contrast control of a small bleeder with large bleeders
small bleeder - wait for it to stop in its own - apply pressure with sterile gause - cauterize, clamp with hemostat large bleeder - clamp with hemostat and tie off with dissolvable suture - cauterize by touching hyfrecator tip to hempstat - tie off with figure of eight suture
what are the other steps in the laceration evaluation and treatment
- stop the bleeding
- assess for contamination
- check: flexion/extension
- R/O fractures
- inject anesthesia - no epi
- clean and debride,
- culture if infx risk
- close and bandage
what is quikclot, when should it be concidered
only use when direct pressure isn’t working, you are really far from medical help, must still get to ER
- gauzy wounds filled with kaolin, that activates blood coagulation.
- it must contact bleeding vessel to work
what is surgigel, when should you use it
absorbable hemostat that is albos bactericidal against G- and G+. plant bases
- only use with ther convential methose for small stff
NOT for hemorrhage from large arteries.
not for closed contaminated
removed when bleeding stops.
contrast treatment of skin loss up to 1 sqcm on finger verses larger wound or avulstion on finger tip
small skin loss- dressing changed regularly
larger wounds - refer to plastic surteon
nail bed damage = plastic surgeon
concerns about a palm wound
assess carefully - easy for nerve involvement and tendons
tetanus admin guidlines
Determine tetanus status, if not sure if had booster withing 10 years give tetanus toxoid
- less than two tetanus toxoid in life and lots of contamination the give toxoid and immune globulin
controllable issues that affect wound healing
Be gentle with tissures
clean tissues well
spint/cast near joints to help prevent dehissence
uncontrollable issues that affect wound healing
- mech of injury
- location
- age and race
- patients healing ability/healthy
- patients nutritional status
- patients tendency to scar
what should be done to wound side prior to applying anesthesia?
asses wound site
- tissue damage
- contamination
- underlying nerve, tendon, muscle and boney damage
how should anesthetic ususally be administered in relation to wound?
- inject from inside or senter of laceration out through side of wound into tissue = less painfull (not through skin surface)
- don’t do this if its really contaminated
what should be done with human bite wounds
they are contaminated and ususally left open for a while to watch for infection.
all wounds are concicered contaminted
what is wound tattooing and how is it prevented
- embedded foreign material that heals inside wound
- clean it, remove material with needle or forceps,
what is the point of trimming a wound edge
wound opening wider at base than surface to help evert edges
how can excessive scar formation be minimized
through gentle handeling and careful cleaning of injured tissue
is there a golden period of 12 -24 hours after which you cant close wound
not anymore
what three types of wounds cant usually be sufficiently closed by steristrips and glue
1- laceration into the deeper dermal layers and sub Q
2 - wounds missing tissue
3 - wounds with increased wound tension
name the 7 wound closure technique basics
1 - handle tissures gently 2 - ensure hemostasis 3 - use fine a suture as feasible 4 - needle at 90 degress 5 - evert wound edges 6- keep skin edges relaxed but opposed 7 - remove sutures early to avoid scarring
what are the closure options for cleaned vs. contaminated/dirty wounds
clean
- small primary
- large: undermine if necessary and suture or allow to heal by secondary intention, or refer to specialist
dirty
- secondary closure
- large - delayed primary closure , little additional risk of infection
should a drain be inserted into a traumatic laceration
routine traumatic laceration ; no drain
suspect future infection : concider draining
suture removal techniques
grasp knot, move enough so you can see,
cut suture,
pull freed knot across suture line.
trmoval times for sutures
face/ 3-5
scalp - 5-7
extremity 6-14
abdomen chest and back = 6-12
when would you use a three point corner stitich
lacerations and plastic surgery procedures