1. Wound Care: Update on Current Techniques. . . and a Few Surprises
Wound Care: Updates on Current Techniques and a Few Surprises
2014 ACHA Annual Meeting May 29, 2014
Wound Care: Update on Current Techniques and a Few Surprises
Michael Huey, MD
Assistant Vice President and Executive Director
Emory University Student Health and Counseling Services
With appreciation to: Menelaos Demestihas, MD
Assistant Professor - Emory Emergency Medicine
Grady Memorial Hospital
ACHA 2014 Annual Meeting
San Antonio, Texas
Thursday, May 29, 1:45 pm
Session TH3-180

2. With special thanks to:
Menelaos Demestihas, MD
Assistant Professor - Emory Emergency Medicine
Grady Memorial Hospital

3. Hey, this looks familiar somehow . . .
This is the exact talk we gave at SCHA in Atlanta, March 2014
It is OK to leave now if you want to I won’t be offended There are lots of good talks at ACHA this year:
TH#-187 – “Clinical Pearls for College Health Providers: Key Evidence Summaries of the Last Year’s Medical Literature”
Hey! What’s up with that?

4. Faculty Disclosure
Neither I nor my spouse have a financial interest, arrangement or affiliation with any organization or business entity (including self-employment or sole proprietorship) that could be perceived as a conflict of interest or source of bias in the context of this presentation.
My wife is the President and CEO of The Center for the Visually Impaired of Georgia

5. Diversity-Focused Presentation
SKIN IS A VERY DIVERSE ORGAN

6. Time does not stand still . . .
Many of us still practice the wound care techniques and approaches we were taught in our training.
However, current approaches in emergency medicine and plastic surgery settings may surprise you.
Tap water from the running faucet to cleanse/lavage wounds?
Choices for wound dressings?
Epinephrine on the face and digits?
Ultrasound to guide digital blocks and triangulate foreign bodies?
New suture choices?

7. Learning Objectives Review the basics of wound healing.
Review current techniques for the cleansing and lavage of traumatic wounds in emergent and urgent settings.
Review options for wound dressings
Describe changes in the approach to local anesthesia on the face, nose and digits.
Describe changes in preferred suture choices in cosmetic and non-cosmetic wounds.
Review use of ultrasound in regional and digital block anesthesia and foreign body localization.

8. Wound Care Updates 2014
Wound healing 101

9. Definitions and Demographics
A wound is a disruption of the normal structure and function of the skin and underlying soft tissue (SSTI).
11 million wounds are treated in emergency departments annually in United States
Normal wounds heal through an orderly sequence of physiologic events:
Hemostasis
Inflammation
Epithelialization
Fibroplasia
Maturation
Armstrong DG and Meyr AJ, UpToDate 2014

10. Wound healing time line
Wound healing time line with dominant cell types and major physiologic events.
Mulholland MW, Maier RV, et al. Greenfield's Surgery Scientific Principles and Practice, 4th ed, Lippincott Williams & Wilkins, Philadelphia Copyright © 2006 Lippincott Williams & Wilkins.

11. Healing time and quality
Restoration of normal skin surface integrity in a healthy individual takes from 2-4 weeks
Wounds can disrupt due to technical error, infection, presence of foreign material, underlying disease states or medications
Quality of the healed tissue depends upon:
The severity of tissue trauma
The suture material used in repair
The presence of factors that may delay healing or reduce the tensile strength of the final scar
Armstrong DG and Meyr AJ, UpToDate 2014

12. Healing time and quality (continued)
In animal models, unsutured fascial wounds have:
Minimal strength in the first week of healing,
30% to 50% of unwounded tissue strength after four to six weeks,
60% at six months, and
Slowly continue to get stronger, but may never achieve 100% of their previous strength

13. Langer’s Lines Avoiding wound tension
Langer (1861) developed his lines by stabbing cadavers with a conical punch. The resulting defects were often oval, rather than circular, because of the direction of the underlying collagen bundles. Langer joined the long axis of these ovals to establish his lines.

