Fremantle Sailing Club Cruising Section. Practical Medical Procedures Wound Management Manual

Transcription

1 Fremantle Sailing Club Cruising Section Practical Medical Procedures Wound Management Manual

2 2

3 Introduction Basic Suturing And Wound Management Learning Module For Long Distance Sailors The purpose of this module is to introduce long distance sailors to the basics of wound management and to provide an opportunity to learn simple suturing. Although suturing technique is important, the sailor managing a wound (from now on referred to as the physician ) must also have a thorough understanding of wound management in general to effectively care for a patient with an injury. Disclaimer These notes are intended for the use by the crews of long distant ocean yachts who do not have ready access to qualified medical care. Cleaning, debriding and dressing a wound is within the skill set of individuals trained in Advanced First Aid. Individuals who do not have an appropriate professional qualification should only utilise the suturing skills discussed in this document if no medical care is available and only if they have undertaken supervised training in simple suturing techniques. Suturing a wound by non medically qualified individuals should be considered as a last resort. Before you suture a wound you should advise the patient of your level of expertise, and of the possible complications. The patient should be assessed by a medically qualified individual as soon as possible after the wound has been treated at sea. Objectives On completion of this module participants will: 1. Understand the principles of wound management as they apply to a simple laceration. 2. Be able to demonstrate the preparation of a simple laceration for closure. 3. Be able to demonstrate sterile technique while preparing and suturing a simple laceration on a model. 4. Be able to demonstrate basic suturing techniques on a model. 5. Have access to notes to assist with the management of other wounds encountered at sea (ie grazes, bites, burns, splinters and embedded fish hooks.) 3

4 Wound considerations Each wound that is encountered and considered for repair must be addressed independently. Factors such as location, size, mechanism of injury, time elapsed since injury, likelihood of contamination and patient dependent factors must be addressed prior to formal treatment. As well, the physician should consider whether or not they have the skill or experience to adequately manage a particular wound. Wound location is important. Lacerations on the face, hands and perineum (bottom), for example, are more complicated for cosmetic and structural reasons. These areas should be reserved for more experienced physicians. Lacerations of the scalp, trunk and proximal extremities (above the hands and feet) tend to be less complex so more appropriate for beginners. As with all forms of medical care, it is important to be aware of one's own abilities and limitations. If in doubt, clean and dress the wound and do not suture. Consider using Steristrips. A functional assessment of nerves, blood vessels, muscles and tendons is essential early in the evaluation of the wound. It must be done prior to injection of local anaesthesia, as this will obviously interfere with the assessment. Knowledge of the mechanism of injury can provide valuable insight into the potential for injury to adjacent structures, the likelihood of contamination and the preferred method of repair. Deep puncture wounds can injure blood vessels and nerves, and contaminate several tissue planes. They are probably best left open after thorough cleansing, as there is a high risk of subsequent infection if sutured straight away. Conversely, a superficial laceration from clean glass may be cleaned and either sutured or taped to approximate the edges. Lacerations resulting from significant blunt force often require debridement (trimming damaged tissue with a scalpel or sharp scissors) and revision of wound edges to make sure there is healthy tissue at the wound edge to optimise healing. In addition the swelling and inflammatory response resulting from blunt injury can adversely affect the already tenuous blood supply to the area. All traumatic wounds must be assumed to have some degree of contamination by virtue of the presence of dirt, micro-organisms and devitalised tissue. An infected wound will not heal properly due to adverse effects on tissue regeneration. The time elapsed from injury to repair has a direct bearing on the subsequent risk of wound infection. Any wound that has been exposed for greater than 8 hours is at significant risk for infection, regardless of the mechanism of injury. Wounds that are more than 8 hours old, and grossly contaminated wounds such as animal bites and farming injuries, are at such high risk for subsequent infection that consideration should be given to leaving them open. Initial management should focus on thorough cleaning and close monitoring for infection. Suturing a 4

5 grossly contaminated wound, which greatly increases the risk of infection, should always be balanced against the benefits of faster healing and better cosmetics. Patient dependent factors known to negatively influence the process of wound healing include advanced age, poor nutritional status and co-existing illness such as diabetes. These factors can lead to delayed healing, wound breakdown, abnormal scarring and infection and must be considered when instructing the patient regarding follow-up. Categories of wound closure Closure by primary intent: This refers to wound closure immediately following the injury and prior to the formation of granulation tissue. In general, closure by primary intent will lead to faster healing and the best cosmetic result. Most patients presenting within 8 hours of injury can have the wound closed by primary intent. Simple and clean facial wounds, by virtue of the rich vascular supply to the face and the need for a good cosmetic result, can be closed by primary intent as late as 24 hours after the injury. Closure by secondary intent: This refers to the strategy of allowing wounds to heal on their own without surgical closure. Of course the wound should be cleaned and dressed as with any wound. Certain wounds such as small partial thickness avulsions (loss of tissue) and fingertip amputations are best left to close by secondary intent. Closure by tertiary intent: This refers to the approach of having the patient return in 3-4 days, after initial wound cleansing and dressing, for wound closure. This is also referred to as delayed primary closure. Closure by tertiary intent is used for patients with wounds who present late (>24 hours) for care, contaminated crush wounds and mammalian bites when leaving the wound open would result in an unacceptable cosmetic result. 5

