Transcript wound care and repair - Hatzalah of Miami-Dade

WOUND CARE AND REPAIR
Epidemiology:
 In
USA > 10,000,000 annual ER visits
 Average cost of $200 per patient
 Hollander et
al: Wound Registry:
Development and Validation. Ann Emerg
Med, May 1995.
Causes of traumatic wounds:
Cause of wound
Blunt object
Sharp object
Glass
Wood
Bite
Human
Dog
Others
No. of Patients %
42
34
13
4
6
1
3
5
Distribution of traumatic wounds:
Location of Wound
No. of Patients (%)
Head and Neck
51
Trunk
2
Upper Extremities
34
Lower Extremities
13
Malpractice:

Karcz: Malpractice claims against emergency
physicians in Massachusetts; 1975-1993. Am J
Emerg Med 1996.
wounds claims 19.85%, and 3.15% total expenses
($1,235,597)
 American College of Emergency Physicians.
Foresight Issue 49, September 2000: Laceration
mismanagement & failure to diagnose a retained
foreign body is the 2nd most common malpractice
claims against emergency physician
Condition
% Claims
% Total dollars paid
1- Missed fracture
2- Wound care
14
12
17
8
3- Missed MI
4- Abdominal pain
5- Missed meningitis
6- Spinal cord injury
10
9
3.5
3
24
4
8
8
7- SAH / Stroke
3
6
8- Ectopic pregnancy
2
8
What patients want?
 Adam:
Patient Priorities With Traumatic
Lacerations. Am J Emerg Med, October
2000.
Aspect of Care
All Participants Facial
(n = 679)
Lacerations (n
= 78)
Other
Lacerations
(n = 263)
Normal function
28%
27%
26%
Avoiding infection
20%
14%
23%
Cosmetic outcome
17%
33%
14%
Least pain
17%
11%
18%
Length of stay
10%
8%
10%
Compassion
5%
4%
5%
Cost
1%
1%
1%
Days missed
2%
1%
3%
100%
100%
100%
Total
Evaluation:
History:
• Mechanism
• Time
• FB
• Medical conditions
• Allergies
• Tetanus status
Exam:
• Size
• Location
• Contaminants
• Neurovascular
• Tendons
Universal Precautions:
 CDC
published guidelines on use of
universal precautions.
 Use of protective barriers:
eg. Gloves/ gowns/ masks/ eyewear
Will decrease exposure to infective material.
Gloves:

Use latex free gloves
 Since March 1999, FDA reported:
2,330 latex allergic reactions
including 21 deaths

Bodiwala: Surgical gloves during wound repair in
the accident and emergency department. Lancet
1982.
 randomized 337 patients to ‘gloves’ or ‘careful
hand-washing, no gloves’:
INFECTION

None
 ‘Mild’
 ‘Severe’
GLOVES
NO GLOVES
167 (82.7%)
27 (13.4%)
8 (4.0%)
170 (82.5%)
27 (13.1%)
9 (4.4%)
 Caliendo:
Surgical masks during laceration
repair. J Am Coll Emerg Phys 1976.
Alternated face mask / no mask for 99
wound repairs:
 Mask:
1 / 47 infected
 No mask: 0 / 42 infected
Local Anesthesia: 2 main groups
1- Esters:
 Cocaine
 Procaine (Novocain)
 Benzocaine
(Cetacaine)
 Tetracaine
(Pontocaine)
 Chloroprocaine
(Nesacaine)
2- Amides:
 Lidocaine (Xylocaine)
 Mepivacaine (Polocaine,
Carbocaine)
 Bupivacaine (Marcaine)
 Etidocaine (Duranest)
 Prilocaine
Properties of commonly used local anesthetics:
Agent
Class
Procaine
Ester
Procaine + Epi
Lidocaine
Bupivacaine + Epi
Onset
(min)
2-5
9
Amide
Lidocaine + Epi
Bupivacaine
Max. save
dose mg/kg
7
5
0.5-1.5
2-5
7
Amide
2
3
Duration
(hrs)
0.25-0.75
1-2
2-4
2-5
4-8
8-16
Why Lidocaine?
 Less
painful
 Rapid onset
 Less cardiotoxic
 Less expensive

