The Principles of

Wound Management
 The goal of emergency wound treatment:
 To restore tissue integrity and function
while avoiding infection and morbidity, and
optimal cosmetic appearance.
 Risk of infection in clean wound <1%, dirty
wound >20%
 Principles of disease
 Thickness=1-4mm
 Anatomy of skin and  Epidermis
fascia  Stratum germinativum
 Dermis
 Composed of CT
 Key layer for ultimate
healing of skin wounds-to
anchor suture placed
percutaneously or
subcutaneously.
 Optimal healing and
minimal scar formation
depend on
 Removal of debris and
devitalized tissue from the
dermis
•Wound Biology
Types of wound
 Clinical features and diagnostic strategies
 In severe hemorrhage
• Secure the ABC  Physical examination
• Establish large bore IV line(s) and fluid
resuscitation.
• GXM 2-4 units
 Optimal visualization under
• Elevate and compress. anesthesia
 Pry the wound apart and ensure
 History blood free field, examine wound
 Detailed history should be obtained to anticipate depth and extend of injury
serious complication such as in patient with
peripheral vascular disease, immunocompromised,
 Clean non-sterile glove should be
or high risk of retained foreign body  may change worn
the wound care management
 Drug history
 mechanism and setting of injury
 Foreign body assessment
 Tetanus status
 X-ray(depend on radiodensity of an
 Risk factors for wound infection object)
 Injury >4-8 hours old  Xerogram
 Location-foot and lower extremity
 Contamination  CT scan
 Blunt (crush) mechanism  Ultrasound
 Presence of subcutaneous sutures
 Anesthesia with epinephrine
 High velocity missile injuries
 Wound Management
 Anesthesia
 Allergy
 Skin preparation
 Wound preparation
 Debridement
 Wound cleansing
 Irrigation
 Wound closure
 Decision making
 Wound tension
 Suture technique
 Antibiotic prophylaxis
 Supportive wound care
 Anesthetic agent
 Lidocaine (Xylocaine)
 Administered as a regional nerve block (onset-4-6mins,lasts 75
mins)
 I% lidocaine solution contain 10mg/ml, safe to use up to 3-5
mg/kg
 Injection done in a 27 gauge needle
 Bupivacaine (Marcaine)
 Onset same with lidocaine but duration of anesthesia is 4-8 time
longer then lidocaine
 Topical anesthesia
 Esp. for children with simple wound
 A solution containing 0.5% tetracaine,1:2000 adrenaline and
11.8% cocaine (TAC)
 For burns and abrasions
 2% lidocaine gel
 Allergy

 Lidocaine and Bupivacaine belong to

amide family
 Alternative-Procaine, tetracaine, and
benzocaine (belong to esters family) or
cardiac lidocaine that does not contain
preservatives can be used.
 Skin preparation
 Disinfection of the surrounding skin with
providone-iodine and chlorhexidine
 Removal of hair-body,facial and head hair,
or apply a petroleum-based product to the
hair adjacent to the wound margins
 Wound preparation
 Debridement
 Remove foreign matter and devitalized tissue from the
wound
 May have the consequences of producing large tissue
defect wider scar
 Meticulous sharp excision of small fragments of nonviable
tissue should be performed only by experienced physicians
esp. the wound on the face and hand
 Wound cleansing and irrigation“dilution is the solution to
pollution”
 Cleaning Agents
 Water
 Normal saline
 Hydrogen peroxide
 Providine-Iodine
 Wound closure
 Decision making
 Closed primarily
 Closed in 4 or 5 days
 Left open and allowed to heal on its own
 Wound tension maybe reduced by:
 Deep suture (but not on hand and foot)
 Avoid suturing adipose tissuenecroticinfection
 Suture materials and techniques
 Suture Materials for wound
closure
 Suture
 Absorbable
1. Catgut (nowadays made from cow or sheep tendon)
a. Plain- very reactive and dissolves in about 1 week
b. Chromic- chromic acid treatment renders it less reactive. It lasts about 2-3 weeks
2. Polyglycolic acid- Dexon (lasts about 4 weeks), Maxon (lasts about 6 months)
3. Polyglactic acid- Vycril (lasts about 4 weeks)
4. Poly dioxanone- PDS
 Non-Absorbable
1. Silk-fairly reactive, frequently gets “spit” out of wound. Now most commonly used to
secure lines and tubes.
2. Cotton
3. Polyester- Dacron, Dermalene, Merselene, Teflon(Tevdek), Silicone (tri-cron), and
Polybutilate (Ethibond)
4. Nylon- Dermalon, Surgilon, and Ethilon
5. Polyprophylene- Prolene and Surgilene
 Other materials
 Staples (for linear lacerations that do not require accurate approximation of
tissue)
 Tape & adhesive strips (for simple, shallow and low tension laceration)
 Suture techniques
Indications Contraindication Advantages
Interrupted Most stellate and low Lacerations overlying Greatest degree of control w
tension lacerations joints/ under high margin alignment, ↓
tension procedural time

Continuous/ Lengthier, well-aligned, Uneven wound margin, Time efficient

running low tension lacerations highly infected

Vertical Deep wounds w dead Where cosmesis Good wound margin eversion
mattress spaces, overlying joints, prominent & apposition
hands & feet

Horizontal Scalp wounds Paeds laceration Good wound margin eversion

mattress (discomfort) while disperse tension

Corner Flaps, ↓ vascularity of Paeds laceration Wounds w ↓ vascularity

margin, scalp-skin (scarring)
junction

Subcuticular Deep lacerations Likely infected wounds ↓ tension on overlying

(buried) sutures / tape sticthes

Subcuticular Paeds laceration : Likely infected wounds ↓ scarring, ↓ painful removal

(intradermal) required prolonged
support

Hair Apposition Simple, clean, linear Deep, contaminated, ↓ scarring, ↓ procedural time
Techniques scalp lacerations complex wounds & discomfort
(HAT)
Interrupted

Continuous

Subcuticular
 
     
                                        
     
                                      

 
     
                                        
     
                                      

 The horizontal mattress suture. (A) Initially, the needle is passed

across the wound. (B and C) The needle is placed backwards in the
needle holder and moved down the wound edge before it is passed
back to the original wound edge. (D) The threads are tied to
complete the horizontal mattress suture.
 
