0
Erik Adler, MD
February 4, 2014
A 6 year old boy presents with a scalp laceration that
requires suturing . His mother tells you that he is scared
of needl...
A patient presents to the Emergency Department with a
laceration to the right forearm. He sustained the injury
while intox...
A 28 year old man attends the emergency department with
a simple laceration requiring suturing. You wonder
whether applica...
Create optimal conditions for healing.
 Preserve function.
 Minimize complications.
 Improve the chances of a cosmetica...




Secondary survey
Mechanism of injury
Elicit host factors that adversely affect wound outcome
◦
◦
◦
◦
◦
◦



Increa...
Adequate setting/lighting
 Hemostasis
 Neurovascular exam
 Foreign body
 Radiography



5th cause of malpractice claims against emergency
physicians



50% was glass



Anver and baker 1992: 7% missing. 21...


Reactive materials, such as wood and vegetative
material



Contaminated material



Clothing (should always be consi...


X-Ray



CT Scan/ MRI



US :sensitivity of 95-98% and a specificity of 89-98%
Anesthesia :


Local anesthetic injections



Topical anesthetics



Regional anesthetics
Essential skill for all ED physicians
 Save time
 Decrease possibility of systemic toxicity
 Less painful than local in...
While data is convincing that local anesthetics
with epinephrine do not cause long term damage
to tissue with single blood...








Small-bore needles
Buffered solutions
Warmed solutions
Slow rates of injection
Injection through wound edge...


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



Face and scalp



Liquid or gel forms
Lidocaine
 Marcaine (Bupivicaine)


◦ Drug concentration is expressed as a percentage (eg,
bupivacaine 0.25%, lidocaine ...


Toxic Doses◦ Lidocaine without epinephrine- 4.5 mg/kg; not to exceed
300 mg total dose
◦ Lidocaine with epinephrine- 7 ...
While generally safe, local anesthetic agents can
be toxic if administered inappropriately.
 Central Nervous System, Card...


Ruthman et al : closure of lacerations without caps and
masks did not lead to an increased incidence of wound
infection...


Non-sterile gloves, which provide “universal precaution “
is appropriate.



Latex gloves should also be avoided







Reduce quantity of bacteria on the surface of the skin
Shaving the hair does make closure easier
Increased ris...


Most important step



Remove bacteria and contamination



15 psi removed 85% of bacterial contamination from a
woun...


Minimum of 250 cc



60 cc/ cm wound length



Large volume with low pressure may be good.


Sterile saline solution



Povidone-Iodine Solution
(Betadine®) 10%
- tissue toxic
-did not reduce
infection incidence...




Hydrogen peroxide no role, tissue toxic.
Tap water : low cost, available.
Sandy : Medline 1966-10/03, 397 papers fo...


Cochrane review database :
-Although evidence is limited, there is no difference in
wound infection rates with the use ...


“Safe” time interval from wounding that allows
primary wound closure



The ACEP clinical policy for penetrating injur...


Bites
◦ Appropriate to close bites if on the face, but loose
approximation preferred to tight closure.
◦ All other bite...


The standard for wound closure



Percutaneous sutures are used for low- to mediumtension wounds



Absorbable suture...


Faster repair time



Less painful



Eliminate the risk for needle sticks



Antibacterial effect



Does not requ...


FDA approval in 1998
=Dermabond®



50% of the strength of
5-0 suture material.



Cochrane review :
comparable cosme...


Short (< 6-8 cm)



Low tension (< 0.5 cm gap)



Clean edged



Straight to curvilinear
wounds that do not cross
jo...


Stellate lacerations



Bites, punctures or crush
wounds



Contaminated wounds



Mucosal surfaces



Axillae and ...


Fast ,low wound reactivity and infection rate.



Less expensive.



Less needle sticks risk.



No cosmetic differe...


Least reactive of all
closure techniques



Lowest tensile strength



May require tincture of
benzoin



Avoid in h...


