Wound care principles
Acute traumatic wound care is the most common intervention in emergency medicine practice. More than 10 million wound care is performed in the US each year.
Objectives of wound care
one. Preserves vivid tissues
2nd. Restoration of tissue continuity and function
3. Optimizing the conditions in the development of wound resistance
4. Prevention of long and excessive inflammation
5. Avoiding infection and other disrupting causes
6. Minimizing scar formation
First Inspection
History: The mechanism of injury, the time of injury, the environmental conditions of the wound and the immune status of the patient are learned.
If the wound is cleaned and closed, contaminated bacteria will proliferate in the wound. Treatment of contaminated wounds results in infection when delayed by up to 3 hours. The time between injury time and the safe closure time without risk of infection is the golden period and does not have a fixed time. While the well-blooded facial skin can be closed within 48 hours, the wound on the foot nail bed of an elderly patient should be closed immediately.
Other important issues in terms of infection risk are the patient's age and health status. Advanced age, chronic diseases and drug use, shock, recurrent traumas, infection, bacteremia, denervation and peripheral vascular diseases slow down the healing rate.
In addition, the presence of special treatments, allergies, tetanus immunization status, potential rabies contact, foreign body and previous traumas and deformities should be learned.
Physical Examination: All wounds should be examined for tissue destruction, degree of contamination, and damage to underlying tissues. The examination should be carried out in accordance with the aseptic technique.
Injury mechanism and classification of wounds: 3 types of mechanical force damages soft tissues. Tear, stress and compression. Wound is defined according to tissue separation or loss. It is classified into 6 categories: Abrasion, laceration, crush wounds, penetrating wounds, avulsion and combined wounds.
Contaminated bacteria and foreign bodies: The presence of bacteria and dead tissues in the wound and local tissue ischemia or hypoxia cause wound infection. Traumatic injuries are divided into two categories according to the degree of bacterial contamination of the wounds. Contaminated wounds: Traumatic wounds older than 12 hours. Dirty wounds: Devitalized or traumatic wounds older than 12 hours are accompanied by a significant number of bacteria and are predominantly contaminated with pathogenic organisms.
Wound localization: The number of bacteria (> 10 5 / cm 2 ) in the scalp, neck, axilla, perineum, penis, vagina, mouth, intertriginous areas and nail endogenous microflora is sufficient to infect the wound. Well-blooded areas such as scalp and face are more resistant to bacterial entry. Distal extremity wounds are more susceptible to infection than injuries to other parts of the body.
Devitalized tissue: An important part of the wound examination is the identification of dead tissues. Tissue damage reduces resistance to infection in the wound.
Underlying tissues: It is important to investigate the injury of the underlying tissues during the examination. Irrigation of the joint space, debridement and reduction of fracture fragments, neurorrhaphy, vascular anastomosis and flexor tendon repair should be performed in the operating room with the help of appropriate light, necessary instruments and assistants.
Cleaning
The cornerstones of wound care are cleaning, debridement, sealing and protection. While most of the wounds are contaminated with less than the infective dose of bacteria, they reach the infective level if time is prolonged and the appropriate environment is provided. Wound cleaning and debridement have common goals. 1. Remove bacteria and reduce them below the level of infection 2. Remove particles and bacteria from the tissue during the inflammatory period of healing or beyond the critical threshold. Wound cleaning methods: mechanical wiping, antiseptics, irrigation, irrigation with antibiotic solutions. Appropriate sedation, local anesthesia and appropriate substance should be chosen for these patients. Irrigations should be done with high pressure and scrub solutions should be applied by applying a sponge. Hydrogen peroxide should not be used on open wounds.
Wound closure preparation
It should be prepared and covered before the wound is closed or debrided. Hair and hair should not be shaved. If it is to be worked between the hair, the hair should be separated from the wound and collected. The hair and hair which may enter the wound can be laid aside with petrolatum gel or water-soluble ointments. Eyebrows should never be shaved.
10% povidone iodine solution is used as standard for skin disinfection. Only a large area around the wound should be stained and no solution should be applied into the wound. After washing the hands, remove the powders from the gloves before touching the wound with sterile gloves. If a URI is present, it is recommended to use a face mask. Perforated cover is covered on the wound. If anesthesia is still not achieved, it is repeated. The wound is opened in depth and examined for any damage to foreign body, particulate material, bone fragments and underlying tissues for repair. Lacerations extending down to the subcutaneous adipose tissue are important because a large amount of particulate material can be hidden within the deep layers of the tissues. With careful examination, these contaminants should be removed from the deep tissues and sutured. If so, infection is monitored.
