What would you want to include in your assessment of a wound?
- What/When/Where/why it happened
- Hand dominance
- Throrough examination after cleaning - deep structure damage
- Tetanus status
- Tendon function
- Neurovascular status
- X-ray - fracture or foreign body risk
Why might you want to do an X-ray in someone with a wound?
Risk of fracture or foreign body
How would you clean and debride a wound?
- Clean wound area - sterile swabs soaked in saline
- Local Anaesthesia around edges
- Mechanical debridement
- Pressure irrigation
- Deep inspection
- Surgical debridement/exploration
What is involved in mechanical cleansing/wound debridement?
Remove debris/contamination/foreignbodies/dead tissue. Use sterile swabs soaked in saline to scrub, and forceps and scalpel to excise tissue if required
What is involved in pressure irrigation?
Squirt sterile saline into the wound using pressure - from syringe via green needle or from pressure infusion bag via orange cannula
What is the aim of deep inspection?
To assess deep structures and ask patient to attempt full ROM movements to assess tendon damage
What are options for wounds that require torough cleaning?
- Debridement under GA
- Urgent sugical exploration
What options are available for closure of a wound?
- Immediate primary closure
- Delayed primary closure
- Secondary intention
- Sking grafts
What is involved in immediate priary closure?
Immediate closure with steri-strips/glue/sutures/clips.
When is immediate primary closure used to close a wound?
- There is neglidgible skin loss
- Wound is clean
- No foreign bodies
- <12 hours old (<24 hours for face wounds)
- Edges come together easily without tension
What is involved in delayed primary closure?
Wound cleaned thoroughly, then dressed and left open for 48 hours. Wound is then reviewed for signs of infection, swelling and bleeding. If these are absent and wound edges can be opposed without tension, wound is sutured closed
When is delayed primary closure used?
- Contaminated wound
- Infected wounds
- Wounds > 2 hours old
What should be used to treat contaminated wounds?
Antimicrobial dressings and prophylactic antibiotics
What is involved in healing by secondary intention?
Allow wound to close by itself - granulation, epithelialisation and scarring
When is healing by secondary intention used for wound closure?
- Tissue loss preventing edge approximation
- Chornic ulcers
- Partial-thickness burns
When are skin grafts used?
Significant skin loss
Beyond cleaning, debriding and wound closure, what are other aspects of wound management to consider?
- Tetanus booster/immunoglobulin
- Rabies immunoglobulin
- RICE - if swelling likely
- Appropriate dressing
- Correct factors which would inhibit healing
What factors can inhibit wound healing?
What would you consider doing as follow up after treating a wound?
- Give wound advice
- Elevate limbs for 24-48hours
- Arrange follow up - delayed primary closure, diabetes/immunocompromised, burns
- Suture removal
How soon should you remove sutures in the head or face?
After 5 days
How soon should you remove sutures on the upper limb/trunk/abdomen?
How soon should you remove sutures in the lower limb?
What are the worst type of bites?
Cat and human bites
What would you consider doing if a puncture wound was deep and appeared contaminated?
Wide debridement in theatre
How would you manage bite wounds?
- Aggressive surgical management, followed by delayed primary closure/healing by secondary intention
- Antibiotics for 5 days
How are gunshot wounds treated?
Thorough debridement and delayed suturing
How would you manage crushed injuries?
Elevated for 7-10 days to reduce risk of compartment syndrome on closure