1. WOUND MANAGEMENT M. Scott Linscott, MD University of Utah

2. WOUND MANAGEMENT  Wound assessment  Wound anesthesia  Wound debridement  Wound preparation  Antibiotics  Wound closure  Dressings

3. FACTORS THAT INCREASE RISK OF INFECTION  Prolonged time since the injury  Crush injury (vs sharp injury - knife, glass, etc.)  Puncture Wounds  Bite wounds  Heavily contaminated wounds, esp. over bursae  Wounds with risk of foreign bodies  All of the above wounds are considered “dirty”

4. PROLONGED TIME SINCE INJURY  FACE / SCALP > 24 HRS  ARM > 18 HRS  HAND > 12 HRS  TRUNK > 12 HRS  LEG > 8 HRS  FOOT > 6 HRS

5. PUNCTURE WOUNDS  SHOULD NEVER CLOSE, ESP. IF ANIMAL BITES  ON BOTTOM OF FEET, DO NOT IRRIGATE  IF POSSIBILITY OF GLASS, ETC. (RUNNING ON BEACH), MUST X-RAY OR DO ULTRASOUND (IF SUSPECT WOOD OR OTHER ISODENSE FB) TO R/O FB

8. BITE WOUNDS  DO NOT CLOSE IF PUNCTURE WOUNDS  IF CAT BITE, DO NOT CLOSE LACERATION (POSSIBLE EXCEPTION: FACE, BUT MUST GIVE ANTIBIOTICS PRIOR TO CLOSURE AND DO AT LEAST 1000 CC HIGH PRESSURE IRRIGATION)  DO NOT CLOSE MOST HUMAN, PRIMATE OR DOG BITES  ORGANISMS: PASTEURELLA MULTOCIDA, EICHINELLA CORODONS

10. BITE WOUNDS  USE PROPHYLACTIC ANTIBIOTICS IN CAT, HUMAN, PRIMATE AND DOG BITES  USE HIGH PRESSURE IRRIGATION AT LEAST 500 CC  RABIES:  NEVER IN RODENTS  IF BAT, SKUNK, OR RACCOON, MUST GET RABIES VACCINE  IF UNPROVOKED ATTACK BY DOG OR CAT AND CAN’T FIND ANIMAL, GIVE VACCINE  IF DOG OR CAT CAN BE FOUND, QUARANTEEN THEM

11. WOUND MANAGEMENT  BADLY CRUSHED, PUNCTURE WOUNDS, CAT, DOG, HUMAN BITES, “OLD” WOUNDS ALL - ”DIRTY WOUNDS”  USE 500-1000 CC IRRIGATION SOLUTION – HIGH PRESSURE  MAY NEED SHARP DEBRIDEMENT  IF NOT BITE OR DIRTY BURSAL WOUNDS, PROPHYLACTIC ANTIBIOTICS PROBABLY DON’T PREVENT INFECTION  THOROUGH CLEANING AND DEBRIDING ARE FAR MORE IMPORTANT IN PREVENTING WOUND INFECTIONS THAN ARE PROPHYLACTIC ANTIBIOTICS

12. Physical Exam  Prior to anesthesia  Always assess neurovascular status distally  Motor exam  Sensory exam  Circulatory exam  If a volar laceration of hand or finger, have patient flex finger against resistance to R/O partial flexor tendon laceration  Examine extremity wounds under a bloodless field (tourniquet) whenever possible  Examine hand, foot and joint wounds through the full range of motion to detect tendon injuries

14. ANESTHESIA  LOCAL ANESTHESIA – 1% LIDOCAINE, 0.25% BUPIVICAINE  REGIONAL ANESTHESIA – 2% LIDOCAINE, 0.5% BUPIVICAINE  NO CROSS ALLERGY BETWEEN AMIDES (LIDOCAINE, BUPIVICAINE) AND ESTERS (PROCAINE - NOVOCAINE)  ALLERGY TO AMIDES IS EXTREMELY RARE  LOCAL INFILTRATION – INJECT BELOW DERMIS, NOT INTO IT

15. DURATION OF ANESTHESIA  LIDOCAINE 1% LOCAL INFILTRATION: 45 MIN  LIDOCAINE 2% NERVE BLOCK: 2 HOURS  BUPIVICAINE 0.25% LOCAL INFILTRATION: 2 HOURS  BUPIVICAINE 0.5% NERVE BLOCK: 8-16 HRS (AVE-12 HRS)

