Wound Management

1. Wound Management • October 11, 2001 • Gavin Greenfield and Bob Johnston

2. Objectives • Wound Healing • Wound Evaluation – History, Physical examination • Wound Preparation • Wound Closure • Specific Wounds • face, scalp, eyebrow, eyelid, ear, lips, intraoral, puncture, fingertip and nail, foreign bodies, bites

3. Wound Healing • “the primary goal of wound care is not the technical repair of the wound; it is providing optimal conditions for the natural reparative processes of the wound to proceed” • Richard L. Lammers (Roberts and Hedges)

4. Skin Anatomy • Epidermis • keratinized squamous epithelium • avascular • Dermis • dense, fibro-elastic tissue • highly vascular • cells of dermis mainly fibroblasts responsible for elaboration of collagen, elastin, ground substance • Subcutaneous layer (superficial fascia) • connects dermis to underlying tissue • contains variable amounts of adipose tissue

6. Case 1 • 1st year medical student comes in with laceration to hand. You evaluate the wound and feel it is appropriate for primary closure. He asks you how the wound will go about healing itself? What do you tell him to appease his curious mind?

7. Wound Healing • Stages • hemostasis • inflammation • epithelialization • fibroplasia • contraction • scar maturation

8. Wound Healing • Inflammation • serves to remove bacteria, foreign debris, and devitalized tissue – a biologic debridement • if this stage is prolonged (from infection, foreign material, etc.) will get persistent inflammation and result in poor wound healing

9. Wound Healing • Epithelialization • in sutured wounds, surface of wound develops epithelial covering impermeable to water in 24-48 hours • eschar and surface debris impair this process by inhibiting the migration of the epithelial cells

10. Wound Healing • Fibroplasia • by fourth day fibroblasts begin synthesizing collagen, initiating scar formation • characterized clinically by pebbled red tissue in wound base

11. Wound Healing • Contraction • movement of skin edges toward center of defect, primarily in direction of underlying muscle • everting skin edges at time of repair accounts for the subsequent wound contraction

12. Wound Healing • Scar Maturation • amount of scar tissue influenced by physical forces acting across wound • strength of wound increases rapidly from day 5-17, more slowly for additional 14 days, and further collagen remodeling / maturation for 2 years • strength of scar tissue never quite reaches that of unwounded skin

13. Case 2 • Pt presents with two wounds – one is sharp, linear laceration on L hand from a clean knife. While riding her bike to hospital she falls on a pristine, flat, clean road and lands on dorsum of hand producing a jagged irregular laceration. • Which of the two has higher chance of infection? Why?

14. Case 3 • Alcoholic, diabetic street person presents with laceration to R forearm. He thinks he did it about 24 hours ago but can’t remember mechanism. On examination small amount of soil type debris in wound. • How will you manage this case?

15. Wound Evaluation – HistoryAmerican College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with penetrating extremity trauma. Ann Emerg Med Vol 33 No. 5 May 1999 • identify all extrinsic and intrinsic factors that jeopardize healing and promote infection • mechanism of injury • time of injury • environment in which wound occurred • potential contaminants, foreign bodies • species of animal if bite • pt’s medical problems / immune status • tetanus immunization status • handedness / vocation

16. Wound Evaluation - History • Risk Factors for wound infection (Singer et al. Risk factors for infection in patients with traumatic lacerations. Academic Emergency Medicine. July 1, 2001; 8(7): 716-20) • older age • diabetes • laceration width • presence of foreign body

17. Wound Evaluation – History (mechanism of injury) • Type of force causing wound • Acute traumatic wounds caused by one or combination of 3 forces • shear • compressive • tensile

18. Wound Evaluation – History (mechanism of injury) • Shear Forces • produced by sharp objects that cut through the skin • amount of energy required to cut skin with sharp object is low therefore little energy directed to surrounding tissue with minimal cell damage • results in lower risk of infection and problems with wound healing because remaining tissue is not devitalized

19. Wound Evaluation – History (mechanism of injury) • Compressive and Tensile Forces • compressive forces produced when blunt object impacts the skin at right angles (wounds tend to be stellate or complex with ragged/shredded edges) • tensile forces produced when a blunt object impacts skin at oblique angles (wounds tend to be triangular or produce a flap) • compared to shear forces much more energy deposited with high amounts applied to area around wound • results in devitalization of surrounding tissue with higher incidence of wound infection

20. Wound Evaluation – History (mechanism of injury) • Shear vs. Compressive / Tensile Forces • Infection • with compressive / tensile forces the critical number of bacteria needed to produce infection is much lower (~100,000 organisms per gram of tissue) • with shear forces the number of bacteria needed to produce infection is much higher ~ 10,000,000 organisms per gram of tissue