6 Wound antisepsis and sterile technique Unquestionably, efforts taken to properly prepare the wound and the surrounding skin surfaces will reduce the risk of infection and will directly improve the process of wound repair. Before you start taking care of the wound, wash your hands well with soap and water to remove any dirt and debris from your hands and finger nails. Then use an antiseptic hand wipe to disinfect your skin. Wear non sterile disposable gloves when cleaning the wound and injecting local anaesthetic. This will protect you from the patient's blood products and from potential needle stick injuries and protect the patient from wound contamination from your skin. After you have cleaned and anaesthetised the wound, remove your gloves, clean your hands again with sterile wipes and ideally use sterile gloves when you suture the wound. If you don't have sterile gloves, clean non-sterile disposable gloves are better than nothing. The skin surface surrounding a wound about to be sutured should be washed with soap and water to remove dirt and debris. A small amount of dish washing liquid in fresh water is also an appropriate alternative to soap to clean the surrounding skin. Most disinfectants are excellent cleansers of the skin but these solutions are potentially toxic to the local wound defences and may increase the rate of subsequent wound infection if they are spilled into a wound in large quantities. If used, these solutions should be irrigated from the wound with a sterile normal saline solution or clean fresh water as the final step in wound cleansing 1. What to do about hairy skin at the site of the wound. It is rarely necessary to remove significant quantities of body hair prior to repair a simple laceration. In fact, razor removal of hair has been shown to damage surface skin follicles and lead to increased rates of wound infection. Occasionally, for repair of scalp lacerations, for example, scissor trimming will allow for easier identification of wound margins and will facilitate later wound care. Due to inconsistent regrowth of eyebrow hair, it should never be shaved when repairing lacerations in that area. 1 To make a sterile normal saline solution, add 1.5 teaspoons of salt to a litre of drinking water (boiled for 10 minutes and cooled) or add one part sea water (boiled for 10 minutes and cooled) to 3 parts cooled boiled drinking water. 6

7 Preparation of the wound itself Prior to cleansing the wound itself, the area around a wound may have to be anaesthetised to reduce the discomfort to the patient. If a local anaesthetic is needed, use 1% lignocaine without adrenaline. This involves cleansing and debridement. 1. Wound irrigation will effectively remove bacteria and other debris. Flush the wound with large quantities of soap and boiled water for 10 minutes, and then irrigate the wound with saline. These solutions are used because they do not irritate body tissues. A syringe can be used for the irrigation. 2. If the wound is dirty apply a dilute solution of Polyvidone-iodine 10% solution (Betadine) before using the irrigation technique described above. Do not use Dettol, alcohol based products or peroxide to clean wounds. 3. Following irrigation, all remaining debris and devitalised tissue must be removed with fine forceps or with a scalpel. Dead tissue does not bleed when cut. Irrigate the wound again. 4. Normal saline should be used as the final solution when cleaning a wound. 5. If the wound was dirty and needed debridement of dead tissue, do not suture. Leave the wound open. Pack it lightly with disinfected or clean gauze that has been moistened in saline and cover the packed wound with a dry dressing. Change the packing and dressing at least daily. (See healing by secondary and tertiary intent in the previous section.) 6. If the wound is a clean wound but the wound edges do not hold together consider Steristrips, or as a last resort suturing. 7

8 Local Anaesthetics For any patient about to be sutured, attention must be given to obtaining adequate analgesia and ensuring overall comfort. After documenting the neurovascular status of adjacent structures (ie determine if there is any nerve or blood vessel damage by identifying any numbness or loss of muscle function downstream from the wound or any major bleeding within the wound) a local anaesthetic can be injected into the tissue in and around the wound. A 1% solution (10 mg/ml) of Xylocaine can be used for most wounds. Xylocaine 1% (10mg/ml) is very safe when used in the small quantities usually required for simple lacerations. The physician should not use in excess of 3mg/kg body weight of Xylocaine (eg for a 70kg person do not use more than 210 mg or 21 ml of a 1% solution of Xylocaine). Its onset of action when infiltrated locally is within seconds and its duration of action is generally 30 to 60 minutes. Adrenaline is added to some of the commercially available Xylocaine solutions. It is a potent vasoconstrictor (constricts blood vessels) and functions to prolong anaesthesia by slowing vascular uptake of the Xylocaine, and to reduce the bleeding into the wound, which can impair visualisation of structures. Solutions containing adrenaline are best avoided by inexperienced physicians as there are risks associated with their use. Xylocaine causes an intense burning sensation when injected locally. The burning is dependent on the rate of injection and the acidity of the solution. The burning can be minimised by slow injection (over 30 seconds using a small gauge needle (25g = orange). An experienced physician can inject local anaesthetic with virtually no discomfort if time and care are taken. Painless wound suturing Illustration 1: A relatively painless method of administering local anaesthetic at a wound site requiring suturing 1. For non contaminated wounds, rather than inserting the needle into the skin, insert it into the subcutaneous tissue through the open wound (Illustration 1). You can irrigate the wound with a small volume of LA first to make the subsequent injections even less painful. 2. Infiltrate for the length of the wound on both sides. 8

