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CUTTING EDGE WOUND CARE. David C. Seaberg, M.D., F.A.C.E.P. Associate Professor and Associate Chairman Department of Emergency Medicine University of Florida College of Medicine. Wound Care Outline. General Principles Wound Evaluation Anesthesia Wound Preparation Suturing and Adhesives

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  1. CUTTING EDGEWOUND CARE David C. Seaberg, M.D., F.A.C.E.P. Associate Professor and Associate Chairman Department of Emergency Medicine University of Florida College of Medicine

  2. Wound Care Outline General Principles • Wound Evaluation • Anesthesia • Wound Preparation • Suturing and Adhesives • Antibiotics Conscious Sedation

  3. Wound Care • Over 11 million lacerations per year treated in ED’s • Over $2 billion spent on wound care per year • Goals of Wound Care: • avoid infection and achieve a functional and aesthetically pleasing scar

  4. Wound Care • Goals Achieved Through: • reducing tissue contamination • debriding devitalized tissue • restoring perfusion in poorly perfused wounds • establishing a well-approximated skin closure

  5. Outpatient Wound Preparation:A National Survey • 19% managed wounds based on provider preferences • 38% soaked wounds • 21% used Betadine or Hydrogen peroxide to cleanse • 67% scrubbed entire wound surface • 27% irrigated wounds with inadequate techniques • 76% infrequently or never used delayed primary closure Howell, Ann Emerg Med, 1992

  6. Evaluation of the Patient • Increased Wound Infection: • Diabetes melitus • obesity • malnutrition • chronic renal failure • advanced age • use of steroids and other immunosuppressants Cruse, Arch Surg, 1973

  7. Evaluation of the Patient • Allergies: anesthetics, latex, tape • Tetanus: TdTIG Uncertain or < 3 doses Yes No/Yes > 3 doses: Last dose within 5 yrs No No Last dose 5 - 10 yrs No No Last dose > 10 yrs Yes No

  8. Evaluation of the Laceration • Mechanism • laceration vs crush • Neurovascular exam • Tendon injury • Examine for foreign bodies

  9. Evaluation of the Laceration Foreign Body Identification • Plain radiography • all glass FB visible at 2 mm, only 61% visible at 0.5 mm • wood splinters, thorns, vegetable matter may not be seen • Ultrasound • detects vegetative FB’s • sensitivity 95 -98%, specificity 89 to 98% • Computed Tomography • most useful in identifying objects and location • expensive, increased radiation dose

  10. Evaluation of the Laceration Use of sterile technique • Comparable infection rates btwn 239 wounds repaired with sterile gloves and masks vs 203 wounds repaired with non-sterile gloves Ruthman, Ill Med J, 1984 • Similar wound rates btwn pts randomly assigned to repair with either full sterile technique vs nonsterile gloves and tap water Whorl,Can Fam Physician, 1987

  11. Anesthesia of the Laceration AgentTradeClassConcDoseOnsetDuration Procaine NovocaineEster 0.5-1.0% 7mg/kg 2-5 min 0.25-0.75 hr Lidocaine Xylocaine Amide 0.5-2.0% 4.5mg/kg 2-5 min 1-2 hr Bupivacaine Marcaine Amide 0.125-0.25% 2mg/kg 2-5 min 4-8 hrs

  12. Anesthesia of the Laceration • Anesthetic reactions • rare • usually vasovagal or mild local reactions • often due to perservative • no cross-reactivity between the esters and amides • can use saline or diphenydramine as alternatives

  13. Anesthesia of the Laceration Reducing the pain of infiltration • Small-bore needles (27 to 30 gauge) • Buffered solutions • Warmed solutions • Slow rate of injection • Injection through wound edges • Subcutaneous rather than intradermal injection • Pretreatment with topical anesthetics

  14. Anesthesia of the Laceration Topical Anesthesia • TAC • LET • EMLA

  15. Anesthesia of the Laceration Schilling, Ann Emerg Med, 1995

  16. Wound Anesthesia Randomized, Controlled Trial of the Use of Music During Laceration Repair Menegazzi, Ann Emerg Med, 1991

  17. Wound Preparation • Shaving • Scrubbing - removes wound coagulum • hydrogen peroxide • chlohexidine (Hibiclens) • providone ioodine • 10% vs 1% • nonionic surfactants (Poloxamer 188 and Pluronic F-68) • Debridement

