WOUND CARE AND REPAIR

FARAS ABUZEYAD, MD.

Epidemiology:
In

USA > 10,000,000 annual ER visits Average cost of $200 per patient
Hollander et

al: Wound Registry: Development and Validation. Ann Emerg Med, May 1995.

Causes of traumatic wounds:

Cause of wound Blunt object Sharp object Glass Wood Bite Human Dog Others No. of Patients % 42 34 13 4 6 1 3 5

Distribution of traumatic wounds:

Location of Wound Head and Neck Trunk Upper Extremities Lower Extremities No. of Patients (%) 51 2 34 13

Malpractice:

Karcz: Malpractice claims against emergency physicians in Massachusetts; 1975-1993. Am J Emerg Med 1996. wounds claims 19.85%, and 3.15% total expenses ($1,235,597) American College of Emergency Physicians. Foresight Issue 49, September 2000: Laceration mismanagement & failure to diagnose a retained foreign body is the 2nd most common malpractice claims against emergency physician

Condition 1- Missed fracture 2- Wound care

% Claims 14 12

% Total dollars paid 17 8

3- Missed MI 4- Abdominal pain 5- Missed meningitis 6- Spinal cord injury 7- SAH / Stroke
8- Ectopic pregnancy

10 9 3.5 3 3

24 4 8 8 6

What patients want?

Adam:

Patient Priorities With Traumatic Lacerations. Am J Emerg Med, October 2000.

Aspect of Care

All Participants Facial (n = 679) Lacerations (n = 78) 28% 27%

Other Lacerations (n = 263) 26%

Normal function

Avoiding infection
Cosmetic outcome Least pain Length of stay Compassion Cost Days missed Total

20%
17% 17% 10% 5% 1% 2% 100%

14%
33% 11% 8% 4% 1% 1% 100%

23%
14% 18% 10% 5% 1% 3% 100%

Evaluation:
History: Mechanism Time FB Medical conditions Allergies Tetanus status Exam: Size Location Contaminants Neurovascular Tendons

Universal Precautions:
CDC

published guidelines on use of universal precautions. Use of protective barriers: eg. Gloves/ gowns/ masks/ eyewear Will decrease exposure to infective material.

Gloves:

Use latex free gloves Since March 1999, FDA reported: 2,330 latex allergic reactions including 21 deaths

Bodiwala: Surgical gloves during wound repair in the accident and emergency department. Lancet 1982. randomized 337 patients to gloves or careful hand-washing, no gloves:
INFECTION GLOVES NO GLOVES

None Mild Severe

167 (82.7%) 27 (13.4%) 8 (4.0%)

170 (82.5%) 27 (13.1%) 9 (4.4%)

 Caliendo:

Surgical masks during laceration repair. J Am Coll Emerg Phys 1976. Alternated face mask / no mask for 99 wound repairs: Mask: 1 / 47 infected No mask: 0 / 42 infected

Local Anesthesia: 2 main groups

1- Esters: Cocaine Procaine (Novocain) Benzocaine (Cetacaine) Tetracaine (Pontocaine) Chloroprocaine (Nesacaine)
2- Amides: Lidocaine (Xylocaine) Mepivacaine (Polocaine, Carbocaine) Bupivacaine (Marcaine) Etidocaine (Duranest) Prilocaine

Properties of commonly used local anesthetics:

Agent Procaine Procaine + Epi Lidocaine Lidocaine + Epi Amide Class Ester Max. save dose mg/kg 7 9 5 7 2-5 Onset (min) 2-5 Duration (hrs) 0.25-0.75 0.5-1.5 1-2 2-4

Bupivacaine
Bupivacaine + Epi

Amide

2
3

2-5

4-8
8-16

Why Lidocaine?
Less

painful Rapid onset Less cardiotoxic Less expensive

Morris: Comparison of pain associated with intradermal and subcutaneous infiltration with various local anesthetic solutions. Anesth Analg 1987. 24 volunteers each injected with 5 anesthetic agents and NS visual analog pain scale Etidocaine> Bupivacaine> Mepivacaine> NS> Chloroprocaine> Lidocaine (least painful)

Methods to reduce pain of Lidocaine local 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

1-Small-bore needles: Edlich, 1988: 30-gauge hurts less than a 27-gauge 27-gauge hurts less than a 25-gauge, etc.