16. ANESTHESIA  WITH EPINEPHRINE 1:100,000 DECREASES OOZING, NOT BLEEDINGDECREASES OOZING, NOT BLEEDING MINIMAL PROLONGATION OF ANESTHESIAMINIMAL PROLONGATION OF ANESTHESIA PREVENTS ABSORPTION OF LOCAL ANESTHETIC – CAN USE ALMOST TWICE AS MUCH LOCAL ANESTHETIC – 80 cc of 0.25% BUPIVICAINEPREVENTS ABSORPTION OF LOCAL ANESTHETIC – CAN USE ALMOST TWICE AS MUCH LOCAL ANESTHETIC – 80 cc of 0.25% BUPIVICAINE AVOID USING NEAR TIP OF NOSE, EARS, FINGERS, TOES, PENIS – MAY CAUSE VASOSPASM AND ISCHEMIAAVOID USING NEAR TIP OF NOSE, EARS, FINGERS, TOES, PENIS – MAY CAUSE VASOSPASM AND ISCHEMIA  TOPICALS – TAC, LAT, TA, ETC – MOST USEFUL IN CHILDREN FOR SMALL LACS, ESP. ON THE FACE NEED COMBINATION OF LOCAL ANESTHETIC PLUS EPINEED COMBINATION OF LOCAL ANESTHETIC PLUS EPI APPLY TO COTTON OR COTTON 4X4, WRING OUT, APPLY TO WOUND FOR 15-20 MINUTESAPPLY TO COTTON OR COTTON 4X4, WRING OUT, APPLY TO WOUND FOR 15-20 MINUTES

17. COMMON DIGITAL NERVE BLOCK Pic 1  INSERT 27g 1.25 INCH NEEDLE DORSALLY BETWEEN MC HEADS UNTIL TENTING THE SKIN VOLARLY  SLOWLY WITHDRAW NEEDLE, INJECTING ANESTHETIC AS THE NEEDLE IS REMOVED

18. RING BLOCK

19. WEB SPACE INJECTION

20. SUPRAORBITAL NERVE BLOCK

22. INFRAORBITAL NERVE BLOCK

23. PIC 8

24. INFRAORBITAL NERVE BLOCK

26. MENTAL NERVE BLOCK

29. POSTERIOR TIBIAL NERVE BLOCK

30. CLEANING AND DEBRIDING WOUNDS  DEBATE RE: SUPERFICIAL/CLEAN WOUNDS  SCRUBBING WITH SURECLENS/HEBICLENS AND SALINE (1:3) vs…  HIGH PRESSURE IRRIGATION (WITH CANYONS IRRIGATION SET)  NO EVIDENCE THAT ONE IS MORE EFFECTIVE THAN THE OTHER – I USE SCRUBBING  FOR DEEP/DIRTY WOUNDS, MUST USE HIGH PRESSURE IRRIGATION 500-1000 cc

31. Wound Cleansing  Dilution is the solution to pollution  High-pressure irrigation significantly reduces infection  Don’t put anything in a wound you wouldn’t put in your eye (BETADYNE, H 2 0 2 )  Saline is the recommended irrigation liquid but tap water is sterile (in U.S.), much less expensive, and as effective

32. CANYONS WOUND IRRIGATION SYSTEM

33. SKIN PREPARATION  PREP SKIN WITH BETASEPT, NOT BETADYNE  SIGNIFICANTLY BETTER ANTISEPTIC  LESS TOXIC TO WOUNDS  PREP 2-3 INCHES MORE IN DIAMETER THAN DRAPE FENESTRATION HOLE SIZE  AFTER PREP, DRAPE WOUND AND DO MORE THOROUGH DEBRIDEMENT, OFTEN SHARP WITH SCALPEL OR SCISSORS  RE-IRRIGATE AFTER DEBRIDEMENT

34. TRIM WOUND EDGES IF WOUND EDGES ARE JAGGED, OF QUESTIONABLE VIABILITY, OR THE LACERATION IS NOT ORTHAGONAL TO THE SKIN EDGE  USE A 15 BLADE TO MAKE AN EPIDERMAL INCISION, THEN COMPLETE REMOVAL OF THE JAGGED WOUND EDGE WITH SCISSORS (EASIER TO GET ORTHAGONAL CUT)  DO NOT TRIM: SCALP (INGROWN HAIRS) SCALP (INGROWN HAIRS) EARS, EYEBROWS, EYELIDS AND LIPS (LOSS OF TISSUE – POOR COSMETIC RESULT) EARS, EYEBROWS, EYELIDS AND LIPS (LOSS OF TISSUE – POOR COSMETIC RESULT)

35. DECISION TO DO PRIMARY CLOSURE OR DELAYED PRIMARY CLOSURE  NEVER CLOSE A DIRTY WOUND  FOR THESE WOUNDS DO DELAYED PRIMARY CLOSURE  DO WET-TO-DRY DRESSING CHANGE DAILY  CLOSE THE WOUND IN 4 DAYS  DO CLOSURE AS YOU WOULD A PRIMARY CLOSURE  VERY LOW INCIDENCE OF INFECTION  SIMILAR COSMETIC RESULT

36. ANTIBIOTICS IN WOUND MANAGEMENT PROPHYLACTIC ANTIBIOTICS  INDICATED FOR CAT, HUMAN, PRIMATE AND DOG BITES; DIRTY WOUNDS OVER BURSAE  SHOULD BE GIVEN FOR 48 HOURS  MULTIPLE OPTIONS AUGMENTIN 875 mg bid OR 500 mg tid X 2 DAYSAUGMENTIN 875 mg bid OR 500 mg tid X 2 DAYS ROCEFIN 500 mg IM qd X 2 DAYSROCEFIN 500 mg IM qd X 2 DAYS LEVOFLOXACIN 500 mg qd X 2 DAYSLEVOFLOXACIN 500 mg qd X 2 DAYS ALL OF THESE ARE EFFECTIVE FOR P. MULTOCIDA, E. CORRODENS, STAPH, STREPALL OF THESE ARE EFFECTIVE FOR P. MULTOCIDA, E. CORRODENS, STAPH, STREP

