2Clinical scenario - IA 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
3Clinical scenario - IIA 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
4Clinical 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
5The GoalsCreate optimal conditions for the patient to heal themselves.Preserve function.Minimize complications.Improve the chances of a cosmetically pleasing result
6ED evaluation Secondary survey Mechanism of injury elicit host factors that adversely affect wound outcomeincreased age, diabetes, width, and contamination or foreign body.tetanus immunization
8Foreign Bodies5th cause of malpractice claims against emergency physicians50% was glassAnver 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.
9FB removal Reactive materials, such as wood and vegetative material Contaminated materialClothing (should always be considered contaminated)Most foreign bodies in the footImpingement on neurovascular structure
10Foreign Bodies wood and plastic foreign bodies Ct scan / MRI U/S :sensitivity of 95-98% and a specificity of 89-98%
12Wound preparation Anesthesia : Local anesthetic injections Topical anestheticsRegional anesthetics
13Methods to reduce pain of Lidocaine local infiltration Small-bore needlesBuffered solutionsWarmed solutionsSlow rates of injectionInjection through wound edgesSubcutaneous rather than intradermal injectionPretreatment with topical anesthetics
15Topical anesthesiaLET (lidocaine, 4%; epinephrine, 0.1%; tetracaine, 0.5%)Face and scalpLiquid or gel forms
16Sterile 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.
17Non-sterile gloves, which provide “universal precaution “ is appropriate. Latex gloves should also be avoided
18Skin and Hair Preparation Reduce quantity of bacteria on the surface of the skinShaving the hair does make closure easierincreased risk of wound infection by inducing traumaSeropian and Reynolds : infection risk increased from 0.6% to 5.6% when hair was shaved from a woundThe use of clippers .
19Wound Irrigations Used since 2200 BC. Most important step Remove bacteria and contamination15 psi removed 85% of bacterial contamination from a wound, whereas (1 psi) removed only 49%5 – 8 psi30-60-cc syringe to push fluid through a 19-gauge catheter with maximal hand pressure.
20Wound Irrigation minimum of 250 cc 60 cc/ cm wound length Large volume with low pressure may be good.
21Irrigation Fluid Sterile saline solution Povidone-Iodine Solution (Betadine®) 10%- tissue toxic-did not reduce infection incidence.Diluted betadine : use indeterminate.
22Irrigation Fluid Hydrogen peroxide no role, tissue toxic. Tap water : low cast, available.Sandy : Medline /03, 397 papers foundTap water is a safe and effective solution for cleaning recent wounds requiring closure and is the treatment of choice
23Tap 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.
24Debridement old technique with little recent research tissue loss versus functiondelayed primary closure.
25Golden period“safe” time interval from wounding that allows primary wound closureThe 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
26Closure Methods Sutures The standard for wound closurePercutaneous sutures are used for low- to medium-tension woundsabsorbable suture material for dermal stitchesinterrupted versus other types of sutures has no effect on infection rate
27Glue Faster repair time Less painful Eliminate the risk for needle sticksAntibacterial effectDoes not require removal of sutures
28Glue :Octyl cyanoacrylate FDA approval in =Dermabond®50% of the strength of 5-0 suture material.Cochrane review : comparable cosmetic outcomes compared to standard suturing
29GlueSimon :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 RCTsGlue is the wound closure method of choice in recent lacerations to the face in children
30Glue me Short (< 6-8 cm) Low tension (< 0.5 cm gap) Clean edged Straight to curvilinear wounds that do not cross joints or creases
31Don’t glue me stellate lacerations Bites, punctures or crush wounds Contaminated woundsMucosal surfacesAxillae and perineum (high-moisture areas)Hands, feet and joints (unless kept dry and immobilized)
32staples Fast ,low wound reactivity and infection rate. Less expensive. Less needle sticks risk.No cosmetic difference.Scalp, trunk, and extremity.
33Surgical Tapes Steri-Strips least reactive of all closure techniqueslowest tensile strengthMay require tincture of benzoinAvoid in hairy and wet area.
34Surgical Tapessimple, 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 .
36Delayed Primary Closure (DPC) much underused method of wound care .reduced the infection rate by 50% in 104 extremity woundsrecommended technique for contaminated wounds that present to the EDTechnique : clean and debride then separate wound edges with gauze, and apply bulky dressing.
37Secondary 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.
38Antibiotic Use prophylaxis studies : no benefits. Indications For Prophylactic Antibiotics:Presence of prosthetic device(s) Class IIIPatients in need of endocarditis prophylaxis Class IIIOpen joint or fractures associated with wound Class IHuman, dog, and cat bites Class IIIntraoral lacerations Class IIImmunocompromised patients Class IIIHeavily contaminated wounds (eg, feces, etc) Class III
39Topical AntibioticsDire 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
40Tetanus Prophylaxis Recommendations Tetanus HistoryClean Minor WoundsAll Other Wounds< 3 doses in primary seriesTdTd + TIGPrimary 3 Series CompletedLast < 5 years agoNillLast > 5 years ago and < 10Last > 10 years ago
41Cost- 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.
42Cost- 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.
43The futureGrowth 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 woundschambers filled with antibiotics and growth factors .
44Key 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 scalpPE alone is inadequate for ruling out a foreign body in a wound.
45Summary determine if it is appropriate to close a wound primarily prevention of a wound infectionmultitude of wound closure methods including “needleless” methods.
46References : Emerg Med Clin N Am 21 2003 EM practice Mar. 2005 Sum search: multiple data base search.BestBETS websiteGoogle search