Concepts in Wound Care

Question 1

What are the steps in wound healing?

Answer 1

1) Coagulation
2) Inflammatory process
3) Epithelialization occurs in epidermis
4) New blood vessel growth
5) Collagen formation
6) Wound contraction

Question 2

Complete bridging of the wound occurs within how many hours after suturing?

Answer 2

48 hours

Question 3

When does new blood vessel growth peak?

Answer 3

Four days after injury

Question 4

What is necessary to restore tensile strength to a wound?

Answer 4

Collagen

Question 5

When does collagen formation begin?

Answer 5

48 hours after injury

Question 6

When does collagen formation peak?

Answer 6

Within the first week

Question 7

When does wound contraction occur?

Answer 7

3-4 days after the injury

Question 8

What are systemic disturbances that influence wound healing?

Answer 8

Renal insufficiency
Diabetes mellitus
Nutritional status
Obesity
Chemotherapy
Corticosteroids
Anticoagulants
Disorders of collagen synthesis
Patients of African/Asian ethnicity can be prone to hypertrophic scar formation of keloids

Question 9

What are examples of acute wounds?

Answer 9

Lacerations
Avulsions
Skin tears
Abrasions

Question 10

What are examples of chronic wounds?

Answer 10

Non-healing or infected surgical or traumatic wounds
Venous ulcers
Pressure ulcers
Diabetic foot ulcers
Ischemic ulcers

Question 11

For acute wounds what does history and PE determine?

Answer 11

Timing of wound closure
Type of closure tape
Need for consultation

Question 12

What are the goals of acute wound treatment?

Answer 12

Avoid infection
Assist in hemostasis
Prove an esthetically pleasing scar

Question 13

What are important historical components for acute wounds?

Answer 13

Mechanism of injury
Location of injury
Time/age of injury
Identification of risk factors that impact healing
Tetanus immunization status
Associated symptoms

Question 14

What is the most important PE component for acute wounds?

Answer 14

Complete neurovascular exam distal to the injury

Question 15

What are the three options for closure of acute traumatic wounds?

Answer 15

Primary closure
Delayed primary closure
Secondary intent

Question 16

Most wounds are closed by what?

Answer 16

Primary closure

Question 17

What is primary closure?

Answer 17

Closed in acute phase, on the initial presentation to the provider

Question 18

When should delayed primary closure be used?

Answer 18

Wounds that present after 24 hours and have increased risk for infection

Question 19

What happens with delayed primary closure?

Answer 19

Wound is irrigated, cleaned, debrided, and bandaged

Repair is scheduled for a later date (4-6 days)

Question 20

What happens in healing by second intention?

Answer 20

Wound heals spontaneously from the inside out

Question 21

What type of wounds are reserved for healing by secondary intention?

Answer 21

Dehisced surgical wounds
Grossly contaminated wounds
Wounds presenting very late after injury

Question 22

Why shouldn’t you clean inside of an open wound with povidone/iodine or chlorhexidine?

Answer 22

They are cytotoxic

Question 23

How should you clean a wound?

Answer 23

Start at wound margins and clean outward towards periphery

Question 24

Should wounds be soaked in water or other solutions?

Answer 24

No

Question 25

What is the benefit of irrigation?

Answer 25

Decreases the amount of bacterial contamination and removes debris

Question 26

What solutions should be used for irrigation?

Answer 26

Sterile water Saline Tap water

Question 27

What is the key factor in decreasing contamination when irrigating a wound?

Answer 27

Volume of irrigant

Question 28

How much fluid should be used to irrigate the wound?

Answer 28

250cc

Question 29

The more contaminated the wound the more or less solution should be used to irrigate it?

Answer 29

More

Question 30

What should you document prior to anesthesia?

Answer 30

Complete neurologic exam

Question 31

What are common local anesthetics?

Answer 31

Lidocaine Lidocaine with epi Bupivacaine

Question 32

Where should you not use lidocaine with epi?

Answer 32

``` Fingers Nose Penis Toes Ears ```

Question 33

What are options for wound approximation/closure?

Answer 33

Adhesive tapes/steri-strips Tissue adhesives Staples Sutures

Question 34

When should adhesive tapes/steri-strips be used?

Answer 34

Low tension Linear Superficial Areas where sutures might not hold

Question 35

When are adhesive tapes/steri-strips contraindicated?

Answer 35

High tension wounds Wounds requiring layered closure Wounds in high moisture areas

Question 36

What are the indications for tissue adhesives/glues?

Answer 36

Low tension Linear Superficial < 4cm length

Question 37

What are the contraindications for adhesives/glues?

Answer 37

High tension wounds Bite wounds Contaminated wounds

Question 38

Should you apply antibiotic ointment to a tissue adhesive?

Answer 38

No (it will dissolve the glue)

Question 39

What are indications for staple use?

Answer 39

Scalp lacerations | Linear laceration on trunk or extremities where cosmesis is not a priority

Question 40

What are contraindications for staple use?

Answer 40

Gaping wounds requiring layered closure | Wounds in areas where cosmesis is high priority

Question 41

Which suture number is the biggest?

Answer 41

Zero

Question 42

What are the nonabsorbable monofilamentous sutures?

Answer 42

Ethilon | Prolene

Question 43

What are the non-absorbable multifilamentous sutures?

Answer 43

Silk

Question 44

What are examples of the absorbable sutures?

Answer 44

