Lacerations – TN 2014

Lacerations – Hx
  • What is the cause? How clean are the surroundings? Was a bite involved? Human/canine / feline?
  • How long ago did it occur?
  • Any FB may remain deep in the wound? Any underlying compound #?
  • Tetanus immunization status & Allergies to local anaesthetics / abx
  • R-handed vs L for hand injuries & occupation

1  When managing a laceration, identify those that are more complicated and may require special skills for repair (e.g., a second- versus third-degree perineal tear, lip or eyelid lacerations involving margins, arterial lacerations).

Simple wound
  • Small (<10cm), Time <6hr
  • No neural, vascular, tendon involvement
  • Not involving complex facial anatomy – eyelid, lip margins, globe
  • No FB

2  When managing a laceration, look for complications (e.g., flexor tendon lacerations, open fractures, bites to hands or face, neurovascular injury, foreign bodies) requiring more than simple suturing.

PEx
  • Sterile condition and good lighting
  • Appropriate analgesia
  • Ensure NVI
    • Note the position of the wound, what surrounding structures may be injured – nerves, vessels, tendons
    • Test for ROM / nerve function distal to the injury
  • Document all findings
  • Never blindly probe into a wound with an instrument
  • Don’t snap or clamp bleeding vessels, use direct pressure for hemostasis

3  Given a deep or contaminated laceration, thoroughly clean with copious irrigation and debride when appropriate, before closing.

Management of Acute Wound (<24h)
  1. Cleanse & irrigate open wound with physiologic solution (NS or RL)
    • Traumatic tattooing can occur if FB left in wound
  2. Evaluate for injury to underlying structures: vessels, nerve, tendon, bone
  3. Control active bleeding
  4. Debridement: removal of FB, devitalized tissue, old blood
    • Debribe all devitalized tissue, irregular or ragged wounds – produce sharp wound edges that will assist healing with approximated
Anesthesia
  • Lidocaine (Xylocaine)
    • w/o Epi – 5mg/kg lasts 45-60min
    • w/ Epi – 7mg/kg lasts 2-6 hr
  • Bupivicaine (Marcaine)
    • w/o Epi – 2mg/kg lasts 2-4 h
    • w/ Epi – 3mg/kg lasts 3-7 h
  • Toxicity of mixtures is no greater than its individual components
  • Debride and irrigate before injecting anesthetic

4  Identify wounds at high risk of infection (e.g., puncture wounds, some bites, some contaminated wounds), and do not close them.

Contaminated Wounds Closure
  • Via secondary intention – most common
  • Delayed wound closure (tertiary closure)
  • Skin graft / flap
  • Successful closure depends on bacterial count ≤ 10^5/cm^3 prior to closure and frequent dressing changes
  • Multifilament suture C/I: Vicryl / Silk
Systemic abx are commonly indicated for
  1. obvious infection: redness, swelling, pain, clinically unwell
  2. severely contaminated
  3. wound >8hr
  4. immunocompromised
  5. involvement of deeper structures (joints, fractures)
Topical Abx beneficial for minor wounds, but no additional benefit for wounds requiring systemic ab.
  • May aid in healing of chronic wounds
Dog / Cat Bites
  • Pathogens: Pasteurella multocida, S Aurus, S Viridans
  • Ix:
    • x-ray prior to r/o FB (tooth) or #
    • Cx for aerobic and anaerobic organisms, gram stain
  • Tx:
    • Clavulin 500mg po q8h started immediately (amoxicillin + clavulanic acid)
    • ± rabies Ig (20IU/Kg around wound or IM) + rabies vaccines 1ml IM in deltoid – repeat in days 3, 7, 14, 28
  • Aggressive irrigation with debridement
  • Healing by secondary intention is mainstay
    • only consider primary closure on the face with close f/u
  • Contact public health if animal status unknown
Human Bites – serious – can lead to septic arthritis
  • Pathogen: Staph > a-hemolytic strep > Eikenella corrodens > Bacteroides
  • consider Hep B/C, HIV
  • Most common – fight-bite – dorsum of MCP
  • Ix:
    • x-ray prior to r/o FB (tooth) or #
    • Cx for aerobic and anaerobic organisms, gram stain
  • Tx:
    • Urgent surgical exploration, drainage and debribement of infected tissue
    • Copious irrigation of wound
    • Clavulin 500mg po q8h + secondary closure
    • Splint

5  When repairing lacerations in children, ensure appropriate analgesia (e.g., topical anesthesia) and/or sedation (e.g., procedural sedation) to avoid physical restraints.

