Transcript Wound care - Oman Medical Journal

Wound Management
in ED
Hood Al-Abri
Clinical scenario - I
A 7 year old boy presents with a scalp laceration
that requires suturing . His mother tells you that
he is scared of needles and is liable to become
upset
Clinical scenario - II
A patient presents to the Emergency Department
with a laceration to the right forearm. The wound
will need cleaning and then closing. There appear
to be many different cleaning solutions available
Clinical scenario - III
A 26 year old man attends the emergency
department with a simple laceration requiring
suturing. You wonder whether application of a
topical antibiotic ointment may promote healing
and reduce incidence of infection
The Goals
• Create optimal conditions for the patient
to heal themselves.
• Preserve function.
• Minimize complications.
• Improve the chances of a cosmetically
pleasing result
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
Wound Examination
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Adequate setting.
Hemostasis.
Neurovascular exam
Foreign body
Radiography
Foreign Bodies
• 5th cause of malpractice claims against
emergency physicians
• 50% was glass
• Anver and baker 1992 :7% missing . 21% in deeper
wounds. Do X-ray !
• In a medical/legal review, Kaiser et al:
unsuccessful defense in 60% of cases.
FB removal
• Reactive materials, such as wood and vegetative
material
• Contaminated material
• Clothing (should always be considered
contaminated)
• Most foreign bodies in the foot
• Impingement on neurovascular structure
Foreign Bodies
• wood and plastic foreign bodies
• Ct scan / MRI
• U/S :sensitivity of 95-98% and a specificity of
89-98%
Wound preparation
Anesthesia :
•
Local anesthetic injections
•
Topical anesthetics
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Regional anesthetics
Methods to reduce pain of Lidocaine
local infiltration
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Small-bore needles
Buffered solutions
Warmed solutions
Slow rates of injection
Injection through wound edges
Subcutaneous rather than intradermal injection
Pretreatment with topical anesthetics
Topical anesthesia
• TAC (tetracaine, 0.25-0.5%; adrenaline, 0.0250.05%; cocaine, 4-11.8%)
• SE : seizures, arrhythmias, and cardiac arrest .
Topical anesthesia
• LET (lidocaine, 4%; epinephrine, 0.1%; tetracaine,
0.5%)
• Face and scalp
• Liquid or gel forms
Sterile Technique
• CDC guidelines : sterile technique
• Ruthman et al : closure of lacerations without
caps and masks did not lead to an increased
incidence of wound infection.
• Worral and later Perelman: sterile versus
nonsterile gloves found no difference in wound
infection rates.
• Non-sterile gloves, which provide “universal
precaution “ is appropriate.
• Latex gloves should also be avoided
Skin and Hair Preparation
• Reduce quantity of bacteria on the surface of the
skin
• Shaving the hair does make closure easier
• increased risk of wound infection by inducing
trauma
• Seropian and Reynolds : infection risk increased
from 0.6% to 5.6% when hair was shaved from a
wound
• The use of clippers
.
Wound Irrigations
• Used since 2200 BC.
• Most important step
• Remove bacteria and contamination
• 15 psi removed 85% of bacterial contamination
from a wound, whereas (1 psi) removed only 49%
• 5 – 8 psi
• 30-60-cc syringe to push fluid through a 19-gauge
catheter with maximal hand pressure.
Wound Irrigation
• minimum of 250 cc
•
60 cc/ cm wound length
• Large volume with low pressure may be good.
Irrigation Fluid
• Sterile saline solution
• Povidone-Iodine
Solution (Betadine®)
10%
- tissue toxic
-did not reduce
infection incidence.
• Diluted betadine : use
indeterminate.
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 for
cleaning recent wounds requiring closure and is
the treatment of choice
Tap water
• Cochrane review database :
although evidence is limited, there is no difference
in wound infection rates with the use of tap water
as an irrigation fluid.
Debridement
• old technique with little recent research
• tissue loss versus function
• delayed primary closure.
Golden period
• “safe” time interval from wounding that
allows primary wound closure
• The ACEP clinical policy for penetrating
injury of the extremity supports an 8-12hour cutoff for primary wound closure.
• 6-10 hours - wounds of the extremities —
and up to 10-12 hours or more for the face
and scalp
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 no
effect on infection rate
Glue
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Faster repair time
Less painful
Eliminate the risk for needle sticks
Antibacterial effect
Does not require removal of sutures
Glue :Octyl cyanoacrylate
• FDA approval in 1998
=Dermabond®
• 50% of the strength
of 5-0 suture
material.