14. Risk factors for non-healing
Peripheral arterial disease
Diabetes, due to vascular disease, neuropathy and impaired immunity
Chronic venous insufficiency
Aging
Malnutrition
Immunosuppressive therapy
Sickle cell disease
Cancer chemotherapy and radiation therapy
Spinal cord disease and immobilization
Infection
Smoking and nicotine replacement therapy
Armstrong DG and Meyr AJ, UpToDate 2014

15. Re-epithelialization
Beautiful granulation tissue!
Epithelialization of a partial- thickness wound occurs from the wound edge.
“Picture-framing”
Mulholland MW, Maier RV, et al. Greenfield's Surgery: Scientific Principles and Practice, Fourth Edition. Philadelphia: Lippincott Williams & Wilkins, Copyright © 2006 Lippincott Williams & Wilkins.

16. Wound Re-pigmentation
Re-pigmentation of healed wounds occurs as melanocytes migrate from the epidermal appendages across the wound bed.
Skin color in a healed wound is difficult to predict.
Exposure to ultraviolet radiation can permanently increase the pigmentation.
Bleaching agents are discouraged because of the risk of further tissue damage.
Mulholland MW, Maier RV. Greenfield's Surgery: Scientific Principles And Practice, Fourth Edition. Philadelphia: Lippincott Williams & Wilkins, Copyright © 2006 Lippincott Williams & Wilkins.

17. Wound assessment and preparation
Wound Care Updates 2014
Wound assessment and preparation

18. Preparation of Acute Minor (“SHS-level”) Wounds for Laceration Repair
Wounds that involve joint spaces, nerves, tendons (at least flexor tendons), significantly deep muscle or other deep underlying structures are not “SHS- level”
Preparation includes assessment, adequate hemostasis, hair and foreign body removal, irrigation and local anesthesia.
Exclude Chain Saw Injuries!

19. Wound Assessment and Preparation
Age of injury
Mechanism of injury (e.g. cut by sharp object, tear, bite, stab, crush)
Foreign bodies
Extent/depth of wound (e.g. joint spaces, underlying fracture)
Neurovascular or tendon injury
Risks of poor outcome (e.g. wound related, delayed presentation, diabetes, keloid area)
Cosmetic significance
Type of closure (e.g. primary, delayed primary, secondary intention)
Debridement
Hemostasis (e.g. direct pressure, lidocaine with epi, Gel foam, careful tourniquet use)
Hair removal
Self Care Decisions, LLC

20. Age of Injury: Berk WA et. al., Ann Emerg Med 1988
372 patients presented to ED for suture repair of wounds not grossly contaminated or infected with no associated injuries to nerves, major blood vessels, tendon or bone
Wounds closed at up to 19 hours after injury had significantly higher rate of healing than those closed later (92% v. 77%)
Healing of head wounds was virtually independent of time from injury to repair: 96% (42 of 44) head wounds were healing when repaired > 19 hours v. 66% (47 of 71) elsewhere on body
“A facial wound can be closed up to 24 hours later with little risk of infection if it is reasonably clean.”

21. Foreign Bodies Important to identify and remove FBs
Retained FBs increase the risk of delayed wound healing and infection
Remove it if you can see it
Carefully remove it if you can palpate it if no risk to underlying structures
Ultrasound replacing soft tissue x-rays!!
Location, location, location: glass and metal can be left if not in a critical area or adjacent to a vital structure
Wood (splinters) and other organic FBs can cause delayed infection, including in the adjacent bone

22. Neurovascular or tendon injury
Careful assessment of circulation and sensation, including two-point discrimination in hand injuries
Any wound overlying a tendon must be evaluated for tendon function; base of the wound must be carefully explored with tourniquet and magnification loupes if necessary
Ends of tendon can retract from view
Consider position of body part at time of injury
“REFER IF UNSURE”

