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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:

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Presentation on theme: "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:"— Presentation transcript:

1 WOUND CARE AND REPAIR FARAS ABUZEYAD, MD.

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 woundNo. of Patients % Blunt object42 Sharp object34 Glass13 Wood4 Bite6 Human1 Dog3 Others5

4 Distribution of traumatic wounds: Location of WoundNo. of Patients (%) Head and Neck51 Trunk2 Upper Extremities34 Lower Extremities13

5 Malpractice:  Karcz: Malpractice claims against emergency physicians in Massachusetts; Am J Emerg Med 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 2 nd most common malpractice claims against emergency physician

6 Condition% Claims% Total dollars paid 1- Missed fracture Wound care Missed MI Abdominal pain94 5- Missed meningitis Spinal cord injury38 7- SAH / Stroke36 8- Ectopic pregnancy 28

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

8 Aspect of CareAll Participants (n = 679) Facial Lacerations (n = 78) Other Lacerations (n = 263) Normal function28%27%26% Avoiding infection20%14%23% Cosmetic outcome17%33%14% Least pain17%11%18% Length of stay10%8%10% Compassion5%4%5% Cost1% Days missed2%1%3% Total100%

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  randomized 337 patients to ‘gloves’ or ‘careful hand-washing, no gloves’: INFECTION GLOVES NO GLOVES  None 167 (82.7%) 170 (82.5%)  ‘Mild’ 27 (13.4%) 27 (13.1%)  ‘Severe’ 8 (4.0%) 9 (4.4%)

13  Caliendo: Surgical masks during laceration repair. J Am Coll Emerg Phys Alternated face mask / no mask for 99 wound repairs:  Mask: 1 / 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: AgentClassMax. save dose mg/kg Onset (min) Duration (hrs) ProcaineEster Procaine + Epi LidocaineAmide Lidocaine + Epi72-4 BupivacaineAmide Bupivacaine + Epi38-16

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  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: StudyNumberPain score McKay, VolunteersReduced Christoph, VolunteersReduced Bartfield, PatientsNo Difference Orlinsky, PatientsReduced Brogan, PatientsReduced Fatovich, Adults children No Difference

22 3-Warmed solutions: StudyNumberTemp. (°C) Pain score Brogan, Patients20 vs 37.6Reduced Martin, Volunteers20 vs 37Reduced Colaric, Volunteers20 vs 37Reduced

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: StudyNumberInjection Rate Pain score Krause, Volunteers0.1ml/sec vs 1ml/sec Reduced with slow rate Scarfone, patients1ml/5sec vs 1ml/30sec Reduced with slow rate

25 5-Injection through wound edges: StudyNumberPain score Kelly, patientsReduced Bartfield, patientsReduced

26 6-Subcutaneous rather than intradermal injection:

27 7- Pretreatment with topical anesthetics: StudyNumberAgentPain score Bartfield, PatientsLidocaineReduced Bartfield, PatientsTetracaineReduced

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 SolutionAntimicrobial activity Mechanism of action UsesTissue toxicity N. Saline - Washing actionCleanse surrounding skin / irrigation - Povidine-iodine 10%, 1% + GermicideCleanse surrounding skin, ? Irrigation contaminated wounds + Chlorhexidine 1%, 0.1% + Bacteriostatic Cleanse surrounding skin + Hydrogen Peroxide + BactericidalCleanse contaminated wounds + Hexachlorophene + Bacteriostatic Cleanse surrounding skin + 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,  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

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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 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

45 Dire DJ: A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med  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 Lineaweaver: Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg,  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  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 Lammers:Bacterial counts in experimental, contaminated crush wounds irrigated with various concentrations of cefazolin and penicillin. Richard Lammers, American Journal of Emergency Medicine, January  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)

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54 5- Soaking: Lammers: Effect of povidone-iodine and saline soaking on bacterial counts in acute, traumatic contaminated wounds. Ann Emerg Med,  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 Berk WA: Evaluation of the "golden period" for wound repair: 204 Cases from a third world emergency department. Ann Emerg Med  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. Ann Emerg Med  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 Nonabsobable suture: MaterialKnot Security Wound Tensile Strength Tissue Reactivity Workability Nylon (Ethilon) Good MinimalGood Polypropylene (Prolene) LeastBestLeastFair SilkBestLeastMostBest

64 Absorbable suture: MaterialKnot Security Wound Strength Security (d) Tissue Reactivity Surgical gutPoorFair5-7Most Chromic gutFair 10-14Most Polyglactin (Vicryl)Good 30Minimal Polyglycolic acid (Dexon) BestGood30Minimal Polydioxanone (PDS) FairBest45-60Least Polyglyconate (Maxon) FairBest45-60Least

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,  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 StudyMaterialNo.Cosmetic outcome Time (min) Complications Simon, 1996 HAB vs Suture 612 months- same7 vs 171 infection (HAB) Simon, 1997 HAB vs Suture 612 months/ 1yr - same __ Quinn, 1997 OCA vs Suture 1303 months- same3.6 vs 12.4Infection: 0 vs1 Dehiscence: 3 vs 1 Singer, 1998 OCA vs Suture 1243 months- same5.9 vs 101 infection + 2 dehiscence (OCA) Osmond, 1999 OCA vs HAB 943 months- same02 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

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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

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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

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

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

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

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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 StudySettingAge% No Protective AB Ruben, 1978Nursing Home Elderly49 Crossley, 1979 Urban> 60yrsF: 59, M: 71 Scher, 1985RuralElderly29 Pai, 1988Urban34-60 yrs, all Females 5 Stair, 1989ER> 65 yrs9.7 Alagappan, 1996 ER> 65 yrs50

99 Recommendations for tetanus prophylaxis: 3 doses History of Tetanus Immunization TdTIGTdTIG Uncertain or <3 dosesYesNoYes Last dose within 5 yNo Last dose 5-10 yNo YesNo Last dose >10 yYesNoYesNo

100 3 doses Infection Rate:  Galvin, %  Gosnold, %  Rutherford, %  Buchanan, %  Baker %

101 Antibiotic Therapy: Cummings P: Antibiotics to prevent infection of simple wounds: A metaanalysis of randomized studies. Am J Emerg Med  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  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  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 2 nd 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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