2-Buffered solutions:

with sodium bicarbonate at a ratio of 1:10 change in the pH of the anesthetic solution does not increase wound infection rates No compromise to anesthesia effect

Studies on buffered lidocaine:

Study McKay, 1987 Christoph, 1988 Bartfield, 1990 Orlinsky, 1992 Brogan, 1995 Number 24 Volunteers 25 Volunteers 91 Patients 61 Patients 45 Patients Pain score Reduced Reduced No Difference Reduced Reduced

Fatovich, 1999

135 Adults + 136 children

No Difference

3-Warmed solutions:
Study Number Temp. (C) Pain score

Brogan, 1995 45 Patients Martin, 1996 40 Volunteers Colaric, 1998 20 Volunteers

20 vs 37.6 Reduced 20 vs 37 20 vs 37 Reduced Reduced

Warming and Buffering have synergistic effect:

Mader, 1994 and Bartfield, 1995: Effect of warming and buffering on pain of Lidocaine infiltration. Warming and Buffering have synergistic effect in reducing pain Temp. used 40 and 38.9 C vs room temp.

4-Slow rates of injection:

Study Krause, 1997 Scarfone, 1998 Number 29 Volunteers Injection Rate 0.1ml/sec vs 1ml/sec 1ml/5sec vs 1ml/30sec Pain score Reduced with slow rate Reduced with slow rate

42 patients

5-Injection through wound edges:

Study
Kelly, 1994 Bartfield, 1998

Number
81 patients 63 patients

Pain score
Reduced Reduced

6-Subcutaneous rather than intradermal

injection:

7- Pretreatment with topical anesthetics:

Study Bartfield, 1995 Bartfield, 1996 Number Agent Pain score Reduced Reduced

54 Patients Lidocaine 57 Patients Tetracaine

8- Digital / Regional nerve block:

A critical skill for all ED physicians Save time Decrease possibility of systemic toxicity Less painful than local infiltration Do not cause the volume-related tissue distortion

Topical Anesthetic instead of local:

TAC: Tetracaine 25 cc of 2% solution Adrenalin 50 cc of a 1:1000 solution Cocaine 11.8 gm Pryor, 1980 and Hegenbarth, 1990: topical TAC vs lidocaine infiltration, in laceration repair No significant difference in anesthetic efficacy

TAC:
Down sides are: Not reliable when used below the head Tissue toxic, Case reports of death and seizures Corneal damage Intense vasoconstriction avoid in digits, nose, pinna and penis Must be mixed by hospital pharmacist Not approved by FDA Expensive up to $35 / dose

LAT, LET, or XAP:

Lidocaine 15cc of 2% viscous Adrenaline 7.5cc of 1:1000 topical Tetracaine 7.5cc of 2% topical Ernst-1995, Blackburn-1995, Ernst-1997: showed effective anesthesia if left in place for 15 to 20 minutes Schilling-1995 and Amy-1995: As efficacious as TAC $5 / dose Much less potential for significant toxicity

Lidocaine with Epinepkrine:

In animal models, there is theoretic concern for increased risk of wound infection Tissue ischemia and necrosis if injected in digits

Skin and Wound preparation:

1- Hair removal 2- Disinfecting the skin 3- Debridement 4-Wound Cleansing and Irrigation 5-Soaking

1- Hair removal: To shave or not to shave!

Seropian, 1971: 406 clean surgical wounds If shaved pre-op, 3.1% infection rate If depilated, 0.6% infection rate Howell, 1988: 68 scalp lacerations repaired without hair removal (93% within 3 hours of injury), no infection at 5day follow-up

2- Disinfecting the skin:

An ideal agent does not exist either tissue toxic or poorly bacteriostatic Simple scrub water around wound should be sufficient No studies have demonstrated the impact of cleaning intact skin on infection rate, however it is important to decrease bacterial load to minimize ongoing wound contamination. Avoid mechanical scrubbing unless heavily contaminated (increase inflammation in animal data)

Solution N. Saline

Antimicrobial activity

Mechanism of action Washing action

Uses Cleanse surrounding skin / irrigation

Tissue toxicity

+ + + + -

+ + + + -

Povidine-iodine 10%, 1% Chlorhexidine 1%, 0.1% Hydrogen Peroxide Hexachlorophene Nonionic detergents

