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Wound Care

History

  • Mecahnism of injury
  • Time of injury
  • environment of injury
  • patient immune status

Examination of Wound

  • Assess
    • Distal perfusion
    • Motor
    • sensory
    • tendon function
  • Visualize wound with bloodless , if need use Tourniquet for <20min

Classsification of Wounds

  • Abrasions - (e.g., grinding of skin against a road surface).
  • Laceration (e.g., a knife cut)
  • Crush
  • Puncture
  • Avulsion - portion of tissue is completely separated from its base,
  • Combination wound

Bacterial Contamination

  • Clean and Remove dead tissue of wound in 3 to 12 hours after the injury
  • bacterial counts will generally remain below the threshold needed to initiate infection.

DEvitalized Tissue /Dead tissu removal in wound

  • helps Bacterial Proliferation
  • Inhibit Leukocyte phagocytosis
  • Anerobic environment for bacterial Growth

Cleaning the wound

  • Goals of Wound Cleaning

    1. Remove bacteria
    2. Remove particulate matter and tissue debris

  • Types of wound Cleaning Techniques

  • Scrubbing
  • Irrigation(NS /Tap water)
    • Hydration , removes deep debris,helps visual examination,reduce infection

Antiseptics in Cleaning

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Irrigation of Wound

Reduce Stap.Aureus levels

  • Types of irigation by Pressure
  • low pressure 1-2psi

  • High pressure >8psi

  • Remove small particles

  • Using 30-50ml Syringe,18-19 Needle ,atleast 250ml NS
  • 30ml syringe on 19guage needle makes 25-40psi on both hand pressure
  • High pressure irrigation , iv tube and NS 400ml in 400mmhg BP Cuff

  • running tap water = 45psi

  • >70 psi Tissue damage

  • No irrigation for highly vascualr region
  • A potential complication of wound irrigation is that infectious material can be splashed into the face of the clinician

Cleaning The wound

  • Irrigation with NS
  • Scrubbbing with sponge {90 pores/inch}
  • Antiseptic to clean
  • Pluronic Polyols /NS for near eyes
  • No H2O2 over open wounds

Debridment

  • Excision for debridment
  • converts traumatic wound to clean wound
  • check no importan tendon,nerves present excise for debridment
  • Complete excision of animal bites , helps wound closure and infection risk similar to uncontaminated laceration wound

Controll HEmorrhage

  • Hemorrhage e can occurr after cleaning , hematoma formation impairs closure and healing
  • Controll hemorrhage
  • direct pressure gloved fingers, gauze sponges, or packing material, and elevate the wound.
  • in multiple injuries and urgent problems
    • Several absorptive sponges over bleeding site and secure with elastic bandage and tighten the elastic bandage
    • ligating with 3 knots in 5-6O absorbable thread the vessels with absorbable suture
    • clamp only vessels not nerve as they run along together
    • clamping with fine point hemoststs
    • if cut wound vessels retracts and cannot ligate ,cauterize
    • controll bleeding by compression
    • use figure of 8 / horizontal matress stitch to compress the tissue therby control the vessel bleed
  • Large superficial varicosities , may bleed spontaneous on stainging up
    • Figure of 8 suture to stop bleeding
  • Small vessels bleeding
    • Epinephrine with moistened sponge over small vessels to stop bleeding
  • Highly vascular area bleeding
    • Lidocaine & Epinephrine ,give anesthtic and provide long term hemostasis Only Use epinephrine in small vessels/capillary hemorrhage on bleeding uncontrolled by direct pressure/ catuerisation
  • also injecting lidocaine and Epinephrine around the wound tissue stops bleeding for cauterisation
  • Fibrin foam, gelatin foam, and microcrystalline collagen may be used as hemostatic agents
  • dermabond (2-octyl-cyanoacrylate ) for hemostasis on skin avulsion on finger tips
  • highly vascualar areas like scalp
    • bleeding profusly and cannot irrigate , clamping and everting galea /dermis with round edge hemostats
    • irrigate and suture even if bleeding present, the suture pressure stops bleeding

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Tourniquets for bleeding control

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  • extremity wound - not stoping even on tourniquet, electrocauterisation,ligation, patient going shock
  • Tourniquet proximal to wound to temperalily control bleeding
  • by Sphygmomanometer cuff on arm/leg without damage underlying structures
  • remove tourniquet if pain develps distal or underneath tourniquet{usually 15-30min in concious patient}
  • Before tourniquet application elevate injured limb to prevent venous return ooze
    • wrap a elastic bandage circumferentially around extermity - from distal to proximal
    • inflate to 250mmhg to 300mmhg / 70mmhg higer than patient systolic pressure
    • then clamp the tube
    • and use for less than 2hrs
  • Tourniques for finger
    • higher chance of complications
    • so limit to 30-45 mins
    • they cause excessive pressure and damage distal nerve and necrosis of vessles
    • for digits only 150mmhg pressure needed for hemoststis
    • Rolled surgical glove pressure is 113-363mmhg based on thickness and amount rolled and pt handsize
  • Complications from Tourniquets
    • ischemia to extermity
    • compress and damage underlying nerves
    • reduce survival risk of wound margin tissue
  • Complication occurs if
    • longer use
    • Excessive pressure

Preparing for Wound Closure

  • Drape wound
  • avoid shaving around wound = ↑increase infections
  • clipping/petrolatum jelly coating/watersoluable gel the hair if it interfers with procedure
  • disinfect surrounding skin with 10% Povidone iodine
  • Sterile gloves doesnt reduce infection rates
  • avoid talking near wound
  • wear face mask