Wound Management Flashcards
(121 cards)
1
Q
What would you want to include in your assessment of a wound?
A
- What/When/Where/why it happened
- Hand dominance
- Thorough examination after cleaning - deep structure damage
- Tetanus status
-
Assess:
- Contamination
- Tendon function
- Neurovascular status
- X-ray - fracture or foreign body risk
2
Q
Why might you want to do an X-ray in someone with a wound?
A
Risk of fracture
Foreign body esp things such as glass
3
Q
How would you clean and debride a wound?
A
- Clean wound area - sterile swabs soaked in saline
- Local Anaesthesia around edges
-
Consider
- Mechanical debridement
- Pressure irrigation
- Deep inspection
- Surgical debridement/exploration
4
Q
What is involved in mechanical cleansing/wound debridement?
A
Remove debris/contamination/foreignbodies/dead tissue. Use sterile swabs soaked in saline to scrub, and forceps and scalpel to excise tissue if required
5
Q
What is involved in pressure irrigation?
A
Squirt sterile saline into the wound using pressure - from syringe via green needle or from pressure infusion bag via orange cannula
https://www.uptodate.com/contents/minor-wound-preparation-and-irrigation/print
6
Q
What is the aim of deep inspection?
A
To assess deep structures and ask patient to attempt full ROM movements to assess tendon damage
7
Q
What are options for wounds that require thorough cleaning?
A
- Debridement under GA
- Urgent sugical exploration
8
Q
What options are available for closure of a wound?
A
- Immediate primary closure
- Delayed primary closure
- Secondary intention
- Sking grafts
9
Q
What is involved in immediate primary closure?
A
Immediate closure with steri-strips/glue/sutures/clips.
10
Q
When is immediate primary closure used to close a wound?
A
If:
- 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
11
Q
What is involved in delayed primary closure?
A
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
12
Q
When is delayed primary closure used?
A
If:
- Contaminated wound
- Contused/bruised
- Infected wounds
- Wounds > 2 hours old
13
Q
What should be used to treat contaminated wounds?
A
Antimicrobial dressings and prophylactic antibiotics
14
Q
What is involved in healing by secondary intention?
A
Allow wound to close by itself - granulation, epithelialisation and scarring
15
Q
When is healing by secondary intention used for wound closure?
A
Wounds with:
- Tissue loss preventing edge approximation
- Chornic ulcers
- Partial-thickness burns
16
Q
When are skin grafts used?
A
Significant skin loss
17
Q
Beyond cleaning, debriding and wound closure, what are other aspects of wound management to consider?
A
- Antibiotics
- Tetanus booster/immunoglobulin
- Rabies immunoglobulin
- Analgesia
- RICE - if swelling likely
- Appropriate dressing
- Correct factors which would inhibit healing
18
Q
What factors can inhibit wound healing?
A
- Smoking
- NSAIDS
- Nutrition
- Diabetes
19
Q
What would you consider doing as follow up after treating a wound?
A
- Give wound advice
- Elevate limbs for 24-48hours
- Arrange follow up - delayed primary closure, diabetes/immunocompromised, burns
- Suture removal
20
Q
How soon should you remove sutures in the head or face?
A
After 5 days
21
Q
How soon should you remove sutures on the upper limb/trunk/abdomen?
A
7 days
22
Q
How soon should you remove sutures in the lower limb?
A
10 days
23
Q
What are the worst type of bites?
A
Cat and human bites
24
Q
What would you consider doing if a puncture wound was deep and appeared contaminated?
A
Wide debridement in theatre
25
How would you manage bite wounds?
* **Aggressive surgical management, followed by delayed primary closure/healing by secondary intention**
* **Antibiotics for 5 days**
26
How are gunshot wounds treated?
Thorough debridement and delayed suturing
27
How would you manage crushed injuries?
Elevated for 7-10 days to reduce risk of compartment syndrome on closure
28
When assessing a wound, what do you need to think about in terms of assessing underlying structures and position of the limb?
The limb or extremity needs to be in the original position it was in when the wound occurred e.g if the hand was in a fist it needs to be in the original position to assess underlying structures including tendons and ligaments
29
What key questions would you want to ask assessing a wound?
* What caused the wound?
* Was there a crush component?
* Where did it occur? (contaminated versus non contaminated)
* Was there a broken glass or China involved?
* When did this occur?
* Who did it?
* Do they need tetanus vaccine?
30
How would you examine a wound?