Germicide

Cleanse surrounding skin, ? Irrigation contaminated wounds

Bacteriostatic Bactericidal

Cleanse surrounding skin Cleanse contaminated wounds Cleanse surrounding skin Wound cleanser

Bacteriostatic Wound cleanser

3- Debridement:

Devitalized soft tissue acts as a culture medium promoting bacterial growth Inhibits leukocyte phagocytosis of bacteria and subsequent kill Anaerobic environment within the devitalized tissue may also limit leukocyte function

Dhingra V: Periphral Dissemination of Bacteria in Contaminated Wounds: Role of Devitalized tissue: Evaluation of Therapeutic Measures. Surgery, 1976. Animal study, devitalized wounds contaminated with 3 Bacteria, treated with NS jet irrigation or debridement at 2, 4, 6 hr Debridement more effective in reducing bacteria count and infection rate

4-Wound Cleansing and Irrigation:

Decreasing wound contamination and hence infection, "the solution to pollution is dilution." Indications Methods Pressure Solution Volume Side effects

1- Indications:

Any contaminated or bite wounds Animal and human studies demonstrate irrigation lowers infection rates in contaminated wounds Hollander JE et al: Irrigation in facial and scalp lacerations: Does it alter outcome? Ann Emerg Med 1998. 1,923 patients 1,090 patients received saline irrigation, and 833 patients did not Nonbite, noncontaminated facial skin or scalp lacerations who presented less than 6 hours No difference in wound infection rate or cosmetic appearance

2- Methods:

Bulb syringe IV bag +/- pressure cuff Syringe and needle Jet lavage

3- Pressure:

lack of clinical studies recommend irrigation pressures in the range of 5 to 8 psi High-pressure irrigation is defined as more than 8 psi (use of a 30- to 60-mL syringe and a 18-20 gauge needle) Animal studies: Rodeheaver, 1975 & Stevenson, 1976, high-pressure irrigation reduce both bacterial wound counts and wound infection rates

4- Solution:
Ideal solution must be: Not toxic to tissues Does not increase rate of infection Does not delay healing Does not reduce tensile strength of wound healing Inexpensive

Dire DJ: A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990. 531 patients were randomized into 3 groups, and irrigated with: NS, 1% PI, or pluronic F-68 No difference in wound infection rate NS has the lowest cost

Lineaweaver: Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg, 1985. 1% povidone-iodine 3% hydrogen peroxide 0.25% acetic acid 0.5% sodium hypochlorite assayed in vitro using cultures of human fibroblasts and Staphylococcus aureus All agents tested killed 100 percent of exposed fibroblasts

Then he looked at different dilutions povidone-iodine 0.01, 0.001, 0.0001% sodium hypochlorite 0.05, 0.005, 0.0005% hydrogen peroxide 3.0, 0.3, 0.03, 0.003% acetic acid 0.25, 0.025, 0.0025% ONLY antiseptic not harmful to fibroblasts yet still bacteriostatic was Povidone iodine 0.001%

Moscati: Comparison of normal saline with tap water for wound irrigation. Am J Emerg Med 1998. lacerations were made on each animal and inoculated with standardized concentrations of Staph. aureus irrigation with 250 cc of either NS from a sterile syringe or water from a tap no difference in bacterial count in 2 groups

Lammers:Bacterial counts in experimental, contaminated crush wounds irrigated with various concentrations of cefazolin and penicillin. Richard Lammers, American Journal of Emergency Medicine, January 2001. An animal bite wound model was created inoculated with 0.4 mL of a standard bacterial solution each wound was scrubbed for 30 seconds with 20% poloxamer 188 and then irrigated with 100 mL of one of 4 solutions: NS(control); cefazolin + penicillin G (LD); CZ + PCN (ID); and CZ + PCN (HD) No differences in the bacterial counts or infection rates

Kaczmarek, 1982: Cultured open bottles of saline irrigating solution 36/169 1000cc bottles were contaminated 16/105 500cc bottles were contaminated Brown, 1985: Approximately one in five of the opened bottles use for irrigation were contaminated

4- Volume:

Irrigation volume not studied use 50 mL to 100 mL of irrigant per cm of laceration

5- Side effects:

Increase tissue inflammation (very high pressure irrigation), but benefit outweigh risk Splatter (use your hand or plastic shield)