9 Recapping of needles Although the recapping of needles should be avoided, probably the safest way, if it really must be done, is to scoop up the needle guard with the used needle and syringe unit, using the dominant hand only. This reinforces the principle of always staying behind the needle, and keeps the thumb and forefinger of the non-dominant hand out of danger. The needle/syringe unit should be disposed in a sharps container or a plastic drink bottle. Use sterile technique when repairing a wound Ensuring sterile technique while repairing a wound is, perhaps, the most difficult concept for the inexperienced person to grasp. A break in sterile technique, with contamination of the field, is a common procedural error. It leads to an increased incidence of wound infection and breakdown. Sterile technique requires that the physician: is able to open and don gloves without contamination to the sterile (outer) surface of the gloves. is able to clean and drape the wound and surrounding area. is able to control the instruments and suture, such that they are not contaminated by non-sterile surfaces. 9

10 The suture tray The basic emergency department suture tray has the equipment necessary to manage a simple laceration. Your kit may not have all of this equipment. It is advisable to obtain several disposable sterile dressing packs from the chemist shop before you depart. If your instruments are not in a sterile pack you can sterilise them by scrubbing them to remove any debris and then placing them in clean, rapidly boiling water for 10 minutes. Surgical Drapes The surgical drapes should be used to completely surround the wound and a portion of the surrounding sterile field. 4" x 4" Gauze The gauze is used to clean the wound area. Suture Materials and 6.0 For facial wounds, a smaller gauge suture such as 6.0 is used. For wounds under greater stress and of less cosmetic importance such as a thigh laceration, a 4.0 suture would be appropriate. Antiseptic Solution and Saline The antiseptic solution is for cleansing the skin around the wound and saline is used to cleanse and irrigate the wound itself. Syringe with splash cover Wound irrigation has been shown to be the most effective means of removing debris and contaminants. The splash cover helps to avoid exposure to the patient's blood and body fluids. Scalpel The operator may request a scalpel to allow a wound to be extended or wound edges to be debrided. Straight Haemostat The straight haemostat can be used for blunt dissection. It should not be used to clamp blood vessels or tissues since it will injure these structures. 10

11 Curved Haemostat The curved haemostat can be used for blunt dissection. It should not be used to clamp blood vessels or tissues since it will injure these structures. Toothed Forceps The toothed forceps are used to grasp the skin edges while suturing. They tend to be less traumatic than non-toothed forceps but can damage tissues if applied forcefully. Non-toothed Forceps This is considered to be a more traumatic instrument than its toothed counterpart for grasping tissue. Needle Driver The needle driver is reinforced instrument designed to grasp the suture needle. Scissors The scissors are intended only to cut sutures. They have no rule in the dissection or removal of tissue. 11

12 Suture Materials There are a number of suture materials available, but it is beyond the scope of this document to cover them in any detail. In selecting a particular suture, the physician needs to consider the physical and biological characteristics of the material in relation to the healing process. Suture materials can be broadly categorised as absorbable and non-absorbable. Absorbable sutures do not require removal as they are digested by tissue enzymes. Non-absorbable or permanent sutures need to be removed at a later date. Absorbable sutures can be further divided into rapidly absorbing (days) and slowly absorbing (months). Fortunately, the choice is often not an issue in the emergency setting because most wounds encountered require support for a matter of days to weeks. Both absorbable and non-absorbable sutures are graded for size or diameter of the strand. The grading system uses the letter O and the number of stated O's indicates the size. The more O's, the smaller the size. For example, a 6-O is smaller than a 4-O. Accordingly, tensile strength of a particular suture type increases as the number of O's decreases. The needles supplied with sutures also have important features. The needles are either large or small and either cutting or non-cutting. Large needles have the advantage of closing a deeper layer of tissue with each "bite". The concern with small needles is that there will be inadequate closure of deep subcutaneous tissues, leaving potential space for haematoma formation (ie collection of blood). However, small needles create smaller puncture wounds and may have the advantage of reducing scarring Cutting needles have at least two opposing cutting edges to facilitate passage through tough tissue. These needles are used for skin closure. Non-cutting or tapered needles are used to close subcutaneous tissue, muscle and fascia. They have sharp points, but do not have cutting edges. 12

