Professional Documents
Culture Documents
– older age
– diabetes
– laceration width
– presence of foreign body
Wound Evaluation – History
(mechanism of injury)
• Type of force causing wound
• Acute traumatic wounds caused by one or
combination of 3 forces
– shear
– compressive
– tensile
Wound Evaluation – History
(mechanism of injury)
• Shear Forces
– produced by sharp objects that cut through
the skin
– amount of energy required to cut skin with
sharp object is low therefore little energy
directed to surrounding tissue with minimal
cell damage
– results in lower risk of infection and problems
with wound healing because remaining tissue
is not devitalized
Wound Evaluation – History
(mechanism of injury)
• Compressive and Tensile Forces
– compressive forces produced when blunt object
impacts the skin at right angles (wounds tend to be
stellate or complex with ragged/shredded edges)
– tensile forces produced when a blunt object impacts
skin at oblique angles (wounds tend to be triangular
or produce a flap)
– compared to shear forces much more energy
deposited with high amounts applied to area around
wound
– results in devitalization of surrounding tissue with
higher incidence of wound infection
Wound Evaluation – History
(mechanism of injury)
• Shear vs. Compressive / Tensile Forces
– Infection
• with compressive / tensile forces the critical
number of bacteria needed to produce infection is
much lower (~100,000 organisms per gram of
tissue)
• with shear forces the number of bacteria needed to
produce infection is much higher ~ 10,000,000
organisms per gram of tissue
Wound Evaluation – History (time
of injury)
• “golden period” refers to time after injury that
wound can be safely closed without increased
risk of infection
– delay in wound cleaning is most important variable
– contrary to popular belief not a fixed number of hours
– “there is little change in wound infection rates in most
areas of the body for up to 19 hours after a variety of
traumatic injuries, and infection rates of simple
wounds involving the head are essentially unaffected
by the interval between injury and repair”
• Berk et al. Evaluation of the “golden period” for wound
repair: 204 cases from a third world emergency department.
Ann Emerg Med 17:496, 1988
Wound Evaluation – History (time
of injury)
• accelerated growth phase of bacteria
starts at 3 hours post wound
Timing of Closure
• primary, delayed primary, secondary
– decision to close a laceration is multifactorial
– base decision on wound history, physical
examination, host factors
• Revisit Case 3
Wound Evaluation – Physical
Examination
• Examine for:
– amount of tissue destruction
– degree of contamination
– damage to underlying structures
• Wounds may be classified into 6 categories
– lacerations
– abrasions
– crush wounds
– avulsion wounds
– puncture wounds
– combination wounds
Wound Evaluation – Physical
Examination
• Lacerations
– if caused by shear force little tissue damage
at wound edge and margins are sharp and
wound appears “tidy”
– if caused by compressive or tensile forces,
more force is required to produce the
laceration and therefore more tissue trauma;
often appear jagged, contused
Wound Evaluation – Physical
Examination
• Abrasions
– results from forces applied in opposite
directions (e.g. skin grinding against road
surface)
Wound Evaluation – Physical
Examination
• Crush Wounds
– caused by impact of an object against tissue,
especially over a bony surface, which
compresses the tissue
– at higher risk for subsequent compartment
syndrome
Wound Evaluation – Physical
Examination
• Avulsions
– wounds in which a portion of tissue is
completely separated from its base and is
either lost or left with a narrow base of
attachment
Wound Evaluation – Physical
Examination
• Puncture Wounds
– wounds with a small opening and whose
depth cannot be visualized
• Combination Wounds
Wound Evaluation – Physical
Examination
• Amount of tissue destruction / devitalized
tissue
Wound Evaluation – Physical
Examination
• Degree of Contamination
– bacteria and foreign material
– primary determinants of wound infection are
the amount of bacteria and dead tissue
remaining in wound
– the presence of undetected reactive foreign
bodies in sutured wounds almost guarantees
infection
Wound Evaluation – Physical
Examination
• Underlying Structures
– nerves, vessels, tendons, bones, joints
Wound Evaluation – Physical
Examination
• Wound Location
– has considerable importance in the risk of
infection
– high endogenous bacterial counts in hairy
scalp, forehead, axilla, groin, foreskin of
penis, vagina, mouth, nails
– wounds in areas of high vascularity more
easily resist infection (scalp, face)’
Delayed Primary Closure
• wound preparation (debridement,
cleansing, etc.), dress with saline soaked
fine mesh gauze, follow up in 72-96 hours
for debridement, repeat cleansing and
closure if no evidence of infection
Skin Preparation
• prevents transfer of bacteria into wound
from instruments, suture needles, gloved
fingers
• use whatever (no research suggest one
better than another)
• important to distinguish between skin
preparation and wound cleansing
Wound Cleansing (not skin
preparation)
• Soaking
– of little value and may actually increase
bacterial counts (Lammers, Fourre, Callaham et al. Effect of poviodine-iodine and
saline soaking on bacterial counts in acute, traumatic contaminated wounds. Ann Emerg Med 19: 709,
1990)
Wound Cleansing (not skin
preparation)
• Mechanical Scrubbing
– gentle scrubbing may be useful in wounds
older than 3-4 hours (a glycoprotein matrix
enters wound and may protect it from further
attempts to lower bacterial counts with
irrigation)
• Debridement of devitalized tissue
paramount to reducing risk of infection
• Scalpel excision of wound margins can be
used in grossly contaminated wounds
Wound Cleansing (not skin
preparation)
• Irrigation
– Equipment?
• 35 cc syringe with 18 G needle produces about 7-8 psi
– Solution?
• NS or 1% poviodine-iodine solution (ie. diluted Betadine) (Dire and Walsh: A comparison
of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990; 19:704-708)
– infection rate in poviodine arm was lower than saline arm but not statistically
significant (4.3% vs 6.9%)
• Hydrogen peroxide kills fibroblasts and occludes microvasculature,
chlorhexadine toxic to tissue defenses, detergents contained in scrub
solutions cause tissue damage in wounds
– How much? (all expert opinion – no clinical trials)
• minimum of 100-300 cc with continued irrigation until all visible particles
removed
• 50-100 cc per cm of wound length
• if irrigation alone is ineffective in removing contaminants from a wound, the
wound should be lightly scrubbed
Prophylactic Antibiotics - Topical
• Ointments
– reduce formation of crust which could inhibit
epithelialization
– prevent dressing from adhering to wound
– routine use encourages pt inspection of
wound
– one randomized, double blind clinical trial
demonstrated reduced infection rate
• Dire et al. Prospective evaluation of topical antibiotics for preventing
infections in uncomplicated soft-tissue wounds repaired in the ED. Acad
Emerg Med 2:4, 1995
Prophylactic Antibiotics - Systemic
• no role for routine antibiotic use for most
wounds (Cumming et al. Antibiotics to prevent infection of simple wounds: A
meta-analysis of randomized studies. Am J Emerg Med 13:396, 1995)