21. Wound Evaluation – History (time of injury) • “golden period” refers to time after injury that wound can be safely closed without increased risk of infection • delay in wound cleaning is most important variable • contrary to popular belief not a fixed number of hours • “there is little change in wound infection rates in most areas of the body for up to 19 hours after a variety of traumatic injuries, and infection rates of simple wounds involving the head are essentially unaffected by the interval between injury and repair” • Berk et al. Evaluation of the “golden period” for wound repair: 204 cases from a third world emergency department. Ann Emerg Med 17:496, 1988

22. Wound Evaluation – History (time of injury) • accelerated growth phase of bacteria starts at 3 hours post wound

23. Timing of Closure • primary, delayed primary, secondary • decision to close a laceration is multifactorial • base decision on wound history, physical examination, host factors • Revisit Case 3

24. Wound Evaluation – Physical Examination • Examine for: • amount of tissue destruction • degree of contamination • damage to underlying structures • Wounds may be classified into 6 categories • lacerations • abrasions • crush wounds • avulsion wounds • puncture wounds • combination wounds

25. Wound Evaluation – Physical Examination • Lacerations • if caused by shear force little tissue damage at wound edge and margins are sharp and wound appears “tidy” • if caused by compressive or tensile forces, more force is required to produce the laceration and therefore more tissue trauma; often appear jagged, contused

26. Wound Evaluation – Physical Examination • Abrasions • results from forces applied in opposite directions (e.g. skin grinding against road surface)

27. Wound Evaluation – Physical Examination • Crush Wounds • caused by impact of an object against tissue, especially over a bony surface, which compresses the tissue • at higher risk for subsequent compartment syndrome

28. Wound Evaluation – Physical Examination • Avulsions • wounds in which a portion of tissue is completely separated from its base and is either lost or left with a narrow base of attachment

29. Wound Evaluation – Physical Examination • Puncture Wounds • wounds with a small opening and whose depth cannot be visualized • Combination Wounds

30. Wound Evaluation – Physical Examination • Amount of tissue destruction / devitalized tissue

31. Wound Evaluation – Physical Examination • Degree of Contamination • bacteria and foreign material • primary determinants of wound infection are the amount of bacteria and dead tissue remaining in wound • the presence of undetected reactive foreign bodies in sutured wounds almost guarantees infection

32. Wound Evaluation – Physical Examination • Underlying Structures • nerves, vessels, tendons, bones, joints

33. Wound Evaluation – Physical Examination • Wound Location • has considerable importance in the risk of infection • high endogenous bacterial counts in hairy scalp, forehead, axilla, groin, foreskin of penis, vagina, mouth, nails • wounds in areas of high vascularity more easily resist infection (scalp, face)’

34. Delayed Primary Closure • wound preparation (debridement, cleansing, etc.), dress with saline soaked fine mesh gauze, follow up in 72-96 hours for debridement, repeat cleansing and closure if no evidence of infection

35. Skin Preparation • prevents transfer of bacteria into wound from instruments, suture needles, gloved fingers • use whatever (no research suggest one better than another) • important to distinguish between skin preparation and wound cleansing

36. Wound Cleansing (not skin preparation) • Soaking • of little value and may actually increase bacterial counts (Lammers, Fourre, Callaham et al. Effect of poviodine-iodine and saline soaking on bacterial counts in acute, traumatic contaminated wounds. Ann Emerg Med 19: 709, 1990)

37. Wound Cleansing (not skin preparation) • Mechanical Scrubbing • gentle scrubbing may be useful in wounds older than 3-4 hours (a glycoprotein matrix enters wound and may protect it from further attempts to lower bacterial counts with irrigation) • Debridement of devitalized tissue paramount to reducing risk of infection • Scalpel excision of wound margins can be used in grossly contaminated wounds

38. Wound Cleansing (not skin preparation) • Irrigation • Equipment? • 35 cc syringe with 18 G needle produces about 7-8 psi • Solution? • NS or 1% poviodine-iodine solution (ie. diluted Betadine) (Dire and Walsh: A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990; 19:704-708) • infection rate in poviodine arm was lower than saline arm but not statistically significant (4.3% vs 6.9%) • Hydrogen peroxide kills fibroblasts and occludes microvasculature, chlorhexadine toxic to tissue defenses, detergents contained in scrub solutions cause tissue damage in wounds • How much? (all expert opinion – no clinical trials) • minimum of 100-300 cc with continued irrigation until all visible particles removed • 50-100 cc per cm of wound length • if irrigation alone is ineffective in removing contaminants from a wound, the wound should be lightly scrubbed

39. Prophylactic Antibiotics - Topical • Ointments • reduce formation of crust which could inhibit epithelialization • prevent dressing from adhering to wound • routine use encourages pt inspection of wound • one randomized, double blind clinical trial demonstrated reduced infection rate • Dire et al. Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med 2:4, 1995