13 Lacerations Lacerations vary enormously in complexity and repairability. Very complex lacerations and those involving nerves or other structures should be referred to an expert. Principles of repair Have the patient lying down and ensure good lighting Good approximation of wound edges minimises scar formation and healing time. Pay special attention to debridement. Inspect all wounds carefully for damage to major structures such as nerves and tendons and for foreign material: o o shattered glass wounds require careful inspection high-energy wounds (e.g. motor mowers, firearms) are prone to have metallic foreign bodies and associated fractures Be aware that lacerated wounds may also have foreign objects or fractures (compound fractures). Trim jagged or crushed wound edges with a scalpel, especially on the face. All wounds should be closed in layers. Avoid leaving dead space. Do not use primary closure for an 'old' wound (greater than 8 hours) or it is contaminated recent wound. Clean, debride and dress regularly for 4 days before suturing if not infected at that time. Take care in poor healing areas, such as backs, necks, calves and knees; and in areas prone to hypertrophic scarring, such as over the sternum of the chest and the shoulder. Use atraumatic tissue-handling techniques. Everted edges heal better than inverted edges. Practise minimal handling of wound edges. A suture is too tight when it blanches the skin between the thread it should be loosened. Avoid tension on the wound, especially in fingers, lower leg, foot or palm. The finest scar and best result is obtained by using a large number of fine sutures rather than a fewer thicker sutures more widely spread. Avoid haematoma. Apply a firm pressure dressing when appropriate, especially with swollen skin flaps. Consider appropriate immobilisation for wounds. Many wound failures are due to lack of immobilisation from a volar slab on the hand or a back slab on the leg. 13

14 Holding the needle The needle should be held in its middle; this will help to avoid breakage and distortion, which tend to occur if the needle is held near its end (Illustration 2). Illustration 2: Correct and incorrect methods of holding the needle Types of sutures simple suture (Illustration 3a) vertical mattress suture (Illustration 3b) Three point (or flap suture) Illustration 3: Everted wounds: (a) correct and incorrect methods of making a simple suture; (b) making a vertical mattress suture It is important to evert the wound edges. Eversion is achieved by making the bite in the dermis (deeper layer) wider than the bite in the epidermis (skin surface) and making the suture deeper than it is wide. Alternatively the mattress suture is the ideal way to evert a wound. Number of sutures One should aim to use a minimum number of sutures to achieve closure without gaps but sufficient sutures to avoid tension. Place the sutures as close to the wound edge as possible. 14

15 In wounds with a triangular flap component, it is often difficult to place the apex of the flap accurately. The three-point suture is the best way to achieve this while minimising the chance of strangulation necrosis at the tip of the flap. Method Pass the needle through the skin of the non-flap side of the wound. Pass it then through the subcuticular layer of the flap tip at exactly the same level as the reception side. Finally, pass the needle back through the reception side so that it emerges well back from the V flap. Illustration 4: The three-point suture Tetanus prevention Tetanus is a serious disease characterised by muscle spasm and rigidity. The mortality rate is approximately 20% and is due to spasm of the muscles of respiration. Tetanus is an illness preventable through primary immunisation and regular booster shots. Make sure all of your crew are up to date with their Tetanus immunisation before they embark on a long distance cruise. Patients with clean, minor wounds are considered adequately immunised if they have received primary immunisation and have had a booster within the past 10 years. If a wound is "dirty" (which includes wounds contaminated with saliva, faeces or dirt, and burn injuries) then a booster within the past 5 years is necessary to ensure immunisation. Ideally it should be less than 5 years since any crew member's last immunisation to cover for the possibility of a crew member receiving a tetanus prone wound in a remote location. 15

16 Infection prevention and treatment Antibiotic prophylaxis is indicated for wounds at high risk of becoming infected such as contaminated wounds, penetrating wounds, abdominal trauma, compound fractures, lacerations greater than 5 cm, wounds with devitalised tissue, high risk anatomical sites such as hand or foot. For antibiotic coverage for bites and coral cuts see separate section pertaining to these injuries Recommended antibiotic prophylaxis (ie prevention when no infection is present) consists of penicillin and metronidazole. In the hospital setting it is given intravenously and only given once: Penicillin G ADULT: IV 8-12 million IU once. CHILD: IV 200,000 IU/kg once. Metronidazole ADULT: IV 1,500 mg once (infused over 30 min). CHILD: IV 20 mg/kg once.however if you only have intramuscular injections or tablets in your first aid kit where a wound is contaminated it is best to give something rather than nothing. For example if the patient is not allergic to penicillin give Procaine penicillin 1.5gm IMI once (adjust dose for children according to information in Pack) or a penicillin based tablet such as Augmentin Duo twice daily for 5 days, penicillin 500 mg 6 hourly, dicloxacillin 500 mg 6 hourly or flucloxacillin 500 mg 6 hourly as well as oral metronidazole (flagyl) 400mg twice times daily for 5-7 days. If the patient is allergic to penicillin use erythromycin 500mg 6 hourly instead of penicillin. Please note that this advice is based on what a long distance sailor is likely to have in his or her first aid kit. Seek medical advice by radio if at all possible to establish the most appropriate antibiotic for your patient from what you have available in your first aid kit. Antibiotic treatment If infection is present seek medical advice. If no medical advice is available commence antibiotics (and continue to seek medical advice). In hospitals, antibiotics for wound infections are given via the IV (intravenous) route. IV Penicillin G and IV metronidazole for 5-10 days provide good coverage or metronidazole 400 mg twice daily for 5 10 days plus either cefotaxime 1 g IV 8 hourly or ceftriaxone 1 g IV daily for 5 10 days. On your yacht it is unlikely you will have IV antibiotics so in that case give the antibiotics as described above in the section on prophylaxis but continue to give them for 7-10 days. If you have IM Procaine give this daily together with the oral metronidazole.infection prevention and treatment If an acute allergic reaction occurs with penicillin give IM adrenaline mg to adults. 0.1 mg/ 10 kg body weight to children. 16

