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Presentation on theme: "WOUND CARE AND REPAIR FARAS ABUZEYAD, MD.."— Presentation transcript:


2 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.

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

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

5 Malpractice: Karcz: Malpractice claims against emergency physicians in Massachusetts; 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

6 2 Condition % Claims % Total dollars paid 1- Missed fracture 14 17
2- Wound care 12 8 3- Missed MI 10 24 4- Abdominal pain 9 4 5- Missed meningitis 3.5 6- Spinal cord injury 3 7- SAH / Stroke 6 8- Ectopic pregnancy 2

7 What patients want? Adam: Patient Priorities With Traumatic Lacerations. Am J Emerg Med, October 2000.

8 Facial Lacerations (n = 78) Other Lacerations (n = 263)
Aspect of Care All Participants (n = 679) Facial Lacerations (n = 78) Other Lacerations (n = 263) Normal function 28% 27% 26% Avoiding infection 20% 14% 23% Cosmetic outcome 17% 33% Least pain 11% 18% Length of stay 10% 8% Compassion 5% 4% Cost 1% Days missed 2% 3% Total 100%

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

10 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.

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

12 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 (82.7%) (82.5%) ‘Mild’ (13.4%) (13.1%) ‘Severe’ (4.0%) (4.4%)

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

14 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   

15 Properties of commonly used local anesthetics:
Agent Class Max. save dose mg/kg Onset (min) Duration (hrs) Procaine Ester 7 2-5 Procaine + Epi 9 Lidocaine Amide 5 1-2 Lidocaine + Epi 2-4 Bupivacaine 2 4-8 Bupivacaine + Epi 3 8-16

16 Why Lidocaine? Less painful Rapid onset Less cardiotoxic
Less expensive

17 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)

18 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

19 1-Small-bore needles: Edlich, 1988: 30-gauge hurts less than a 27-gauge 27-gauge hurts less than a 25-gauge, etc.

20 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

21 Studies on buffered lidocaine:
Study Number Pain score McKay, 1987 24 Volunteers Reduced Christoph, 1988 25 Volunteers Bartfield, 1990 91 Patients No Difference Orlinsky, 1992 61 Patients Brogan, 1995 45 Patients Fatovich, 1999 135 Adults children

22 3-Warmed solutions: Study Number Temp. (°C) Pain score Brogan, 1995
45 Patients 20 vs 37.6 Reduced Martin, 1996 40 Volunteers 20 vs 37 Colaric, 1998 20 Volunteers

23 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.

24 4-Slow rates of injection:
Study Number Injection Rate Pain score Krause, 1997 29 Volunteers 0.1ml/sec vs 1ml/sec Reduced with slow rate Scarfone, 1998 42 patients 1ml/5sec vs 1ml/30sec

25 5-Injection through wound edges:
Study Number Pain score Kelly, 1994 81 patients Reduced Bartfield, 1998 63 patients

26 6-Subcutaneous rather than intradermal injection:

27 7- Pretreatment with topical anesthetics:
Study Number Agent Pain score Bartfield, 1995 54 Patients Lidocaine Reduced Bartfield, 1996 57 Patients Tetracaine

28 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

29 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

30 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

31 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

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

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

34 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 5-day follow-up

35 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)

36 - + Solution Antimicrobial activity Mechanism of action Uses
Tissue toxicity N. Saline - Washing action Cleanse surrounding skin / irrigation Povidine-iodine 10%, 1% + Germicide Cleanse surrounding skin, ? Irrigation contaminated wounds Chlorhexidine 1%, 0.1% Bacteriostatic Cleanse surrounding skin Hydrogen Peroxide Bactericidal Cleanse contaminated wounds Hexachlorophene Nonionic detergents Wound cleanser

37 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

38 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

39 4-Wound Cleansing and Irrigation:
Decreasing wound contamination and hence infection, "the solution to pollution is dilution." Indications Methods Pressure Solution Volume Side effects

40 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   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