Simple, low-tension pediatric
facial wounds, Steri-Strips™
resulted in a cosmetically
equivalent wound closure
compared...






Twisting hair on either side
of the wound and tying the
twists together to pull
together and close the
wound.
Lac...


Much underused method of wound care .



Reduced the infection rate by 50% in 104 extremity
wounds



Recommended tec...


Allowing a wound to heal without formal closure .



Simple but more wound scaring.



Quinn et al in 2002 : conserva...


Prophylaxis studies : no benefits.



Indications For Prophylactic Antibiotics:
-Presence of prosthetic device(s) Clas...


Dire et al (1995), triple antibiotic ointment reduced the
incidence of postclosure infection compared to a
petroleum je...
Tetanus History

Clean Minor Wounds

All Other Wounds

< 3 doses in primary
series
Primary 3 Series
Completed
Last < 5 yea...
1. Staples and glue are the quickest closure
methods.
2. Small, simple hand lacerations (< 2 cm) do not
require primary cl...
4. Clean tap water is as effective as (and cheaper
than!) sterile saline for wound irrigation.
5. Cyanoacrylates or absorb...


High-pressure irrigation with normal saline or tap water.



Clean wounds presenting within 8 hours of occurrence
can ...


Determine if it is appropriate to close a wound primarily



Prevention of a wound infection



Multitude of wound cl...
Wound care in ER.  Dr Erik Adler
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Wound care in ER. Dr Erik Adler

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Transcript of "Wound care in ER. Dr Erik Adler"

