Trauma

Question 1

For wound management, what questions in a history are important to ask? (8)

Answer 1

1. Mechanism of injury
2. Possibility of infection?
3. Non-accidental injury?
4. When did the injury occur?
5. Do they have other injuries?
6. PMHx - any conditions that might delay healing or make them more prone to infection?
7. DHx and allergies
8. Tetanus??

Question 2

What aspects of examination are important to cover for someone with a wound that needs managing? (5)

Answer 2

1. Dirt and debris? - foreign bodies - is an X-ray required?
2. Damage? - size of wound - is local anaesthetic required?
3. Bleeding?
4. Function? - damage to nerves etc.
5. Evidence of infection?

Question 3

What foreign bodies will show up on an X-ray? (4)

Answer 3

1. Glass
2. Metal
3. Teeth
4. Fragments of lead based paint

Question 4

In what situations should wounds also be referred for specialist closure? (9)

Answer 4

1. Open fracture
2. Neurovascular compromise
3. Tendon damage
4. Vermillion border
5. Near the eye
6. Cosmetically sensitive wounds
7. Penetrating wound where unable to assess damage
8. Deep dirty wounds
9. Infected wounds

Question 5

If the wound is a clean laceration, how can it be cleaned? and what if the wound is contaminated?

Answer 5

By a low pressure irrigation using a syringe only - if the wound is contaminated then high pressure irrigation is required and this can be achieved by attaching a green needle

Question 6

Why should you never used adrenaline with local anaesthetic on a digit?

Answer 6

You risk causing ischaemia

Question 7

How many mm deep does a laceration need to be to require deep dermal sutures to close the dead space?

Answer 7

5mm

Question 8

For wound closure, when are sutures preferred? (3)

Answer 8

1. For any laceration longer than 5cm
2. When deep dermal sutures are needed to close the dead space
3. The wound is over an area subject to excessive movement eg. a joint

Question 9

Which type of suture - absorbable or non-absorbable is preferred for skin?

Answer 9

Non-absorbable

Question 10

What size suture is normally used on the face/neck and what size on hands/limbs?

Answer 10

5-6 on face/neck

4-5 on hands/limbs

Question 11

When are staples useful for closing a wound?

Answer 11

Frequently used on the scalp and useful with aggressive patients where needle stick injury may be at risk

Question 12

When can skin glue be used on an open wound?

Answer 12

When the wound is less than 5cm long and where there is no risk of infection and the wound edges can be easily apposed.
It can also be used in combination with steristrips, or sutures in larger wounds

Question 13

When is skin glue not suitable even if the wound is less than 5cm?

Answer 13

Over areas of movement or if the area is exposed to excessive sweating/wetting e.g. the mouth, groin and axilla

Question 14

When are adhesive strips (steristrips) used?

Answer 14

Small minor wounds less than 5cm long, always use for pre-tibial flaps

Question 15

When are adhesive strips for wound closure not suitable? (6)

Answer 15

If the wound is:

1. Bleeding
2. Infected
3. Exudate is present
4. Over joints
5. Wet or sweaty
6. Hairy

Question 16

What % of dog bites typically become infected?

Answer 16

30%

Question 17

What % of cat bites become infected?

Answer 17

50%

Question 18

If a wound is showing signs of infection, what should you do? (4)

Answer 18

1. Take a swab for culture and debride slough and non-viable tissue
2. Clean the wound and pack with non-adherent dressing to prevent wound edges apposing
3. Do not close the wound, apply a suitable dressing
4. Treat with broad spectrum ABX - NICE = co-amoxiclav (if penicillin allergy = erythromycin + metronidazole)

Question 19

How should you manage a pre-tibial laceration? (5)

Answer 19

These are very common in older people as a result of a fall or blunt injury.

1. Cover with moist saline soaked dressing whilst awaiting closure to prevent drying out and shrinkage of the flap
2. Irrigate with sterile saline, and debride as necessary
3. Use steristrips without tension to close flap
4. Cover with supportive dressing
5. Review regularly

Question 20

Which patients are at risk of developing an infection with a wound? (5)

Answer 20

1. Diabetic patients
2. Elderly
   3 Immunocompromised
3. Delayed presentation
4. Extensive/deep injury

Question 21

What should be considered if a patient is deemed high risk of infection e.g. has diabetes, but has a clean laceration?

Answer 21

Treat using flucloxacillin or erythromycin

Question 22

When using staples to close wounds, how far apart should they be placed and when should they be removed?

Answer 22

Placed 5-7mm apart and removed after 5-14 days

Question 23

If closing a wound using glue, how many layers are appropriate?

Answer 23

3-4 layers of glue, it will dissolve after 10 days

Question 24

What documentation needs to be recorded after wound closure/care? (11)

Answer 24

1. Time and date
2. Mode of injury
3. Depth/length of injury
4. Sensation
5. Pulses
6. Immunisation status
7. Cleaned with?
8. Anaesthetic used
9. No. of sutures/staples
10. Removal date of sutures
11. Date to review

Question 25

What advice just be offered to patients after wound care? (5)

Answer 25

1. Take OTC analgesia if necessary 2. Advise to rest 3. Keep wound and dressing clean and dry 4. Observe for signs of infections - redness, swelling, fever, malaise, discharge 5. Practice nurse for suture removal (head and neck = 3-4 days, over joints = 10-14 days)

Question 26

How do you review a post-operative surgical wound for infection? (4)

Answer 26

1. Observe vital signs of patient looking for evidence of infection 2. Observe the wound for erythema, pain, heat, viscous or purulent discharge, leaking, abnormal smell 3. Try to avoid removing dressings unnecessarily 4. Palpate gently as the wound is likely to be tender, but feel for hard collections below the incision

Question 27

What is the most common cause of wound dehiscence?

Answer 27

Infection

Question 28

What patient factors might contribute to a bust abdomen? (7)

Answer 28

1. Age 2. Male 3. Co-morbidities - diabetes 4. Steroids 5. Smoking 6. Obesity 7. Malnutrition

Question 29

What post-op factors might contribute to wound dehiscence and a bust abdomen? (5)

Answer 29

1. Prolonged ventilation 2. Post-op blood transfusion 3. Poor tissue perfusion 4. Excessive coughing 5. Radiotherapy

Question 30

When does wound dehiscence most typically occur post-operatively? (which day?)

Answer 30

Day 6 post-op

Question 31

What is the management for wound dehiscence? (5)

Answer 31

1. Take swabs for culture 2. Take bloods - FBC, CRP, blood cultures 3. Either surgical closure or conservative closure 4. Debridement of necrotic tissue 5. If full bust abdomen - start analgesia, IV fluids, IV ABX, ASAP.