Transcript Boo-Boo and Owie Repair for Dummies

Basic Boo-Boo and
Owie Repair
Kalpesh Patel, MD
Dept. of Pediatric Emergency
Medicine
July 26, 2006
Pathophysiology
 Wounds regain 5%
strength in 2 weeks
 Collagen synthesis
begins within 48 hours
of injury and peaks at 1
week
 30% strength in 1-2
months
 Full tensile strength in
6-8 months
 Remodeling can occur
up to 12 months
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Pathophysiology
 Normal skin is
under constant
tension produced
by underlying joints
and muscles.
 Lacerations parallel
to joints and skin
folds heal more
quickly and better
 Tension widens
scars
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Pathophysiology
 All wounds leave scars, but shallow ones heal better
 Fibroblasts cause wound contraction – Evert edges!
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Wound Infections
 Areas of high bacteria counts (>100,000/gm) are
more prone to infection:
• Axilla, perineum, hands, face and feet
• Areas of high vascularity, resist infection despite
high bacteria counts: face and scalp
 Sharp wounds (i.e. knife wounds) rarely infected
 Blunt injury causes irregular wounds, flaps and
crushes underlying skin. More likely to be infected
and cause unacceptable scarring
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Evaluation
 History:
• Mechanism of injury - Shearing, Tension (Blunt),
or Compression (Crush)
• Age of wound
• Possibility of foreign body
• Location and damage to adjacent structures
• Environment in which injury occurred
• Patient’s health status: diabetes,
immunocompromised, cyanotic heart disease,
chronic respiratory problems, renal insufficiency
• Medications – steroids
• Allergies to latex, antibiotics or anesthetics
• Tetanus status
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Evaluation
 Physical:
• Vascular damage – pressure for active bleeding
Brisk dark blood = vein, can be ligated;
Brisk bright blood = artery
 Tourniquet if needed for up to 2 hours
• Nerve damage – when sensation is intact, motor
function is usually intact
• Tendon injury
 check full ROM of nearby joints
 Inability to withdraw from noxious stimuli
implies injury
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Evaluation
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 Physical:
• Foreign material
 Glass and metal are radiopaque, so X-ray
 Ultrasound is useful for other foreign bodies
 Explore for foreign bodies after anesthesia
• Bones
 Palpate nearby bones for tenderness or
crepitance and X-ray if found
 Refer vascular, nerve or tendon injuries or deep,
extensive lacerations to the face
• HAND: Ortho and Plastics alternate days
• FACE: ENT, Plastics, and OMFS alternate
Decision to Close
 Infection rate for children is 2% for all sutured
wounds.
 “Golden period” is within 6 hours for primary closure
 Low risk wounds can be primarily closed 12-24
hours after injury
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Decision to Close
 Face can be primarily closed up to 24 hours after
injury with excellent cosmetic effect
 Some contaminated wounds (animal or human
bites, barnyard injuries) or immunocompromised
host should not be sutured even if presenting
immediately
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Decision to Close
 Secondary intention healing (secondary closure)
should be allowed for infected wounds, ulcers,
many animal bites, small puncture wounds
• Small wick of iodoform gauze placed inside
wound to keep edges open and removed in 2-3
days to allow subsequent granulation
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Decision to Close
 Delayed primary closure (tertiary closure)
considered for heavily contaminated wounds or
extensive wounds
• Considered after 3-5 days, once infection risk
decreases due to re-epithelialization (about
1mm/day)
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Decision to Close
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Management
 Preparation:
• Tell the patient and family what is going to
happen, unhurried and with confidence
• Arrange distractions: Child life, TV, music, etc
• Keep parents in the room, sitting and focusing on
the child
• Consider pain medication and
sedation/anxiolysis prior to procedure
• Prepare injections, use needles, and open your
kit away from child
• Immobilization for young children – use staff to
hold the wounded body part and the family to
hold the rest. Avoid papoose.
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Wound Preparation
 Do not shave hair
• Secure with petroleum jelly or clip with scissors if
needed to keep hair from entering wound
 Clean the wound periphery with 10% povidoneiodine
• A 1% solution may also be used for dirty wounds
• Avoid chlorhexidine, H2O2, Alcohol, and surgical
scrub in the wound
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Wound Preparation
 Anesthetize locally or
with a regional block
 http://www.mainehealth.org/em_bo
dy.cfm?id=3235
 Pressure irrigation to
wound (7-8 PSI) with
Saline 100 ml per 1cm
of laceration
 Do not soak wounds –
causes skin maceration
and edema
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Wound Preparation
 Only scrub dirty
wounds and consider
non-ionic detergents
 Remove embedded
foreign material (road
rash) to avoid tattooing
of skin
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Wound Preparation
 Trim irregular
lacerations, debride
necrotic skin
• Subcutaneous fat
can be removed in
small amounts or
undermined
• Don’t remove facial
fat as it may leave
depressions
• Stellate or highly
irregular lesions may
need excision to
minimize scar
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Wound Closure Equipment
 Choose suture material that has adequate strength
while producing little inflammatory reaction
• Non-absorbable sutures for skin
 Nylon or polypropylene
 Silk causes tissue reaction
 Use 4-5 throws per knot
• Absorbable for skin or deep sutures
 Monocryl, Vicryl, Dexon – synthetic
 Guts are natural and cause more reaction
 Fast Gut for face or scalp
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Wound Closure Equipment
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• Size:
 5-0 to 6-0 for face
 4-0 for deep tissues with light tension
 3-0 for tissues with strong tension (joints, sole
of foot or thick skin)
 3-0 to 4-0 for oral mucosa
 4-0 to 5-0 for everything else
• Needles
 3/8 reverse cutting needle satisfies most
needs
 Round needles for oral mucosa
 High grade plastic for face (P or PS)
 Fine needle (P3) for fine cosmesis
Wound Closure
 2 goals:
• Match the layers of
injured tissue
 Identify all skin
layers and appose
each layer as
closely as
possible to original
location
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Wound Closure
 Evert the wound edges
• Enter skin at 90 degrees
perpendicular and
pronate wrist
• Use slight thumb
pressure on the wound
edge as needle enters
the opposite side
• Take equal bites on both
sides
• Do not pull the knot
tightly. Causes
puckering
• Minimize skin tension
with deep sutures
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Suture Techniques
 Deep sutures – to reduce skin tension and repair deep
structures
• Buried subcutaneous suture
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Suture Techniques
 Simple interrupted
• Loop knot allows
minimal tension and
allows for edema
 Running sutures –
used to close large,
straight wounds or
multiple wounds
• Horizontal dermal stitch
(subcuticular)
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Suture Techniques
 Vertical mattress – for
deep wounds, reduces
tension, closes dead
space