17 Wound dressing Dressings are applied after suturing for several reasons. They shield the wound from gross contamination, which is more or less important depending on the patient's occupation. As well, a dressing can absorb blood and serous material oozing from the wound, which serves to protect clothing and bed linen. Finally, a dressing can improve patient comfort by immobilising injured tissue and avoiding further injury. Although dressings can prevent gross contamination, it has been shown that wounds which remain covered for periods of greater than 48 hours without an inspection or change are more likely to become infected than wounds left open. After suturing a simple laceration, the patient should be instructed to change the dressing at 48 hours. Dressing material should be clean, but does not necessarily have to be sterile. Most wounds are covered with a simple, light dressing. If a layered dressing is required for the purpose of greater absorption or application of pressure or splinting, then the first layer should be a non-adherent material such as Vaseline gauze. Subsequent layers can include absorptive gauze and a pressure pad, if desired. The final layer should be a Kling wrap or elastic bandage to secure the dressing and apply pressure as needed. Bulky pressure dressings can improve patient comfort by splinting the wound and by supporting the surrounding tissues and may reduce the risk of dehiscence 2. They also serve to reduce wound drainage and deter haematoma formation. Haematoma formation can increase the potential for infection. Dressings wet from wound seepage should be changed immediately and dirty dressings should be changed as often as hours. Many patients will ask when they can get the sutured wound wet. A clean minor wound can be immersed for brief periods after 48 hours. This allows them to bathe, shower and even swim. The patient should be cautioned against prolonged immersion, as this tends to break down the wound. 2 Wound dehiscence is a surgical complication in which an apparently healed wound breaks open along the previous surgical suture line. 17

18 Instructing the patient After wound management and suturing, patients need a specific set of instructions for ongoing wound care and routine follow-up. As well, they need to be cautioned about possible complications. Wound care will vary, but in general patients should be told to keep the area clean and dry. The wound may be gently cleaned with plain water, saline or soapy water to remove crusting and debris. Dressings that have become wet or dirty should be changed. If there is significant swelling associated with the wound, elevation of the affected area will improve patient comfort. In areas under stress, such as over joints, splinting for a few days can improve comfort and aid in healing. Instructions for suture removal need to be given in each case. The length of time sutures are left in depends on the amount of tension in the tissues in the area of the wound, balanced against the fact that sutures will cause additional scarring when left in too long. The most common and important complication for patients to be aware of is infection. Signs and symptoms of infection include increased pain, swelling, redness, fever or red streaks spreading proximally (ie up the limb). Sutures should be removed if the wound is infected. The wound should be cleaned and dressed and the patient should be given antibiotics (as described above). Time after insertion for removal of sutures Area Days later Scalp 6 Face 3 (or alternate at 2, rest 3 4) Ear 5 Neck 4 Chest 8 Arm (including hand and fingers) 8 10 Abdomen 8 10 (tension 12 14) Back 12 Inguinal and scrotal 7 Perineum 2 Legs 10 Knees and calf 12 Foot (including toes) Table 1: Time after insertion for removal of sutures 18

19 Removal of skin sutures Suture marks are related to the time the suture remains in the skin, its tension and position. The objective is to remove the sutures as early as possible, as soon as their purpose is achieved. The timing of removal is based on common sense and individual cases (Table 1 below provides some guidance). Nylon sutures are less reactive than silk and can be left for longer periods. After suture removal it is advisable to support the wound with micropore skin tape (e.g. steristrips) for 1 2 weeks, especially in areas of skin tension. Decisions need to be individualised according to the nature of the wound and health of the patient and healing. In general, take sutures out as soon as possible. One way of achieving this is to remove alternate sutures a day or two earlier and remove the rest at the usual time. Steristrips can then be used to maintain closure and healing. Method 1. Use good light and have the patient lying comfortably. 2. Use fine, sharp scissors which cut to the point, a stitch cutter or the tip of a scalpel blade, and a pair of fine, non-toothed dissecting forceps that grip firmly. 3. Cut the suture close to the skin below the knot with scissors or a scalpel tip (Illustration 5a). Illustration 5:Removal of skin sutures: (a) cutting the suture; (b) removal by pulling towards wound 4. Gently pull the suture out towards the side on which it was divided that is, always towards the wound (Illustration 5b). 19