40. Prophylactic Antibiotics - Systemic • no role for routine antibiotic use for most wounds (Cumming et al. Antibiotics to prevent infection of simple wounds: A meta-analysis of randomized studies. Am J Emerg Med 13:396, 1995) • specific wounds: contaminated with debris, feces, saliva; punctures, bites, extensive tissue destruction, wounds in avascular areas, oral lacerations, wounds involving joint spaces, tendons, or bones; presence of impaired host defenses

41. Wound Closure - Sutures • Classification: nonabsorbable vs absorbable • Size (according to diameter): 6-0 face, 5-0,4-0 trunk and extremities, 3-0 scalp, sole of foot

42. Wound Closure – Sutures - Nonabsorbable • Natural or Synthetic / Monofilament or Multifilament • natural incite tissue reactivity (therefore increase risk of infection, synthetic less so) • monofilament have less pliability and knot security than multifilament but multifilament increase risk of wound infection • Natural multifilament - silk • easiest to handle but poses greatest risk of infection because of tissue reactivity (it is both a natural suture and multifilament) • Synthetic monofilament – nylon (Ethilon), polypropylene (Prolene), polybutester (Novafil) • Synthetic multifilament – nylon, polyester (Mersilene)

43. Wound Closure – Sutures - Absorbable • Natural (collagen) or Synthetic (polymers) • Natural – plain gut and chromic gut • plain gut loses tensile strength the quickest (half life 5-7 days); produces marked tissue reactivity; generally used only for oral mucosal closures (because heal so quickly) • chromic gut absorbed less rapidly than plain gut but faster than synthetics (half life 10-14 days); less tissue reactivity than plain gut because of chromic coating; useful in situations where suture removal may be difficult

44. Wound Closure – Sutures - Absorbable • Synthetic Multifilament – polyglycolic acid (Dexon), polyglactin 910 (Vicryl) • most commonly used in emerg for sq layers • Synthetic Monofilament - polyglyconate (Maxon), polydioxanone (PDS II) • Remember – presence of any suture material in a wound increases risk of infection; subcutaneous sutures have highest risk

45. Wound Closure - Staples • lower tissue reactivity than even the least reactive suture material • get less accurate closure with higher chance of malapposition of wound edges and development of scar • generally reserved for sites where scar is less of an issue (hairy scalp) • Kanegaye et al. Comparison of skin stapling devices and standard sutures for pediatric scalp laceration: A randomized study of cost and time benefits. J Pediatr 130:808, 1997

46. Wound Closure - Tapes • useful for flat, dry, nonmobile surfaces where wounds fit together with no tension –ie superficial, straight laceration under little tension • more resistant to infection than sutured wounds • adherence of tapes improved with use of benzoin to skin surface • recommend not getting wet but… • should stay in place as long as equivalent suture and will spontaneously detach as underlying epithelium exfoliates

47. Wound Closure – Tissue Adhesives (2-octylcyanoacrylate) • closes wounds by forming an adhesive layer on top of intact epithelium, which holds edges together • cause inflammatory reaction within wounds • Useful • edges less than 5 mm apart, clean, sharp edges, clean nonmobile areas, laceration less than 5 cm in length • Not useful • wounds near eye, on mucous membranes or mucosal surfaces, wet wounds or those exposed to body fluids, or in areas with dense hair, wounds under significant tension

48. Wound Closure – Tissue Adhesives (2-octylcyanoacrylate) • Literature • in selected lacerations produces cosmetic appearance that is comparable with standard suture closure • Singer et al. Prospective, randomized, controlled trial of tissue adhesive (2-octylcyanoacrylate) vs. standard wound closure techniques for laceration repair. Acad Emerg Med 1998; 5:94-99 • Quinn et al. A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of laceration. JAMA 1997;277:1527-1530 • Quinn et al. Tissue adhesive versus suture wound repair at 1 year: Randomized clinical trial correlating early, 3 month, and 1 year cosmetic outcome. Ann Emerg Med 1998;32:645-649 • Maw et al. A prospective comparison of octylcyanoacrylate tissue adhesive and suture for the closure of head and neck incisions. J Otolaryngol 1997;26:26-30 • may be useful for wounds under higher skin tension • Saxena Octylcyanoacrylate tissue adhesive in the repair of pediatric extremity lacerations. Am Surg 1999 May;65(5):470-2 • in above study they looked at 32 children with high skin tension lacerations (hand, feet, over joints). Following closure splints were applied to restrict movement

49. Wound Closure – Tissue Adhesives (2-octylcyanoacrylate) • Application • hold wound edges together with tissue forceps (???), lightly wipe applicator tip over area starting at least 5 mm from edge of wound in direction of long axis of wound (some authors support perpendicular application), 3-4 thin layers, hold wound edges together for 60 s post application • avoid ointments and dressings

50. Wound Closure – Tissue Adhesives (2-octylcyanoacrylate) • Tips • avoid latex gloves – use vinyl gloves • avoid plastic instruments (ie. tissue forceps) • if enters wound needs to be wet sponged immediately • use antibiotic ointment for removal of hardened Dermabond in wound