38. INFECTED WOUNDS INFECTED WOUNDS  USUALLY >1 cm ERYTHEMA / WARMTH BEYOUND THE SKIN EDGE  IF WOUND SUTURED OR STAPLED, REMOVE ALL SUTURES AND/OR STAPLES  IRRIGATE, DEBRIDE WOUND AND LOOK FOR FOREIGN BODIES  WET–TO–DRY DRESSING CHANGES DAILY

39. ANTIBIOTICS FOR INFECTED WOUNDS  ANTIBIOTICS:  BITE WOUNDS: UNASYN / AUGMENTIN; LEVAFLOXACIN  OTHER INFECTED WOUNDS  MUST BE CONCERNED RE: MRSA – IV VANCOMYCIN, IV CLINDAMYCIN, ORAL CLINDAMYCIN, SULFAMETHOXAZOLE TRIMETHAPRIM +/- RIFAMPIN  IF UNLIKELY TO BE MRSA: AUGMENTIN, LEVAQUIN

40. Wound Closure Options  Sutures  Staples  Glue  Steri-strips  Delayed primary closure  Leave open

41. Basic Principles  Everted edges will result in less scarring  Use the smallest suture needed to approximate the edges  Use small sutures placed closer together rather than large ones placed further apart  Approximate, don’t strangulate the edges

42. Simple Interrupted Stitch

45. Vertical Mattress Stitch

47.  Used to evert tissue at the wound edges  Decreases tension at the wound edge  Can be used in combination with simple sutures to assure eversion

48. Horizontal Mattress Stitch

50. Corner Stitch

52. Running Stitch

53. Problem of Scar Spreading  Patients end up with ½ inch wide scars on legs, arms, trunk  Takes 2 years for a wound to completely heal  Wound has 97% of it’s tensile strength in 6 months  If put skin sutures in and take out in 1-2 weeks, the wound pulls apart and is filled with scar tissue = wide scar  Can obviate this by using buried, interrupted, subcuticular sutures  Use PDS, Maxon – monofilament absorbable sutures  These dissolve in 6 months and effectively prevent scar spreading

54. Buried Subcuticular Stitch

56. Problem of Scar Spreading  After closing with absorbable subcuticular sutures, usually have a slight gap between the edges of epidermis  Use steristrips, dermabond, or running 6-0 monofilament sutures to close this gap.  Advantages of subcuticular closure are:  No scar spreading  Can remove skin sutures in 4-5 days, rather than 7-14, this avoiding stitch marks

57. Subcuticular sutures  Do not use a two-layer closure on:  Scalp  Ears  Tip of nose  Hands  Feet  Increased incidence of infection with additional foreign body present

58. Facial Lacerations  The face is unique – subcutaneous tissue and muscle are attached to the skin (why we can wrinkle our foreheads, smile)  If laceration through the muscle, close the muscle and subcutaneous tissue with 4-0 or 5-0 Vicryl or Polysorb (braided absorbable sutures) – will prevent scar spreading  Don’t need to use subcuticular sutures, only subcutaneous sutures

59. Staples  Usually used only for scalp lacerations in the ED  Recommended for linear wounds without significant tension  Except scalp, remove 2-3 days earlier than sutures. Scalp – 7 days  Should be replaced with steristrips after removal

62. GLUE (DERMABOND)

65. DRESSINGS  PREVENT FOREIGN BODIES AND BACTERIA FROM ENTERING WOUND  VANITY  BACITRACIN, ADAPTIC, 4X4  KLING, KERLEX, TUBE GUAZE, TAPE  KEEP ON AND KEEP DRY FOR 48 HOURS, THEN REMOVE, CHECK WOUND, BATHE  REDRESS OR LEAVE OPEN  CHANGE IF BLOOD SOAKS THROUGH DRESSING (GOOD IDEA TO GIVE Pt MATERIAL FOR ONE DRESSING CHANGE AT DC)

66. SUTURE REMOVAL  SCALP – 7 DAYS  FACE – 4-5 DAYS, THEN STERISTRIP  UPPER EXTREMITIES – 7 DAYS, EXCEPT AREAS WHERE THERE IS EXCESS MOVEMENT (HANDS) AND OVER EXTENSOR SURFACES (DIP, PIP, MCP, ELBOW) – 14 DAYS  NECK, TRUNK – 10 DAYS  LOWER EXTREMITY – 12-14 DAYS  IF USE SUBCUTICULAR SUTURES – 3-4 DAYS

67. Sharps Safety  Most likely time to get stuck is in your first three years of learning  1 million occupational needle sticks per year in U.S. – much less now with safety needles  Don’t hold the needle with your fingers!  Use forceps  Always know where the needle is in your field  Dispose of all sharps after procedure

68. QUESTIONS?