Wound Management in ED

Hood Al-Abri

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

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

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

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

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

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

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.

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

Foreign Bodies
wood and plastic foreign bodies
Ct scan / MRI

U/S :sensitivity of 95-98% and a specificity of 89-98%

Wound preparation
Anesthesia : Local anesthetic injections
Topical anesthetics Regional anesthetics

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

Topical anesthesia
TAC (tetracaine, 0.25-0.5%; adrenaline, 0.0250.05%; cocaine, 4-11.8%) SE : seizures, arrhythmias, and cardiac arrest .

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

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.

 Non-sterile gloves, which provide universal precaution is appropriate.

Latex gloves should also be avoided

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

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.

Wound Irrigation
minimum of 250 cc
60 cc/ cm wound length

Large volume with low pressure may be good.

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

Irrigation Fluid
Hydrogen peroxide no role, tissue toxic. Tap water : low cast, available.
Sandy : Medline 1966-10/03, 397 papers found

Tap water is a safe and effective solution for cleaning recent wounds requiring closure and is the treatment of choice

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.

Debridement
old technique with little recent research
tissue loss versus function

delayed primary closure.

Golden period
safe time interval from wounding that allows primary wound closure
The ACEP clinical policy for penetrating injury of the extremity supports an 8-12hour cutoff for primary wound closure. 6-10 hours - wounds of the extremities and up to 10-12 hours or more for the face and scalp

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

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
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 1966-07/99 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

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

Dont glue me
stellate lacerations Bites, punctures or crush wounds Contaminated wounds Mucosal surfaces Axillae and perineum (highmoisture 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.

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

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 .

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.

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

Topical Antibiotics
Dire et al, triple antibiotic ointment reduced the incidence of postclosure infection compared to a petroleum jelly control (4.5-5.5% for bacitracin and Neosporin vs 17.6% for petroleum control). BestBETs :Medline 1966-07/02

71 papers.

There is not enough evidence here to change current practice. A large multicentre study is indicated to provide more relevant answers

Tetanus Prophylaxis Recommendations

Tetanus History < 3 doses in primary series Primary 3 Series Completed Last < 5 years ago Nill Nill Clean Minor Wounds Td All Other Wounds Td + TIG

Last > 5 years ago and Nill < 10

Last > 10 years ago Td

Td
Td

Cost- And Time-Effective Strategies

For Wound Care
1. 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.

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.

The future
Growth factors :epidermal growth factor (EGF),
fibroblast growth factor (FGF), insulin-like growth factor (IGF), keratinocyte growth factor (KGF), and plateletderived growth factor (PDGF).

PDGF gel has been shown to speed healing of punch biopsy wounds chambers filled with antibiotics and growth factors

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.

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

References :
1. 2. 3. 4. 5. Emerg Med Clin N Am 21 2003 EM practice Mar. 2005 Sum search: multiple data base search. BestBETS website Google search