• Cochrane review :
comparable cosmetic
outcomes compared to
standard suturing
Glue
Simon :
• 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 RCTs
Glue is the wound closure method of choice in recent
lacerations to the face in children
Glue me
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Short (< 6-8 cm)
Low tension (< 0.5 cm gap)
Clean edged
Straight to curvilinear
wounds that do not cross
joints or creases
Don’t glue me
• stellate lacerations
• Bites, punctures or crush
wounds
• Contaminated wounds
• Mucosal surfaces
• Axillae and perineum (highmoisture areas)
• Hands, feet and joints
(unless kept dry and
immobilized)
staples
• Fast ,low wound reactivity and infection rate.
• Less expensive.
• Less needle sticks risk.
• No cosmetic difference.
• Scalp, trunk, and extremity.
Surgical Tapes
Steri-Strips
• least reactive of all
closure techniques
• lowest tensile
strength
• May require tincture
of benzoin
• Avoid in hairy and wet
area.
Surgical Tapes
• simple, low-tension
pediatric facial
wounds, Steri-Strips™
resulted in a
cosmetically
equivalent wound
closure compared to
cyanoacrylate closure
“Hair” Closure in Scalp Wounds
• twisting hair on either side
of the wound and tying the
twists together to pull
together and close the
wound.
• lacerations 10 cm or less in
length and hair longer than
3 cm .
• close the outermost skin
layers, no hemostasis .
Delayed Primary Closure (DPC)
• much underused method of wound care .
• reduced the infection rate by 50% in 104
extremity wounds
• recommended technique for contaminated wounds
that present to the ED
• Technique : clean and debride then separate
wound edges with gauze, and apply bulky dressing.
Secondary Intention
• allowing a wound to heal without formal closure .
• Simple but more wound scaring.
• Quinn et al in 2002 : conservative management
resulted in no cosmetic or functional difference
compared to primary closure in selected hand
lacerations.
Antibiotic Use
• prophylaxis studies : no benefits.
• Indications For Prophylactic Antibiotics:
Presence of prosthetic device(s) Class III
Patients in need of endocarditis prophylaxis Class III
Open joint or fractures associated with wound Class I
Human, dog, and cat bites Class II
Intraoral lacerations Class II
Immunocompromised patients Class III
Heavily contaminated wounds (eg, feces, etc) Class III
Topical Antibiotics
• Dire et al, triple antibiotic ointment reduced the
incidence of postclosure infection compared to a
petroleum 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 change
current practice. A large multicentre study is
indicated to provide more relevant answers
Tetanus Prophylaxis Recommendations
Tetanus History
Clean Minor Wounds
All Other Wounds
< 3 doses in primary
series
Td
Td + TIG
Nill
Nill
Primary 3 Series
Completed
Last < 5 years ago
Last > 5 years ago and Nill
< 10
Td
Last > 10 years ago
Td
Td
Cost- And Time-Effective Strategies
For Wound Care
1. Staples and glue are the quickest closure
methods.
2. Small, simple hand lacerations (< 2 cm) do not
require primary closure.
3. Sterile gloves have no advantage over
nonsterile gloves in reducing wound infection.
Cost- And Time-Effective Strategies
For Wound Care
4. Clean tap water is as effective as (and
cheaper than!) sterile saline for wound
irrigation.
5. Cyanoacrylates or absorbable sutures are
cost-effective for patients, as they do not
require return visits.
6. Application of LET in triage allows a wound to
be anesthetized by the time you see the
patient.
The future
• Growth factors :epidermal growth factor (EGF),
fibroblast growth factor (FGF), insulin-like growth factor
(IGF), keratinocyte growth factor (KGF), and plateletderived growth factor (PDGF).
• PDGF gel has been shown to speed healing of
punch biopsy wounds
• chambers filled with antibiotics and growth
factors
.
Key points
• high-pressure irrigation with normal saline or tap
water.
• Clean wounds presenting within 8 hours of
occurrence can typically be closed primarily. This
does not apply to wounds on the face or scalp
• PE alone is inadequate for ruling out a foreign
body in a wound.
Summary
• determine if it is appropriate to close a wound
primarily
• prevention of a wound infection
• multitude of wound closure methods including
“needleless” methods.
References :
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5.
Emerg Med Clin N Am 21 2003
EM practice Mar. 2005
Sum search: multiple data base search.
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