Wound Care Suzana Tsao, DO

Why do we care?

Layers of the Skin Closure at the dermal level Subcutaneous adds little strength Complex wounds  in/below fascial layer need multi-layer closure

Healing Initially edges retract and tissue contracts Platelet aggregation and clotting cascade activated Initial epithelialization 24-48 h Peak collagen synthesis 5-7d Strength of wound 5% at 2 weeks 35% at one month

Initial Evaluation Always start with the ABCD’s Airway Breathing Circulation Disability

Wound Evaluation Location Active bleeding Exposed tissue/bone/organs Check for peripheral pulses

History Where When How Location, location, location Golden period Mechanism Potential for foreign body

Where Anatomic location Special Consideration Mouth Ear Joints periorbital Head injuries bleed less chance of infection Hand and feet more prone to infection

When Golden Hour of Wounds Infectious inoculum 105 per gram Need 3-5 hours for proliferation of bacteria Extremities  6 hours Face and scalp  24 hours But wait ….

When to close Studies show can close as late as 19 hours on extremities ACEP clinical policy supports 8-12 hours Depends on the clinical scenario Consider other types of closure Primary closure Delayed primary closure Healing by secondary intention

How Mechanism Assess concern for foreign body Clean wound Dirty wound Contaminated wound

High Risk Mechanisms Open fractures Intraoral wounds Mamillian bites Crush injuries/devascularized tissue High pressure injuries Jagged edges/stellate shape/deeper than subcutaneous layer Foreign body Visible contamination Mamillian bites have 6% risk of infection

PMH/SocHx Co-Morbid Conditions Hand dominance Occupation Last tetanus booster

Tetanus < 3 doses in primary series Primary 3 series completed Clean/minor Tetanus toxoid All other Toxoid and immunoglobulin Primary 3 series completed < 5 years None needed > 5 years but < 10 years Clean minor All others Give toxoid > 10 years

Pertussis Give Tdap regardless of last Td to update pertussis if not updated as an adult Replaces one of the 10 year Td booster doses Boostrix when feasible for > 65 y/o Tdap during each pregnancy b/w 27 and 36 weeks CDC link http://www.cdc.gov/vaccines/vpd-vac/pertussis/recs- summary.htm

Co-Morbid Conditions Age (very young/very old) Diabetes Renal Failure Malnutrition Obesity Immunocompromised

Physical Exam Type of wound Superficial/deep Length/shape Bleeding/revascularization Associated injuries Retained foreign body Complete neurovascular exam 2 point discrimination most accurate for sensory function in extremities

Active Bleeding Direct pressure BP cuff 2 hours max Figure of 8 stitch

Associated Injuries Assess for tendon injuries 90% lacerated tendon can still maintain normal neuro function Assess for joint involvement May need to inject joint Assess for underlying fracture X-ray if suspected before manipulating the area

Retained Foreign Body Direct visualization X-ray Ultrasound CT/MRI? May need anesthesia to fully evaluate X-ray 80-90% can be detected Does not visualize organic material Ultrasound CT/MRI? RFB 5th leading cause of malpractice claims against em physicians

Indications for FB removal Reactive materials Wood Vegetative material Contaminated materials Clothes Most fb in foot Impingement on neurovascular structures Impairment of function Easy to remove

Indications for consultation Nerve injury Vascular injury Tendon or joint involvement Difficult to remove foreign body High pressure injection injury

Irrigation Dilution is the solution to the pollution Amount High pressure (5-8 psi) 30-60 cc syringe with 19 gauge angiocath or splash shield Amount Min 250ml 50-100ml/cm of laceration Type of fluid Tap water just as good as normal saline NEVER, EVER, NEVER Betadine or peroxide 1% Betadine may be ok, but no increased benefit

Debridement Remove necrotic tissue May need to debride for better approximation and cosmetic results

Sterile Gloves Several trials showed no difference if final outcome Dealer’s choice

Anesthesia Topical pretreatment Consider procedural sedation Allergies Most are from preservative Consider using cardiac lidocaine 1% Benadryl

Local vs. Regional Block Large areas When needed to avoid tissue distortion Areas where infiltration is painful Plantar surface of foot

Anesthesia Amides Esters Lidocaine Procaine Lidocaine with epinephrine Max 4.5mg/kg Duration 1-2 h Lidocaine with epinephrine Max 7mg/kg Duration 2-4 h No epi in fingers/toes, ear, nose, penis Bupivacaine Max 2mg/kg 0.25% Duration 4-8 h Esters Procaine Max 7mg/kg Duration 15-45 min

Types of Repair Primary closure Delayed primary closure Closure of the wound at the time of the ED visit Delayed primary closure Closure of wound 3-4 days after injury Healing by secondary intention Allow wound to heal without closure through scarring

Methods of Closure Tape Skin Adhesives Staples Sutures Superficial, straight, under little tension Skin Adhesives Does not involve deep layers Little tension Staples Linear on trunk, extremities, scalp Sutures

Types of Sutures Absorbable Nonabsorbable Gut PDS (polypropylene) Maxon (polyglyconate) Dexon (polyglycolic acid) Coated Vicryl (polyglactin) Nonabsorbable Dermalon or ethilon Prolene or surgilene (polypropylene) Silk steel

Suture size by location Face 5-0 to 6-0 Scalp/Chest/Back/Abdomen 3-0 to 5-0 Extremities 4-0 to 5-0 Oral 3-0 to 5-0 (absorbable)

Indications for antibiotics Prosthetic device Endocarditis prophylaxis Open joints and/or fractures Mamillian bites Intraoral lesions Immunocompromised patients Heavily contaminated wounds

Discharge instructions Signs and symptoms of infection Fever, discharge, red lines from wound, erythema, swelling Elevation +/- splinting When to do wound checks at one or two days Suture removal instructions Face 3-5 days Scalp 5 days Extremities 7-10 days, high tension 10-14 days Washing - showering - avoid long baths, pools, ocean Triple antibiotic ointment

Pearls No such thing as absolute golden hour Tap water is as good and normal saline Do not soak in betadine Nonsterile gloves ok Hand wounds less than 2cm -> big, bulky dressing as good as sutures

Pitfalls Always remember ABC’s Look for associated injuries Bone, vascular, nerve Don’t dismiss high pressure injuries Always assess for foreign body Antibiotics vs. delayed primary closure for high risk wound and/or co-morbid conditions Remember special locations Ear, nose, vermillion border Fight bites  do not close