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Wound Management in ED

Wound Management in ED. Hood Al- Abri. 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.

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Wound Management in ED

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  1. Wound Managementin ED Hood Al-Abri

  2. 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

  3. 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

  4. 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

  5. The Goals • Create optimal conditions for the patient to heal themselves. • Preserve function. • Minimize complications. • Improve the chances of a cosmetically pleasing result

  6. 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

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

  8. 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.

  9. 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

  10. Foreign Bodies • wood and plastic foreign bodies • Ct scan / MRI • U/S :sensitivity of 95-98% and a specificity of 89-98%

  11. Wound preparation Anesthesia : • Local anesthetic injections • Topical anesthetics • Regional anesthetics

  12. 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

  13. Topical anesthesia • TAC (tetracaine, 0.25-0.5%; adrenaline, 0.025-0.05%; cocaine, 4-11.8%) • SE : seizures, arrhythmias, and cardiac arrest .

  14. Topical anesthesia • LET (lidocaine, 4%; epinephrine, 0.1%; tetracaine, 0.5%) • Face and scalp • Liquid or gel forms

  15. 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.

  16. Non-sterile gloves, which provide “universal precaution “ is appropriate. • Latex gloves should also be avoided

  17. 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 .

  18. 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.

  19. Wound Irrigation • minimum of 250 cc • 60 cc/ cm wound length • Large volume with low pressure may be good.

  20. Irrigation Fluid • Sterile saline solution • Povidone-Iodine Solution (Betadine®) 10% - tissue toxic -did not reduce infection incidence. • Diluted betadine : use indeterminate.

  21. 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

  22. 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.

  23. Debridement • old technique with little recent research • tissue loss versus function • delayed primary closure.

  24. 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

  25. Closure MethodsSutures • 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

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

  27. 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

  28. Glue Simon : • 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

  29. 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

  30. 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)

  31. staples • Fast ,low wound reactivity and infection rate. • Less expensive. • Less needle sticks risk. • No cosmetic difference. • Scalp, trunk, and extremity.

  32. Surgical TapesSteri-Strips • least reactive of all closure techniques • lowest tensile strength • May require tincture of benzoin • Avoid in hairy and wet area.

  33. Surgical Tapes • simple, low-tension pediatric facial wounds, Steri-Strips™ resulted in a cosmetically equivalent wound closure compared to cyanoacrylate closure

  34. “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.

  35. 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.

  36. 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.

  37. 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

  38. 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

  39. Tetanus Prophylaxis Recommendations

  40. Cost- And Time-Effective Strategies For Wound Care • 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.

  41. 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.

  42. 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 .

  43. 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.

  44. Summary • determine if it is appropriate to close a wound primarily • prevention of a wound infection • multitude of wound closure methods including “needleless” methods.

  45. References: • Emerg Med Clin N Am 21 2003 • EM practice Mar. 2005 • Sum search: multiple data base search. • BestBETS website • Google search

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