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Wound Management

in ED

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 8-12-hour 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

Clean Minor Wounds

All Other Wounds

< 3 doses in primary


series
Primary 3 Series
Completed
Last < 5 years ago

Td

Td + TIG

Nill

Nill

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 costeffective 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.

Emerg Med Clin N Am 21 2003


EM practice Mar. 2005
Sum search: multiple data base search.
BestBETS website

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