20 Summary Of Skills Required For Wound Management Step 1: History and physical examination Each wound that is encountered must be addressed independently. Factors such as location, size, mechanism of injury, time elapsed since injury, likelihood of contamination and patient dependent factors must be addressed prior to formal treatment. Mechanism of injury: provides insight into potential injury to adjacent structures, likelihood of contamination and preferred method of repair. Laceration resulting from blunt force often require debridement and revision of wound edges to optimise healing. Time elapsed from injury to repair: any wound that has been exposed for greater than 8 hours is at significant risk for infection, regardless of the mechanism of injury. Grossly contaminated wounds such as animal bites and farm injuries are at such great risk for infection that they are best left open. Patient dependent factors: include advanced age, poor nutritional status and coexisting illnesses such as diabetes which can lead to delayed healing, abnormal scarring and infection and must be considered when instructing the patient regarding follow-up. A functional assessment of nerves, blood vessels, muscles and tendons is essential and must be done prior to injection of local anaesthesia as this will obviously interfere with the assessment. As with all medical care, it is important to be aware of one's own abilities and limitations and to request assistance if necessary. Step 2: Use of non-sterile gloves Exploration of any open wound should be done with universal precautions in mind. As such, it is necessary for the student or physician to use non-sterile gloves during the initial physical examination and when injecting local anaesthesia. Step 3: Drawing up local aesthetic Step 4: Injecting local aesthetic Step 5: Donning Sterile gloves Step 6: Clean and irrigate wound Step 7: Draping Step 8: Simple interrupted suture Step 9: Vertical mattress suture Step 10: Disposing of sharps In the interest of safety, all sharps should be disposed in a yellow sharps container immediately upon completion. This includes needles, scalpels and scalpel blades. Step 11: Instructing the patient Step 12: Suture removal 20

21 Special Situations 1. Beware of slivers of glass in wounds caused by glass explore carefully 2. Avoid suturing the tongue, and animal and human bites (see below). 3. Gravel rash wounds are a special problem because retained fragments of dirt and metal can leave a dirty tattoo-like effect in the healed wound. 4. A haematoma is a large collection of extravasated blood that produces an obvious and tender swelling or deformity. The blood usually clots and becomes firm, warm and red; later (about 10 days) it begins to liquify and becomes fluctuant. Principles of management Explanation and reassurance RICE (for larger bruises/haematomas) for 48 hours R: rest I: ice (for 20 minutes every 2 waking hours) C: compression (firm elastic bandage) E: elevation (if a limb) Analgesics: paracetamol/acetaminophen Avoid aspiration (some exceptions) Avoid massage Heat may be applied after 72 hours as local heat or whirlpool baths Abrasions Abrasions vary considerably in degree and potential contamination. They are common with bicycle or motorcycle accidents and skateboard accidents. Special care is needed over joints such as the knee or elbow. Rules of management Clean meticulously, remove all ground-in dirt, metal, clothing and other material. Scrub out dirt with sterile normal saline under anaesthesia (local infiltration or general anaesthesia for deep wounds). Treat the injury as a burn. When clean, apply a protective dressing (some wounds may be left open). Use paraffin gauze and non-adhesive absorbent pads such as Melolin. Ensure adequate follow-up. Immobilise a joint that may be affected by a deep wound. Repair of tongue wound Wherever possible, it is best to avoid repair to wounds of the tongue because these heal rapidly. However, large flap wounds to the tongue on the dorsum (top) or the lateral border may require suturing. Afterwards the patient should be instructed to rinse the mouth regularly with salt water until healing is satisfactory. 21

22 The amputated finger In this emergency situation, instruct the patient to place the severed finger directly into a fluid-tight sterile container, such as a plastic bag or sterile specimen jar. Then place this unit in a bag containing iced water with crushed ice. Note: Never place the amputated finger directly in ice or in fluid such as saline. Fluid makes the tissue soggy, rendering micro-surgical repair difficult. Care of the finger stump: Apply a simple, sterile, loose, non-sticky dressing and keep the hand elevated. Bite wounds Human bites and clenched fist injuries Human bites and clenched fist injuries can present a serious problem of infection. Antibiotics at the time of injury reduce the risk of infection. Principles of treatment Clean and debride the wound carefully (e.g. aqueous antiseptic solution or dilute betadine then flush with saline). Give prophylactic penicillin if a severe or deep bite. Avoid suturing if possible. Tetanus toxoid (although minimum risk). Consider rare possibility of HIV and hepatitis B or C infections. For high-risk wounds, give procaine penicillin 1.5 g IM one dose and/or amoxycillin/clavulanate 875/125 mg twice daily for 5 days. If established infection in a deep wound seek medical advice. Until this advice is available give antibiotics as described in the section on infection above. Dog bites (Non-rabid) Dog bites typically have poor healing and carry a risk of infection with anaerobic organisms, including tetanus, staphylococci and streptococci. Puncture and crush wounds are more prone to infection than laceration. Up to 25% of dog bite wounds become infected with the first signs appearing in about 24 hours. Principles of treatment Clean and debride the wound with dilute betadine, allowing it to soak for minutes. Aim for open healing avoid suturing if possible (except in privileged sites with an excellent blood supply such as the face and scalp). Apply non-adherent, absorbent dressings (paraffin gauze and Melolin) to absorb the discharge from the wound. Ensure your patient has had a tetanus immunisation within the past 5 years, if not seek medical care ASAP. 22