1. Length
2. Site
3. Orientation - vertical, horizontal or oblique
4. Contamination
5. Infection signs - indication of delayed presentation
6. Neurological injury - test and record motor and sensory function
7. Tendons - assess function per tendon, and examine in the position of injury so as not to miss injury
8. Vascular injury
9. Depth
10. Type of wound
31
How would you classify the following wounds?
Incised wounds - Caused by sharp injury e.g. knives/broken glass and characterised by clear cut edges. These typically include stab wounds (deeper than they are wide) and slash wounds (longer than they are deep)
32
How would you classify the following wound?
**Laceration** - Caused by blunt injury (impact of the scalp against a pavement or intact glass bottle), the skin is torn, resulting in irregular wound edges. Unlike most incised wounds, tissues adjacent to laceration wound edges are also injured by crushing and will exhibit evidence of bruising
33
How would you classify the follwing wound?
**Puncture wound** - Most result from injury with sharp objects, although a blunt object with sufficient force will also penetrate the skin
34
How would you classify the following wound?
**Abrasion -** commonly known as grazes these results from blunt injury applied tangentially. Abrasions are often engrained with dirt with the risk of infection and in the longer term unwanted and unsightly skin tattooing. Skin tags visible at one end of the abrasion indicate the edge of skin last in contact with the abrading surface and imply the direction in which the skin was abraded
35
How would you classify the following wound?
**Bruises** - bruising reflects blunforce or crush injury to the blood vessels within that issues resulting in tender swelling with discoloration. Sometimes localised bleeding can collect form a hematoma. They may be patterned and can reproduce the shape of the weapon or object responsible (e.g a shoe or fingertip bruises where a grip has been applied. Sometimes a characteristic tramline bruise results from forceful contact with a rounded or squared-off weapon such as a baseball bat
36
`
What does yellow colour in bruising imply?
The injury is \>18 hours old
37
How would you classify the following injury?
**Hematoma** - hematomas are palpable collections of blood usually in muscle in soft tissue. A common example is the peri orbital hematoma or black eye. This is often caused by a direct blow, in which case there may be an associated abrasion or laceration
38
how would you classify the following injury?
**Bite** - Bites are a pattern of injury produced by human or animal dentitions and associated structures. Bite marks are classified as a form of crush injury because the tooth compresses the skin which leaves an indentation or break. The injury usually consists of abraded and bruised components and often have a curved profile. Bites can be a useful source of DNA and can be expertly analysed by forensic odontologists.
39
How would you classify the following wound?
**Lacerations -** Caused by blunt injury (impact of the scalp against a pavement or intact glass bottle), the skin is torn, resulting in irregular wound edges. Unlike most incised wounds, tissues adjacent to laceration wound edges are also injured by crushing and will exhibit evidence of bruising
40
What features do lacerations typically exhibit?
* Often gaping
* May be irregular, but can also be linear
* Associated bruising (from being crushed)
* Associated abrasions to the edges
* Tissue bridges in depth of the wound (in contrast the incised wounds)
* Rarely self-inflicted
* Presence of intact hairs which cross the wound (in contrast to incised wounds)
* Relatively little blood loss (unless on the scalp or intra-orally)
* Can be associated with fractures (e.g underlying depressed skull fracture)
41
What is the most important investigation to do when assessing a wound?
Exploration under anaesthesia
42
What type of local anaesthetic would you use when either exploring a wound or suturing/stapling a wound?
Lidocaine 1% or Lidocaine 2%
43
How many milligrams per mil local anesthetic are in a 0.25% solution?
2.5 mg/ml
44
How many milligrams per mil of a local anesthetic are in 1% solution?
10 mg/ml
45
How would you calculate the number of milligrams per mil of local anaesthetic solution from the percentage given?
Multiply the percentage solution by 10 to give the concentration in mg/ml
46
How many milligrams per mil of local anaesthetic are in a 2% solution?
20 mg/ml
47
What is the maximum dose of lidocaine that can be given?
3 mg/kg
48
What is the maximum dose per kg of lidocaine with adrenaline that can be given?
7 mg/kg
49
What is the maximum dose per kilogram of levobupivicaine that can be given?
7 mg/kg
50
What is the maximum dose of lidocaine without adrenaline that can be given to a 70 kilo person?
210 mg = 21 ml
51
What is the maximum dose of lidocaine without adrenaline that can be given to a 60 kg person?
180 mg = 18 ml
52
What is the maximum dose of lidocaine without adrenaline that can be given to and 80 kg person?
240 mg = 24 ml
53
What is the maximum dose of lidocaine 2% without adrenaline in a 70 kilo person?