41 2- Methods: Bulb syringe IV bag +/- pressure cuff Syringe and needle
Jet lavage


43 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 gauge needle) Animal studies: Rodeheaver, 1975 & Stevenson, 1976, high-pressure irrigation reduce both bacterial wound counts and wound infection rates

44 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

45 531 patients were randomized into 3 groups, and irrigated with:
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

46 All agents tested killed 100 percent of exposed fibroblasts
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

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

48 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

49 An animal bite wound model was created
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

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

51 4- Volume: Irrigation volume not studied
use 50 mL to 100 mL of irrigant per cm of laceration

52 5- Side effects: Increase tissue inflammation (very high pressure irrigation), but benefit outweigh risk Splatter (use your hand or plastic shield)


54 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)

55 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

56   Wound Closure: Time Delayed primary closure Options Suturing method

57 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   300 hand and forearm lacerations closed < 4hr had infection rate 7% closed > 4hr had infection rate 21% 

58 evaluation in a third-world country - 204 patients
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 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

59 Baker: The management and outcome of lacerations in urban children
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

60 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

61 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

62 Options: Nonabsobable suture Absorbable suture Tissue adhesive
Adhesive tapes Staples

63 Wound Tensile Strength
Nonabsobable suture: Material Knot Security Wound Tensile Strength Tissue Reactivity Workability Nylon (Ethilon) Good Minimal Polypropylene (Prolene) Least Best Fair Silk Most

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

65 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

66 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%

67 Tissue adhesive: Octylcyanoacrylate (OCA), or Dermabond
Approved by FDA in 1998 Antibacterial effect Cost $25 per single-use ampule Greater strength than HAB

68 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

69 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)

70 Advantages of Adhesive vs Sutures:
Faster repair time Less painful Eliminate the risk for needle sticks Antibacterial effect Does not require removal of sutures

71 Study Material No. Cosmetic outcome Time (min) Complications Simon, 1996 HAB vs Suture 61 2 months- same 7 vs 17 1 infection (HAB) Simon, 1997 2 months/ 1yr - same _ Quinn, 1997 OCA vs Suture 130 3 months- same 3.6 vs 12.4 Infection: 0 vs1 Dehiscence: 3 vs 1 Singer, 1998 124 5.9 vs 10 1 infection + 2 dehiscence (OCA) Osmond, 1999 OCA vs HAB 94 2 dehiscence (HAB)

72 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


74 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: 87 ER patients with 87 lacerations (2/3 scalp, trunk, and extremities) 65% closed in 30 seconds using staples No infections

75 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

76 Suturing methods: Simple interrupted Simple running
Horizontal mattress Vertical mattress Running subcuticular (intradermal)

77 Simple Interrupted: Most common Easy to master
Can adjust tension with each suture Stellate, multiple components, or directions wound

78 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


80 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


82 Vertical Mattress: High-tension wounds
Prone to skin suture marks if left in too long


84 Running Subcuticular (Intradermal):
Best for areas where cosmetic result is of utmost importance Time-consuming Difficult to master Low tension wounds Absorbable suture


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









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

96 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

97 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

98 Study Setting Age % No Protective AB Ruben, 1978 Nursing Home Elderly 49 Crossley, 1979 Urban > 60yrs F: 59, M: 71 Scher, 1985 Rural 29 Pai, 1988 34-60 yrs, all Females 5 Stair, 1989 ER > 65 yrs 9.7 Alagappan, 1996 50

99 Recommendations for tetanus prophylaxis:
History of Tetanus Immunization Td TIG Uncertain or <3 doses Yes No Last dose within 5 y Last dose 5-10 y Last dose >10 y 3 doses

100 Infection Rate: Galvin, 1976 4.8% Gosnold, 1977 4.9%
Rutherford, % Buchanan, % Baker % 3 doses

101 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

102 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

103 Prophylactic Antibiotics:
Amoxicillin, Clavulin Keflex Erythromycin recommended course is 3 to 5 days

104 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%)

105 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%

106 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


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