创伤和战伤--英语.ppt

Wound Management,Wound Management,Objectives Preserve viable tissue Restore tissue continuity and function Avoid infection Minimize scar formation,Wound Management,Lacerations-are one of the most common problems treated in the ED Accounts for more than 25% of malpractice Failure to dx. Retained foreign body Failure to dx. nerve or tendon injury infection,Initial Approach,ABC’s Relevant H&P History Allergies, tetanus status Wound mechanism, contamination, potential FB Other injuries Occupation, handedness,High Risk Wounds,Location Hand, foot, joints Scalp or face Configuration Puncture, linear, stellate Mechanism Crush, object causing lac,High Risk Wounds,History of patient Diabetic Age 50 Chronic alcoholic HIV, chronic steroids Peripheral vascular disease Prosthetic cardiac valve Asplenic,Physical Exam,Control local bleeding Expose pt and look for other wounds Evaluate distal neurovascular function Motor function, 2 point sensation Describe the wound Laceration, puncture, abrasion, avulsion, crush, bite Consider X-rays R/O FB, bony injury,Steps in Wound Closure,Inspection Preparation Anesthesia Irrigation,Exploration Debridement Closure Dressings,Inspection,Physical exam Description of wound Location, length, width Neurovascular check,Preparation,First step in reducing infection and optimizing cosmesis Positioning patient Universal precautions Gloves, gown, goggles Skin cleansing Povidine-iodine (betadine) Polaxamer-188 (Sur Clens),Anesthesia,Topical Local Nerve blocks IV sedation,Local Anesthesia,Through the open edge of the wound At the junction of dermis and superficial fascia Laceration length equals cc’s of anesthetic Use small needle (27 or 25) and slow infiltration to minimize pain,Irrigation,Purpose is to remove foreign material and debris without damaging tissue High pressure, large volume 16 or 18 gauge angiocath attached to 30cc syringe NS or sterile water,Exploration,After wound in anesthetized With fingertip, q-tip or hemostat Liberal use of X-rays,Wound Closure Materials,Suture Steri-strips Staples Tissue adhesive (Dermabond©),Suture Types,Absorbable Plain gut Chromic gut Monocryl Vicryl,Non-absorbable Silk Nylon Prolene Polyester/dacron,Debridement,Removal of foreign matter, bacteria and devitalized tissue Creates sharp wound edges which are easier to repair Results in more cosmetically acceptable scar,Debridement,Suture Techniques,Simple interrupted Continuous (running) Vertical Mattress Horizontal Mattress,Suture Tips,First sutures are most crucial Should be placed with regards to aligning landmarks Handle tissue gently Approximate and evert wound edges Do not strangulate tissue Align knots on one side of wound Decreases inflammatory response,Eversion of wound edges,Eversion of wound edges,Handling the Needle Holder,,Motion of the Needle Holder,Simple Interrupted Suture,,Vertical Mattress,,Horizontal Mattress,,Stellate Laceration,Parallel Lacerations,Aftercare,Check tetanus status Pre-printed wound care instructions Wound check 24-48 hrs Hand wounds Bites Heavily contaminated Wounds requiring antibiotics Pt must understand signs of infection,Aftercare,Dressings Non-adherent Antibiotic ointment Avoid sun exposure Consider splinting digits, joint surfaces,Suture Removal,Face 3-5 d Scalp 7-10 d Arm/hand 10 d,Joint surface 10-14 d Leg/foot 8-14 d Trunk 10-14 d,The End,Thank you,。