Wound ManagementWound Managementin EDin ED

Wound ManagementWound Managementin EDin ED

Clinical scenario - I

A 7 year old boy presents with a scalp laceration that requires suturing . His mother tells you that he is scared of needles and is liable to

become upset

Clinical scenario - II

A patient presents to the Emergency Department with a laceration to the right

forearm. The wound will need cleaning and then closing. There appear to be many different cleaning solutions available

Clinical scenario - III

A 26 year old man attends the emergency department with a simple laceration requiring suturing. You wonder whether application of a

topical antibiotic ointment may promote healing and reduce incidence of infection

The Goals• Create optimal conditions for the

patient to heal themselves.• Preserve function.• Minimize complications.• Improve the chances of a

cosmetically pleasing result

ED evaluation• Secondary survey• Mechanism of injury• elicit host factors that adversely affect wound

outcome • increased age, diabetes, width, and

contamination or foreign body.

• tetanus immunization

Wound Examination• Adequate setting.• Hemostasis.• Neurovascular exam• Foreign body• Radiography

Foreign Bodies • 5th cause of malpractice claims against

emergency physicians • 50% was glass• Anver and baker 1992 :7% missing . 21% in

deeper wounds. Do X-ray !• In a medical/legal review, Kaiser et al:

unsuccessful defense in 60% of cases.

FB removal • Reactive materials, such as wood and

vegetative material • Contaminated material • Clothing (should always be considered

contaminated) • Most foreign bodies in the foot • Impingement on neurovascular structure

Foreign Bodies• wood and plastic foreign bodies

• Ct scan / MRI

• U/S :sensitivity of 95-98% and a specificity of 89-98%

Wound preparation

Anesthesia : • Local anesthetic injections

• Topical anesthetics

• Regional anesthetics

Methods to reduce pain of Lidocaine local infiltration

• Small-bore needles • Buffered solutions• Warmed solutions• Slow rates of injection• Injection through wound edges• Subcutaneous rather than intradermal

injection• Pretreatment with topical anesthetics

Topical anesthesia

• TAC (tetracaine, 0.25-0.5%; adrenaline, 0.025-0.05%; cocaine, 4-11.8%)

• SE : seizures, arrhythmias, and cardiac arrest .

Topical anesthesia • LET (lidocaine, 4%; epinephrine, 0.1%;

tetracaine, 0.5%)

• Face and scalp

• Liquid or gel forms

Sterile Technique • CDC guidelines : sterile technique

• Ruthman et al : closure of lacerations without caps and masks did not lead to an increased incidence of wound infection.

• Worral and later Perelman: sterile versus nonsterile gloves found no difference in wound infection rates.

• Non-sterile gloves, which provide “universal precaution “ is appropriate.

• Latex gloves should also be avoided

Skin and Hair Preparation • Reduce quantity of bacteria on the surface of

the skin • Shaving the hair does make closure easier• increased risk of wound infection by inducing

trauma • Seropian and Reynolds : infection risk

increased from 0.6% to 5.6% when hair was shaved from a wound

• The use of clippers .

Wound Irrigations• Used since 2200 BC.• Most important step • Remove bacteria and contamination• 15 psi removed 85% of bacterial

contamination from a wound, whereas (1 psi) removed only 49%

• 5 – 8 psi • 30-60-cc syringe to push fluid through a 19-

gauge catheter with maximal hand pressure.

Wound Irrigation• minimum of 250 cc

• 60 cc/ cm wound length

• Large volume with low pressure may be good.

Irrigation Fluid • Sterile saline solution • Povidone-Iodine

Solution (Betadine®) 10%

- tissue toxic -did not reduce

infection incidence.• Diluted betadine :

use indeterminate.

Irrigation Fluid• Hydrogen peroxide no role, tissue toxic.• Tap water : low cast, available.

• Sandy : Medline 1966-10/03, 397 papers found

Tap water is a safe and effective solution for cleaning recent wounds requiring closure and

is the treatment of choice

Tap water

• Cochrane review database : although evidence is limited, there is no

difference in wound infection rates with the use of tap water as an irrigation fluid.

Debridement• old technique with little recent research

• tissue loss versus function

• delayed primary closure.

Golden period • “safe” time interval from wounding that

allows primary wound closure • The ACEP clinical policy for penetrating injury

of the extremity supports an 8-12-hour cutoff for primary wound closure.