Morris: Comparison of pain associated with
intradermal and subcutaneous infiltration with
various local anesthetic solutions. Anesth Analg
1987.
 24 volunteers
 each injected with 5 anesthetic agents and NS
 visual analog pain scale
 Etidocaine> Bupivacaine> Mepivacaine> NS>
Chloroprocaine> Lidocaine (least painful)
Methods to reduce pain of Lidocaine local
infiltration:

1-Small-bore needles
 2-Buffered solutions
 3-Warmed solutions
 4-Slow rates of injection
 5-Injection through wound edges
 6-Subcutaneous rather than intradermal
injection
 7- Pretreatment with topical anesthetics
1-Small-bore needles:
Edlich, 1988:
 30-gauge hurts less than a 27-gauge
 27-gauge hurts less than a 25-gauge, etc.
2-Buffered solutions:

with sodium bicarbonate at a ratio of 1:10
 change in the pH of the anesthetic solution does
not increase wound infection rates
 No compromise to anesthesia effect
Studies on buffered lidocaine:
Study
McKay, 1987
Number
24 Volunteers
Pain score
Reduced
Christoph, 1988
25 Volunteers
Reduced
Bartfield, 1990
91 Patients
No Difference
Orlinsky, 1992
61 Patients
Reduced
Brogan, 1995
45 Patients
Reduced
Fatovich, 1999
135 Adults + 136
children
No Difference
3-Warmed solutions:
Study
Number
Temp.
(°C)
Pain score
Brogan, 1995 45 Patients
20 vs 37.6 Reduced
Martin, 1996 40 Volunteers
20 vs 37
Reduced
Colaric, 1998 20 Volunteers
20 vs 37
Reduced
Warming and Buffering have synergistic
effect:
Mader, 1994 and Bartfield, 1995: Effect of
warming and buffering on pain of Lidocaine
infiltration.
 Warming and Buffering have synergistic effect in
reducing pain
 Temp. used 40 and 38.9 °C vs room temp.
4-Slow rates of injection:
Study
Number
Injection
Rate
Pain score
Krause,
1997
29 Volunteers
0.1ml/sec vs
1ml/sec
Reduced
with slow
rate
Scarfone,
1998
42 patients
1ml/5sec vs
1ml/30sec
Reduced
with slow
rate
5-Injection through wound edges:
Study
Number
Pain score
Kelly, 1994
81 patients
Reduced
Bartfield, 1998
63 patients
Reduced
6-Subcutaneous rather than intradermal
injection:
7- Pretreatment with topical anesthetics:
Study
Number
Agent
Pain score
Bartfield, 1995
54 Patients Lidocaine
Reduced
Bartfield, 1996
57 Patients Tetracaine
Reduced
8- Digital / Regional nerve block:

A critical skill for all ED physicians
 Save time
 Decrease possibility of systemic toxicity
 Less painful than local infiltration
 Do not cause the volume-related tissue distortion
Topical Anesthetic instead of local:
TAC:
 Tetracaine – 25 cc of 2% solution
 Adrenalin – 50 cc of a 1:1000 solution
 Cocaine – 11.8 gm
Pryor, 1980 and Hegenbarth, 1990:
 topical TAC vs lidocaine infiltration, in laceration
repair
 No significant difference in anesthetic efficacy
TAC:
Down sides are:
 Not reliable when used below the head
 Tissue toxic, Case reports of death and seizures
 Corneal damage
 Intense vasoconstriction avoid in digits, nose,
pinna and penis
 Must be mixed by hospital pharmacist
 Not approved by FDA
 Expensive – up to $35 / dose
LAT, LET, or XAP:







Lidocaine – 15cc of 2% viscous
Adrenaline – 7.5cc of 1:1000 topical
Tetracaine – 7.5cc of 2% topical
Ernst-1995, Blackburn-1995, Ernst-1997: showed
effective anesthesia if left in place for 15 to 20 minutes
Schilling-1995 and Amy-1995: As efficacious as TAC
$5 / dose
Much less potential for significant toxicity
Lidocaine with Epinepkrine:

In animal models, there is theoretic concern for
increased risk of wound infection
 Tissue ischemia and necrosis if injected in digits
Skin and Wound preparation:

1- Hair removal
 2- Disinfecting the skin
 3- Debridement
 4-Wound Cleansing and Irrigation
 5-Soaking
1- Hair removal:
To shave or not to shave!
Seropian, 1971:
 406 clean surgical wounds
 If shaved pre-op, 3.1% infection rate
 If depilated, 0.6% infection rate
Howell, 1988:
 68 scalp lacerations repaired without hair removal
(93% within 3 hours of injury), no infection at 5day follow-up
2- Disinfecting the skin:
An ‘ideal agent’ does not exist – either tissue toxic
or poorly bacteriostatic
 Simple scrub water around wound should be
sufficient
 No studies have demonstrated the impact of
cleaning intact skin on infection rate, however it is
important to decrease bacterial load to minimize
ongoing wound contamination.
 Avoid mechanical scrubbing unless heavily
contaminated (increase inflammation in animal
data)

Solution
Antimicrobial
activity
Mechanism of
action
Uses
N. Saline
-
Washing action
Cleanse surrounding skin /
Tissue
toxicity
-
irrigation
Povidine-iodine 10%,
1%
+
Germicide
Chlorhexidine 1%,
0.1%
+
Bacteriostatic
Hydrogen Peroxide
+
Bactericidal
Hexachlorophene
+
Nonionic detergents
-
Cleanse surrounding skin, ?
+
Irrigation contaminated wounds
Bacteriostatic
Wound
cleanser
Cleanse surrounding skin
+
Cleanse contaminated wounds
+
Cleanse surrounding skin
+
Wound cleanser
-
3- Debridement:

Devitalized soft tissue acts as a culture medium
promoting bacterial growth
 Inhibits leukocyte phagocytosis of bacteria and
subsequent kill
 Anaerobic environment within the devitalized
tissue may also limit leukocyte function
Dhingra V: Periphral Dissemination of Bacteria
in Contaminated Wounds: Role of Devitalized
tissue: Evaluation of Therapeutic Measures.
Surgery, 1976.
 Animal study, devitalized wounds contaminated
with 3 Bacteria, treated with NS jet irrigation or
debridement at 2, 4, 6 hr
 Debridement more effective in reducing bacteria
count and infection rate
4-Wound Cleansing and Irrigation:

Decreasing wound contamination and hence
infection, "the solution to pollution is dilution."
 Indications
 Methods
 Pressure
 Solution
 Volume
 Side effects
1- Indications:


Any contaminated or bite wounds
Animal and human studies demonstrate irrigation lowers
infection rates in contaminated wounds
Hollander JE et al: Irrigation in facial and scalp
lacerations: Does it alter outcome? Ann Emerg Med 1998.
 1,923 patients 1,090 patients received saline irrigation, and
833 patients did not
 Nonbite, noncontaminated facial skin or scalp lacerations
who presented less than 6 hours
 No difference in wound infection rate or
cosmetic appearance
2- Methods:
•
Bulb syringe
• IV bag +/- pressure cuff
• Syringe and needle
• Jet lavage
3- Pressure:

lack of clinical studies
 recommend irrigation pressures in the range of 5
to 8 psi
 High-pressure irrigation is defined as more than 8
psi (use of a 30- to 60-mL syringe and a 18-20
gauge needle)
 Animal studies: Rodeheaver, 1975 & Stevenson,
1976, high-pressure irrigation reduce both
bacterial wound counts and wound infection rates
4- Solution:
Ideal solution must be:
 Not toxic to tissues
 Does not increase rate of infection
 Does not delay healing
 Does not reduce tensile strength of wound healing
 Inexpensive
Dire DJ: A comparison of wound irrigation
solutions used in the emergency department.
Ann Emerg Med 1990.
 531 patients were randomized into 3 groups,
and irrigated with:
 NS, 1% PI, or pluronic F-68
 No difference in wound infection rate
 NS has the lowest cost
Lineaweaver: Cellular and bacterial toxicities of
topical antimicrobials. Plast Reconstr Surg, 1985.
 1% povidone-iodine
 3% hydrogen peroxide
 0.25% acetic acid
 0.5% sodium hypochlorite
 assayed in vitro using cultures of human
fibroblasts and Staphylococcus aureus
 All agents tested killed 100 percent of exposed
fibroblasts
Then he looked at different dilutions…
 …povidone-iodine 0.01, 0.001, 0.0001%
 …sodium hypochlorite 0.05, 0.005, 0.0005%
 …hydrogen peroxide 3.0, 0.3, 0.03, 0.003%
 …acetic acid 0.25, 0.025, 0.0025%
 ONLY antiseptic not harmful to fibroblasts yet still
bacteriostatic was Povidone iodine 0.001%
Moscati: Comparison of normal saline with tap
water for wound irrigation. Am J Emerg Med
1998.
 lacerations were made on each animal and
inoculated with standardized concentrations of
Staph. aureus
 irrigation with 250 cc of either NS from a sterile
syringe or water from a tap
 no difference in bacterial count in 2 groups
Lammers:Bacterial counts in experimental, contaminated
crush wounds irrigated with various concentrations of
cefazolin and penicillin. Richard Lammers, American
Journal of Emergency Medicine, January 2001.
 An animal bite wound model was created
 inoculated with 0.4 mL of a standard bacterial solution
 each wound was scrubbed for 30 seconds with 20%
poloxamer 188 and then irrigated with 100 mL of one of 4
solutions: NS(control); cefazolin + penicillin G (LD); CZ +
PCN (ID); and CZ + PCN (HD)
 No differences in the bacterial counts or infection rates
Kaczmarek, 1982: Cultured open bottles of saline
irrigating solution
 36/169 1000cc bottles were contaminated
 16/105 500cc bottles were contaminated
Brown, 1985: Approximately one in five of the
opened bottles use for irrigation were
contaminated
4- Volume:

Irrigation volume not studied
 use 50 mL to 100 mL of irrigant per cm of
laceration
5- Side effects:

Increase tissue inflammation (very high pressure
irrigation), but benefit outweigh risk
 Splatter (use your hand or plastic shield)
5- Soaking:
Lammers: Effect of povidone-iodine and saline soaking on
bacterial counts in acute, traumatic contaminated wounds.
Ann Emerg Med, 1990.
 Contaminated traumatic wounds within 12 hours of injury
 33 wounds randomized into:
soaking in either 1% PI, NS, or covered with dry gauze
(control) for 10 min.
 Bacterial counts not changed in PI + control groups, but
increased in NS group
 Infection rate: PI=12.5% (1/8), control= 12.5% (1/8),
NS=71% (5/7)
Foreign Bodies:

Glass, metal, and gravel are Radiopaque
 Wooden objects and some aluminum products are
radiolucent
 Glass is accurately visualized on 2-view
radiographs if it is 2 mm or larger
 and gravel if it is 1 mm or larger
Wound Closure:

Time
 Delayed primary closure
 Options
 Suturing method
Time:

The Golden Period: the time interval from injury
to laceration closure and the risk of subsequent
infection, (is highly variable)
 Morgan WJ: The delayed treatment of wounds of
the hand and forearm under antibiotic cover. Br J
Surg 1980.
 300 hand and forearm lacerations
 closed < 4hr had infection rate 7%
 closed > 4hr had infection rate 21%
Berk WA: Evaluation of the "golden period" for
wound repair: 204 Cases from a third world
emergency department. Ann Emerg Med 1988.
 evaluation in a third-world country - 204 patients
 <19 hours to repair 92% satisfactory healing
 >19 hours to repair 77% satisfactory healing
 Exception: head and face lacerations had 95.5%
satisfactory healing, regardless of time

Baker: The management and outcome of
lacerations in urban children. Ann Emerg Med
1990.
 2,834 pediatric patients
 No difference in infection rate for lacerations
closed less than or more than 6hrs
Delayed primary wound closure:

High risk wounds that are contaminated or contain
devitalized tissue
 Wound is initially cleansed and debrided
 Covered with gauze and left undisturbed for 4 to 5
days
 If the wound is uninfected at the end of the
waiting period, it is closed with sutures or skin
tapes
Dimick, 1988: Delayed Primary Closure
Wound left open for 4 or 5 days until edema
subsides, no sign of infection, and all debris and
exudates removed
 >90% success rate in closure without infection
 Final scar as same as primary closure
Options:

