Name: Dr Amna HussainClinical Lead for Minor Trauma Sidra ED

Third QPEM Conference 11-13th of January 2019

Title: Management of the Traumatic Wound. Not Just ensuring Healing

I do not have any relevant financial relationship with commercial interest to disclose.

DISCLOSURE

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At the end of the presentation, the attendee will be able to:

Learning Objectives

Formulate a strategy to apply the updated management of prevention of complications

Outline the principles of traumatic wound management, incorporating recent research in wound care

Pain

1. PAIN. Topical Anesthesia.

• Lidocaine, epinephrine, tetracaine (LET) for an open wound and mixture of local anesthetics (EMLA/ametop) –good in reducing the pain of local injection-non broken skin.

• EMLA cream as pretreatment before infiltrative local anesthesia increases patient satisfaction (adults).

• Cochrane review in 2011 regarding efficacy showed medium to high risk of bias.re efficacy. More low risk bias studies needed.

• Trials on lidocaine putty ongoing-do not distort tissue.

1. PAIN. Intradermal Anesthesia

• Lidocaine 1%. Also procaine 1% and bupivacaine 0.25%. Adding epinephrine 1%-clearer field with less blood loss.

• Can be used on the fingers, toes, or nose.

• Allows higher total doses of anesthetic to be used, increasing the maximum dose of lidocaine from 4.5 mg/kg to 7mg/kg.

• For children- Inject slowly, warm the medication, use small needles, avoid large injections in one location, and use distracting vibratory stimulation in the area. Can add 1:10 sodium bicarbonate 8.4%, decreases pain but also shortens time to anesthesia onset.

1. PAIN. Nerve Block

• New best practice for performing digital anesthesia.

• Evidence from multiple studies supports use of single palmar injection in the middle of the proximal phalanx over traditional dual dorsal web space injection.

• The pain of injection found to be no different than in the dorsal webbing of the finger and requires only one injection instead of two

1. PAIN. Wound closure.

• Tissue adhesives and adhesive strips have been shown to be non inferior to sutures when used appropriately.

• Well-evaluated over the last 20 years and found to be excellent, less painful or painless alternatives to sutures for the closure of appropriate lacerations.

• Expedite care and improve efficiency in the ED, while improving patient experience.

1. PAIN. Wound Closure

• Suitable lacerations for adhesive:• low tension (so as not to risk wound dehiscence), do not

require deep-layer sutures, not complicated by hair growth.

• Infection rates and cosmetic comparable with wounds closed with sutures.

• Staples-Quick, cost-effective. One pediatric prospective, randomized trial showed staples resulted in shorter procedures at a lower cost with statistically equal outcomes as sutures. Not to be used when CT or MRI may be needed

Preventing Infection

2. INFECTION. Irrigation

• Sterile normal saline should be used.• Antibiotic solution -shown to increase complications compared

to soap!-increase in wound healing failures and dehiscence • Low-pressure irrigation with a slow, gentle wash. Sufficient for

cleaning simple, non-bite, uncontaminated wounds in vascular area-scalp or face.

• High-pressure irrigation using a 30 mL or larger syringe with 19-gauge needle -regarded as more effective for removal of debris and reduction in post-repair wound infection.

• Recommendations by wound care experts -25 to 100 mL of irrigation fluid per cm of laceration

2. INFECTION. Timing of wound Closure

• Previously more than 6 hours quoted as increased risk of infection. Based on older study from 1995 (Robson et al)

2014 Quinn et al.• 2,663 patients treated for traumatic lacerations in three

U.S. EDs• No difference in the rate of infection for wounds closed

before or after 12 hours from injury. • Important factors impacting on wound infection-Wound

more than 5cm, Diabetes, Wound below head and neck, contamination of wound.

2. INFECTION Prophylactic Antibiotics.

• Prophylactic Antibiotics• No clear evidence in reduction rate of post-repair infections for

majority of traumatic wounds repaired in the ED –including hand lacerations. • However, for prophylactic coverage of non-bite lacerations-

beta lactam. • For plantar puncture wounds -theoretical risk for Pseudomonas infection, prophylaxis with ciprofloxacin can be considered; however, local antibiotic resistance patterns must be taken into account

2. INFECTION: Wound Care

• Non-adherent dressings over the wound - moist, clean environment for wound healing to take place.