23. Cosmetic significance
Don’t be sexist in your decision- making (Matthew McConaughey could enroll in your school)
Who has sutured an Oscar winner?
Cosmetically sensitive areas
Vermillion border of lip
Tissue avulsed
Orientation of wound to tension lines (Langer, others) -- perpendicular orientation leads to worse scarring
Eyelid margin (plus it is not just cosmetic here)
Stellate lacerations

24. Debridement
Many/most wound experts consider it to be equally or more important than irrigation in the management of a contaminated wound
Removes permanently devitalized tissue that inhibits wound’s ability to resist infection
However, you cannot damage underlying structures or make wound difficult to close without tension

25. Hair removal
Hair does not need to be removed unless it interferes with wound closure or knot formation
Scalp: Lubricate to comb hair away or snip with scissors, don’t shave
Shaving to skin level increases risk of infection and can leave small particles in wound
Do not clip or shave eyebrows (lose landmark; can grow back irregularly)

26. Wound lavage: what’s new. . . And old . . . And new again
Wound Care Updates 2014
Wound lavage: what’s new And old And new again

27. We clean wounds with water +/- soap at home

28. Wound antiseptics
For years, traumatic wounds were cleaned with antiseptic solutions (e.g. Bactine at home, Betadine at work) to lower bacterial counts and promote healing
Published research in the mid1980s-early 1990s using animal models (Brennan 1985, Bergstrom 1994, others) showed evidence of tissue damage and delayed healing with antiseptics

29. Forced sterile saline lavage
“Traumatic wounds should be cleaned with forced lavage of sterile saline”
Use of goggles, a splash shield or both
How much pressure is too much?

30. Cochran Review 2010 Water for Wound Cleaning (Fernandez, R et. al.)
The objective of the review was to assess the effects of water compared with other solutions for wound cleaning
Literature search and looked at 10 randomized controlled trials
7 compared rates of infection and healing in wounds cleansed with water v. normal saline
3 compared cleaning v. no cleaning

31. Tap water more effective than normal saline for preventing infection in adults (Cochran Review 2010)
For chronic wounds in adults, Relative Risk (RR) of developing infection was lower with tap water cleaning than with saline (RR 0.16, 95% CI 0.01 to 2.96)
For acute wounds in adults, RR of developing infection with tap water cleaning v. saline was (95% CI )
In children, the difference was not statistically significant (RR 1.07)

32. Wounds cleaned with tap water v
Wounds cleaned with tap water v. no cleaning at all (Cochran Review 2010)
3 studies compared tap water cleaning to no cleaning at all.
There was no statistically significant difference in infection rate (RR 1.06, 95% CI ).
Specifically, the meta analysis showed no difference in healing rates post- operatively when wounds were cleaned with tap water (showered) and those that were not cleaned.

33. Conclusions (Cochran Review 2010)
There is no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it.
However, there is not strong evidence that cleansing wounds per se increases healing or reduces infection at all.
In areas where tap water is high quality (i.e. drinkable), it may be as effective for wound cleaning as sterile water or saline and it is less expensive.
Showering with a sutured/surgically repaired wound does not increase infection rate.

34. Irrigation of Clean Facial and Scalp Lacerations
Hollander, JE et. al., Irrigation in facial and scalp lacerations; does it alter outcomes?, Ann Emerg Med 1998; 31(1): 73
Is there a difference in infection rates in clean facial and scalp wounds irrigated v. not irrigated before primary closure?
1,923 consecutive patients to an academic ED with non-bite, non- contaminated facial and scalp lacerations presenting less than 6 hours after injury; 1,090 lavaged with saline, 833 no lavage

35. Irrigation of Clean Facial and Scalp Lacerations (2)
Hollander, JE et. al., Ann Emerg Med 1998
Primary outcome parameters = incidence of wound infection and short-term cosmetic appearance
Groups similar in time to presentation to ED, frequency of linear wound morphology, frequency of smooth wound margins, number of layers of closure, number of skin and deep sutures applied, use of oral antibiotic prophylaxis