Nonabsobable suture
 Absorbable suture
 Tissue adhesive
 Adhesive tapes

Staples
Nonabsobable suture:
Material
Knot
Security
Wound
Tensile
Strength
Tissue
Reactivity
Workability
Nylon
(Ethilon)
Good
Good
Minimal
Good
Polypropylene
(Prolene)
Least
Best
Least
Fair
Silk
Best
Least
Most
Best
Absorbable suture:
Material
Surgical gut
Knot
Security
Poor
Wound
Strength
Fair
Security
(d)
5-7
Tissue
Reactivity
Most
Chromic gut
Fair
Fair
10-14
Most
Polyglactin (Vicryl)
Good
Good
30
Minimal
Polyglycolic acid
(Dexon)
Polydioxanone
(PDS)
Best
Good
30
Minimal
Fair
Best
45-60
Least
Polyglyconate
(Maxon)
Fair
Best
45-60
Least
Tissue adhesive:

N-butyl-2-cyanoacrylate, Histoacryl blue (HAB),
GluStitch
 First described in 1949 and first used medically in
1959
 Antibacterial effect
 Cost $5 per single-use ampule
 Reduction in cost (Canadian $) per patient of
switching from nondissolving sutures $49.60

S. Mizrahi: Use of Tissue Adhesives in the Repair
of Lacerations in Children. Journal of Pediatric
Surgery,April, 1988.
 1500 pediatric patients with simple laceration in
ED, closed with HAB
 Infection 1.8%
 Dehiscence 0.6%
Tissue adhesive:

Octylcyanoacrylate (OCA), or Dermabond
 Approved by FDA in 1998
 Antibacterial effect

Cost $25 per single-use ampule
 Greater strength than HAB
Which laceration?

Short (< 6-8 cm)
 Low tension (< 0.5 cm gap)
 Clean edged
 Straight to curvilinear wounds that do not cross
joints or creases
Contraindications:

Jagged or 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)
Advantages of Adhesive vs Sutures:

Faster repair time
 Less painful
 Eliminate the risk for needle sticks
 Antibacterial effect
 Does not require removal of sutures
Study
Material No. Cosmetic
outcome
Time
(min)
Complications
Simon,
1996
HAB vs
Suture
61
2 months- same
7 vs 17
1 infection (HAB)
Simon,
1997
HAB vs
Suture
61
2 months/ 1yr same
_
_
Quinn,
1997
OCA vs
Suture
130 3 months- same
3.6 vs 12.4
Infection: 0 vs1
Dehiscence: 3 vs 1
Singer,
1998
OCA vs
Suture
124 3 months- same
5.9 vs 10
1 infection + 2
dehiscence (OCA)
94
0
2 dehiscence
(HAB)
Osmond, OCA vs
1999
HAB
3 months- same
Adhesive tapes:

Seldom recommended for wound closure in the
ED
 Require the use of adhesive adjuncts (eg, tincture
of benzoin)
 May be used with tissue adhesive or after suture
removal to decrease tension
Staples:



Consider staples for linear lacerations not involving the
face or other cosmetically sensitive areas
Frequently used for scalp, trunk, or extrimities lacerations.
Optimally, two operators perform this procedure
Brickman KR: Evaluation of skin stapling for wound
closure in the emergency department. Ann Emerg Med
1989;18:1122-1125.
 87 ER patients with 87 lacerations (2/3 scalp, trunk, and
extremities)
 65% closed in 30 seconds using staples
 No infections
John T. Kanegaye:
 88 child with scalp lacerations, nonabsorbable
suture vs staples
 Shorter overall times for wound care and closure:
395 vs 752 sec
 Total cost based on equipment and physician time:
$23.55 vs $38.51
 F/U rate 91%, with no cosmetic or infectious
complications in either group
Suturing methods:

Simple interrupted
 Simple running
 Horizontal mattress
 Vertical mattress
 Running subcuticular (intradermal)
Simple Interrupted:

Most common
 Easy to master
 Can adjust tension with each suture
 Stellate, multiple components, or directions
wound
Simple Running:

Minimize time of suture repair
 Even distribution of tension
 Low-tension, simple linear wounds
 Removed within 7 days to avoid suture marks
 Optimal suture material is nonabsorbable
Horizontal Mattress:

Cause wound edges eversion
 Single layer closure with significant tension
 Decrease repair time, less knots required
 Need delayed suture removal, so risk of suture
marks
Vertical Mattress:

High-tension wounds
 Prone to skin suture marks if left in too long
Running Subcuticular (Intradermal):