``` Vicryl Polysorb Cat gut "Chromic" Monocril ```

Question 45

What size suture should you use for face?

Answer 45

5-0 | 6-0

Question 46

What size suture should you use for scalp?

Answer 46

4-0 | 5-0

Question 47

What size suture should you use for trunk?

Answer 47

4-0

Question 48

What size suture should you use for extremities?

Answer 48

3-0 | 4-0

Question 49

What size suture should you use for oral?

Answer 49

4-0 | 5-0

Question 50

When should you remove stitches from face?

Answer 50

5 days

Question 51

When should you remove stitches from scalp?

Answer 51

5 days

Question 52

When should you remove stitches from trunk?

Answer 52

7-10 days

Question 53

When should you remove stitches from extremities?

Answer 53

7-10 days

Question 54

How long should the dressing be kept on after suturing?

Answer 54

24 hours

Question 55

What should wounds closed with nonabsorbable sutures but cleaned with?

Answer 55

Mild soap and water | Half-strength peroxide

Question 56

How often should antibiotic ointment be used after suturing a wound?

Answer 56

2 times per day until suture removal

Question 57

Do you prescribe prophylactic antibiotics for patients with low risk of infection?

Answer 57

No

Question 58

For what patients should you prescribe prophylactic antibiotics?

Answer 58

``` Animal/human bites Intraoral lacerations Open fractures Wounds that extend into cartilage, joints, or tendons Patients with vascular insufficiency Patients with immunocompromised state ```

Question 59

What are decubitus ulcers?

Answer 59

Pressure-induced skin and soft tissue injuries

Question 60

Where do decubitus ulcers typically occur?

Answer 60

Over bony prominence

Question 61

Where are decubitus ulcers found in people who are wheelchair bound?

Answer 61

Sacral Ischial Trochanter

Question 62

Treatment of pressure ulcers depends on what?

Answer 62

Stage of the ulcer

Question 63

What are the stages of decubitus ulcers?

Answer 63

1) Intact skin with localized area of nonblanchable erythema 2) Partial thickness loss of skin with exposed dermis 3) Full-thickness loss of skin, in which adipose is visible and granulation tissue often present 4) Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle tendon, ligament, cartilage, or bone in the ulcer

Question 64

How are diabetic foot ulcers initially treated?

Answer 64

Broad spectrum antibiotics

Question 65

What should be considered before surgery and in between surgical debridements in diabetic foot ulcers?

Answer 65

Negative pressure wound therapy

Question 66

What causes ischemic ulcers and gangrene?

Answer 66

Lack of vascular supply (PAD, microvascular disease)

Question 67

What is the treatment for ischemic ulcers and gangrene?

Answer 67

Optimization of blood supply and surgery

Question 68

What causes venous stasis ulcers?

Answer 68

Venous hypertension secondary to chronic venous insufficiency, dysfunction of venous valves, and/or obstruction of venous outflow

Question 69

What is the treatment for venous ulceration?

Answer 69

Local wound care and compression therapy

Question 70

When is skin grafting indicated in venous stasis ulcers?

Answer 70

Inappropriate wound healing after 12 months of medical care

Question 71

What are the goals for chronic wound treatment?

Answer 71

``` Reduce pain, itching, odor Minimize infection and bleeding from wound Deal with excessive exudate Address psychological issues Tissue coverage over wound ```

Question 72

What is the treatment for chronic wounds?

Answer 72

1) Optimization of wound bed 2) Application of dressing to the wound 3) Topical agents such as antiseptics and antimicrobial agents 4) Sharp surgical debridement of devitalized tissue 5) Negative pressure therapy 6) Delayed closure or skin grafts

Question 73

What are the wound bed requirements for optimal healing of chronic wounds?

Answer 73

Well vascularized Free of devitalized tissue Clear of infection Moist

Question 74

How do wound dressings facilitate chronic wound healing?

Answer 74

Eliminating dead space Controlling exudate Preventing bacterial overgrowth Ensuring proper fluid balance

Question 75

Only what chronic wound infections should be addressed with culture and antibiotic treatment?

Answer 75

"Clinically evident infections"