36. Irrigation of Clean Facial and Scalp Lacerations (3)
Hollander, JE et. al., Ann Emerg Med 1998
The incidence of wound infection was not statistically different between the two groups (0.9% irrigated v. 1.4% not irrigated, P=0.28)
The percentage of patients with “optimal” cosmetic appearance was similar in the two groups (75.9% irrigated v. 81.7% not, P=0.07)
CONCLUSION: Irrigation before primary closure did not significantly alter rate of infection or cosmetic appearance with clean, non- contaminated facial and scalp lacerations

37. Wound Care Updates 2014
Wound dressings

38. Characteristics of an ideal wound dressing (Scales 1956)
High moisture vapor permeability
Non-adherent
High capacity for absorption
Provide barrier to external contaminants
Prevents capillary loops penetrating into dressing material
Capable of being sterilized
Good adhesion to surrounding undamaged skin
Hypoallergenic
Comfortable to wear
Cost effective

39. “Road Rash” A challenging wound to dress!
Deep, weeping abrasions from falls onto concrete, blacktop, dirt (“base stealer’s strawberry), grass, artificial turf
Very painful, weeps serum heavily
Often contaminated with rocks, soil, grass, glass and other foreign bodies
Significant risk of tattooing if not aggressively cleaned
Risk of secondary infection
After cleaning, could use Polysporin or Silvadene and 30 Telfa pads and several packages of 4 x 4 gauze pads and a huge Ace bandage or several Cling/Conform rolls Or not . . .

40. Abrasion dressings
Hydrocolloid dressings (Tegaderm, Duoderm, others) can be very effective in controlling pain & reducing healing time
Gelatin, pectin and/or carboxymethylcellulose, serve as occlusive or semi-occlusive dressings
Absorb wound exudates to form a hydrophilic gel
Waterproof, allow water vapor and gases to cross
Long wear time (up to 7 days) can reduce visits and costs

41. Abrasion dressings (2)
Hermans, MH, Intl J Sports Med 12(6),1991: Hydrocolloid v. Gauze
38 racing cyclist abrasions in 24 athletes
Hydrocolloid occlusive dressings had faster healing times (5.6 v days), smaller risk of infection (0% v. 10%), less pain at race time (91% no pain at race time v. 30% with gauze dressings) + higher overall comfort

42. Abrasion dressings (3)
Transparent film dressings (OpSite, Comfeel, others)
Adhesive, semi-permeable, polyurethane membrane dressings
Waterproof, allow water vapor and gases to cross
Transparent, can inspect wound without removing
Hydrogel dressings (Restore, Intrasite Gel, others)
Polymers, glycerin or water-based gels, impregnated gauzes or sheet dressings
High water content of the dressing does not allow it to absorb large volumes of exudates, so they cannot be used on heavy exuding wounds; best suited for dry or minimal exuding wounds
Gentle yet effective debriding action by rehydrating necrotic tissue and removing it with the dressing
Rehydrate the wound bed, reduce pain through a cooling effect, are non- adhesive, fill dead spaces and are easy to apply and remove
They do require a secondary covering dressing.
Indian J Plast Surg 45(2), 2012

43. Abrasion dressings (4)
Beam, JW, J Athl Train 2008: Occlusive dressings and the healing of standardized abrasions
16 healthy women (n=10) and men (n=6)
“Inflicted” 4 standardized, partial thickness abrasions
Film, hydrogel, hydrocolloid and no dressing (control)
Day-by-day scoring of wound contraction, color (chromatic red) and luminance

