Transcript EO_016.04_Part_C_Perform Advanced Wound Care

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Perform Advanced Wound Care
Outline
Management of traumatic wounds
Principles of wound closure
Selected skin closures
Discuss the complications of suturing
Describe the suturing of traumatic wounds
Describe cautery devices
List the three main factors that promote wound infection
Definitions of Infection Types
Management of Wound Infections
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Traumatic Wounds
Wounds under tension/Undermining
– push the skin edges of the area together to see how
much tension will be placed on sutures
– if there is tension undermining will be required
– undermining is performed by blunt dissection to
mobilize adequate tissue for closing.
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Traumatic Wounds
Wounds under tension/Undermining cont’d
– decrease wound tension by beginning wound closure
with the placement of subcutaneous absorbable sutures
to approximate the edges
– next use interrupted non absorbable sutures to close the
skin
– One rule of thumb is that one should undermine
about the same radius as the maximum width of the
wound.
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Traumatic Wounds
Irregular Wounds
– these wounds may need debridement
– edges trimmed or deformities corrected
Suturing across joints
– splinting will be required to immobilize the area
– suture in full extended position
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Traumatic Wounds
Dog Ear Deformity
Correction
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Traumatic Wounds
Avulsion, V or T Shaped and Stellate Wounds
– the corner stitch is best used hear to avoid formation of
necrotic tissue
– use of steri strips will help adhere edges down
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Perform Advanced Wound Care
Outline
Management of traumatic wounds
Principles of wound closure
Selected skin closures
Discuss the complications of suturing
Describe the suturing of traumatic wounds
Describe cautery devices
List the three main factors that promote wound infection
Definitions of Infection Types
Management of Wound Infections
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Cautery Devices
Hyfrecator
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electrical
actually burns tissue with heat
good for small vessel bleeds
good for base of small lesion excisions
• skin tags
• warts
• small nevi
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Cautery Devices
Silver Nitrate Sticks
– good for small bleeds
– often used in epistaxis
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Perform Advanced Wound Care
Outline
Management of traumatic wounds
Principles of wound closure
Selected skin closures
Discuss the complications of suturing
Describe the suturing of traumatic wounds
Describe cautery devices
List the three main factors that promote wound infection
Definitions of Infection Types
Management of Wound Infections
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Management of Injured Tissue
Three main factors that promote wound infection
– the infectious agent
• aerobic and/or anaerobic bacteria, fungi etc.
– the susceptible host
• immunosuppressed, trauma, surgery
– a closed unperfused space
• such as a wound or surgical site
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Wound Infections
Definitions
Septicemia
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presence of pathogenic micro-organisms in the blood
bacteria invade a superficial area of the body
• is usually accompanied by sudden high temperature
Cellulitis
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is a common invasive non-suppurative infection of connective
tissue
characterized by hyperemia, WBC infiltration and edema without
cellular necrosis
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Wound Infections
Erysipelas
– an acute febrile disease with localized inflammation
and erythema of the skin and subcutaneous tissue
accompanied by systemic signs and symptoms
– has distinct borders
Lymphangitis
– inflammation of lymphatic channels
– channels are swollen and readily palpable
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Wound Infections
Lymphadenitis
– inflammation of the lymph nodes
Abscess
– a localized collection of pus that results from invasion
of a pyogenic bacterium
– staph is the most common cause
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Management of Infections
Bacterial Synergistic Gangrene
– is an anaerobic infection in the skin and or soft tissue
following trauma, inadequate blood supply or surgery
– are commonest in areas that are contaminated by oral or
fecal flora
– there may be progressive tissue necrosis and a putrid
odor
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Wound Infections
Tetanus
– an acute infectious disease of the CNS caused by an
endotoxin of the tetanus bacillus
– early clinical manifestations are elevated temperature,
muscle spasm or tetanic spasm and stiffness or locking
of the jaw
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Perform Advanced Wound Care
Outline
Management of traumatic wounds
Principles of wound closure
Selected skin closures
Discuss the complications of suturing
Describe the suturing of traumatic wounds
Describe cautery devices
List the three main factors that promote wound infection
Definitions of Infection Types
Management of Wound Infections
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Perform Advanced Wound Care
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Cellulitis
Generalized tetanus
Post operative wound infection
Necrotizing fasciitis
Clostridial myonecrosis
Osteomyelitis
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Management of Infections
Cellulitis
Signs and Symptoms
– infection is most common in lower extremities
– appears as a brawny red or reddish brown area of
edematous skin
– skin can be hot and erythematous
– infiltrated skin often resembles the skin of an orange
– borders are usually indistinct except in erysipelas
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Cellulitis
Signs and Symptoms
– petechiae are common
– vesicles and bullae may develop and rupture
– systemic manifestations may precede the cutaneous
findings, however many patients will not appear ill
– leukocytosis is common
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Cellulitis
Diagnosis
– dependant upon clinical findings
– unless pus has formed or an open wound is present, the
responsible organism is difficult to isolate
– strep is the most common cause
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Cellulitis
Treatment*
Uncomplicated: mild
– S. Aureus or Group A Strep
• First line –Cephalexin
• Second line – Cloxacillin or Clindamycin
Uncomplicated severe non facial
– S. Aureus or Group A Strep
• First line – IV Ancef +/- PO Clindamycin
• Second line – IV Clindamycin
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Cellulitis
Treatment cont’d
Special considerations: facial
– S. Aureus or Group A Strep
• First line – IV Cefazolin or IM/IV Ceftriaxone
