Wound Management
UNC Emergency Medicine
Medical Student Lecture Series
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Principles of Wound Management
Goals of Wound Care
Facilitate hemostasis
 Decrease tissue loss
 Promote wound healing
 Minimize scar formation
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Principles of Wound Management
Mechanism of Injury
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Wounds are caused by three
different types of forces
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Shear
Compressive
Tensile
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Principles of Wound Management
Shear Forces
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Result from sharp objects
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Low energy
Minimal cell damage
Result in straight edges, little contamination
Heals with a good result
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Principles of Wound Management
Compressive Forces
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Result from blunt objects impacting
the skin at a right angle
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Results in stellate or complex laceration
Ragged or shredded edges
More prone to infection
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Principles of Wound Management
Tensile Forces
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Result from blunt objects impacting
the skin at an oblique angle
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Results in triangular wound
Sometimes produces a flap
More prone to infection
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Principles of Wound Management
Evaluation of Wounds
ABC’s first  Always!
 Ensure hemostasis
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Remove obstructions
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Saline gauze dressing
Compression
Rings, clothing, other jewelry
History
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Principles of Wound Management
History
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Symptoms
Type of Force
Contamination
Event
Potential for
foreign body
Function
Non-accidental
trauma
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Tetanus status
Allergies
Medications
Comorbidities
Previous scar
formation
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Principles of Wound Management
Wound Examination
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Location
Size
Shape
Margins
Depth
Alignment with
skin lines
Neuro function
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Vascular function
Tendon function
Underlying
structures
Wound
contamination
Foreign bodies
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Principles of Wound Management
Wound Consultation
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Tarsal plate or lacrimal duct
Open fracture or joint space
Extensive facial wounds
Associated with amputation
Associated with loss of function
Involves tendons, nerves, or vessels
Involves significant loss of epidermis
Any wound that you are uncertain about
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Principles of Wound Management
Wound Preparation - Anesthesia
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Topical
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Local
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Solution or paste
LET
EMLA
Direct infiltration
1% lidocaine with or without epinephrine
Bupivicaine or sensorcaine for longer acting anesthesia
Regional Block
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Local infiltration proximally in order to avoid tissue disruption
Smaller amount of anesthesia required
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Principles of Wound Management
Wound Preparation - Anesthesia
Drug
Max Dose
Onset
Duration
Cocaine
6.6 mg/kg
Rapid
1 hour
Procaine
10-15 mg/kg
Rapid
30min-1hr
Tetracaine
1.5 mg/kg
Moderate
2 hours
Lidocaine
5 mg/kg
5-30 min
2 hours
(with Epi)
7 mg/kg
5-30 min
2-3 hours
Bupivacaine
2 mg/kg
7-30 min
> 6 hours
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Principles of Wound Management
Minimize the Pain of Injection
Use sodium bicarbonate mixed with
the anesthetic (1 ml/10 ml solution)
 Use smallest needle possible
 Inject slowly
 Insert needle through open wound
edge and skin that has already been
anesthetized
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Principles of Wound Management
Wound Preparation - Hemostasis
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Physical vs. chemical
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Direct pressure
Epinephrine
Gelfoam
Cautery
Refractory
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Use a tourniquet
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Principles of Wound Management
Wound Preparation – Foreign
Body Removal
Visual inspection
 Imaging
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Glass, metal, gravel fragments >1mm should
be visible on plain radiographs
Organic substances and plastics are usually
radiolucent
Always discuss and document
possibility of retained foreign body
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Principles of Wound Management
Wound Preparation – Irrigation
Local anesthesia prior to irrigation
 Do not soak the wound
 Use normal saline
 Large syringe (60mL) with Zerowet
attachment
 Do not use iodine, chlorhexidine,
peroxide or detergents
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Principles of Wound Management
Wound Preparation – Debridement
Removes foreign matter & devitalized
tissue
 Creates sharp wound edge
 Excision with elliptical shape
 Respect skin lines
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Principles of Wound Management
Wound Preparation – Antibiotics
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Infections occur in ~3-5% of traumatic
wounds seen in the ED
Factors that increase risk
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Heavily contaminated wound, especially with soil
Immunocompromised patients
Diabetics
Human bites > animal bites
Most important prevention  adequate
irrigation & debridement
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Principles of Wound Management
Wound Preparation – Antibiotics
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Dog & cat bites
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Human bites
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Cover pasteurella
Augmentin
Cover eikenella
Augmentin
Puncture wounds
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Cover pseudomonas
Cipro, levaquin
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Principles of Wound Management
Wound Preparation – Tetanus Prophylaxis
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Clean wounds
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Incomplete immunization toxoid
>10 years, then give toxoid
Tetanus prone wound
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Incomplete immunization
 Toxoid
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& immune globulin
> 5 years, give toxoid
Remember to think about rabies!
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Principles of Wound Management
Wound Closure
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Primary closure
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Secondary closure
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Suture, staple, adhesive, or tape
Performed on recently sustained lacerations: <12
hours generally and <24 hours on face
Secondary intent
Allowed to granulate
Tertiary closure
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Delayed primary (observed for 4-5 days)
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Principles of Wound Management
Suture Material
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Absorbable
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Non-Absorbable
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Chromic gut
Vicryl
PDS II
Silk
Prolene
Dermalon
Monofilament vs. braided
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Principles of Wound Management
Staples, Adhesives & Tape
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Staples
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Adhesives
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Quick, poor aesthetic result
Dermabond- painless, petroleum dissolves
Tape
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Steri-strips
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Principles of Wound Management
Wound Closure
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Undermine the wound edges
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Release tension
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Principles of Wound Management
Suture Techniques
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Deep layer
approximation
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Absorbable sutures
Buried knot
Serves two purposes
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Closes potential
spaces
Minimizes tension on
the wound margins
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Principles of Wound Management
Skin Closure
Key – wound edge eversion
 “Approximate, don’t strangulate”
 Anticipate wound edema
 Choose appropriate size of suture for
location of laceration
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Principles of Wound Management
Suture Techniques
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Simple Interrupted
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Used on majority of wounds
Each stitch is independent
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Principles of Wound Management
Suture Techniques
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Simple Continuous
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Useful in pediatrics
 Rapid
 Easy
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removal
Provides effective hemostasis
Distributed tension evenly along length
Can also be locked with each stitch
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Principles of Wound Management
Suture Techniques
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Horizontal Mattress
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Useful for single-layer closure of lacerations
under tension
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Principles of Wound Management
Horizontal Mattress
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Principles of Wound Management
Suture Techniques
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Vertical Mattress
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Useful for everting skin edges
“Far-far-near-near”
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Principles of Wound Management
Vertical Mattress
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Principles of Wound Management
Suture Techniques
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Purse-string
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Useful for stellate lacerations
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Principles of Wound Management
Suture Techniques
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Instrument tie
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Principles of Wound Management
Wound Care
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Dressing
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Maintain dry for 24-48 hours
Use antibiotic to maintain moist environment
If overlying a joint, splint in a position of
function
Sun protection to prevent scar
hyperpigmentation
Suture removal instructions!
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Principles of Wound Management
Practice Time!
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