44. Abrasion dressings (5) Beam, JW, J Athl Train 2008:
Film and hydrocolloid produced greater wound contraction than the hydrogel and no dressing (control) on days 7 and 10
Film, hydrogel and hydrocolloid resulted in greater wound contraction than no dressing (control) on day 14
Film, hydrogel and hydrocolloid resulted in smaller measures of color and greater measures of luminance than no dressing (control) on day 14

45. Wound Care Updates 2014
anesthesia of face, nose and digits (Updates from the Emergency Department)

46. Wound Care: Updates on Current Techniques and a Few Surprises
2014 ACHA Annual Meeting May 29, 2014
Regional Anesthesia
Trying something new
Sensitive areas that demand best possible cosmetic outcomes
Most of this information comes from Dental literature
Questions
1) How to do these nerve blocks?
2) Useful for the clinic, urgent care or ED setting?
Poll audience:
Physicians
Associate Providers
Students
Other?
Also:
Family Medicine
Poll if
Does regional or blocks
Would consider it?
No way
Highlights
Small amount of lidocaine for large skin area
Have to know your anatomy

47. Infraorbital Nerve Block (1)
Do this for:
Lower eyelid
Lateral nose
Medial Cheek
Technique:
Topical at needle insertion point
Identify notch of infraorbital rim
Retract lip, bevel towards foramen
1cc infiltration

48. Infraorbital Nerve Block (2)

49. Forehead Nerve Block Not just for laceration repair Burns
Foreign body removal

50. Digital Nerve Block Better tolerated than local
Palmar single injection better than double volar injection

51. Cutaneous Nerve Blocks
For more extensive wounds
Injuries proximal to fingers

52. Sensory Innervation of Hand

53. Lidocaine with Epinephrine
Mantra of “never use” in digits, blocks, face… deeply ingrained
Great to debate
Textbooks say no
Surgical subspecialties routinely use
Good studies show is likely safe

54. Digital anesthesia with epinephrine: An old myth revisited Krunic AL et al, J Am Acad Dermatol 2004 Nov; 51(5): 755-9
PubMed search  total of 16 papers
50 cases of distal gangrene, most in earliest 20th century
21 cases associated with anesthetic mixed with epinephrine (often onsite); actual concentration known in only 4 cases
None associated with a commercial lidocaine with epinephrine mixture
No evidence to support the “dogma”
Epinephrine actually reduces tourniquet use and volume of anesthetic, better pain control

55. Topical anesthesia: LET
LET is a combination of lidocaine (4 percent), epinephrine (0.1 percent), and tetracaine (0.5 percent) available as an aqueous solution or methylcellulose based gel.
Topical anesthetic prior to local injection
Replaces Tetracaine-Adrenaline-Cocaine (TAC)
Safe down to age 2 years
Kundu (2002) Am Fam Physician 66(1):99-102

56. LET

57. Don’t Have 20 Minutes? Topical 20% benzocaine Faster onset
Beware of side- effects (loss of gag, difficulty swallowing, methemoglobinemia)

58. Wound SUTURE CHOICES AND Glue TIPS & TRICKS
Wound Care Updates 2014
Wound SUTURE CHOICES AND Glue TIPS & TRICKS

59. Skin sutures haven’t changed much: Nylon or Prolene (purple)

60. Suture away . . . Doc Hollywood!
6-0 Nylon
6-0 Prolene

61. Absorbable suture has!
Absorbable suture breaks down over time in the body.
Absorption time depends upon:
Suture type
Suture size
Braided v. Monofilament
Location
Host factors: Fever, nutrition status, infection

62. Absorbable suture breakdown times
Vicryl Rapide – 2 weeks
Undyed Monocryl – 3 weeks
Dyed Monocryl – 4 weeks
Coated Vicryl – 4 ½ weeks
PDS (Polydioxanone) – 9 weeks
Chromic Gut – 12 weeks
Panacryl – 70 weeks (recalled for complications)

63. "Give me a 4-0 Vicryl on a PS-2"
Needle size and type matter
Cutting Suture Needles
FSLX - Large skin closure when a lot of tension is present common for retention sutures or large orthopedic use.
FSL – Often used for sewing in drains or skin closure needing higher tension closure.
FS2 or PS2 - For common skin closure.
P3 – Used for skin closure of small incisions such as hand surgery or facial plastic surgery.

