EMERGENCY

MEDICINE WOUND
MANAGEMENT
Dr. De Guzman
WOUND MANAGEMENT o Removal of portion of object
− Management of acute wounds begins with obtaining − Function
a careful history of the events surrounding the injury, o Occupation & handedness
followed by a meticulous examination of the wound − Allergies
− Examination of the wound may require irrigation & o Anesthetics, analgesics, antibiotics & latex
debridement of the edges of the wound and is − Medications
facilitated by use of local anesthesia o Chronic medical conditions that increases risk of
− Antibiotic administration & tetanus prophylaxis may infection
be needed o Chronic medical conditions that increases
− Planning the type & timing of wound repair should likelihood of poor prognosis
take place.
− Must Remember: examine the whole patients WOUND EXAMINATION
according to acute trauma life support (ALS) − Thorough wound examination should be conducted
principles when the patient is calm & cooperative and
positioned appropriately, with optimal lighting
conditions, and with little or no residual bleeding
− Wound characteristics (type, length, breadth, dep,
extent of non-viable tissues)
− Location
− Presence of Foreign body
− Associated with bony/tendon/muscle injury
− Associated with compartment syndrome
− Distal Neurovascular Deficit

ADJUNCTIVE TESTING
− Most laceration will not require any diagnostic testing
− Imaging for bony injuries (fracture/dislocations etc) is
WOUND EVALUATION necessary (radiographs)
− Evaluation of the patient with a traumatic wound − Wound imaging for detection of foreign bodies may
begins with overall patient assessment (ABCDE) be necessary
− More serious life-threatening injuries need care before
directing attention to wound management WOUND PREPARATION
− Remove rings or other jewelry that encricle the − The single most important step in treating a traumatic
injured body part as soon as possible wound
− External bleeding can usually be controlled by direct − Proper ED wound management can help restore
pressure over the bleeding sit. When possible, replace integrity and function of injure tissue, minimize the risk
skin flaps to their original position before applying of infection and assure the best possible cosmetic
pressure result
− The majority (80-90%) of wounds treated in EDs heal
HISTORY with good outcome
− Symptoms − Careful preparation is particularly important when
o Pain, swelling, paresthesias, muscle weakness underlying medical conditions affecting wound
− Type of force causing injury healing are present
o Crush (blunt) or shear (sharp) − COMPONENTS:
o Bite or puncture o Sterile technique
− Elements of contamination o Anesthesia & analgesia
o Time elapsed from injury until cleansing until initial o Hemostasis
cleansing o Foreign-body removal
o Time elapsed from injury until presentation o Skin disinfection
o Wound care performed prior to ED arrival o Hair removal
o Object that caused injury (glass, wood, etc) o Irrigation
o Cleanliness of body & environment at time of injury o Debridement
and afterward o Prophylactic antibiotics
− Factors resulting in injury
o Intentional vs unintentional
o Occupation or nonoccupation related
o Assault or self-inflicted
− Foreign body potential
o Did the object break or shatter
o Foreign body sensation
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 Wound Management
− Extent of adoption of aseptic technique required for
ED wound repair remains unclear
o Full sterile technique, with the physician wearing
hair cap and face mask in addition to sterile gloves,
does not reduce the incidence of post-repair
infections
o The benefits of hand antisepsis prior to wound
repair in the ED is unproven
o Clean, non-sterile gloves have similar post-repair
infection rates when compared to sterile gloves
− These findings suggest that aspects of the sterile
technique may be curbed, leading to time & cost
saving per laceration by using common-sense
cleanliness
ANESTHESIA & ANAGLESIA
− In general, pain control should be provided before
extensive wound preparation
− Administration of anesthesia and analgesia will
enable better preparation and treatment if patients
are relaxed ad able to cooperate without undue
anxiety and pain
− Prior ton the administration of local or regional
anesthetic, the sensory, motor and vascular
examination should be performed at, and distal to,
the wound site
− Two additional assessments may be required before
local or regional anesthesia
o Testing of two-point discrimination on the volar
pads of the thumb & fingers
▪ (two-point discrimination (<6mm) checks for
possible injury to the digital nerve)
o Comparison of the systolic blood pressure in the
injured extremity with noninjured one.
▪ (Systolic blood pressure comparison (using
doppler stethoscope and pneumatic cuff)
assesses for hemodynamically significant
arterial obstruction
− Lidocaine (0.5-1%) or bupivacaine (0.25-0.5%)
combined with a 1:100,000 to 1:200,000 dilution of
epinephrine
− Contraindications of Epinephrine: Should not be used in
wounds of the fingers, toes, ear, nose or penis due to
the risk of tissue necrosis secondary to terminal
arteriole vasospasm in these structure
MAXIMUM DOSE
w/o epinephrine w/ epinephrine Toxicity
Lidocaine 4.5mg/kg 7mg/kg
CNS (seizure)
(05-1%) > CVS
(300mg) (500mg)
(arrythmia)
Bupibacaine Most
2mg/kg 3mg/kg cardiotoxic
(0.25-0.5%)
LA
− Necessary for control further blood-loss & proper
evaluation of a wound
− Diffuse bleeding most often occurs from subdermal
plexus & superficial veins. Direct pressure with saline-
soaked sponges or gauze is usually effective in
stopping this type of bleeding
− Bleeding from a minor exposed lacerated vessel of
the extremities is best controlled by direct pressure
applied with a gloved fingertip directly on the vessel.
o More permanent control can be achieved by
clamping the involved vessel, isolating a short
length & ligating it with absorbable synthetic
suture (typically 5-0)
− Major arteries of an extremity should not be ligated,
and surgical consultation is needed for further
hemorrhage control
− Exercise caution clamping vessels in facial wounds to
avoid damaging facial nerves.
− Scalp lacerations can bleed extensively from the
wounds edges due to the highly vascular cutaneous
layer.
o Scalp bleeding can be controlled by the use of
specially designed clips applied along the wound
edges
− For bleeding wounds where the involved vessel is not
visible, a figure-of-eight or horizontal mattress suture
applied adjacent to the wound edge near the site of
bleeding will sometimes achieve control.
− Chemical means of hemostasis is typically done using
epinephrine mixed w/ local anesthetics in
concentrations of 1:100,000 or 1:200,000 and injected
into the area
− Physical Means of applying pressure to bleeding
include the use of gelatin, cellulose, or collagen
sponges placed directly into the wound
− Bipolar electrocautery can achieve hemostasis in
blood vessels <2mm in diameter, battery-powdered,
hand-held cautery units are more readily
availablebut do not generate sufficient heat to
produce coagulation in vessels larger than capillaries.
− Extremity wounds that are refractory to direct
pressuer, ligation or cautery may require an arteial
tourniquet.
− Tourniquets may compress and damage underlying
blood vessels and nerves, reducing tissue viability.
o The simplest tourniquet to use in an ED is a blood
pressure cuff placed proximal to the wound and
inflated above the patient’s systolic pressure.
− Elevating the extremity to reduce venous blood
volume prior to cuff inflation is useful.
− If an extremity tourniquet is needed to control
bleeding, the best course of action is exploration and
repair in the operating room
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 Wound Management

