1. Wound Management in 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%

12. Wound preparation Anesthesia : Local anesthetic injections
Topical anesthetics
Regional anesthetics

13. 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

14. Topical anesthesia
TAC (tetracaine, %; adrenaline, %; cocaine, %)
SE : seizures, arrhythmias, and cardiac arrest .

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

16. 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.

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

18. 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 .

19. 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.

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

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

22. Irrigation Fluid Hydrogen peroxide no role, tissue toxic.
Tap water : low cast, available.
Sandy : Medline /03, 397 papers found
Tap water is a safe and effective solution for cleaning recent wounds requiring closure and is the treatment of choice

23. 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.

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

25. 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 hours or more for the face and scalp

26. 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

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

28. Glue :Octyl cyanoacrylate
FDA approval in =Dermabond®
50% of the strength of 5-0 suture material.
Cochrane review : comparable cosmetic outcomes compared to standard suturing

29. 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 /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

30. 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

31. 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)

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

33. Surgical Tapes Steri-Strips
least reactive of all closure techniques
lowest tensile strength
May require tincture of benzoin
Avoid in hairy and wet area.

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

35. “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 .

36. 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.

37. 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.

38. 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

39. Topical Antibiotics
Dire et al, triple antibiotic ointment reduced the incidence of postclosure infection compared to a petroleum jelly control ( % for bacitracin and Neosporin® vs 17.6% for petroleum control).
BestBETs :Medline /02 , 71 papers.
There is not enough evidence here to change current practice. A large multicentre study is indicated to provide more relevant answers

40. 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

41. 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.

42. 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.

43. 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 .

44. 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.

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

46. References : Emerg Med Clin N Am 21 2003 EM practice Mar. 2005
Sum search: multiple data base search.
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