primary Closure
• Keep wound clean and dry for 48 hours
• Apply antibiotic ointment after 48 hours TID
  until healed
• Return to ED for suture removal in
• Face 5 days
• Remainder 7 days
• Return to ED for signs of wound infection

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Core Curriculum Wound Management
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Disposition

• Delayed Primary Closure
• Wet to dry dressing changes TID
• Return to ED in 48-96 hours for wound recheck and
  primary closure
• Return to ED for signs of infection
• No Antibiotics

• Antibiotics
• Allergies
• IV
• Heavily contaminated wounds
• Open fractures
• PO
• Hand/Foot
• Ear
• Nose
• Diabetes

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Core Curriculum Wound Management
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Disposition

• Pain Medications
• Allergies
• Not to be overlooked
• Tylox/Lortab/Darvoset/Lorcet
• High dose Motrin
• No drinking, driving, or operating machinery
  while taking prescribed narcotic

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Core Curriculum Wound Management