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WOUND CARE AND REPAIR

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: Wound Registry: Development and Validation. Ann Emerg Med, May 1995. Causes of traumatic wounds:. Distribution of traumatic wounds:.

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WOUND CARE AND REPAIR

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  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:

  4. Distribution of traumatic wounds:

  5. Malpractice: • Karcz: Malpractice claims against emergency physicians in Massachusetts; 1975-1993. 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. What patients want? • Adam:Patient Priorities With Traumatic Lacerations.Am J Emerg Med, October 2000.

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

  8. 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.

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

  10. 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 167 (82.7%) 170 (82.5%) • ‘Mild’ 27 (13.4%) 27 (13.1%) • ‘Severe’ 8 (4.0%) 9 (4.4%)

  11. Caliendo: Surgical masks during laceration repair. J Am Coll Emerg Phys 1976. Alternated face mask / no mask for 99 wound repairs: • Mask: 1 / 47 infected • No mask: 0 / 42 infected

  12. 1-  Esters: Cocaine Procaine (Novocain) Benzocaine (Cetacaine) Tetracaine (Pontocaine) Chloroprocaine (Nesacaine) 2-Amides: Lidocaine (Xylocaine) Mepivacaine (Polocaine, Carbocaine) Bupivacaine (Marcaine) Etidocaine (Duranest) Prilocaine Local Anesthesia:2 main groups

  13. Properties of commonly used local anesthetics:

  14. Why Lidocaine? • Less painful • Rapid onset • Less cardiotoxic • Less expensive

  15. 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)

  16. 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

  17. 1-Small-bore needles: Edlich, 1988: • 30-gauge hurts less than a 27-gauge • 27-gauge hurts less than a 25-gauge, etc.

  18. 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

  19. Studies on buffered lidocaine:

  20. 3-Warmed solutions:

  21. 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.

  22. 4-Slow rates of injection:

  23. 5-Injection through wound edges:

  24. 6-Subcutaneous rather than intradermal injection:

  25. 7- Pretreatment with topical anesthetics:

  26. 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

  27. 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 andHegenbarth, 1990: • topical TAC vs lidocaine infiltration, in laceration repair • No significant difference in anesthetic efficacy

  28. 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

  29. 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

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

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

  32. 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

  33. 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)

  34. 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

  35. 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

  36. 4-Wound Cleansing and Irrigation: • Decreasing wound contamination and hence infection, "the solution to pollution is dilution." • Indications • Methods • Pressure • Solution • Volume • Side effects

  37. 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 1998.   • 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

  38. 2- Methods: • Bulb syringe • IV bag +/- pressure cuff • Syringe and needle • Jet lavage

  39. 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 18-20 gauge needle) • Animal studies: Rodeheaver, 1975 & Stevenson, 1976, high-pressure irrigation reduce both bacterial wound counts and wound infection rates

  40. 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

  41. 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

  42. 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

  43. Then helooked at different dilutions… • …povidone-iodine 0.01, 0.001, 0.0001% • …sodium hypochlorite 0.05, 0.005, 0.0005% • …hydrogen peroxide 3.0, 0.3, 0.03, 0.003% • …acetic acid 0.25, 0.025, 0.0025% • ONLY antiseptic not harmful to fibroblasts yet still bacteriostatic was Povidone iodine 0.001%

  44. 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

  45. 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

  46. Kaczmarek, 1982: Cultured open bottles of saline irrigating solution • 36/169 1000cc bottles were contaminated • 16/105 500cc bottles were contaminated Brown, 1985: Approximately one in five of the opened bottles use for irrigation were contaminated

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