     
                                                                                    

 
     
                                      

                                             
The far-far, near-near technique for vertical mattress suture
placement. (A) The needle is initially placed forward in the
needle driver for a right-handed physician and is passed
through both wound edges for the far-far pass. (B) The needle
is then placed backwards in the needle driver. (C) The near-
near pass is performed with the needle passing within 1 to 2
mm of the wound edge. The depth of the near-near pass is
within the upper dermis, or about 1 to 2 mm deep. (D) The
knot is tied over the wound edge, where the initial pass of the
suture was placed. (E) Wound edge eversion is achieved
through a row of vertical mattress sutures.
  FIGURE 4. Proper closure using the
corner stitch. The subcutaneous suture
passage is identified by dotted lines.

FIGURE 5. Closure of an X-shaped

wound using the corner stitch. The
subcutaneous suture passage is
identified by dotted lines.
  
    
                                         
                                           


                                           
                                           

     6. Corner suture. (A) To begin the corner suture, consider drawing a plumb line that
FIGURE
bisects the angle opposite the corner wound that will be closed. Insert the needle next to the line.
The needle is passed into the wound in the level of the deep dermis, 4 to 6 mm from the corner.
(B) The corner flap is elevated with Adson forceps (pick-ups), and the needle is passed from one
side of the flap tip to the other side in the deep dermis. (C) The needle then passes back into the
wound edge about 4 to 6 mm from the tip and (D) exits the skin. The suture thread passing to
and from the corner flap is elevated by the needle driver for demonstration purposes.
Staple
 Supportive wound care
1-Antibiotics prophylaxis
 No role in simple wound
 For contaminated wound, bites, puncture wound
or intraoral laceration.
 For immunocompromised patients

2-Tetanus immunization
Tetanus agents T and dT toxoids
Dose 0.5mL, dependent on age of patient
Indications Dirty wounds in patients who have
not received booster in 5 years
AND clean wounds in patients who
have not received booster in 10
years
Tetanus Immunoglobulin *
1. 75 units < 5yrs of age
2. 125 units for ages 5-10
years
3. 250 units > 10 years of age
Patients who never completed the
series of tetanus immunisation
3- Wound care instructions

 Elevate the injured extremity above the level of the heart. Wear a sling when
appropriate
 Cleanse daily in a gentle fashion to remove debris and crusting that
develops. Use dilute hydrogen peroxide.
 Immobilization should be maintained at least until suture removal.
 Signs of infection
 Redness
 Increasing pain
 Swelling
 Fever
 Red streaks progressing up an extremity
 Wound check
 As needed to check signs of infection
 Routine at 48 hours for high-risk wounds
 Suture removal (NOTE: Suture may be removed earlier if Steri Strips reinforce the
wound.)
 Face: 3 to 5 days (always replace with Steri Strips)
 Scalp: 7 to 10 days
 Trunk: 7 to 10 days
 Arms and legs: 10 to 14 days
 Joints: 14 days
 The Management Of
Problematic Wounds
 Scalp
 Tend to bleed persistentlycontrolled haemorrhage by direct pressure,rapid
closure,epinephine infiltration,crown touniquet or Raney scalp clips
 Lacerations of the galea aponeurotica must be repaired
 Individual closure using 3’0 or 4’0 non-absorbable sutures. (Interrupted stitches,
Horizontal stitches, Staples, HAT)

 Tendons of The Hands

 Flexor tendons
 -urgent consultation with a hand surgeon
 -minimize triggering, bow stringing and adhesions and identify nerve injuries
 Extensor tendons
 Partial extensor tendon (4’0 or 5’0 absorbable synthetic sutures)
 Complete extensor tendon (4’0 or 5’0 non-absorbable suture,closure of
overlying skin and antibiotic prophylaxis)
 Nail Bed Injuries
 Traditional repair(removal of nail and primary closure of nail
bed laceration)
 Conservative repair(using nail as a splinter)
 Subungual haematoma > 25%(trephinate the nail)
 Subungual haematoma > 50% or nail is significantly avulsed
(remove nail bed with with 6’0 or 7’0 absorbable sutures)
 Anchor the original nail or petroleum gauze splint underneath the
eponychium for 2-3 weeks to facilitate formation of a new nail
plate.

 Eye
 Complete eye examinination with visual acuity
 X-ray of the orbit(Indications :History of FB entry but no FB
found on corneal surface or distortion of shape of iris)
 Referral to Ophthalmology Department (Indications :Lid
lacerations that cross lid margins, cuts through both surfaces of
lid or may have damaged the lacrimal gland or duct)
 Flap
 Importance :
 Blood supply of wounds may be compromised
 especially distally-based flaps
 For young patient
 Primary suturing (also can be done in the region of the face)
 For elderly patients
 Flap may die if sutured under tension.
 Clean wound and appose with Steristrips and reviewed early
 Primary excision and grafting (if flap is large)
 Summary of Wound Care
 Stabilize patient
 History
 Physical examination and foreign body
assessment
 Wound management- debridement,
cleansing, closure
 Antibiotics
 Wound care instructions