− Obvious foreign debris should be carefully removed − Effective irrigation decreases bacterial count & helps
from the wound, using forceps to avoid injury to the to remove debris & foreign bodies, thereby reducing
physician from sharp edges or points the risk of wound infection
− Probing wounds with gloved fingertip to detect Low Pressure Irrigation High Pressure Irrigation
foreign by palpation is discouraged 0.5 psi 7 psi or greater
− Visual wound inspection, down to the full depth and Used for Used for
along the full course of the wound, is the most −For uncontaminated −Wounds with high levels
important method for detecting foreign bodies wounds of contamination
− Imaging modalities (plain radiographs, high −For loose tissues around −In areas of the body that
frequency U S , C T a n d M R I ) m a y b e u t i l i z e d i n the scrotum or eyelids are at higher risk of
selected patients infection such as
extremities
Achieved with a slow Achieved with any
gentle, wash with saline & combination of syringes &
water 18 gauge intravenous
catheters
(commonly used 50mL
syringe with a splash guard)

− Volume of irrigant required: exact volume not known

o A common recommendation is to use at least
200mL for wound irrigation
− Irrigant agent
o Sterile normal saline, most commonly used, lowest
SKIN DISINFECTION toxicity
− A common practice is to disinfect intact skin around
o Tap water is easily obtained in large quantities
the wound either a povidone-iodine-based or
clorhexidine-containing agent
− Although these agents suppress bacterial growth on IRRIGATION ADDITIVES
intact skin, they impair host defenses and promote
bacterial growth in the wound itself
− Skin disinfectants should be applied from the wound
edges outward and care taken to avoid spillage into
the wound