  18. Wound Preparation • Soaking 3 treatment groups: Tx GroupBacterial counts No soak Decrease of 6.4 x 105 Saline soak Increased 3.39 x 107 Povidone-iodine soak Decreased 9.19 x 106 Lammers, Ann Emerg Med, 1990

  19. Wound Preparation Lammers, Ann Emerg Med, 1990

  20. Wound Irrigation • High pressure irrigation (5 to 8 psi) • 30 - 60 ml syringe with a 19-gauge needle or Zerowet • avoid in noncontaminated wounds with loose areolar tissue

  21. Wound Irrigation Irrigation Fluid • Normal Saline - 60 ml per cm of wound length • Tap Water • pathogenic bacteria were not isolated from tap water Riyat, J Accid Emerg Med, 1997 • animal models using tap water irrigation showed no increase in infection rate Moscati, Acad Emerg Med, 1998

  22. Wound Closure Timing • Nylen: 108 hand lacerations, no correlation btwn incidence of infection and time of repair up to 18 hrs Nylen, J Palst Reconst Surg, 1980 • Berk: 204 lacerations: 92% satisfactory healing if primary closure within 19 hrs compared to 77% in those sutured after 19 hrs. Head lacerations not affected by time Berk, Ann Emerg Med, 1988

  23. Berk, Ann Emerg Med, 1988

  24. Wound Closure • Nonabsorbable sutures • retain most of their tensile strength longer than 60 days • relatively nonreactive • appropriate for skin closure SutureKnot TensileTissue ReactivityWorkability Nylon (Ethilon) Good Good Minimal Good Polypropylene Least Best Least Fair Silk Best Least Most Best

  25. Wound Closure • Absorbable Sutures • closure of deeper structures than the epidermis • deep sutures help relieve skin tension, decrease dead space and hematoma formation, improve cosmetic outcome • avoid deep sutures in contaminated wounds SutureKnotTensile SecurityTissue Reactivity Surgical gut Poor Fair 5-7 d Most Chromic gut Fair Fair 10-14 d Most Polyglactin (Vicryl) Good Good 30 d Minimal Polyplycolic (Dexon) Best Good 30 d Minimal Polydioxanone (PDS) Fair Best 45-60 d Least

  26. Wound Closure • Wound eversion • Intradermal technique - subQ stitches increase wound inflammation and risk of infection • Vertical Mattress - useful on lax skin

  27. Wound Closure • Staples • quicker than sutures • lower rate of foreign body reaction and infection • animal models have demonstrated lower bacterial growth and lower infection rates than sutures • useful for scalp, trunk, and extremity wounds • Disadvantages: do not allow as meticulous a closure and are slightly more painful to remove

  28. Wound Closure • Adhesive Tapes • surgical tapes are even less reactive than staples • adhesive adjuncts (i.e Benzoin) increase local induration and wound infection • tape alone cannot maintain wound integrity in areas subject to tension • often used after suture removal

  29. Wound Closure • Tissue Adhesives • monomeric cyanoacrylates polymerize in the presence of hydroxyl ions which can be found in water and blood 1. n-butylcyanoacrylates 2. 2-Octylcyanoacrylates (Dermabond) • more stable • greater flexibility • maintains a stronger bond • degrades more slowly • less toxic

  30. 2-Octylcyanoacrylates (Dermabond) • Two large studies (331 and 1500 pts) found: • infection rates less than 2% • dehiscence rates of 0.6 to 1.8% • Cosmetic results at 3-months and one year have been found to be the same as suturing • time required for closure and the pain associated were less for the tissue adhesive

  31. 2-Octylcyanoacrylates (Dermabond • Dermabond is packaged in a sterile, single-use ampule and is colored with violet dye • manually approximate the skin and apply 3 to 4 coats • usually sloughs off in 7 to 10 days • excellent for facial lacerations • can be used in areas of higher tension but only if sucutaneous or subcuticular absorbable sutures are used first

  32. Wound Closure Delayed Primary Closure • Leaving contaminated laceration open for 3 - 5 days • Bacterial counts fall in open wounds, reaching their nadir at 96 hrs • Indications for DPC: • grossly contaminated wounds that can not be cleaned adequately • non-facial lacerations that are too old for closure