23 Give prophylactic penicillin for a severe or deep bite: 1.5 million units procaine penicillin IM immediately, then orally for 5 10 days. An alternative is amoxycillin/clavulanate (Augmentin)for 5 7 days. Use this antibiotic for 7 10 days for an established infection. Inform the patient that slow healing and scarring are likely. Rabid or possibly rabid dog (or other animal) (not currently applicable in Australia) Treat bite as above and seek medical help. Cat bites Cat bites have the greatest potential for suppurative infection with Pasteurella multocida being the most common organism. The same principles apply as for the management of human or dog bites. Use amoxycillin + clavulanate (Augmentin)for prophylaxis for 5 days. For infection commence metronidazole + doxycycline or ciprofloxacin. It is important to clean a deep and penetrating wound. Another problem is cat-scratch disorder, presumably caused by a Gram-negative bacterium, Bartonella henselae. Clinical features of cat-scratch disorder An infected ulcer or papule/ pustule at bite site (30% of cases) after 3 days or so 1 3 weeks later: fever, headache, malaise regional swollen lymph glands (may discharge pus) Benign self-limiting course Sometimes severe symptoms for weeks, especially in immuno-compromised Treat with erythromycin or roxithromycin for 10 days Coral cuts Wounds from coral cuts are at risk of serious infection with Vibrio organisms (marine pathogens) or Streptococcus pyogenes. Such wounds require cleaning with antiseptics, debridement, dressing and antibiotic cover with doxycycline 100 mg bd or cephalexin 500 mg bd for 7 days. Scalp lacerations in children If lacerations are small but gaping use the child's hair for the suture, provided it is long enough. Method Make a twisted bunch of the child's own hair on each side of the wound. Tie a reef knot and then an extra holding knot to minimise slipping. Ask an assistant to drop compound benzoin tincture solution (Friar's balsam) on the hair knot. Leave the hair suture long and get the parent to cut the knot in 5 days. 23

24 Forehead and other lacerations in children Despite the temptation, avoid using reinforced paper adhesive strips (steristrips) for children with open wounds. They will merely close the dermis and cause a thin, stretched scar. Steristrips can be used only for very superficial epidermal wounds in conjunction with sutures. Adhesive glue for wound adhesion A tissue adhesive glue can be used successfully to close superficial smooth and clean skin wounds, particularly in children. An expensive commercial preparation Histoacryl (active ingredient enbucrilate) is available, but Superglue also serves the purpose although sterility and toxicity have to be considered. The glue should be used only for superficial, dry, clean and fresh wounds. No gaps are permissible with this method. Avoid glues if possible. Repair of cut lip While small lacerations of the buccal mucosa (inner part) of the lip can be left safely, more extensive cuts of the lip require careful repair of muscles and mucosal surfaces with absorbable cat gut suture. You will almost certainly not have this in your first aid kit so do not use your non-absorbable suture inside the lip. If you are suturing the outside of the lip and the wound crosses the vermilion (lip/skin) border, meticulous alignment is essential. The slightest step is unacceptable (Illustration 6). It may be advisable to pre-mark the vermilion border with a marker pen. Insert a monofilament nylon suture to bring both ends of the vermilion border together. This is the key to the procedure. Illustration 6: The lacerated lip: ensuring meticulous suture of the vermilion border The outer skin of the lip (above and below the vermilion border) is closed with interrupted nylon sutures. Post repair 1. Apply a moisturising lotion along the lines of the wound. 2. Remove nylon sutures in 3 4 days (in a young person) and 5 6 days (in an older person). 24