HAIR REMOVAL
− Hair can interfere with wound closure, becoming
entangled in sutures or staples and/or acst as foreign
body potentially increasing risk of wound infection.
− Shaving the area with razor damages the hair follicle,
allowing bacterial invasion and is associated with an
increase in infection rates when compared with
clipping or a depilatory cream.
− Hair is best removed by clipping it 1-2 mm above the
skin w/ scissors
− An alternative method: use of ointment or saline to
allow hair to be parted away from wound edges
− Wounds in well-perfused locations (ie. Scalp & face(
may be closed without prior hair removal and with
no apparent increase in infection.
− Hair should never be removed from the eyebrows or
at the hairline because of the potential for impaired
or abnormal regrowth
− Simple scalp wounds, without contamination or
active bleeding, may be closed via hair-apposition
technique. Surrounding hair (>3cm long) on either
side of the laceration is bought together, twisted &
secured with tissue adhesive, thereby closing the
− Generally the skin should be debrided until there is
wound
− There is no added benefit to the addition of an
antiseptic such as povidone-iodine or hydrogen
peroxide
− Universal precautions should be observed while
participating wound care
DEBRIDEMENT
− Debridement not only removes foreign mater,
bacteria & devitalized tissue, but it also creates a
clean wound edge that is easier to repair
− Techniques of debridement
o Autolytic debridement
o Mechanical debridement (irrigation & wet-to-dry
dressings)
o Excisional debridement (to reestablish a margin of
normal tissue at wound edges)
o After debridement is completed, wound should be
re-irrigated
bleeding edge. This should not be done under

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 Wound Management

tourniquet control because the skin may not be

known.
− Muscle debridement should remove all nonviable
muscle that is noncontractile or grossly contaminated

PROPHYLACTIC ANTIBIOTICS
− Infections occur in approxiately 3-5% of traumatic
wounds repaired in Eds
− The most important step in prevention of a wound
infection is adequate irrigation & debridement
− No clear evidence that antibiotic prophylaxis
prevents wound infections in most patient whose
wounds are closed in the ED
− Antibiotics have an inclusive role in intra-oral SAMPLEX
traumatic wounds
− Prophylactic antibiotics do not reduce the incidence 1. Which of the following foreign body can be seen
of wound infection after dog or cat bites on areas excellently through plain radiographs & CT scan?
other the hands a) Wood
− For wounds contaminated by debris or feces or b) GLASS
caused by punctures, or bites, wounds with tissue c) Organic
destruction or in avascular areas & neglected d) Plastic
wounds, sufficient bacteria may be present to cause
infection and prophylactic antibiotics are often
administered.
− Recommended for all human bites to hands and feet 2. Contraindication to use of epinephrine due to risk of
as well as those overlying joints or cartilage tissue necrosis.
− Wounds contaminated fresh water & plantar a) EARS
puncture through athletic shoes should include b) Arms
Pseudomonas coverage c) Legs
− Most non-bite wound infection are due to d) Back
Staphylococci or Streptococci and despite the
increase in methicillin-resistant S. aureus skin
infections, prohylactic coveragge with a becta-
lactam is still adequate 3. Elevating the extremity to reduce venous blood volume
prior to cut off inflation is useful. TRUE
PRINCIPLES OF ANTIBIOTIC PROPHYLAXIS
1. Initiated before significant tissue manipulation is
done − Elevating the extremity to reduce venous blood
2. Performed with agents that are effective against
predicted pathogens
3. Administered by routes that rapidly achieve desired 4. Hair is best removed by carefully shaving the scalp
blood levels using a razor. FALSE
a) There are no studies that compare the common
practice of IV administration of the initial dose
of prophylactic antibiotics with PO − Hair is best removed by clipping it 1-2 mm above
administration
b) The duration for antibiotic prophylaxis is
unknown: 5. Used in areas of the body that are higher risk of
− 3-5 days for non bite wounds infection such as extremities.
− 5-7 days for bite wounds a) Low pressure irrigation
− Patients with establised wound infections b) HIGH PRESSURE IRRIGATION
usually require longer treatment c) Both
d) Neither
END OF THE LECTURE

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 Wound Management

6. Which is the single most important step in wound

care:
a) Wound preparation
b) Wound Closure
c) Imaging
d) Post-repair wound care

7. You are carefully inspecting a wound sustained by a

male patient who punched a glass window. You note
you cannot localize the bleeding and that the bleeding
is controllable only through the use of a tourniquet.
The best course of action is:
a) Exploration and repair in the OR
b) Attempt to ligate the bleeder with a figure 8
c) Continue applying direct pressure for at least 15
more minutes and recheck if bleeding is still
active
d) Attempt to ligate the bleeder with an horizontal
mattress suture

8. The antibiotic of choice for human bites is”

a) Amoxicillin-Clavulanate
b) Ampicillin-Sulbactam
c) Clindamycin
d) Doxycycline

9. Which among the following is the most appropriate

way of cleaning a wound?
a) Irrigation with normal saline
b) Scrubbing with hydrogen peroxide
c) Irrigation with Povidone-iodine
d) Scrubbing with Povidone-iodine

10. The maximum dose of bupivacaine without

epinephrine is:
a) 3 mg/kg
b) 2 mg/kg
c) 4 mg/kg
d) 5 mg/kg

Added by: kends 2022

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