• Help contain drainage and minimize dried crust formation.• Not been proven to prevent bacterial contamination,• Avoid immersing the wound in water until the wound has closed

and the sutures are removed but getting wound wet not shown to increase risk of infection

• Tissue adhesives and adhesive strips cannot get wet, or they will lose their strength.

Scarring

3. SCARRING. Common Question “Will it scar doctor?”Correct Answer “Well yes, it’s a break in the skin

but we will be careful to minimize it”

• Hypertrophic scars -hard, red or pink, raised scars, elevated but remaining within the limits of the original wound. May regress over time.

• Keloids raised, reddish-purple, nodular scars, harder than hypertrophic scars, invading adjacent tissue extending beyond the margins of the original wound, and rarely regressing over time. Common in darker skinned people.

• Can prevent hypertrophy with good wound closure, no evidence that keloid formation can be prevented.

SCARRING. Absorbable or non absorbable?

Suture Choice

• Absorbable sutures- convenient –do not require follow up for removal.

• Previous belief that enzymatic process responsible for suture dissolution will leave a visible mark.

• Newer research shows no increase in adverse appearance when used properly

• Cosmetic outcomes for absorbable and non absorbable options generally are equivalent.

3. SCARRING. Sub speciality follow up?

• Specialty consultation is not always available eg in a remote environment or late at night.

• Complex facial lacerations warrant referral or consult. • Study of facial laceration repair - satisfaction scores were

similar between wounds repaired by plastic surgeons and those repaired by ED physicians.

• A subset of females and parents of small children preferred plastic surgeon repair-bias because of patient awareness of provider specialty.

• Dermatology referral - scar management, laser surgery and pharmacologic management once the wound has healed.

Take home messages

No “Golden Hour” of wound repair- especially of head and face. Up to 19 hours is no greater risk of infection than before if no clinical evidence of infection. Topical anesthetics reduce pain of local infiltration-important in children, but increase ED stay.

Effective irrigation if contaminated wound to help prevent infection.

Prophylactic antibiotics in high risk contaminated wounds only

Scarring can be minimized but may still be present

References

• Childs DR, Murthy AS. Overview of wound healing and management. Surg Clin North Am 2017;97:189-207.

• Hamer ML, Robson MC, Krizek TJ, Southwick WO. Quantatative bacterial analysis of comparative wound irrigations. Ann Surg 1975;181:819-822.

• Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: What are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emerg Med J 2014;31:96-100.

• Ali S, McGrath T, Drendel AL. An evidence-based approach to minimizing acute procedural pain in the emergency department and beyond. Pediatr Emerg Care 2016;32:36-42; quiz 43-44.

• Singer AJ, Stark MJ. Pretreatment of lacerations with lidocaine, epinephrine, and tetracaine at triage: A randomized double-blind trial. Acad Emerg Med 2000;7:751-756.

References

• Sanders JE. Pediatric wound care and management in the emergency department. Pediatr Emerg Med Pract 2017;14:1-24.

• Al Youha S, Lalonde DH. Update/review: Changing of use of local anesthesia in the hand. PlastReconstr Surg Glob Open 2014;2:e150.

• Mattick A, Clegg G, Beattie T, Ahmad T. A randomised, controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Emerg Med J2002;19:405-407.

• Wilbur L, Seupaul R. Evidence-based emergency medicine. Are tissue adhesives an acceptable alternative for simple lacerations? Ann Emerg Med 2011;58:373-374.

• Forsch RT, Little SH, Williams C. Laceration repair: A practical approach. Am Fam Physician2017;95:628-636.

• Khan AN, Dayan PS, Miller S, et al. Cosmetic outcome of scalp wound closure with staples in the pediatric emergency department: A prospective, randomized trial. Pediatr Emerg Care 2002;18:171-173.

• Prevaldi C, Paolillo C, Locatelli C, et al. Management of traumatic wounds in the emergency department: Position paper from the Academy of Emergency Medicine and Care (AcEMC) and the World Society of Emergency Surgery (WSES). World J Emerg Surg 2016;11:30.

THANK YOU