5- Soaking:
Lammers: Effect of povidone-iodine and saline soaking on bacterial counts in acute, traumatic contaminated wounds. Ann Emerg Med, 1990. Contaminated traumatic wounds within 12 hours of injury 33 wounds randomized into: soaking in either 1% PI, NS, or covered with dry gauze (control) for 10 min. Bacterial counts not changed in PI + control groups, but increased in NS group Infection rate: PI=12.5% (1/8), control= 12.5% (1/8), NS=71% (5/7)

Foreign Bodies:

Glass, metal, and gravel are Radiopaque Wooden objects and some aluminum products are radiolucent Glass is accurately visualized on 2-view radiographs if it is 2 mm or larger and gravel if it is 1 mm or larger

Wound Closure:

Time Delayed primary closure Options Suturing method

Time:

The Golden Period: the time interval from injury to laceration closure and the risk of subsequent infection, (is highly variable) Morgan WJ: The delayed treatment of wounds of the hand and forearm under antibiotic cover. Br J Surg 1980. 300 hand and forearm lacerations closed < 4hr had infection rate 7% closed > 4hr had infection rate 21%

Berk WA: Evaluation of the "golden period" for wound repair: 204 Cases from a third world emergency department. Ann Emerg Med 1988. evaluation in a third-world country - 204 patients <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

Baker: The management and outcome of lacerations in urban children. Ann Emerg Med 1990. 2,834 pediatric patients No difference in infection rate for lacerations closed less than or more than 6hrs

Delayed primary wound closure:

High risk wounds that are contaminated or contain devitalized tissue Wound is initially cleansed and debrided Covered with gauze and left 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

Dimick, 1988: Delayed Primary Closure Wound left open for 4 or 5 days until edema subsides, no sign of infection, and all debris and exudates removed >90% success rate in closure without infection Final scar as same as primary closure

Options:

Nonabsobable suture Absorbable suture Tissue adhesive Adhesive tapes

Staples

Nonabsobable suture:
Material Knot Security Wound Tensile Strength Good Tissue Reactivity Workability

Nylon (Ethilon) Polypropylene (Prolene) Silk

Good

Minimal

Good

Least

Best

Least

Fair

Best

Least

Most

Best

Absorbable suture:
Material Surgical gut Chromic gut Polyglactin (Vicryl) Polyglycolic acid (Dexon) Polydioxanone (PDS) Polyglyconate (Maxon) Knot Security Poor Fair Good Best Fair Fair Wound Strength Fair Fair Good Good Best Best Security (d) 5-7 10-14 30 30 45-60 45-60 Tissue Reactivity Most Most Minimal Minimal Least Least

Tissue adhesive:

N-butyl-2-cyanoacrylate, Histoacryl blue (HAB), GluStitch First described in 1949 and first used medically in 1959 Antibacterial effect Cost $5 per single-use ampule Reduction in cost (Canadian $) per patient of switching from nondissolving sutures $49.60

S. Mizrahi: Use of Tissue Adhesives in the Repair of Lacerations in Children. Journal of Pediatric Surgery,April, 1988. 1500 pediatric patients with simple laceration in ED, closed with HAB Infection 1.8% Dehiscence 0.6%

Tissue adhesive:

Octylcyanoacrylate (OCA), or Dermabond Approved by FDA in 1998 Antibacterial effect

Cost $25 per single-use ampule Greater strength than HAB

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:

Jagged or 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)

Advantages of Adhesive vs Sutures:

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

Study Simon, 1996 Simon, 1997 Quinn, 1997 Singer, 1998

Material No. Cosmetic outcome HAB vs Suture HAB vs Suture OCA vs Suture OCA vs Suture 61 61 2 months- same 2 months/ 1yr same

Time (min) 7 vs 17 _ 3.6 vs 12.4 5.9 vs 10 0

Complications 1 infection (HAB) _ Infection: 0 vs1 Dehiscence: 3 vs 1 1 infection + 2 dehiscence (OCA) 2 dehiscence (HAB)

130 3 months- same 124 3 months- same 94 3 months- same

Osmond, OCA vs 1999 HAB

Adhesive tapes:

Seldom recommended for wound closure in the ED Require the use of adhesive adjuncts (eg, tincture of benzoin) May be used with tissue adhesive or after suture removal to decrease tension

Staples:

Consider staples for linear lacerations not involving the face or other cosmetically sensitive areas Frequently used for scalp, trunk, or extrimities lacerations. Optimally, two operators perform this procedure

Brickman KR: Evaluation of skin stapling for wound closure in the emergency department. Ann Emerg Med 1989;18:1122-1125. 87 ER patients with 87 lacerations (2/3 scalp, trunk, and extremities) 65% closed in 30 seconds using staples No infections

John T. Kanegaye: 88 child with scalp lacerations, nonabsorbable suture vs staples Shorter overall times for wound care and closure: 395 vs 752 sec Total cost based on equipment and physician time: $23.55 vs $38.51 F/U rate 91%, with no cosmetic or infectious complications in either group

Suturing methods:

Simple interrupted Simple running Horizontal mattress Vertical mattress Running subcuticular (intradermal)

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 nonabsorbable

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

Running Subcuticular (Intradermal):

Best for areas where cosmetic result is of utmost importance Time-consuming Difficult to master Low tension wounds Absorbable suture

McLean, 1980: 51 patients with continuous, running 54 patients with interrupted stitch Two infections in each group

Topical AB:
Dire DJ: Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med, 1995. prospective, randomized, double-blinded, placebocontrolled (426 Lacerations) Bacitracin - 5.5% infection (6/109) Neosporin - 4.5% infection (5/110) Silvadene - 12.1% infection (12/99) Placebo 4.9% infection (5/101)

Dressing:
Chrintz, 1989: 1202 patients with clean wounds Dressing off at 24 hours - 4.7% infection Dressing off at suture removal - 4.9%

Goldberg, 1981: 100 patients with sutured scalp lacerations allowed to wash hair with no infection or wound disruption
Noe, 1988: 100 patients with surgical excision of skin lesions allowed to bathe next day with no infection or wound disruption

Tetanus:

More than 250,000 cases annually worldwide with 50% mortality 100 cases annually in USA About 10% in patients with minor wound or chronic skin lesion In 20% of cases, no wound implicated 2/3 of cases in patients over age 50

Study
Ruben, 1978

Setting
Nursing Home

Age
Elderly

% No Protective AB 49

Crossley, 1979
Scher, 1985

Urban
Rural

> 60yrs
Elderly

F: 59, M: 71
29

Pai, 1988
Stair, 1989

Urban
ER

34-60 yrs, all Females > 65 yrs > 65 yrs

5
9.7

Alagappan, 1996

ER

50

Recommendations for tetanus prophylaxis:

History of Tetanus Immunization Uncertain or <3 doses
Last dose within 5 y Last dose 5-10 y

Td
Yes No No

TIG
No No No

Td
Yes No Yes

TIG
Yes No No

Last dose >10 y

Yes

No

Yes

No

Infection Rate:

Galvin, 1976 Gosnold, 1977 Rutherford, 1980 Buchanan, 1981 Baker 1990

4.8% 4.9% 7.0% 10.0% 1.2%

3 doses

Antibiotic Therapy:
Cummings P: Antibiotics to prevent infection of simple wounds: A metaanalysis of randomized studies. Am J Emerg Med 1995. 7 randomized trials (1,734 patients) Assigned patients to AB or control Patients treated with AB slightly higher infection rate

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:

Amoxicillin, Clavulin Keflex Erythromycin recommended course is 3 to 5 days

Level of Training and Rate of Infection:

Adam: Level of Training, Wound Care Practices, and Infection Rates, American J Emerg. Med, May 1995. Wounds were evaluated in 1,163 patients Medical students 0/60 (0%); All resident 17/547 (3.1%) Physician assistants 11/305 (3.6%) Attending physicians 14/251 (5.6%)

Level of Training and Cosmetic outcome:

Adam: Association of Training level and Short-term Cosmetic Apperance of Repaired Lacerations, Academic Emerg. Med, April 1996. Retrospective study, 552 patients % achieving optimal cosmetic score Medical student 50% R1 54% R2 66% R3 68% Physician assistance 70% Attending physician 66%

Points to Take Home:

Laceration mismanagement & failure to Dx. FB is 2nd most common malpractice Be aware of different methods to reduce pain from Lidocaine infiltration In contaminated wounds with devitalized tissues debride and irrigate You have a wide options for wound closure Always check tetanus status AB only for high risk wounds