wound care in er

8/12/2019 Wound Care in ER

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Wound Managementin ED

Hood Al-Abri


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Clinical scenario - I

A 7 year old boy presents with a scalp lacerationthat requires suturing . His mother tells you that

he is scared of needles and is liable to becomeupset


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Clinical scenario - II

A patient presents to the Emergency Departmentwith a laceration to the right forearm. The woundwill need cleaning and then closing. There appearto be many different cleaning solutions available


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Clinical scenario - III

A 26 year old man attends the emergencydepartment with a simple laceration requiringsuturing. You wonder whether application of a

topical antibiotic ointment may promote healingand reduce incidence of infection


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The Goals

Create optimal conditions for the patientto heal themselves.

Preserve function. Minimize complications.

Improve the chances of a cosmeticallypleasing result


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ED evaluation Secondary survey Mechanism of injury elicit host factors that adversely affect wound

outcome increased age, diabetes, width, and

contamination or foreign body.

tetanus immunization


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Wound Examination

Adequate setting.

Hemostasis.

Neurovascular exam Foreign body

Radiography


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Foreign Bodies 5th cause of malpractice claims againstemergency physicians

50% was glass

Anver and baker 1992 :7% missing . 21% in deeperwounds. Do X-ray !

In a medical/legal review, Kaiser et al:unsuccessful defense in 60% of cases.


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FB removal Reactive materials, such as wood and vegetative

material

Contaminated material

Clothing (should alwaysbe consideredcontaminated)

Most foreign bodies in the foot

Impingement on neurovascular structure


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Foreign Bodies wood and plastic foreign bodies

Ct scan / MRI

U/S :sensitivity of 95-98% and a specificity of89-98%


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Wound preparation

Anesthesia:

Local anesthetic injections

Topical anesthetics

Regional anesthetics


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Methods to reduce pain of Lidocainelocal infiltration

Small-bore needles Buffered solutions Warmed solutions

Slow rates of injection Injection through wound edges Subcutaneous rather than intradermal injection Pretreatment with topical anesthetics


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Topical anesthesia TAC (tetracaine, 0.25-0.5%; adrenaline, 0.025-

0.05%; cocaine, 4-11.8%)

SE : seizures, arrhythmias, and cardiac arrest .


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Topical anesthesia LET (lidocaine, 4%; epinephrine, 0.1%; tetracaine,0.5%)

Face and scalp

Liquid or gel forms


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Sterile Technique CDC guidelines : sterile technique

Ruthman et al : closure of lacerations without

caps and masks did not lead to an increasedincidence of wound infection.

Worral and later Perelman: sterile versusnonsterile gloves found no difference in wound

infection rates.


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Non-sterile gloves, which provide universal

precaution is appropriate.

Latex gloves should also be avoided


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Skin and Hair Preparation Reduce quantity of bacteria on the surface of theskin

Shaving the hair does make closure easier

increased risk of wound infection by inducingtrauma Seropian and Reynolds : infection risk increased

from 0.6% to 5.6% when hair was shaved from awound

The use of clippers.


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Wound Irrigations Used since 2200 BC.

Most important step

Remove bacteria and contamination

15 psi removed 85% of bacterial contaminationfrom a wound, whereas (1 psi) removed only 49%

5 8 psi

30-60-cc syringe to push fluid through a 19-gaugecatheter with maximal hand pressure.


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Wound Irrigation minimum of 250 cc

60 cc/ cm wound length

Large volume with low pressure may be good.


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Irrigation Fluid Sterile saline solution Povidone-Iodine

Solution (Betadine)

10%- tissue toxic

-did not reduceinfection incidence.

Diluted betadine : useindeterminate.


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Irrigation Fluid Hydrogen peroxide no role, tissue toxic. Tap water : low cast, available.

Sandy : Medline 1966-10/03, 397 papers found

Tap water is a safe and effective solution forcleaning recent wounds requiring closure and is

the treatment of choice


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Tap water Cochrane review database :

although evidence is limited, there is no difference

in wound infection rates with the use of tap wateras an irrigation fluid.


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Debridement old technique with little recent research

tissue loss versus function

delayed primary closure.


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Golden period safe time interval from wounding thatallows primary wound closure

The ACEP clinical policy for penetratinginjury of the extremity supports an 8-12-hour cutoff for primary wound closure.

6-10 hours - wounds of the extremities and up to 10-12 hours or more for the faceand scalp


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Closure Methods

Sutures The standard for wound closure

Percutaneous sutures are used for low- to

medium-tension wounds

absorbable suture material for dermal stitches

interrupted versus other types of sutures has noeffect on infection rate


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Glue Faster repair time

Less painful

Eliminate the risk for needle sticks

Antibacterial effect Does not require removal of sutures


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Glue :Octyl cyanoacrylate

FDA approval in 1998=Dermabond

50% of the strength

of 5-0 suturematerial.

