wound care and repair

wound healing steps

hemostasis and clot formation, inflammation, proliferation, remodeling

hemostasis and clot formation timeline

within minutes

hemostasis and clot formation includes

fibrin release to promote clotting and healing

inflammation includes

body increases blood flow to promote healing by increasing permeability, vasodilation, cellular migration

proliferation timeline

within 2 days of closure

proliferation includes

endothelial cells arise to help close wound

remodeling timeline

24 hours after injury

remodeling includes

formation of fibrin matrix, wound contracts, and scar begins to form

primary intention

all layers closed, minimizing scarring

secondary intention

wound kept open to heal on its own, must apply dressing and keep clean

secondary intention indications

excess tissue loss, infection, pressure sores

third intention/primary delayed

wound open until reevaluation and if clean and granulation tissue has formed it is irrigated and closed

wound repair methods

steri strips, staples, sutures, dermabond

wound repair indications

decrease time required for wound healing, reduce infection rate and scarring, repairs function of tissue

how to preserve cosmesis

incisions made across langer’s lines

wound repair complications

infection, scarring, keloid, loss of function, wound dehiscence, tetanus

contraindications to closure

superficial, high likelihood of infection, may require skin grafting

when face, neck, scalp wounds can get closed

up to 24 hours after injury

when clean wounds can be closed

up to 18 hours after injury in healthy individuals

wounds with high likelihood of infection

open for a long time, seeded with infection, puncture wounds, foreign bodies

wound evaluation steps

mechanism of injury, wound age, degree of contaminants, wound size, presence of neurovascular compromise, adjacent injuries, tetanus status, potential for impaired wound healing

mechanism of injury

ways to change management

foreign body, animal/human/”fight” bite, potential for fracture/dislocation

if suspected foreign body in wound

FB MUST be removed prior to closure, non-organic material will show up on XR

animal bites pathogens

pasteurella 50% dogs, 75% cats

human/”fight” bites pathogen

eikenella

animal/human/”fight” bite management

MUST irrigate EXTENSIVELY, may not close

treat with augmentin

potential for fractures/dislocations

depends on mechanism, consider imaging, open fractures MUST get abx

wound age concerns

increased wound age can cause infection

degree of contaminant steps

inspect wound, understand mechanism of injury

address contamination with - irrigation, abx, surg consult

potential surrounding tissue that can be disrupted in a wound

bone, tendon/ligament, nail bed, eyes, vermillion border

wound size/adjacent injury

determine size and what surrounding tissue is disrupted

determining neurovascular compromise

perform exam DISTAL to wound

sx of neurovascular compromise

numbness, tingling, decreased pulses/strength

two point discrimination

determine if patient feels one or two points of contact with something sharp

tetanus indication

routine every 10 years

open wound tetanus

clean - 10 years

dirty - 5 years

tetanus administration timeline

within 48-72 hours of injury

needed for a wound to heal?

blood supply, no devitalized tissue, no infection, moisture

impairs wound healing

immunocompromise, diseases with decreased blood flow, infection

dermabond

adhesive skin glue, multiple layers required for closure

dermabond removal

polysporin

dermabond use

superficial or well approximated

not high-tension area, gaping, or oozing

steri-strips

adhesive strips that can be placed over a wound

benzoin can help them adhere to skin

can use to suture through if tissue is friable

staples indication

often scalp because of hair, linear wounds

staples downside

increases scarring compared to suture, must be removed

scalp staple removal

7-10 days

trunk/upper extremities staple removal

7 days

lower extremities staple removal

8-10 days

suture types

absorbable, nonabsorbable

absorbable sutures

vicrul, chromic gut, fast absorbing gut

nonabsorbable suture

nylon (ethion), prolene

suture size

higher number = thinner and less likely to scar

recommended suture size for face

6-0

recommended suture size for extremities

4-0

hold suture with needle driver at…?

swage/base of needle

cleanser that decreases wound healing

povidone/iodine

percutaneous closure types

simple interrupted, horizontal mattress, vertical mattress, running

percutaneous closure

closure on top of the skin

knot number for absorbable sutures

3-4

knot number for nonabsorbable sutures

4-5

edges for proper healing of wounds

everted

nonabsorbable suture knot type

surgeon’s knot

absorbable suture knot type

square knot

dermal closure indication

helps with cosmesis,prevents abscess/hematoma

dermal closure requirements

absorbable suture, square knot

usually surgical closure

MC suture

simple interrupted

second MC suture

vertical mattress

vertical mattress indication

high tension areas, often need 2 layers

horizontal mattress indication

high tension areas or with a flap of tissue/tension on ONE side

running suture advantage

fast

running suture disadvantage

one broken loop = entire wound may open, can cause railroad track scar

horizontal half-buried mattress advantage

minimizes strangulation of blood at tip of wound

horizontal half buried mattress indication

tip of skin flap, Y shaped wound

buried dermal indication

reduce tension

buried dermal technique

deep to superficial first side

superficial to deep second side

buried dermal requirement

absorbable suture

suture removal requirements

do not bring outside suture through skin

ensure no suture is left in skin

scalp lac suture requirement

must go through galea/aponeurosis

suture patient education

keep dry and clean for at least 24 hours (healing), no soaking, return WWS, tylenol/NSAIDs for pain, apply sunscreen to scars

face suture removal time

5 days

eyelids suture removal time

3 days for low tension wounds

7 days for high tension wounds

neck suture removal time

5 days

scalp suture removal time

7-10 days

trunk/upper extremity suture removal time

7 days

lower extremity suture removal time

8-10 days

digits, palm, and sole suture removal time

10-14 days

when to use abx with sutures

fight bite, visual infection, prolonged time prior to closure