WOUND EVALUATION & CARE Rachel Steinhart, MD, MPH Emergency Medicine CCRMC Family Practice Resident ER Rotation - August 2009

General Wound Evaluation History: Mechanism Mechanism Time Time Foreign Body Foreign Body Medical Conditions Medical Conditions Allergies Allergies Tetanus Status Tetanus StatusExam: Size Size Location Location Contaminants Contaminants Neurovascular Neurovascular Tendons & Bones Tendons & Bones

TETANUS PRONE WOUND?   Compound fractures   Deep penetrating wounds   Wounds containing foreign bodies (especially wood)   Wounds complicated by pyogenic infections   Wounds with extensive tissue damage   Burns   Wounds contaminated with soil, dust or horse manure   Re-implantation of an avulsed tooth

Recommendations for tetanus prophylaxis 3 doses History of Tetanus Immunization TdTIGTdTIG Uncertain or <3 dosesYesNoYes Last dose within 5 yNo Last dose 5-10 yNo YesNo Last dose >10 yYesNoYesNo Not Prone Prone Be certain to clarify history of dT - patients confuse PPD with dT CAUTION with tetanus prone wounds in elderly & foreign born => Seriously consider TIG => Seriously consider TIG

Importantwounds to recognize

High Pressure Injection Injury Extent of injury easy to underestimate

PATIENT WITH HIGH PRESSURE INJECTION WOUND NEEDS URGENT SURGICAL CONSULTATION FOR TIMELY DEBRIDEMENT TO AVOID LOSS OF LIMB

Knuckle Laceration = Fight Bite

Fight Bite   Avoid closing any wound over a knuckle unless you have explained to the patient the risks of closing a wound that has had contact with saliva PATIENT WITH INFECTED FIGHT BITE NEEDS URGENT SURGICAL CONSULTATION FOR TIMELY DEBRIDEMENT TO AVOID LOSS OF LIMB

Know Kanaval’s Signs for Flexor Tenosynovitis

Kanavel’s Signs   Fusiform swelling   Finger held in flexion   Severe pain with passive extension   Tenderness to palpation along proximal tendon sheath URGENT SURGICAL CONSULTATION REQUIRED FOR TIMELY DEBRIDEMENT TO AVOID LIMB LOSS

TASER INJURY

Taser injury is a marker for “AGITATED DELIRIUM” Pull dart Basic puncture wound care Verify tetanus Assess for rhabdomyolysis - UA Beware of chest pain complaint

Necrotizing Fasciitis

 Pain out of proportion  Toxic appearance  Tachycardia  Hypotension  Crepitus  Dishwater drainage  Disrupted fascia IMMEDIATE SURGICAL CONSULTATION REQUIRED FOR EMERGENT DEBRIDEMENT TO AVOID LOSS OF LIFE OR LIMB

Wound Closure  Anesthesia  Wound preparation  Time to closure  Closure techniques  Post closure management

Properties of commonly used local anesthetics: AgentClass Max. safe dose mg/kg Onset (min) Duration (hrs) Procaine (Novocaine) Ester Procaine + Epi LidocaineAmide Lidocaine + Epi72-4 Bupivacaine (Marcaine) Amide Bupivacaine + Epi38-16

Reducing pain of local anaesthetic infiltration:  1-Small-bore needles  2-Buffered solutions  3-Warmed solutions  4-Slow rates of injection  5-Injection through wound edges  6-Subcutaneous rather than intradermal injection  7- Pretreatment with topical anesthetics

Consider regional nerve block   May save time   Decrease possibility of systemic toxicity with large wound area   Less painful than local infiltration   Avoid volume-related tissue distortion

Skin and Wound Preparation   Remove hair? → NO   Disinfect skin? → NO (H2O2, iodine)   Debride wound? → YES   Irrigate wound? → YES (Tap=Bottled) Pressure & volume important   Sterile gloves? → NO (infection rate same)

Foreign Bodies   Most glass, metal, and gravel are radiopaque   Wood and some aluminum are radiolucent   Glass is visualizable on 2-view radiographs if it is  2 mm, gravel if it is  1 mm   It is always wise to discuss risk of retained foreign body in spite of aggressive exploration and irrigation

