WOUND MANAGEMENT

The step most commonly omitted in wound management is adequate exploration, debridement and irrigation.  A superb closure is rendered useless in an undiagnosed injury, infected wound or retained foreign body.

STEPS IN WOUND MANAGEMENT

ANTISEPSIS

LOCAL ANAESTHESIA

Two common techniques can be used

TECHNIQUES PROS CONS
Infiltrative Easy to do
Reasonably safe
Large wounds may exceed toxic dose of local anaesthetic
Less effective around infected sites (acid environment)
Multiple needle insertions
Nerve blocks Lower total dose of local anaesthetic required
Anaesthetise large areas with single needle insertion
Does not distort wound edge during closure
More technical expertise required
Potential to damage a nerve

LOCAL ANAESTHETIC MAXIMAL DOSES

ANAESTHETIC Maximum dose Maximum dose  (with adrenaline)
Lignocaine 2 mg/kg 5mg/kg
Bupivaine (MARCAIN) 3mg/kg  
Prilocaine (CITACAINE) 4mg/kg  

LOCAL ANAESTHETIC TOXICITY

Early symptoms - tingling lips, lightheadedness, nausea

Full blown - arrhythmias, hypotension, seizures (Call for help)

SYSTEMIC ANALGESIA

See IV opiates

EXPLORATION

Look/Feel for:

Remember structures may retract underneath wound edge!

DEBRIDEMENT

Excise with scalpel or scissors:

IRRIGATION

CLOSURE

Options

  PROS CONS
Steristrips Easy
Quick
Painless
Good cosmesis
Not as strong
Not good for ragged wounds, wounds under tension
Dermabond glue Strong
Easy
Quick
Painless
Low infection risk
Good cosmesis
Expensive
Not good for ragged wounds, wounds under tension
Sutures Strong
Precise approximation
Needs more skill
Slow
Infection risk
Suture marks
Staples Strong
Quick
Very expensive

Barriers to good wound healing

General principles

Removal of sutures

LOCATION DAYS
Face 3-5
Extremities 7
Scalp 10
Back/Over joints 14

Dressings

Elevate all hand wounds in a sling for at least 48 hrs

TETANUS IMMUIZATION

see Indications for immunization

ANTIBIOTICS

rarely indicated (antibiotics should not substitute for correct debridement and irrigation of wounds)

Indications

Choice of antibiotic (many choices, none best)

AFTERCARE