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http://www.jpatrick.net/WND/woundcare.html
Suture Techniqes
 Horizontal mattress –
relieves tension


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http://www.jpatrick.net/WND/woundcare.html
http://www.bumc.bu.edu/Dept/Content.aspx?De
partmentID=69&PageID=5236
Suture Techniques
 Corner stitch (half-buried
mattress stitch) – to close a
flap
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Suture Alternatives - Tape
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 Leaves no marks, minimal tissue
reaction
 Can be placed between sutures to
relieve tension
 Can be used primarily for small
lacerations
 Can be used for loose approximation of
dirty wounds
 Use benzoin to adjacent skin (not
wound)
 Don’t pull tape or wound edges won’t
approximate well, apply perpendicularly
across wound
 Do not bandage if possible to minimize
moisture
 Don’t tape in moist areas: palms or
axillae
Suture Alternatives - Staples
 Staples
• Best for scalp, trunk, and extremity
wounds
• Use when saving time is important,
such as mass casulties
• Does not allow for meticulous
cosmetic repair
• Should not be used on face, neck,
hands or feet
• Should not be used prior to MRI or
CT as they may interfere with
imaging
• More painful to remove
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Suture Alternatives - Glue
 Tissue Adhesives
• Rapid and painless closure
• Sloughs off in 7-10 days so no follow up
required
• Antimicrobial effects against Gram positives
• High viscosity adhesives are less likely to
migrate during repair
• Clean and dry wound, achieve hemostasis
• Hold edges together manually and apply.
• Avoid getting into wound, it acts as a foreign
body
• Dry for 30 seconds between layers
• Don’t use over high tension areas
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Suture Alternatives - Glue
Dressings
 Dressings protect the wound, absorb secretions
and immobilze the part
 For simple wounds a clean absorbent gauze is
sufficient with bacitracin or polysporin (not
neosporin)
 A non-adherent gauze (Telfa or Xeroform) can be
used underneath if desired
 Tegaderm can be used for small wounds of the face
and trunk
 Scalp wound need no dressing
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Dressings
 Dressings should remain in place for 24-48 hours or
for active children, until sutures removed
 Daily dressing changes should be done and wound
inspected
 Dressing changed sooner if soiled, wet or saturated
 If the wound overlies a joint, splint it for no more
than 72 hours
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Antibiotics
 Antibiotics are not recommended for routine use
 Proper irrigation is more efficacious than antibiotics
to prevent wound infection
 Consider antibiotics for heavily contaminated
wounds, bites, crush injuries, or wounds > 12 hours
old
 Use antibiotics for
• oral wounds
• wounds of the hands, feet or perineum
• open fractures or exposed cartilage, joints or
tendons
 1st generation cephalosporin or Augmentin
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Tetanus
 Document immunization status of patients with
wounds
 For minor or clean wounds, 3 previous doses of
tetanus toxoid and a booster given > 10 years, then
give tetanus (DTaP, or Tdap)
 For a dirty wound, give tetanus toxoid if last tetanus
was more than 5 years ago
 If unknown status and a dirty wound, then give
tetanus toxoid and tetanus immune globulin (TIG)
 If massive tissue destruction and contamination
have occurred, consider hospitalization
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Discharge and Follow-Up
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 Return for signs of infection: increasing pain, redness,
edema, wound discharge or fever
 Keep wound elevated
 Bathing allowed after 24-48 hours, but PAT dry and
recover
 Notify family that the wound was inspected for foreign
body, but retained foreign body or undetected injury
cannot be excluded
 All wounds leave a scar and scar appearance is not
complete for 6-12 months
 Minimize sun exposure and use sunscreen for 6
months to prevent hyperpigmentation
 Massage frequently to soften scar after sutures
removed
Suture Removal
 Follow up all but very simple wounds
in 24-48 hours
 Remove Sutures in:
• Neck 3-4 days
• Face, scalp 5 days
• Upper extremities, trunk 7-10
days
• Lower extremities 8-10 days
• Joint surface 10-14 days
 Remove sutures if well approximated
 Remove sutures early if wound
infected
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Questions?
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