Wound Closure   Time to closure   Delayed primary closure   Options Glue Staples Sutures   Suturing method

TIME TO CLOSURE Berk WA: Evaluation of the "golden period" for wound repair: 204 Cases from a third world ED. Ann Em Med <19 hours to repair 92% satisfactory healing >19 hours to repair 77% satisfactory healing Exception: head and face lacerations had 95.5% satisfactory healing, regardless of time Morgan WJ: The delayed treatment of wounds of the hand and forearm under antibiotic cover. Br J Surg hand and forearm lacerations closed < 4hr had infection rate 7% closed > 4hr had infection rate 21%

Delayed primary wound closure   High risk wounds that are contaminated or contain devitalized tissue   Wound is initially cleansed and debrided   Covered with gauze   Leave undisturbed for 4 to 5 days   If the wound is uninfected at the end of the waiting period, it is closed with sutures or skin tapes

TISSUE ADHESIVE   S. Mizrahi: Use of Tissue Adhesives in the Repair of Lacerations in Children. Journal of Pediatric Surgery,April, pediatric patients with simple laceration glued in ED Infection 1.8% Dehiscence 0.6%

Which laceration?   Short (< 6-8 cm)   Low tension (< 0.5 cm gap)   Clean edged   Straight to curvilinear wounds that do not cross joints or creases

Contraindications for glue   Jagged or stellate lacerations   Bites, punctures or crush wounds   Contaminated wounds   Mucosal surfaces   Axillae & perineum (high-moisture areas)   Hands, feet & joints (unless kept dry and immobilized)

STAPLES  Consider staples for linear lacerations not involving the face  Frequently used for scalp, trunk, extremities  Optimally, two operators perform this procedure  Cosmetic effect is equivalent to sutures/glue

SUTURES Simple interrupted  Most common  Easy to master  Can adjust tension with each suture  Stellate, multiple components, or directions wound Simple running  Minimize time of suture repair  Even distribution of tension  Low-tension, simple linear wounds  Removed within 7 days to avoid suture marks  Optimal suture material is non-absorbable

Prophylactic Antibiotics?  Bite wounds  Contaminated or devitalized wounds  High risk sites eg. Foot  Immunocompromised  Risk for infective endocarditis  Intraoral through and through lacerations  PVD  DM  Lymphedema  Indwelling prosthetic device  Extensive soft tissue injury  Deep puncture wounds

Prophylactic Antibiotics? 3-5 Days  Augmentin  Keflex  Erythromycin

Alternate Suturing Techniques

SIMPLE RUNNING

Horizontal Mattress   Cause wound edges eversion   Single layer closure with significant tension   Decrease repair time, less knots required   Need delayed suture removal, so risk of suture marks

Vertical Mattress   High-tension wounds   Prone to skin suture marks if left in too long

COMPLEX WOUND CLOSURE

COSMETIC ISSUES

HIGH RISK COMPLEX LACERATIONS

- Do NOT suture cartilage - Give antibiotics

Possible lacrimal duct laceration - Consult optho

Possible parotid duct laceration - Consult ENT/HNS

Suggested Suture Removal Time AreaRemoval time (days) Face3 to 5 Neck5 to 8 Scalp7 to 9 Upper extremity8 to 14 Trunk10 to 14 Extensor surface Hands14 Lower extremity14 to 28

DISCHARGE  Keep initial dressing clean, dry, and in place for first 24 hours  After 24 hours okay to wash but not soak  Apply antibiotic ointment 2 times daily - primarily to facilitate suture removal  If extremity splinted to avoid dehiscence, keep splint in place at all times  Return for progressive redness, swelling, pus or pain

Procedure Note  Size location and shape of wound  Thorough sensory-motor & vascular exam  Wound explored in bloodless field, no FB  Amount and type of anesthesia  Amount, type and method of irrigation  Number & type of stitches & suture used  Dressing applied  Instructions to patient  Tetanus & Antibiotics