name the ways to deal with bleeders that may appear in a surgical wound or traumatic laceration
- wait for them to stop on their own
- apply pressure with sterile gauze
- clamp with hemostat
- cauterize with a battery powered high temp cautery pen (hot wire loop)
- cauterize with the hyfrecator tip directly to tissue or to hemostat
Contrast control of small bleeder with larger bleeders
for larger bleeders, clamp with hemostat and tie off with dissolvable suture or cauterize by touching hyfrecator tip to hemostat
- tie off with figure eight suture
what are the other steps in laceration evaluation and treatment
- assess for wound contamination and tissue damage
- check flexion/extension for nerve/tendon damage
- R/O fractures
- in cleaner wounds first inject anesthesia inside wound toward edge
- in contaminated wounds clean skin first
- inject anesthesia
- no epi in limited blood supply areas
- clean and debride
- culture if risk of infection
- close wound and bandage appropriately
what is Quikclot and when should you use it?
gauzy wound pads infused with kaolin - a mineral composite known to activate teh coagulation of blood.
- must come into contact with bleeding blood vessel to work.
- use only as a stop-gap measure (if you are in wilderness)
what is Surgicel and when should you use it?
- absorbable “hemostat” proven bactericidal
- oxidized, regenerated cellulose, plant based.
- use only as adjunct to ligation or other conventional methods to control capillary, venous, and small arterial hemorrhage.
- do not use to control hemorrhage from large arteries
contrast treatment of an area of skin loss up to 1cmx 1cm: in a fingertip vs a larger wound avulsion of the fingertip
up to 1cmx 1cm: treat with dressings changed regularly
greater than 1cmx 1cm: refer for plastic surgical opinion
what are particular concerns about palm wounds
deeper structures (nerves, tendons) may be involved
tetanus and immune globulin administration guidelines
if not certain that pt has had tetanus, give tetanus toxoid
if pt received fewer than two doses of tetanus toxoid in lifetime and wound is contaminated, give both tetanus toxoid and immune globulin
what are the controllable and uncontrollable issues that affect wound healing?
uncontrollable: mechanism of injury
- location of wound
- age and race of pt
- pt inherent ability to heal
- pt tendency toward abnormal scar formation
- nutritional status
Controllable:
- tissue handling
- careful, thorough cleaning
- splint/cast wounds near joints
before applying anesthesia, do what?
assess the wound site for tissue damage, contamination, and possible underlying nerve, tendon, muscle, bone damage.
How would you reduce pain of anesthesia injection in a wound?
anesthetic should be administered by injecting the inside or center of the laceration out through the side of the wound into the tissue rather than through the skin surface because it will be less painful (unless it is very contaminated)
which wounds should be considered contaminated?
All wounds, especially human bite wounds, which should not be initially closed
what do you do to prevent wound tattooing?
embedded foreign materials must be removed with a forceps or hypodermic needle and wound copiously irrigated with sterile saline under pressure
in terms of debridement of wounds, when should you remove debris?
all debris and devitalized and necrotic tissue should be removed from the wound, but if there is any question concerning tissue viability, best to minimize debridement and either close it or opt for delayed primary closure
what is the goal of trimming a wound edge?
to produce an opening wider at the base than the surface which helps produce eversion of the wound edges
what are the alternatives to consider if a wound can’t be closed by primary intention?
second or third intention depending on wound
or steri-strips or glue
?? not sure about this one
name the factors that affect the appearance of a wound site after healing
??? couldn’t find this one
how can scar formation be minimized?
through gentle handling and careful cleaning of the injured tissue
is there a golden period of 12-24 hours after which a wound should not be surgically closed?
- depends on each wound
- best results within 6 hours
- face can be up to 24 hours
steri-strips and glue are usually not sufficient for repairing what three types of wound?
lacerations into deeper dermal layers and sub-q
wounds missing tissue
wounds with increased wound tension
Name the 7 wound closure technique basics
- handle tissue gently
- ensure hemostasis
- use a fine suture
- enter needle at 90 degree to skin surface
- evert wound edges
- keep skin edges relaxed
- remove sutures as early as possible to reduce scarring
what are the closure options for clean vs contaminated wounds
clean:
- small: primary closure
- large: undermine, possibly need to use secondary intention or refer
contaminated:
- small: secondary closure
- large: delayed primary closure (DPC)
should a drain be inserted into a traumatic laceration? If so, when?
No
Only use a drain if an infection is anticipated
Understand suture removal technique
- shift knot back and forth to free it up
- cut suture with scissors and pull freed knot ACROSS suture line