25 Burns Management depends on extent and depth (burns are classified as superficial or deep otherwise first, second or third degree). First-degree burns are superficial and involve only the epidermis, causing pain, redness and swelling. A scald, which is a burn caused by moist heat, is an example. Healing proceeds quickly. Second-degree or partial skin thickness burns cause the epidermis to blister and become necrotic with subsequent serous ooze. In third-degree or full thickness burns, there is deep necrosis and perhaps anaesthesia from destroyed nerve endings. If extensive (> 9% of body surface area) and deep there is a possibility of loss of body fluids and shock. First aid The immediate treatment of burns, especially for smaller areas, is immersion in cold running water such as tap water, for a minimum of minutes (ideally 20 minutes). Do not disturb charred adherent clothing but remove wet clothing Chemical burns should be liberally irrigated with water. Apply 1 in 10 diluted vinegar to alkali burns and sodium bicarbonate solution for acid burns. Refer the following burns to hospital: > 9% surface area, especially in a child > 5% in an infant all deep burns burns of difficult or vital areas (e.g. face, hands, perineum/genitalia, feet) burns with potential problems (e.g. electrical, chemical, circumferential) suspicion of inhalational injury For extensive burns always give adequate pain relief such as morphine. During transport, continue cooling by using a fine mist water spray. Treatment 1. Very superficial intact skin. Can be left with application of a mild antiseptic only, e.g. aqueous chlorhexidine (Savlon). Review if blistering. 2. Superficial blistered skin. Apply a dressing to promote healing (e.g. hydrocolloid sheets, hydrogel sheets) covered by an absorbent dressing or (best option) a retention adhesive material (e.g. Fixomull, Mefix, Hyperfix) with daily or twice daily cleaning of the serous ooze and reapplication of outer stretch bandage. Fixomull can be left in place for up to 2 weeks. 25

26 Guidelines for retention dressings First 24 hours: keep dry. If there is any ooze coming through the dressing, pat dry with a clean tissue. From day 2: wash over dressing twice daily. Use gentle soap and water, rinse then pat dry. Do not soak. Rinse only. Do not remove the dressing as it may cause pain and damage to the wound. If the wound becomes red, hot or swollen or if pain increases treat as for infected wound. From day 7 : Removal of the dressing. Soak the dressing with olive oil then cover with plastic wrap e.g. Glad Wrap for two hours. The dressing is then soaked off with oil (e.g. olive, baby, citrus or peanut). Debride popped blisters. Only pop blisters that interfere with skin circulation. 3. Deep burns: If considerable ooze, apply the following in order: Solosite gel non-adherent neutral dressing (e.g. Melolin) layer of absorbent gauze or cotton wool (larger burns) Change every 2 4 days with analgesic cover. Surgical treatment, including skin grafting, may be necessary. Exposure (open method) Keep open without dressings (good for face, perineum or single surface burns) Renew coating of antiseptic cream every 24 hours Dressings (closed method) Suitable for circumferential wounds Cover area with non-adherent tulle (e.g. paraffin gauze) Dress with an absorbent bulky layer of gauze and wool Use a plaster splint if necessary Burns to hands For superficial blistered burn to the hand or similar complex shaped parts of the body apply strips of the retention stretch adhesive dressings as described above. They conform well to digits. Apply an outer bandage. At 7 days soak the dressings in oil for 2 hours prior to removal as described above. 26

27 Splinters under the skin The splinter under the skin is a common and difficult procedural problem. Instead of using forceps or making a wider excision, use a disposable hypodermic needle to spear the splinter (Illustration 7) and then use it as a lever to ease the splinter out through the skin. Illustration 7: Removal of splinters in the skin A buried wooden foreign body can be detected by ultrasound. Embedded fish hooks Two methods of removing fish hooks are presented here, both requiring removal in the reverse direction, against the barb. Method 2 is recommended as first-line management. Method 1 1. Inject 1 2 ml of LA around the fish hook. 2. Grasp the shank of the hook with strong artery forceps. 3. Slide a D11 scalpel blade in along the hook, sharp edge away from the hook, to cut the tissue and free the barb (Illustration 8). 27

28 Illustration 8: Removal of fish hooks by cutting a path in the skin Method 2 4. Withdraw the hook with the forceps. This method, used by some fishers, relies on a loop of cord or fishing line to forcibly disengage and extract the hook intact. It requires no anaesthesia and no instruments only nerves of steel, especially for the first attempt. 1. Take a piece of string about cm long and make a loop. One end slips around the hook, the other hooking around one finger of the operator. 2. Depress the shank with the other hand in the direction that tends to disengage the barb. 3. At this point give a very swift, sharp tug along the cord. 4. The hook flies out painlessly in the direction of the tug (Illustration 9). Illustration 9: Fisherman's method of removing a fish hook intact Note: You must be bold, decisive, confident and quick half-hearted attempts do not work. For difficult cases, some local anaesthetic infiltration may be appropriate. Instead of a short loop of cord, a long piece of fishing line double looped around the hook and tugged by the hand, or flicked with a thin ruler in the loop, will work. 28

29 Credits This module has been adapted by Dr Kaye Miller for the use by Fremantle Sailing Club sailors on long distance ocean going yachts. The source documents were from a module developed by Adam Szulewski based on content written by Dr. Bob McGraw, Jaelyn Caudle, Jordan Chenkin, and Kari Sampsel for the Queen's University Department of Emergency Medicine Summer Seminar Series and Technical Skills Program). An additional source document used was Practice Tips by Dr John Murtagh. Useful Web Links Document: Practical plastic surgery for non-surgeons Chapter 1: Video: How to give an IM injection: Video: How to suture in a hospital setting: Video: How to suture in Austere conditions: Video: How to give a subcutaneous injection: Video: How to prepare for giving an intramuscular injection: Document: How To Give An Intramuscular Injection: 29