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Updated: Jan 1 2022

Wound Management

Images prophylaxis.jpg
  • Snapshot
    • A 45-year-old man presents to the ED after being blown into a wall following a gas explosion. Due to extensive evidence of lacerations and intraabdominal injuries, he is emergently taken to the OR for exploratory laparotomy. He undergoes splenectomy and partial colectomy with colostomy. Once negative pressure vacuum wound dressings are applied and hemodynamic stability is attained, the patient is taken to the surgical intensive care unit. On the fourth postoperative day, the nurse reports redness and tenderness along the patient's incision margins. The patient is taken back to the OR, where purulent material is drained and nonviable tissue along the margins are debrided.
  • Introduction to Wound Management
    • In trauma setting, challenge is to identify all injuries, both obvious and non-obvious
      • triad of management is control of bleeding, pain, infection
  • Presentation
    • Types of wounds and stages of wound healing affect management
      • laceration
        • cut or torn tissue caused by tearing mechanism
      • abrasion
        • superficial graze caused by rubbing or scraping mechanism
      • contusion
        • bruise caused by high-force mechanism
        • outer layer of skin is intact but injured
      • avulsion
        • "degloving" injury that forcefully separates skin/soft tissue from underlying tissue
      • puncture
        • tissue torn by puncturing mechanism (including bites)
      • crush injury
        • tissue injury due to high-pressure mechanism
      • thermal/chemical wound (i.e., burns)
    • Primary and secondary survey with resuscitation
      • all clothing must be removed to visualize all possible lesions
      • all structures deep to a laceration is considered injured until proven otherwise
        • evaluate functional and neurovascular status distal to all lesions
        • use radiography or ultrasound for any suspected foreign bodies
      • evaluate for coagulopathy (e.g., family history, liver disease) and anticoagulant use
      • consider amputation if blood supply or soft tissue severely compromised
  • Management
    • Focus on control of bleeding, pain, potential infection
    • Bleeding
      • obtain hemostasis quickly
      • fluid resuscitation as necessary
      • drain all hematomas
    • Pain
      • local anesthetic (e.g., lidocaine)
      • systemic analgesic (e.g., morphine)
      • systemic anesthesia (e.g., propofol)
    • Infection
      • for all wound types, cleaning as early as possible with irrigation and exploration for foreign bodies
      • abrasions: antiseptic ointment for facial abrasions especially
      • prophylactic antibiotics for animal/human bites, intraoral lesions, puncture wounds to foot
      • tetanus prophylaxis (see chart below)
        • based on wound type (clean/dirty), age, and immunization history
        • age
          • < 7 years: DTaP
          • 7 - 64 years: Tdap
          • > 65 years: Td
    • Amputated body parts
      • wrap amputated body part in saline-moistened sterile gauze and seal in a sterile plastic bag
      • cooling prolongs opportunity for replantation and increases probability of replantation success
        • 6 hours of cold ischemia = 1 hour of warm ischemia

    • Clean, Minor Wound
      All Other Wounds
      Vaccination history
      Vaccinate Based on AgeTetanus ImmunoglobulinVaccinate Based on Age Tetanus Immunoglobulin
      Unknown of < 3 dosesYesNoYesYes
      ≥ 3 doses
      Only if last dose > 10 years agoNoOnly if last dose > 5 years agoNo
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