210mg = 10.5 ml
54
What is the maximum dose of lidocaine 2% without adrenaline in an individual weighing 80 kg?
240 mg = 12 ml
55
What is the maximum dose of lidocaine 2% without adrenaline that can be used in someone weighing 60 kilograms?
180 mg = 9 ml
56
What are the different types of local anaesthetic blocks that can be used when managing wounds?
* **Field block** - infiltration around the wound
* **Peripheral nerve block** - specific nerve is anaesthatised
* **Spinal anaesthetic** - blocks motor and sensory nerves below the level at which it is injected
* **Haematoma block** - injection of anaesthetic into a haematoma formed around a long bone fracture
57
What wounds should you not explore in the emergency department?
* Stab wounds to the neck chest abdomen or perineum
* Compound fracture winds requiring surgery in theatre
* Wounds of a suspected septic joints or infected tendon sheaths
* Most wounds with obvious neurovascular/tendon injury needing repair
* Other wounds requiring specialist input
58
What is the best antibiotic to use for wound prophylaxis?
Co-Amoxiclav - has both aerobic and anaerobic cover
59
What are risk factors for wound infection?
* Foreign body present
* Heavily soiled wounds
* Bites (including human)
* Puncture wounds
* Open fractures
60
How long would it take for muscle to no longer require support from sutures?
Days
61
How long would it take fascia or tendons 2 no longer require support from sutures?
Weeks to months
62
How long would it take skin or subcutaneous tissue to no longer require sutures?
Days
63
What 2 categories can sutures be broadly subdivided into?
Absorbable vs non-absorbable
64
when are absorbable sutures most commonly used?
For deep tissues and tissues that heal rapidly
65
What is the complete absorbption time for vicryl sutures?
60 days
66
What is the average complete absorption time monocryl sutures?
100 days
67
Which sutures are monofilament?
* PDS
* Monocryl
* Nylon
* Prolene
68
Is proline absorbable?
No - it is non-absorbable
69
Is vicryl absorbable?
Yes
70
Is vicryl monofilament or multifilament?
Multifilament
71
Is prolene monofilament or multifilament?
Monofilament
72
How does the size of the suture correlate with the diameter?
The larger the size (e.g. 7-0), the smaller the diameter, and vice versa
73
What is the general rule of thumb when choosing suture size?
Choose the smallest size possible taking into account the natural strength of the tissue
74
How are sutures subdivided based on their origin?
Natural vs synthetic
75
What is the downfall of using natural sutures?
They tend to provoke greater tissue reactions
76
Which structure of suture is more prone to infection - monofilament or multifilament?
Multifilament
77
What size sutures would you use for scalp?
2-0 or 3-0
78
What size sutures would you use on the trunk?
3-0
79
What size of sutures would you use on the limbs?
4-0
80
What size of sutures would you use on the hands?
5-0
81
What size of sutures would use on the face?
5-0
82
How long would you leave non absorbable sutures for on the trunk?
10 days
83
How long would you leave in non absorbable sutures for on the limbs?
10 days
84
How long would you leave it non-absorbable sutures on the hands?
10 days
85
How long would you leave non absorbable sutures on the face?
3-5 days
86
What features of a wound increase the risk of infection?
* Contamination/foreign material
* Devitalised tissue
* Haematoma
* Poor nutrition
* Decreased immunity (e.g. steroid therapy)
87
What local factors affect wound healing?
* Type, size and location
* Local blood supply
* Infection
* Foreign material/contamination
* Radiation damage
88
What systemic factors influence wound healing?
* Increasing age
* Co-morbiditis, especially CVS disease and DM
* Nutritional deficiencies
* Obesity
89
What are the four stages of healing via primary intention?
1. **Haematostasis -** action of platelets and cytokines forms haematoma and causes vasoconstriction, limiting blood loss at the affected area
2. **Inflammation**- a cellular inflammatory response acts to remove any cell debris and pathogens present
3. **Proliferation** - Cytokines released by inflammatory cells drive the proliferation of the fibroblasts and the formation of granulation tissue
4. **Remodelling** - collagen fibres deposited within the wound to provide strength in the region, with the fibroblasts subsequently undergoing apoptosis
90
What can happen when a wound is sutured too loosely?
The wound edges will not oppose properly, limiting the primary intention healing and reduce wound strength
91
What happens if you suture wounds too tightly?
The blood supply to the region may become compromised and lead to tissue necrosis and wound breakdown
92
How does healing by secondary intention differ from primary intention in terms of stages?
