Wound Management.

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

What is a Wound? Any break in the continuity of body tissue Examples: grazes, burns, surgical incisions, stabs, leg ulcers, decubitus ulcers ( pressure sores)

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

Wound preparation Anesthesia : Local anesthetic injections Topical anesthetics Regional anesthetics

Stages of Wound Healing Stage 1 - traumatic inflammation ( 0-3 days)- redness, heat, swelling Stage 2 -destructive phase ( 2-5 days)- polymorphs and macrophages clear the wound of debris and stimulate new growth Stage 3- the proliferative phase( 3-24 days increased collagen formation Stage 4- maturation phase ( 24 days-1 year) scar tissue decreases granulating tissue gets stronger and changes from reddish to pale

. Wound healing is complex and affected by intrinsic (patient related) and extrinsic (wound related) factors and this affects the choice of treatment Holistic assessment - treat the whole person (e.g. full medical history, factors which may delay healing such as immobility, poor nutrition, obesity, personal circumstances) Signs of clinical infection tetanus immunization

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.

Cleansing wounds: an area where ritualistic practice predominates Key questions: 1. Does the wound really need cleaning? 2. What is the safest method that causes no ill effects and maintains the wound temperature? 3. What is acceptable to the patient? Wounds that are clean and healthy do not require cleaning and should be left alone

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

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

Irrigation Fluid Tap water : low cast, available. Sandy : Medline /03, 397 papers found 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.

NHS Wound care is a high cost area for patients and NHS in terms of prescribing costs, patient Quality indicators and NHS workforce time Value for money for the NHS is an important factor when choosing treatments.

Wound Closure Primary closure –Suture, staple, adhesive, or tape –Performed on recently sustained lacerations: <12 hours generally and <24 hours on face Secondary closure –Secondary intent –Allowed to granulate Tertiary closure –Delayed primary (observed for 4-5 days)

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

Suture Material Absorbable –Chromic gut –Vicryl Non-Absorbable –Silk –Prolene Monofilament vs. braided

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 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.

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.

MOIST WOUNDS If its wet……..DRY it! If its dry………MOISTEN it! If its irritated…SOOTHE it! If its chronic…IRRITATE it! If its palliative..COMFORT it!

Tetanus Prophylaxis Recommendations IMMUNISATION STATUS CLEAN WOUNDTETANUS-PRONE WOUND Vaccine Human Tetanus Immunoglobulin Fully immunised, i.e. has received a total of 5 doses of vaccine at appropriate intervals None required Only if high risk Primary immunisation complete, boosters incomplete but up to date None required (unless next dose due soon and convenient to give now) Only if high risk Primary immunisation incomplete or boosters not up to date A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity) Yes: one dose of human tetanus immunoglobulin in a different site Not immunised or immunisation status not known or uncertain An immediate dose of vaccine followed, if records confirm the need, by completion of a full 5- dose course to ensure future immunity Yes: one dose of human tetanus immunoglobulin in a different site

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

Wound Preparation – Antibiotics Dog & cat bites –Cover pasteurella –Augmentin Human bites –Cover eikenella –Augmentin Puncture wounds –Cover pseudomonas –Cipro

Wound Preparation – Antibiotics Infections occur in ~3-5% of traumatic wounds seen in the ED Factors that increase risk –Heavily contaminated wound, especially with soil –Immunocompromised patients –Diabetics –Human bites > animal bites Most important prevention  adequate irrigation & debridement

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 wounds chambers filled with antibiotics and growth factors.