Cochrane review :comparable cosmetic

outcomes compared tostandard suturing


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GlueSimon : In [children with facial lacerations requiring

closure] is [wound glue better than sutures] at[improving cosmetic outcome and reducing the

distress of the procedure]? Medline 1966-07/99 using the OVID interface .

138 papers found, 8 RCTsGlue is the wound closure method of choice in recent

lacerations to the face in children


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Glue me Short (< 6-8 cm) Low tension (< 0.5 cm gap)

Clean edged

Straight to curvilinearwounds that do not crossjoints or creases


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Dont glue me stellate lacerations Bites, punctures or crush

wounds

Contaminated wounds

Mucosal surfaces

Axillae and perineum (high-moisture areas)

Hands, feet and joints

(unless kept dry andimmobilized)


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staples Fast ,low wound reactivity and infection rate.

Less expensive.

Less needle sticks risk.

No cosmetic difference.

Scalp, trunk, and extremity.


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Surgical Tapes

Steri-Strips least reactive of all

closure techniques

lowest tensile

strength May require tincture

of benzoin

Avoid in hairy and wet

area.


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Surgical Tapes simple, low-tension

pediatric facialwounds, Steri-Strips

resulted in acosmeticallyequivalent woundclosure compared tocyanoacrylate closure


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Hair Closure in Scalp Wounds twisting hair on either sideof the wound and tying thetwists together to pulltogether and close thewound.

lacerations 10 cm or less inlength and hair longer than3 cm .

close the outermost skin

layers, nohemostasis.


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Delayed Primary Closure (DPC) much underused method of wound care .

reduced the infection rate by 50% in 104

extremity wounds recommended technique for contaminated woundsthat present to the ED

Technique : clean and debride then separatewound edges with gauze, and apply bulky dressing.


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Secondary Intention allowing a wound to heal without formal closure .

Simple but more wound scaring.

Quinn et al in 2002 : conservative managementresulted in no cosmetic or functional differencecompared to primary closure in selected hand

lacerations.


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Antibiotic Use prophylaxis studies : no benefits. Indications For Prophylactic Antibiotics:

Presence of prosthetic device(s) Class III

Patients in need of endocarditis prophylaxis Class IIIOpen joint or fractures associated with wound Class IHuman, dog, and cat bites Class IIIntraoral lacerations Class IIImmunocompromised patients Class IIIHeavily contaminated wounds (eg, feces, etc) Class III


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Topical Antibiotics Dire et al, triple antibiotic ointment reduced theincidence of postclosure infection compared to apetroleum jelly control (4.5-5.5% for bacitracin

and Neosporin vs 17.6% for petroleum control). BestBETs :Medline 1966-07/02, 71 papers.

There is not enough evidence here to changecurrent practice. A large multicentre study is

indicated to provide more relevant answers


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Tetanus Prophylaxis Recommendations

Tetanus History Clean Minor Wounds All Other Wounds< 3 doses in primaryseries

Td Td + TIG

Primary 3 SeriesCompleted

Last < 5 years ago Nill Nill

Last > 5 years ago and

< 10

Nill Td

Last > 10 years ago Td Td


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Cost- And Time-Effective Strategies

For Wound Care

1. Staples and glue are the quickest closuremethods.

2. Small, simple hand lacerations (< 2 cm) do notrequire primary closure.

3. Sterile gloves have no advantage overnonsterile gloves in reducing wound infection.


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Cost- And Time-Effective Strategies

For Wound Care4. Clean tap water is as effective as (andcheaper than!) sterile saline for woundirrigation.

5. Cyanoacrylates or absorbable sutures arecost-effective for patients, as they do notrequire return visits.

6. Application of LET in triage allows a wound tobe anesthetized by the time you see thepatient.


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The future

Growth factors :epidermal growth factor (EGF),fibroblast growth factor (FGF), insulin-like growth factor(IGF), keratinocyte growth factor (KGF), and platelet-derived growth factor (PDGF).

PDGF gel has been shown to speed healing of

punch biopsy wounds chambers filled with antibiotics and growth

factors.


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Key points high-pressure irrigation with normal saline or tapwater.

Clean wounds presenting within 8 hours of

occurrence can typically be closed primarily. Thisdoes not apply to wounds on the face or scalp

PE alone is inadequate for ruling out a foreign

body in a wound.


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Summary

determine if it is appropriate to close a woundprimarily

prevention of a wound infection

multitude of wound closure methods includingneedleless methods.


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References

:

1. Emerg Med Clin N Am 21 2003

2. EM practice Mar. 2005

3. Sum search: multiple data base search.

4. BestBETS website5. Google search

wound care in er

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