  33. Wound Closure Delayed Primary Closure • Technique: • clean the wound • apply damp, sterile layer of fine mesh gauze to all would surfaces, followed by a bulky dressing • antimicrobials may be indicated to lower bacterial counts • wound should be reassessed in 3-5 days • removal of gauze will autodebride the wound surface • suture the wound if no gross infection exists

  34. Antibiotics Antibiotics to Prevent Infection of Simple Wounds: A Meta-Analysis of Randomized Studies • 9 studies, 1,734 patients • Patients treated with antibiotics had a slightly greater incidence of infection compared to untreated controls OR = 1.16 • No benefit from using penicillinase-resistant antibiotics • Non-bite wounds only Cummings, Am J Emerg Med, 1995

  35. Antibiotics Indications for Antimicrobial Prophylaxis in Extremity Lacerations: • Location on hand or lower extremity • Presence of devitalized tissue • Significant contamination • Involvement of joint spaces, tendons, or bones • Human and mammalian bites (not superficial) • Impaired host immune response 1999 ACEP Clinical Policy

  36. Selected Indications for Antibiotics in Traumatic Wounds • Delay in wound cleansing and repair > 3 hrs • Pus present in wound • Wound contamination with saliva, vaginal secretions, or feces • Prevention of transient bacteremia in pts at risk for endocarditis • Wounds with a prosthetic joint • Lacertions to lymphedematous tissues • Wounds to immunocompromised host • Bites affecting the hand or face or forming deep punctures

  37. Antibiotics • Infected Traumatic Lacerations • Staph and Strep species most common • Semisynthetic penicillins: cloxacillin or dicloxacillin • First-generation Cephalosporins • For pen-allergic pts: cephalosporins or clindamycin 1999 ACEP Clinical Policy

  38. Antibiotics Prophylactic Antibiotics for Dog Bite Wounds: Parenteral antibioticsOral antibiotics Cefazolin Dicloxacillin Nafcillin Cephalexin Oxacillin Erythromycin 1999 ACEP Clinical Policy

  39. Antibiotics Prophylactic Antibiotics for Cat Bite Wounds: Parenteral antibioticsOral antibiotics Pen G Pen VK Ampicillin Amoxicillin Cefuroxime Cefuroxime axetil Ceftriaxone Cefixime Tetracycline Erythromycin 1999 ACEP Clinical Policy

  40. Antibiotics Empiric Antibiotic Regimens for Dog and Cat Bite Infections: Presumed P. multocida infections: • IV or IM pen G or VK, followed by oral amoxicillin • for Pen allergy: cefuroxime or cefixime • for cephalosporin allergy: fluoroquinolone, erythromycin, tetracycline Presumed staph or strep infections: • Diclox or first-generation cephalosporin • for cephalosporin allergy: fluoroquinolone, erythromycin, or clinda 1999 ACEP Clinical Policy

  41. Antibiotics Antibiotics for Human Bite Wounds: Parenteral antibioticsOral antibiotics Pen G Pen VK Cefuroxime Dicloxacillin Ceftriaxone Augmentin Cephalexin 1999 ACEP Clinical Policy

  42. Pediatric Conscious Sedation The old ways: 1. Chloral hydrate • 25 mg/kg to 100 mg/kg 2. DPT • 2mg/1mg/1mg IM 3. Pentobarbital • 5 -7 mg/kg

  43. Pediatric Conscious Sedation The new methods: 1. Intranasal/Oral Midazolam • 0.2 - 0.3 mg/kg 2. Ketamine • 2-4 mg/kg IM/IV 3. Propofol • 5 -7 mg/kg bolus

  44. Pediatric Conscious Sedation Intranasal/Oral Midazolam • average LOS 90-120 minutes • few side effects but can have hypoxia, apnea • cost analysis study noted that oral midazolam significantly increased ED visit LOS and cost. Up to 1/3 of parents surveyed would not want to wait the extra time or pay the extra money for the sedation

  45. Pediatric Conscious Sedation Ketamine - study in 1,022 pediatric cases: • average LOS 110 minutes • acceptable sedation attained in 98% of patients • transient airway complications in 1.4% • emesis in 6.7% and mild recovery agitation occurred in 17.6% Green, Ann Emerg Med, 1998

  46. Pediatric Conscious Sedation Propofol vs Midazolam • average LOS 15 min vs. 76 min • acceptable sedation attained equally in both groups • transient hypoxemia in 11.6% vs 10.9%

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