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 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

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

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 History Clean Minor Wounds All Other Wounds < 3 doses in primary series Td Td + TIG Primary 3 Series Completed Last < 5 years ago Nill Last > 5 years ago and < 10 Last > 10 years ago

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.

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