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, 2014 @ 1:45 pm Session TH3-180

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

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?

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

Diversity-Focused Presentation SKIN IS A VERY DIVERSE ORGAN

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?

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.

Wound Care Updates 2014 Wound healing 101

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

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 2006. Copyright © 2006 Lippincott Williams & Wilkins.

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

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

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.

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

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, 2006. Copyright © 2006 Lippincott Williams & Wilkins.

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, 2006. Copyright © 2006 Lippincott Williams & Wilkins.

Wound assessment and preparation Wound Care Updates 2014 Wound assessment and preparation

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! www.photobucket.com

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 2000-2011 Self Care Decisions, LLC

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.”

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

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”

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 www.usatoday.com

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 www.deadline.com 

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) www.entertainmentwallpaper.com 

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

We clean wounds with water +/- soap at home

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

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?

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

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 0.63 (95% CI 0.40-0.99) In children, the difference was not statistically significant (RR 1.07)

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 0.07-16.50). 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.

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.

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

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 www.aafp.org

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 www.theidearoom.net

Wound Care Updates 2014 Wound dressings

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

“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 . . . www.photobucket.com

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 www.organicfacts.net

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. 8.9 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 www.firstaid.about.com

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

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 www.photobucket.com

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 www.photobucket.com

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

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

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

Infraorbital Nerve Block (2)

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

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

Cutaneous Nerve Blocks For more extensive wounds Injuries proximal to fingers

Sensory Innervation of Hand

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

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

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

LET

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

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

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

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

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

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)

"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.

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

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

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

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

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

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

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

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

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

What will it look like?

Doesn’t Have to be Messy

QUESTIONS?

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): 379-387. Hermans, MH, Hydrocolloid dressing versus tulle gauze in the treatment of abrasions in cyclists, Intl J Sports Med 1991 Dec; 12(6): 581-4 Beam, JW, Occlusive Dressings and the healing of standardized abrasions, J Athl Train 2008 Nov-Dec; 43(6): 600-607.

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

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 2005. 7; 2. Overton DT, Uehara DT. Evaluation of the injured hand. Emergency Medicine Clinics of North America, Aug 1993; 11(3):585-600. Trott AT. Wounds and Lacerations: Emergency Care and Closure. 3rd Edition. Elsevier; Feb 2005.

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