* **Inflammation stage** - has more cellular debris, and inflammatory reaction tends to be more intense
* **Proliferation stage** - More important step - epithelia can only regenerate once granulation tissue has filled the wound up to level of the epithelia
93
What are vital cells in healing via secondary intention?
**Myofibroblasts** - Modified smooth muscle cells that contain actin and myosin, and act to contract the wound, decreasing the space between the dermal edges. They also can deposit collagen for scar healing
94
What is the following?
Keloid scars - uncommon complication whereby there is excessive collagen production, leading to extensive scarring. this can occur with primary or secondary intention
95
What is the definition of a clean wound?
Elective, non-emergency, non-traumatic, and primarily closed, with GI, biliary, and GU tracts remaining intact
96
What is the associated infection rate in a clean wound?
2.1%
97
What defines a clean-contaminated wound?
* Urgent or emergency case that is otherwise clean
* Elective opening of respiratory, GI, biliary, or GU tract with minimal spillage and not encountering infected urine or bile
98
What is infection rate associated with clean contaminated wounds?
3.3%
99
What is are the defining criteria for a contaminated wound?
* Gross spillage from GI tract or entry into biliary or GU tract (in the presence of infected bile or urine)
* Penetrating trauma \<4 hours old or a chronic open wound to be grafted or covered
100
What are the defining criteria for a dirty wound?
* Purulent inflammation (e.g. abscess)
* Preoperative perforation of respiratory, gastrointestinal, biliary, or genitourinary tract, or a penetrating trauma \>4 hours old
101
What is the infection risk associated with a dirty wound?
7.1%
102
What are bite wounds a combination of in terms of types of wounds?
Contaminated punture wound and crush injury
103
What types of bite injuries are bacterial infection particularly likely in?
* Animal/human bite injuries
* Hand wounds, particularly those \> 24 hours
* Bite wounds in immunocompromised, diabetics or alcoholics
104
What antibiotics would you use as prophylaxis for bite wounds?
* Co-Amoxiclav - appropriate broad spectrum
* Can consider doxycycline and metronidazole if peniciilin allegric
105
What bacteria are often responsible for infection in those with bite wounds?
106
What would you want to ask about in terms of stratifying what prophylactic treatments you would want to give to someone with a bite wound?
* Tetanus
* Rabies
* HIV and hepatitis
107
When should you not use when anaesthatising appendages?
Lidocaine with adrenaline - risk of causing necrotic damage to appendage
108
What are the 5 main aspects of wound cleaning?
Remember with mnemonic DADDI:
1. Disinfect - use antiseptic
2. Decontaminate - manually remove foreign bodies
3. Debride - any devitalised tissue
4. Irrigate - with sterile water/saline
5. Antibitotics - for high risk wounds
109
How would you irrigate a contaminated wound?
LA + high pressure irrigation
110
What is wound dehiscence?
Wound fails to heal, and often re-opens
111
What is superficial dehiscence?
The skin wound alone fails, with the rectus sheath remaining intact
112
What is full thickness dehiscence?
Sheath/fascia fails to heal and bursts, with protrusion of internal contents. Can occur due to raised intra-compartment pressure, poor surgical technique, or if patient is critically unwell
113
What is the most common cause of wound dehiscence?
Infection
114
What patient factors increase the risk of wound dehiscence?
* Increasing age
* Male gender
* Co-morbidities, especially diabetes mellitus
* Steroids
* Smoking
* Obesity or malnutrition
115
What are intraoperative factors which increase the risk of wound dehiscence?
* Emergency surgery
* Abdominal surgery
* Length of operation (\>6hrs)
* Wound infection
* Poor surgical technique
116
What post-operative factors increase the risk of wound dehiscence?
* Prolonged ventilation
* Post-operative blood transfusion
* Poor tissue perfusion (e.g. post-operative hypotension)
* Excessive patient coughing
* Radiotherapy
117
What are clinical features of wound dehiscence?
Typically occurs 5-7 days post-operatively
Superficial and deep:
* Visible opening of the wound
Full thickness:
* Bulding of the wound
* Pink serous or blood-stained fluid
* Sudden increase in wound discharge
118
How would you investigate a dehisced wound?
* Remove sutures/skin clips and explore wound
* Swab site to rule out infection
119
How would you manage wound dehiscence?
**Irrigation and simple wound care**
**Will need to heal via secondary intention** - can be helped by vacuum assisted closure
**If full thickness**
* Antibiotics
* Analgesia
* Saline soaked gauze and return to theatre
120
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