Wound Repair Flashcards
(45 cards)
1
Q
List common causes of superficial wounds.
A
- lacerations
- bites
- small burns
- puncture wounds
- abrasions
2
Q
3 Goals of Wound Care
A
- eliminate complications
- restore function (check tendon and nerve status)
- reduce scarring as much as possible
3
Q
Steps in Good Wound Care
A
- cleansing
- hemostasis
- anesthesia
- wound irrigation and exploration
- removal of devitalized tissue
- tissue preservation
- closure tension, deep sutures if necessary
- tissue handling during closure
- dressing
- F/U
4
Q
3 Stages of Wound Healing
A
- inflammatory phase
- proliferative phase: epithelialization, neovascularization, collagen synthesis
- remodeling: wound contraction and remodeling, scar management
5
Q
Inflammatory Phase
A
- usually 1-5 days
- begins with hemostasis
- granulocytes released to wound followed by lymphocytes and immunoglobulins
- function is to control bacterial growth and suppress infection
- often resembles purulence/pus
6
Q
Proliferative Phase I: Epithelialization
A
- inflammatory response ongoing
- w/in 24 hours, intact cells at wound edge replicate
- forms pseudopod like structures that facilitate cell migration and res-establish normal epidermis layers
- most evident days 5-14
7
Q
Proliferative Phase II: Neovascularization
A
- new vessel formation crucial to wound repair and healing by replacing old, injured network and O2/nutrient delivery to healing wound
- evident by day 3, most active day 7
- gives erythematous appearance to wound
- new vessels = loops of capillaries –> granulation
8
Q
Proliferative Phase III: Collagen Synthesis
A
- rapid mitosis of fibroblasts due to establishment of vascular supply and macrophage stimulation results in new collagen fibril production
- begins day 2, peaks day 5-7
- greatest collagen mass by 3 weeks
- random amorphous gel –> little tensile strength
- final tensile strength takes several months
9
Q
Remodeling Phase I: Wound Contraction and Remodeling
A
- wounds continue remodeling over several months
- some degree of contraction occurs where normal surrounding skin is pulled over the defect
- scar changes in appearance with remodeling
- final appearance may take 6-12 months
10
Q
Remodeling Phase II: Scar Management and Revision
A
- if final scar is unacceptable, multiple options for revision: cryotherapy, pressure dressings, dermabrasion, radiation, intralesional corticosteroids
- important to identify pts with hx of keloids/hypertrophic and refer to skilled specialists after initial repair
11
Q
What chronic medical conditions might interfere with healing?
A
- advanced age
- EtOHism
- acute uremia
- severe anemia
- malnutrition
- diabetes
- peripheral vascular disease
12
Q
What technical factors might interfere with healing?
A
- inadequate wound prep
- excessive suture tension
- reactive suture materials
- local anesthetics
13
Q
What anatomic factors might interfere with healing?
A
- skin tension
- pigmented skin
- oily skin
- location of wound
14
Q
What drugs/meds might interfere with healing?
A
- corticosteroids
- NSAIDs
- penicillin
- beta blockers (coumadin, plavix)
- anticoagulants
- colchicines
- antineoplastic agents
- tobacco
15
Q
General Management of a Wound
A
- ABCs
- control hemorrhage
- pain relief
- abx/Tdap vaccine if necessary
- wound evaluation
- wound management
- consultation
16
Q
What are some important pieces of information to gather in H&P for a patient with a wound?
A
- MOI: what happened, presence of foreign body, possibility of tendon injury
- age of wound: imp when deciding how to treat (6 hour suture?)
- underlying disorders
- prior healing
- allergies
- last tetanus
- interval for suture removal (depends on body region and other factors)
17
Q
Why is it important to not put betadine in a wound?
A
causes tissue necrosis
18
Q
What variables affect choice of anesthesia?
A
- type of wound
- location of wound
- estimated repair time
19
Q
What reactions can occur with local anesthetic?
A
- cardiovascular reactions
- excitatory CNS effects
- vasovagal syncope secondary to pain/anxiety (common, esp with kids)
20
Q
3 Most Commonly Used Anesthetics for Local Infiltration and Nerve Blocks
A
- lidocaine/xylocaine
- mepivacaine
- bupivicaine
21
Q
Lidocaine
A
- most commonly used
- rapid onset 4-10 minutes
- good tissue preserving properties
- duration for nerve block: 60-120 minutes
- lidocaine w/ epi increases duration and reduces bleeding
22
Q
When is use of epi with lidocaine contraindicated?