• 6-10 hours - wounds of the extremities — and

up to 10-12 hours or more for the face and scalp

Closure Methods

Sutures • The standard for wound closure

• Percutaneous sutures are used for low- to medium-tension wounds

• absorbable suture material for dermal stitches • interrupted versus other types of sutures has

no effect on infection rate

Glue• Faster repair time • Less painful• Eliminate the risk for needle sticks • Antibacterial effect• Does not require removal of sutures

Glue :Octyl cyanoacrylate • FDA approval in 1998

=Dermabond® • 50% of the strength of

5-0 suture material. • Cochrane review :

comparable cosmetic outcomes compared to standard suturing

GlueSimon :• In [children with facial lacerations requiring

closure] is [wound glue better than sutures] at [improving cosmetic outcome and reducing the distress of the procedure]?

• Medline 1966-07/99 using the OVID interface . 138 papers found, 8 RCTs Glue is the wound closure method of choice in recent

lacerations to the face in children

Glue me• Short (< 6-8 cm)• Low tension (< 0.5 cm

gap)• Clean edged• Straight to curvilinear

wounds that do not cross joints or creases

Don’t glue me• stellate lacerations • Bites, punctures or crush

wounds • Contaminated wounds • Mucosal surfaces • Axillae and perineum

(high-moisture areas) • Hands, feet and joints

(unless kept dry and immobilized)

staples• Fast ,low wound reactivity and infection rate.• Less expensive.

• Less needle sticks risk.

• No cosmetic difference.

• Scalp, trunk, and extremity.

Surgical Tapes Steri-Strips

• least reactive of all closure techniques

• lowest tensile strength

• May require tincture of benzoin

• Avoid in hairy and wet area.

Surgical Tapes• simple, low-tension

pediatric facial wounds, Steri-Strips™ resulted in a cosmetically equivalent wound closure compared to cyanoacrylate closure

“Hair” Closure in Scalp

Wounds • twisting hair on either

side of the wound and tying the twists together to pull together and close the wound.

• lacerations 10 cm or less in length and hair longer than 3 cm .

• close the outermost skin layers, no hemostasis .

Delayed Primary Closure (DPC) • much underused method of wound care .

• reduced the infection rate by 50% in 104 extremity wounds

• recommended technique for contaminated wounds that present to the ED

• Technique : clean and debride then separate

wound edges with gauze, and apply bulky dressing.

Secondary Intention • allowing a wound to heal without formal

closure .

• Simple but more wound scaring.

• Quinn et al in 2002 : conservative management resulted in no cosmetic or functional difference compared to primary closure in selected hand lacerations.

Antibiotic Use • prophylaxis studies : no benefits.• Indications For Prophylactic Antibiotics: Presence of prosthetic device(s) Class III Patients in need of endocarditis prophylaxis Class III Open joint or fractures associated with wound Class I Human, dog, and cat bites Class II Intraoral lacerations Class II Immunocompromised patients Class III Heavily contaminated wounds (eg, feces, etc) Class III

Topical Antibiotics • Dire et al, triple antibiotic ointment reduced the

incidence of postclosure infection compared to a petroleum jelly control (4.5-5.5% for bacitracin and Neosporin® vs 17.6% for petroleum control).

• BestBETs :Medline 1966-07/02 , 71 papers.

There is not enough evidence here to change current practice. A large multicentre study is

indicated to provide more relevant answers

Tetanus Prophylaxis

Recommendations Tetanus HistoryClean Minor

WoundsAll Other Wounds

< 3 doses in primary series

TdTd + TIG

Primary 3 Series Completed

Last < 5 years ago NillNill

Last > 5 years ago and < 10

NillTd

Last > 10 years ago TdTd

Cost- And Time-Effective

Strategies For Wound Care 1. Staples and glue are the quickest

closure methods.

2. Small, simple hand lacerations (< 2 cm) do not require primary closure.

3. Sterile gloves have no advantage over nonsterile gloves in reducing wound infection.

Cost- And Time-Effective Strategies For Wound Care

4. Clean tap water is as effective as (and cheaper than!) sterile saline for wound irrigation.

5. Cyanoacrylates or absorbable sutures are cost-effective for patients, as they do not require return visits.

6. Application of LET in triage allows a wound to be anesthetized by the time you see the patient.

The future • Growth factors :epidermal growth factor (EGF),

fibroblast growth factor (FGF), insulin-like growth factor (IGF), keratinocyte growth factor (KGF), and platelet-derived growth factor (PDGF).

• PDGF gel has been shown to speed healing of

punch biopsy wounds • chambers filled with antibiotics and growth

factors .

Key points• high-pressure irrigation with normal saline or

tap water. • Clean wounds presenting within 8 hours of

occurrence can typically be closed primarily. This does not apply to wounds on the face or scalp

• PE alone is inadequate for ruling out a foreign body in a wound.

Summary • determine if it is appropriate to close a wound

primarily

• prevention of a wound infection

• multitude of wound closure methods including “needleless” methods.

References :1. Emerg Med Clin N Am 21 20032. EM practice Mar. 20053. Sum search: multiple data base search.4. BestBETS website