debridement
It is important in the treatment of contaminated wounds. With this technique, the doctor removes tissues such as foreign bodies, bacteria and devitalized tissue that prolong the period of inflammation and impair the resistance of the wound to infection. Very dirty wounds, irregular wounds, defined devitalized tissues are prepared by this technique. For this purpose, 1 or 2 hooks of appropriate size, 15 scalpel and handle, tissue shears, hemostats and small tissue forceps are required. Grasping the edge of the blackened tissue with hook or forceps or scissors or tissue scissors to the other end of the devitalized tissue is cut away. After debridement, the missing part is irrigated outside the wound. Since tissues that have lost viability such as dura, fascia and tendon cause significant functional losses, these tissues are not debrided and cleaned properly.
excision
If the tissue has a certain elasticity or tension and does not contain important tissues such as tendons, nerves and is contaminated, the entire wound can be removed. It is a more effective technique than debridement. The trunk, gluteal region and thigh are suitable for this technique. It is made with the materials used in debridement and similar technique.
Selective debridement
Selective tissue debridement technique is used in the wounds of the tissues where skin elasticity is insufficient or tissue loss or which have important functions that need to be protected (such as dura, fascia, nerve, tendon).
After excision or debridement, the tissue is irrigated and the remaining tissues are removed.
Bleeding control
Bleeding from the wound is common and should be checked before examination, cleaning or debridement. Sometimes wound exploration and cleaning can cause bleeding. Hemostasis is required at any stage of wound care. Hematoma that will occur in the wound causes suturing at the edges of the suture, delaying healing and infection.
There are many methods for bleeding control. Pressure control with glove finger, sponge or compress are effective methods for emergency control of a small number or from one place of bleeding. At least 5 min. pressure should be applied. The pressure is more effective if the bleeding wound is raised above the heart level.
Bleeding can be controlled with compression dressings in patients with multiple injuries and various emergency problems.
Another method used in hemostasis is the ligation of the blood vessel with a well absorbed suture material. A common mistake is to spend too much time to connect small blood vessels. Hemostasis is achieved by carefully holding only the vessel with the tip of a hemostasis clamp. A 5-0 or 6-0 synthetic absorbable suture material is wrapped around the hemostat to remove the knot. Once the suture on the vessel is secured, the hemostat is removed. It is cut so that at least the suture material is left behind. In cases of hemorrhage from the wound wall that cannot be held with hemostat, a horizontal matres or 8 sutures are placed around the bleeding point and ligated.
Core diameter 2 mm. greater than is connected. 2 mm. veins under the direct compression or cautery bleeding is controlled.
1: 100000 epinephrine is a good topical vasoconstrictor agent and reduces bleeding from small vessels. When combined with local anesthetics, it provides hemostasis in well-blooded areas. Topical or intradermal administration may increase the risk of wound infection.
Fibrin foam, gelatin foam and microcrystalline collagen can be used as hemostatic agent.
Tourniquet
They are used to temporarily control bleeding in wounds on the extremities that are resistant to direct compression, electrocautery, or ligation. It also facilitates the examination of small foreign bodies, partial laser tendon or joint capsule in bleeding areas in lacerations.
The tourniquet causes injury in 3 ways: It causes ischemia in the extremities, It causes compression and damage to the lower vessels and nerves, and it can threaten the survival of borderline viable tissue. To avoid these injuries, attention should be paid to tourniquet pressure and duration. For this, systolic pressure (250-300 mmHg according to some authors) at a pressure of 30-45 min. (max 1 hour) should be applied. Veins should be evacuated before tourniquet application. A tourniquet should not be applied with thin materials. When the process is completed, the tourniquet should be removed. A tourniquet can be applied to the finger with the help of a penren drain or glove finger.
CLOSING
Open wound care and delayed closure
If the skin in the defect area is immobilized, such as the scalp or pre-tibial area, it is impossible to close the defect completely. In very dirty wounds, the risk of wound infection increases as a result of closure. Therefore, the general rule is to close the wounds that you believe are clean or that you believe will be cleaned by brushing, irrigation or debridement. Wounds to be left open for wound healing are cleaned and, if necessary, debrided and covered with sterile, SF moistened sponge. The wound is wrapped with a thin, absorbent, sterile drape. If fever does not develop, the wound is not mixed for 4 days, unnecessary inspection increases the risk of contamination and infection. At the end of the 4th day, the wound is re-evaluated. If there is no infection and the wound edges are appropriate or the wound is excised, delayed closure is performed.
Wounds requiring open maintenance and delayed closure: wounds contaminated with soil, organic matter, saliva, faeces, vaginal secretions and purulent materials, wounds with extensive tissue damage, and many animal bites. In animal bites, the wounds on the face are completely excised and sutured. Dog bites outside the extremity can be sutured.
methods
The appropriate closure technique is selected according to the location and configuration of the wound. These techniques are suturing, tape bonding and metal stapler. The tapes are easy to apply and are preferred for non-cooperating and fearful patients. It causes minimal skin reaction, no suture marks on the skin, and the lowest risk of infection is the technique. Metal staplers can be applied quickly in suitable places but can be used in non-cosmetic areas and linear wounds. In many cases suturing is the most preferred method.