A
DO NOT USE ANESTHETICS WITH EPI IN ANATOMICAL AREAS WITH TERMINAL CIRCULATION (aka fingers, toes, ears, penis, nose)
23
Q
Mepivicaine
A
- widely used in ED
- 6-10 min onset
- duration 30-60 min for simple blocks, 90-180 mins for nerve blocks
- less vasoconstricting effect than lidocaine so does not require addition of epi
24
Q
Bupivicaine/Marcaine
A
- becoming more popular
- effective but slower onset 8-12 min
- LOOOONG duration 240-480 mins (4-8hrs)
- can be combined with lidocaine
25
Technique: Direct Wound Infiltration
- used for most minimally contaminated lacerations
- plane of injection: beneath dermis at junction of superficial fascia
- may use 25, 27, 30G needles
- simple lac 3-4 cm requires 3-5 mL (length of wound typically amount of lidocaine needed)
- can buffer with bicarb to decrease burning
26
Technique: Parallel Margin Infiltration (Field Block)
- alternative to direct infiltration
- advantage of fewer needle sticks
- preferred for grossly contaminated wounds so debris does not seed uncontaminated tissue
- approach is through intact skin
27
Technique: Digital Nerve Blocks
- most common nerve block in minor wound care
- usually need 6 mL
- recommended for lacerations distal to the level of the mid proximal phalanx of finger/toe
- preferred for nail removal, repair of digital lacs
28
What influences timing of wound closure? What is a rough guideline on when a wound should be closed?
- mechanism of injury, anatomic location, level of contamination
- rough guideline: 6-8 hours from time of injury is considered safe
29
Primary Closure
- used for relatively clean and uncontaminated lacs with minimal tissue loss
- repair w/in 6-8 bours of injury
- very important to aggressively clean, irrigate and debride wound prior to closure
30
Secondary Closure
- for skin infections, ulcerations, abscesses, punctures, small cosmetically unimportant animal bites, partial thickness abrasions, second degree burns
- wound care consists of thorough cleansing, irrigation and debridement
- wounds heal gradually through granulation formation and eventual re-epithelialization
31
Tertiary Closure
- include bite wounds and lacs beyond the golden period
- high bacteria count (abx may be helpful)
- delayed wounds may be converted to fresh wounds by I&D and closure
32
How can the provider decrease tension and improve healing/reduce scar formation?
- follow Langer's lines --> go with flow of skin
- undermine when necessary: creates "free" tissue under wound edges
- use layered closure techniques when possible
33
Monofilament thread is named in the following manner: 6-0, 2-0, etc. What type of thread would be used on the eyelid or other facial structure? What would be used on the foot?
- face: 7-0, 6-0, 5-0
| - foot/sole: 4-0, 3-0
34
Steri-strips: Indications
- superficial, straight lacs under little tension
- flaps in which sutures may compromise vascular supply
- lacs with greater than usual potential for infection
- lacs in elderly or steroid dependent pt (thin fragile skin)
- support for lacs after suture removal
35
Steri-strips: Advantages
- easy application
- even distribution of tension
- no suture marks
- no need to remove sutures
- application by non-providers
36
Steri-strips: Disadvantages
-don't work well on oily surface, hair, joints, shin lacs, gaping wounds, wounds under tension, young or uncooperative pts
37
Stapling Indications
- linear, sharp lacs of scalp, forehead, neck, trunk, butt, extremities
- temporary, rapid closure of extensive superficial lacs in patients requiring immediate surgery for life threatening trauma
38
Stapling Advantages
- quick
| - tolerated well once placed
39
When should staples not be used?
-if pt needs CT or MRI
40
Tissue Adhesives: Indications
- fresh lac within golden period
- lacs under low tension which are easy to approximate
- edges of wound are clean and even, closing without gaps
- dry wounds with little bleeding
- DO NOT USE NEAR EYES
41
Tissue Adhesives: Advantages
- flexible
- bacterial barrier
- high breaking strength
- may be used on many wounds/lacs
- esp good for face
- don't need anesthesia
- can shower normally
- works well on aged/thin/steroid affected skin
- peels off spontaneously 5-10 days
42
3 Key Principles of Wound Aftercare
1. protection
2. elevation
3. cleanliness
43
What is involved in wound aftercare for the patient?
- schedule for suture removal
- aftercare instructions
- info on what to expect as wound heals (manage pt expectations, do not promise no scar)
- provide written instructions and verbal explanation
44
Suture Removal
- technique is to cut under knot, close to skin surface
- this means previously exposed/contaminated portion won't travel through the wound
- consider betadine cleansing prior to suture removal
45
Signs of Wound Infection
- most appear w/in 4-5 days
- excessive discomfort
- mucopurulent discharge
- erythema (>5 mm beyond wound margins)
- lymphangitic steaks
- fever
