Wound Management

Wound Management from Sun YaiCheng

Wound Management
Emerg Med Clin North Am, 2007;25: 873–899

Goal of Wound Management

• Providing painless, quick wound closure
• Excellent cosmetic result
• Avoiding infection

Contaminated wounds

• mammalian bites, human bites, 
• wounds incurred in submerged bodies of water (eg, streams, lakes, ponds). 
• “ old” wounds, high level of bacteria 6 to 8 hours after wounding.

Golden Period for Wounds Repair

• The accepted interval from injury to wound closure is up to 6 hours for wounds to the extremities and up to 24 hours for face and scalp wounds.

Tetanus-Prone Wounds 

• Age of wound > 6 hours
• Stellate wound or avulsion
• Depth of wound >1 cm, mechanism of injury is a missile, crush, burn, or frostbite
• Signs of infection
• Devitalized tissue
• Presence of contaminants (dirt, feces, soil, or saliva)
• Presence of denervated or ischemic tissue

Physical Examination

• Location
• Length in centimeters
• Neurovascular examination
• Motor examination
• Exploration for tendon or joint involvement
• Presence of foreign body

Wound Preparation
High-pressure irrigation

• Recommended irrigation pressure is 5 to 8 psi which can be achieved by using a 30 to 60 ml syringe and a 19 gauge needle or splash shield
• Use 50 to 100 ml of irrigant per cm of laceration
• If saline is not available for irrigation, tap water may be a good alternative
• Detergents, hydrogen peroxide, and concentrated povidone-iodine should be avoided in wound irrigation

Types of Wound Closure

• Primary closure is closure of the wound before formation of granulation tissue.
• All “clean” wounds can be closed primarily.
• Delayed primary closure can be performed after 3 to 5 days to allow the patient's defense system to decrease the bacterial load.
• Secondary closure is healing by granulation tissue. This type of closure is suited for partial-thickness avulsions (ie, fingertip injuries), contaminated small wounds (ie, puncture wounds, stab wounds), and infected wounds.

Techniques of Wound Closure 

• When the goal is to obtain the best function, the laceration should be closed in a single layer with the least amount of sutures.
• When cosmesis is most important, a multiple-layer closure should be used.

Oral Cavity and Mucous Membranes

• Lacerations of the buccal mucosa and gingiva generally heal without repair.

Face

• With cheek lacerations, there is potential for injury to the parotid gland and to the 7-th cranial nerve.

Bites

Gunshot Wounds

• Wounds caused by bullets should be debrided, irrigated, and left open to be repaired with delayed primary closure or by secondary closure.