  1. 1. Erik Adler, MD February 4, 2014
  2. 2. A 6 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. Are there other options?
  3. 3. A patient presents to the Emergency Department with a laceration to the right forearm. He sustained the injury while intoxicated last night. Upon waking, he noticed the wound and came to the ED. The injury was 14 hours ago. He requests it be stitched closed.
  4. 4. A 28 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. You also wonder if washing the wound with tap water is appropriate.
  5. 5. Create optimal conditions for healing.  Preserve function.  Minimize complications.  Improve the chances of a cosmetically pleasing result. 
  6. 6.    Secondary survey Mechanism of injury Elicit host factors that adversely affect wound outcome ◦ ◦ ◦ ◦ ◦ ◦  Increased age Diabetes Peripheral Vascular Disease Smokers Wound width Contamination or foreign body. Tetanus immunization
  7. 7. Adequate setting/lighting  Hemostasis  Neurovascular exam  Foreign body  Radiography 
  8. 8.  5th cause of malpractice claims against emergency physicians  50% was glass  Anver and baker 1992: 7% missing. 21% in deeper wounds.  In a medical/legal review, Kaiser et al: unsuccessful defense in 60% of cases.  When in doubt, do the X-ray!
  9. 9.  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
  10. 10.  X-Ray  CT Scan/ MRI  US :sensitivity of 95-98% and a specificity of 89-98%
  11. 11. Anesthesia :  Local anesthetic injections  Topical anesthetics  Regional anesthetics
  12. 12. Essential skill for all ED physicians  Save time  Decrease possibility of systemic toxicity  Less painful than local infiltration  Does not cause volume-related tissue distortion 
  13. 13. While data is convincing that local anesthetics with epinephrine do not cause long term damage to tissue with single blood supply (fingers, toes, nose, penis), it is still recommended that local anesthetic with epinephrine be avoided in these areas.  Epinephrine will cause vasoconstriction, which can be beneficial when requiring bloodless field 
  14. 14.        Small-bore needles Buffered solutions Warmed solutions Slow rates of injection Injection through wound edges Subcutaneous rather than intradermal injection Pretreatment with topical anesthetics
  15. 15.  LET (lidocaine, 4%; epinephrine, 0.1%; tetracaine, 0.5%)  Face and scalp  Liquid or gel forms
  16. 16. Lidocaine  Marcaine (Bupivicaine)  ◦ Drug concentration is expressed as a percentage (eg, bupivacaine 0.25%, lidocaine 1%). ◦ Percentage is measured in grams per 100 mL (ie, 1% is 1 g/100 mL [1000 mg/100 mL], or 10 mg per mL).
  17. 17.  Toxic Doses◦ Lidocaine without epinephrine- 4.5 mg/kg; not to exceed 300 mg total dose ◦ Lidocaine with epinephrine- 7 mg/kg ◦ Bupivicaine without epinephrine- 2.5 mg/kg; not to exceed 175 mg total dose ◦ Bupivicaine with epinephrine- Not to exceed 225 mg total dose
  18. 18. While generally safe, local anesthetic agents can be toxic if administered inappropriately.  Central Nervous System, Cardiovascular System, Methemoglobinemia, Allergic Response.  Etiology ◦ ◦ ◦ ◦ Inadvertent intravascular administration Excessive dose or rate of injection Delayed drug clearance Administration into vascular tissue
  19. 19.  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.
  20. 20.  Non-sterile gloves, which provide “universal precaution “ is appropriate.  Latex gloves should also be avoided
  21. 21.      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 .
  22. 22.  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 18-gauge catheter with maximal hand pressure.
  23. 23.  Minimum of 250 cc  60 cc/ cm wound length  Large volume with low pressure may be good.
  24. 24.  Sterile saline solution  Povidone-Iodine Solution (Betadine®) 10% - tissue toxic -did not reduce infection incidence.  Diluted betadine : use indeterminate.
  25. 25.    Hydrogen peroxide no role, tissue toxic. Tap water : low cost, 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
  26. 26.  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.
  27. 27.  “Safe” time interval from wounding that allows primary wound closure  The ACEP clinical policy for penetrating injury 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 face and scalp
  28. 28.  Bites ◦ Appropriate to close bites if on the face, but loose approximation preferred to tight closure. ◦ All other bites should be left for delayed primary closure or closure by secondary intent. ◦ All bites deserve ABX (Augmentin is preferred)  Stab Wounds ◦ Wound packing with wet to dry for 5 days followed by delayed primary closure  Infected tissue or significantly contaminated tissue
  29. 29.  The standard for wound closure  Percutaneous sutures are used for low- to mediumtension wounds  Absorbable suture material for dermal stitches  Interrupted versus other types of sutures has no effect on infection rate
  30. 30.  Faster repair time  Less painful  Eliminate the risk for needle sticks  Antibacterial effect  Does not require removal of sutures
  31. 31.  FDA approval in 1998 =Dermabond®  50% of the strength of 5-0 suture material.  Cochrane review : comparable cosmetic outcomes compared to standard suturing
  32. 32.  Short (< 6-8 cm)  Low tension (< 0.5 cm gap)  Clean edged  Straight to curvilinear wounds that do not cross joints or creases
  33. 33.  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)
  34. 34.  Fast ,low wound reactivity and infection rate.  Less expensive.  Less needle sticks risk.  No cosmetic difference.  Scalp, trunk, and extremity.
  35. 35.  Least reactive of all closure techniques  Lowest tensile strength  May require tincture of benzoin  Avoid in hairy and wet area.
  36. 36.  Simple, low-tension pediatric facial wounds, Steri-Strips™ resulted in a cosmetically equivalent wound closure compared to cyanoacrylate closure
  37. 37.    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 .
  38. 38.  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.
  39. 39.  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.
  40. 40.  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
  41. 41.  Dire et al (1995), 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).  Important to address patient allergies and avoid if allergic to Neomycin, Bacitracin, Polymyxin.
  42. 42. Tetanus History Clean Minor Wounds All Other Wounds < 3 doses in primary series Primary 3 Series Completed Last < 5 years ago Td Td + TIG Nill Nill Last > 5 years ago and < 10 Last > 10 years ago Nill Td Td Td
  43. 43. 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.
  44. 44. 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.
  45. 45.  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.
  46. 46.  Determine if it is appropriate to close a wound primarily  Prevention of a wound infection  Multitude of wound closure methods including “needleless” methods.
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