• Second line Clindamycin IV/PO
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Management of Infections
Subcutaneous Abscess
Signs and Symptoms
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heat
swelling
tenderness
redness
fever may occur
local pain and tenderness
systemic symptoms
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Subcutaneous Abscess
Diagnosis
– culture for C&S or gram stain to determine causative
agent
Treatment
– healing usually requires surgical drainage with
thorough removal of pus, necrotic tissue and debris
– warm moist compresses
– antibiotics either po or IV depending on severity and
organism cultured
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Management of Infections
Tetanus
Signs and Symptoms
– incubation period 2-50 days with 5-10 being the
average
– localized tetanus can occur, with spasticity of a group
of muscles near the wound without trismus
– most frequent symptom is jaw stiffness
– difficulty in swallowing
– restlessness
– irritability
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Tetanus
Signs and Symptoms cont’d
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stiff neck, arms or legs
headache
fever
sore throat
tonic spasms
late signs are difficulty opening jaw (trismus)
facial muscle spasm
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Tetanus
Diagnosis
– history of a wound in a patient with muscle stiffness or
spasm
– C. tetani can sometimes be cultured from the wound
– Diagnosis – can be confused with meningocephalitis of
bacterial or viral origin, but the combination of an
intact sensorium, normal CSF and muscle spasms
suggest tetanus
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Tetanus
Treatment
– on initial patient presentation determine tetanus
immunization status and give boost if required
– if tetanus has developed therapy involves:
• maintaining adequate airway
• early and adequate use of human immune serum
globulin
• preventing further toxin development
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Tetanus
Treatment
• providing sedation
• controlling muscle spasms
• fluid balance
• treatment of concurrent infection
– Wound care
• dirt and debris promote growth of C. tetani
• prompt thorough debridement especially of deep
puncture wounds is essential
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Tetanus
Treatment
– role of antibiotic therapy is minor in contrast to wound
debridement and general support
– Pen G 2 million units IV q6h or Tetracycline 500mg IV
q6h should be given for 10 days (adults)
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Management of Infections
Post Operative Wound Infection
– results from bacterial contamination during or after a
surgical procedure
– infection is usually confined to the subcutaneous tissues
Signs and Symptoms
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usually appear between the 5th and 10th day post op
first sign is fever
may have wound pain
edema may be present due to the tightness of sutures
palpation of the wound may disclose an abscess
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Post Operative Wound Infection
Treatment
– basic treatment is to open the wound and allow it to
drain
– antibiotics are not necessary unless the infection has
become invasive
– wound cultures must be taken in order to determine best
antibiotic
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Management of Infections
Necrotizing Fasciitis
– invasive infection of fascia
– usually due to multiple pathogens
– often rapid progression of the disease
Signs and Symptoms
– usually begins in a localized area such as a puncture
wound, leg ulcer or surgical wound
– spreads along the relatively ischemic fascial planes
causing the penetrating vessels to thrombose
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Necrotizing Fasciitis
Signs and Symptoms
– skin is devascularized
– involved site is red, hot and swollen
– with progression there may be purplish (violaceous)
discoloration of the skin, bullae, crepitus and dermal
gangrene
– fever is nearly always present
– typically accompanied by systemic toxicity
– evidence of intravascular volume depletion, including
hypotension is frequent
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Necrotizing Fasciitis
Diagnosis
– cultures and gram stains
– X-rays of the area often demonstrates soft tissue gas
Treatment
– red, hot, tender and markedly edematous skin suggests
an underlying necrotizing subcutaneous infection
– this is a dermatological emergency
– incision is usually indicated
– thorough surgical debridement
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Necrotizing Fasciitis
Treatment cont’d
– systemic support
– identification of causative organism will determine
antibiotic
• Group A Strep - first line – Clindamycin IV +
Cefazolin IV or Pen G IV
- second line – Vancomycin IV
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Management of Infections
Clostridial Myonecrosis (Gas Gangrene)
– produced by entry of one of several clostridia into
devitalized tissue
Signs and Symptoms
– onset is sudden, with rapidly increasing pain in the
affected area
– fall in blood pressure
– tachycardia
– fever is present but not proportional to the severity of
infection
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Clostridial Myonecrosis
Signs and Symptoms cont’d
– wound becomes swollen and the surrounding skin is
pale
– foul smelling brown, blood tinged serous discharge
– as disease advances, surrounding tissue changes from
pale to dusky and eventually becomes deeply
discolored, with coalescent, red, fluid filled vesicles
– gas may be palpable in the tissues
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Clostridial Myonecrosis
Diagnosis
– gas gangrene is a clinical diagnosis
– gas may be present on xray
– anaerobic culture confirms diagnosis
Treatment
– surgical debridement and exposure of infected areas is
essential
– radical surgical excision is often necessary
– penicillin is effective as an antibiotic
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Management of Infections
Osteomyelitis
– inflammation and destruction of bone caused by aerobic
and anaerobic bacteria, mycobacteria and fungi
– Staph Aureus is most common organism
Signs and Symptoms
– long bones and vertebra are common sites
– fever if peripheral bones affected but may be absent if
in vertebrae
– unwillingness to move affected area
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Osteomyelitis
Signs and Symptoms
– history of weight loss and fatigue
– localized erythema, warmth, swelling and tenderness
– abscess formation is a late and unusual manifestation
Diagnosis
– Culture of S. aureus from site
– Xrays often normal in early stages but may show
abnormalities in later stages
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Osteomyelitis
Treatment
– antibiotics such as IV Nafcillin, Oxacillin, Vancomycin
or Cefazolin
– prolonged therapy is required for staph osteomyelitis
– parental regimes are recommended during the acute
phase then oral dicloxacillin or cephalexin
– surgical debridement may be necessary