Best for areas where cosmetic result is of utmost
importance
 Time-consuming
 Difficult to master
 Low tension wounds
 Absorbable suture
McLean, 1980:
 51 patients with continuous, running
 54 patients with interrupted stitch
 Two infections in each group
Topical AB:
Dire DJ: Prospective evaluation of topical antibiotics for
preventing infections in uncomplicated soft-tissue wounds
repaired in the ED. Acad Emerg Med, 1995.
 prospective, randomized, double-blinded, placebocontrolled (426 Lacerations)
 Bacitracin - 5.5% infection (6/109)
 Neosporin - 4.5% infection (5/110)
 Silvadene - 12.1% infection (12/99)
 Placebo – 4.9% infection (5/101)
Dressing:
Chrintz, 1989: 1202 patients with clean wounds
 Dressing off at 24 hours - 4.7% infection
 Dressing off at suture removal - 4.9%
Goldberg, 1981: 100 patients with sutured scalp
lacerations allowed to wash hair with no infection
or wound disruption
Noe, 1988: 100 patients with surgical excision of
skin lesions allowed to bathe next day with no
infection or wound disruption
Tetanus:

More than 250,000 cases annually worldwide with
50% mortality
 100 cases annually in USA
 About 10% in patients with minor wound or
chronic skin lesion
 In 20% of cases, no wound implicated
 2/3 of cases in patients over age 50
Study
Setting
Age
Ruben, 1978
Nursing
Home
Elderly
% No Protective
AB
49
Crossley,
1979
Urban
> 60yrs
F: 59, M: 71
Scher, 1985
Rural
Elderly
29
Pai, 1988
Urban
5
Stair, 1989
ER
34-60 yrs, all
Females
> 65 yrs
9.7
Alagappan,
1996
ER
> 65 yrs
50
Recommendations for tetanus prophylaxis:
History of Tetanus
Immunization
Uncertain or <3 doses
Td
TIG
Td
TIG
Yes
No
Yes
Yes
Last dose within 5 y
No
No
No
No
Last dose 5-10 y
No
No
Yes
No
Last dose >10 y
Yes
No
Yes
No
Infection Rate:

Galvin, 1976
 Gosnold, 1977
 Rutherford, 1980
 Buchanan, 1981
 Baker 1990
3 doses
4.8%
4.9%
7.0%
10.0%
1.2%
Antibiotic Therapy:
Cummings P: Antibiotics to prevent infection of
simple wounds: A metaanalysis of randomized
studies. Am J Emerg Med 1995.
 7 randomized trials (1,734 patients)
 Assigned patients to AB or control
 Patients treated with AB slightly higher infection
rate
Prophylactic Antibiotics:

Bite wounds
 Contaminated or
devitalized wounds
 High risk sites eg. Foot
 Immunocompromised
 Risk for infective
endocarditis
 Intraoral through and
through lacerations






PVD
DM
Lymphedema
Indwelling prosthetic
device
Extensive soft tissue
injury
Deep puncture wounds
Prophylactic Antibiotics:

Amoxicillin, Clavulin
 Keflex
 Erythromycin
 recommended course is 3 to 5 days
Level of Training and Rate of Infection:
Adam: Level of Training, Wound Care Practices,
and Infection Rates, American J Emerg. Med, May
1995.
 Wounds were evaluated in 1,163 patients
 Medical students 0/60 (0%);
 All resident 17/547 (3.1%)
 Physician assistants 11/305 (3.6%)
 Attending physicians 14/251 (5.6%)
Level of Training and Cosmetic outcome:
Adam: Association of Training level and Short-term
Cosmetic Apperance of Repaired Lacerations, Academic
Emerg. Med, April 1996.
 Retrospective study, 552 patients
 % achieving optimal cosmetic score
 Medical student 50%
 R1 54%
 R2 66%
 R3 68%
 Physician assistance 70%
 Attending physician 66%
Points to Take Home:

Laceration mismanagement & failure to Dx. FB is
2nd most common malpractice
 Be aware of different methods to reduce pain from
Lidocaine infiltration
 In contaminated wounds with devitalized tissues
debride and irrigate
 You have a wide options for wound closure
 Always check tetanus status
 AB only for high risk wounds