64. Skin Glue – Tips and Tricks (1)
Draw glue into a TB syringe
Replace needle tip with the plastic part of a 24 gauge IV catheter

65. Skin Glue – Tips and Tricks (2)
Avoid complications
Use a hydrocolloid dressing (Tegaderm, others) to protect the eye!

66. Elderly – Tips and Tricks
Can have friable skin that is difficult to suture without tearing
Use tape or hydrocolloid dressing (Tegaderm, others) to close wound and suture through

67. Wound Care Updates 2014
use of ultrasound in regional and digital block anesthesia and foreign body EVALUATION

68. Why Ultrasonography?
Most ED’s have or are looking to acquire ultrasound machines
Common uses:
Central venous placement
Guiding difficult peripheral venous access
As technology becomes more affordable and accessible will see more of these machines

69. Basic Ultrasonography
Transmission of sound waves and recording what gets “bounced back”
Tips:
White structures (hyperechoic) are solid/dense
Dark areas (hypoechoic) are liquid & have density approaching water

70. Ultrasonography for Nerve Block
Usually peripheral nerves are bundled with an artery and vein
Examine in cross-section

71. Foreign Bodies
Fifth leading cause of malpractice claims against Emergency Medicine physicians
Most common is glass
Always XR if concerned, visual inspection is not good enough
Wood and plastic… may not show on XR

72. Use of US with Foreign Bodies
2 studies show, for radio-opaque objects (Annals 1991: West JEM 2011)
Sensitivity of 95-98%
Specificity of 89-98%
Alternative is CT or MRI, with MRI being significantly more sensitive

73. What will it look like?

74. Doesn’t Have to be Messy

75. QUESTIONS?

76. Bibliography
Fernandez, R and Ussia, C, Water for wound cleansing (Review), The Cochran Collaboration 2010.
Sarabahi, S, Recent Advances in Topical Wound Care, Indian J Plast Surg 2012 May-Aug, 45(2):
Hermans, MH, Hydrocolloid dressing versus tulle gauze in the treatment of abrasions in cyclists, Intl J Sports Med Dec; 12(6): 581-4
Beam, JW, Occlusive Dressings and the healing of standardized abrasions, J Athl Train 2008 Nov-Dec; 43(6):

77. Bibliography (2) 2014 UpToDate, Inc., Release: 22.2 - C22.44
Hollander, JE et. al., Irrigation in facial and scalp lacerations; does it alter outcomes?, Ann Emerg Med 1998; 31(1): 73
Berk WA et. al., Evaluation of the “golden period” for wound repair, Ann Emerg Med 1988; 17:496
Benko, Kip. Fixing Faces Painlessly: Facial Anesthesia In Emergency Medicine, Emergency Medicine Practice Dec 2009; 11:12
Krunic, AL et. al., Digital anesthesia with epinephrine: an old myth revisited, J Am Acad Dermatol 2004 Nov; 51(5):755-9

78. Bibliography (3)
Malamed SF, Daniel L. Handbook of Local Anesthesia. 5th ed. St Louis, MO: Mosby; 2004
Harrison B & Holland P. Diagnosis and Management Of Hand Injuries In The ED. Emergency Medicine Practice Feb ; 2.
Overton DT, Uehara DT. Evaluation of the injured hand. Emergency Medicine Clinics of North America, Aug 1993; 11(3):
Trott AT. Wounds and Lacerations: Emergency Care and Closure. 3rd Edition. Elsevier; Feb 2005.

79. Thank you! mhuey@emory.edu menelaos4@emory.edu Emory University
Student Health and Counseling Services
Grady Memorial Hospital
Department of Emergency Medicine