Equipment
Tools: Needle holder (suture) and suture scissors are required in addition to those used in debridement. The portugal size is selected according to the needle to be used. New instruments should be used for debridement of highly contaminated wounds. If the instruments have clotted blood contamination, they should be used after flushing with hydrogen peroxide.
Suture Materials: Many suture materials are available. They can be defined by 4 characteristics.
one. Chemical and physical properties
2nd. Structural and mechanical performance
3. Absorption and reactivity
4. Persistence and magnitude of tensile strength
Suture materials are of various compositions. They can be grouped as natural, synthetic, monofilament, multiflorant. Depending on the structure and performance, it is important that the suture is preferred to pass through the tissue smoothly, to be easily knotted and to be stable. Multiflatable sutures have the best structural properties.
If the knot 3 mm. 3 sutures in silk or other braided, nonabsorbable materials, 3 synthetic monofilaments absorbable and nonabsorbable sutures should be discarded.
Absorption and reactivity: Those that break down rapidly in tissue are called absorbable. Those who maintain the tensile strength for more than 60 days are called nonabsorbable. Plain catgut absorbs in 10-40 days, chrome catgut 15-60 days, ethikon 10-14 days, vicryl 60-90 days and dexon 120-210 days. Plain catgut in the oral cavity 3-5 days, chrome catgut 7-10 days, polyglycolic acid disappear in 16-20 days. The complete absorption of silk from the skin is approximately 2 years. The absorption rates of synthetic absorbable sutures are independent of suture size.
The sutures lose their resistance before being fully absorbed from the tissue. Braided absorbable sutures lose all of their resistance at 21 days, monofilament absorbable, and PDS, ethicon lose 60% of their resistance at 28 days. In a study comparing suture resistance and wound resistance catgut 7 days; chrome catgut, dexon, and vicryl remained intact for 10-21 days and nylon, silk and wire for 20-30 days.
All sutures provoke host defense and inflammation with tissue damage. The size of the reaction is characterized by the nature (diameter and length) of the material placed in the tissue and the chemical structure of the suture. Among the absorbable sutures, polyglycolic acid and polyglactin sutures are the least reactive. Nonabsorbable polypropylene is less reactive than nylon and dacron. The reaction with catgut, silk and cotton sutures is more pronounced.
The chemical structure of the suture is important in identifying early infection. The infection rate in polyglycolic acid sutures is lower than catgut. Lubricants coated on sutures do not alter suture reactivity, absorption characteristics, decreased resistance or risk of infection.
Size and resistance: The size of the suture material (yarn diameter) is the measurement of the tensile strength of the suture. The greater the yarn diameter, the greater the durability. The correct suture size depends on the tensile strength of the tissue layers to be applied.
The most necessary suture materials for wound closure to the emergency physician are dexon and coated vicryl for subcutaneous tissues and synthetic nonabsorbable materials (nylon or polypropylene) to close the skin. The fascia can be repaired with any material absorbable or nonabsorbable 3-0 or 4-0. 4-0 or 5-0 absorbable subcutaneous tissues, 4-0 or 5-0 nonabsorbable materials are used on the skin. 6-0 for wounds on the face, 3-0 or 4-0 sutures are used in areas exposed to dynamic stresses such as the articular surface or static stresses such as scalp.
Needles: Needless eye is used in most emergency departments. The selection of the appropriate needle size and curvature is based on the characteristics of the tissue to be sutured and the size of the wound. When the repositioning motion is made by holding the needle with the holder at the distal end of the needle, it must be large enough to move deeply through the tissue and exit from the opposite skin. In wound repair, the needles should be strongly penetrated and the fibrous tissues should be able to pass with minimal resistance or trauma without breaking. Needles are used to close subcutaneous tissues with ½ or 3/8 twisted needles. In percutaneous closure, conventional needles provide precise insertion and require less penetration power.
Suture Techniques
Preparation is made by wound care. 4 principles should be followed in the suture of laceration anywhere.
1. Minimal trauma should be applied to the schools. Tissues should not be traumatized when using instruments.
2.The resistance on the wound edges should be reduced. This resistance can be reduced in two ways. Loosening under the wound edges and layered closure.
3.Closed in accordance with the floors. There are usually 3 layers in the wounds closed in the emergency department. Fasia, subcutaneous tissue and skin. Tissues that are not applied in layers: Scalp, finger, hand, foot, nail, nose skin. It is not recommended to close the layers in layers with weak tension without blood supply. The surface stitch of these wounds and wounds should be placed deeper.
4. Skin lines and contours should be observed.
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