Procedural sedation
  • Sedative / dissociative ± analgesics to induce a state that allows a pt to tolerate an unpleasant procedure while maintaining all CV functions
  • Used in
    • Setting #, reducing dislocations
    • Draining abscesses, exploring wounds / ulcers / superficial infections
    • Endoscopic examination
    • Reduce pt agitation if imaging is acutely required
    • Pediatric pt
Safe Procedural sedation in ED
  1. Airway suitable for safe intubation / ventilation
  2. Appropriate equipment / personnel available
  3. Intact and functional CV and neurologial system
  4. NPO >4-6 hr – ideally
  5. Appropriate IV access & monitoring – O2 Sat, BP, HR, etc
  6. Informed consent obtained
Common procedure sedation medications
  • Ketamine + propofol
    • Ketamine 1 mg/kg IV or 2mg/kg IM
    • Propofol 0.25-1 mg/kg IV
      • C/I: apnea, decreased BP
  • Fentanyl + Midazolam
    • Fentanyl 0.5-1ug/kg/IV
    • Midazolam 50ug/kg/IV
      • C/I: apnea

6  When repairing a laceration, allow for and take adequate time to use techniques that will achieve good cosmetic results (e.g., layer closure, revision if necessary, use of regional rather than local anesthesia).

Steps to Ensuring Good Suturing Cosmesis
  • Incisions along relaxed skin tension lines
  • Attain close apposition of wound edges
  • Min tension on skin by closing layers
  • Evert wound edges
  • Use the finest needle/suture possible: 5-0 / 6-0 on face, 3-0 / 4-0 elsewhere
  • Ensure equal width and depth of tissue on both sides
  • Remove sutures within 5-7 d from face, 10-14 d from scalp/torso/extremities
  • Immobilize the wound with a splint if needed to keep tension off the wound
    • Splinting a hand in the position of safety
Basic Suture Methods
  • Simple interrupted: in almost all situations
  • Sub-cuticular: good cosmetic result but weak, used in combination w/ deep sutures
  • Vertical mattress: areas difficult to evert
  • Horizontal mattress: everting, time saving
  • running: time saving, good for hemostasis

Use stapler in an intoxicated or hemodynamically unstable pt


7  In treating a patient with a laceration:
a)  Ask about immunization status for tetanus.
b)  Immunize the patient appropriately.

If 3 doses of Tetanus immunization is certain
  • If >10 yr since last booster for clean minor wound & > 5 yr for all other wounds
    • Td or Tdap 0.5ml IM (tetanus, dipheria toxoid, acellular pertusis)
Uncertain or ❤ doses of immunization –
  • Td or Tdap 0.5ml IM +
  • Tetanus immunoglobulin 250 u deep IM (at a different site from Td/Tdap)
    • except clean, minor wound
  • Both are safe in pregnancy
Wound is more Tetanus-prone if
  1. >6hr since injury, depth >1cm, + devitalized tissue
  2. Crush, burn, gunshot, frostbite, puncture through clothing, farming injury
  3. Contamination: soil, dirt, saliva, grass or Retained FB
Post-exposure Tx of puncture
  • Hep B, HIV, Hep C (if titres confirmed at 6mo)

 


References:
  • TN 2014
Advertisements
Tagged with:
Posted in 56 Lacerations, 99 Priority Topics, FM 99 priority topics, Others
One comment on “Lacerations – TN 2014
  1. Dr. Soomro says:

    Hello
    Fantastic job…Great
    Would you please help as I need this Blog material in PDF form. I can not read on screen.
    Thank you very much

    Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

w

Connecting to %s

Follow Preparing for the CCFP Exam 2015 on WordPress.com
CCFP ExamApril 30th, 2015
The big day is here.
March 2015
M T W T F S S
« Feb   Apr »
 1
2345678
9101112131415
16171819202122
23242526272829
3031  
%d bloggers like this: