This is a presentation which was done in my post graduate training on Wound Management In the ED. (Intended for learning purposes only)

1. Advanced
concepts in
wound
management
in the ED
Presented By: Dr Peter Andre Soltau
PGY4 DM Emergency Medicine

2. The ED is the most common place
for management of lacerations
11 million traumatic lacerations
are seen in the United States
annually

3. The history and physical exam
features determine the most prudent
course of treatment

4. Goals of Wound Care
– Painless
– Quick
– Excellent cosmesis
– Devoid of infection

5. – For each wound : individually
– Time of injury
– Mechanism of injury
– Wound characteristics
– Host characteristics

6. Wound Characteristics
– The nature of the wound
– Elective versus traumatic
– Location and orientation of the wound
– Vascularity of the tissues
– Elasticity and tension of soft tissues
– Degree of contamination

7. Host Factors
– Age
– Comorbid conditions
– Diabetes mellitus
– Chronic renal failure
– Inherited or acquired connective tissue
disorders
– Obesity
– Malnutrition
– Ethnicity
– Skin type
– Medications
– Corticosteroids
– Anticoagulants
– NSAIDs
– Antineoplastic drugs

8. Technical Factors
– Handling of tissues
– Debridement
– Sutures used
– Method of wound repair

11. Pathophysiology
–After laceration repair
– 24-48hrs initial epithelialization
– Day 5-7  peak synthesis of collagen
– 2 weeks 5% ultimate tensile strength
– 1 month 35% ultimate tensile strength

12. Controversies in Wound
Management
– Indications for immediate versus delayed closure
– Wounds at high risk of infection
– Use of local anesthetic agents
– Sterile technique
– Indications for antibiotic administration
– Suture material

13. When to close?

14. Definitions
– Primary Closure – closure of the wound at the
time of ED presentation (before granulation)
– Delayed Primary Closure – closure of the wound
3-4 after wounding
– Secondary Intention – allowing the wound to heal
naturally

15. The Golden Period
– The time after which primary closure should not be
performed
– The presumption that time from wounding to repair plays
a critical role in the extent of bacterial proliferation within
wounds
– 3 to 5 hours generally is required for proliferation of
bacteria

16. – A prospective study of the effect of late primary
closure on wound healing was undertaken at KPH,
Jamaica in 1986. All traumatically induced lacerations
treated over a 4 month period were included
– 372 patients underwent suture repair; 204 (54.8%) returned for
review seven days later. The mean time from wounding to
repair for all patients was 24.2 + 18.8 hours. Wounds closed at
up to 19 hours after wounding had a significantly higher rate of
healing than those closed later: 82 of 89 (92.1%) compared
with 89 of 115 (77.4%) (P < .01)
– Conclusion: A 19-hour "golden period“ for repair of simple wounds involving body areas other
than the head, after which sutured wounds are significantly less likely to heal.
Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘golden period’ for wound repair: 204 cases
from a third world emergency department. Ann Emerg Med 1988;17(5):496–500.

17. –In 2003 Lammers et al studied 1142
wounds and found that wound age
over 10hrs, or 8 hrs in hand wounds
was an important risk factor for
infection

18. ACEP
The ACEP clinical policy for penetrating
injury of the extremity also supports an 8-
12-hour cutoff for primary wound closure

19. Guidelines
– Extremity wounds have a “golden period” 6-10
hours
– Face and scalp wounds ≥ 10-12 hrs
– All ‘‘clean’’ wounds can be closed primarily
except puncture wounds that cannot be
irrigated adequately

20. Guidelines
– Irrigate and debride:
– Contaminated wounds
– Noncosmetic animal bites
– Abscess cavities
– Delayed presentation
– Delayed primary closure is performed to allow
the patient’s defense system to decrease the
bacterial load

21. Guidelines
– Secondary closure:
– Partial-thickness avulsions (ie, fingertip injuries)
– Contaminated small wounds (ie, puncture
wounds, stab wounds)
– Infected wounds

22. Which
wounds have
an increased
rate of
infection?

23. Degree of Contamination
– Contaminated wounds have a high degree of
bacterial inoculation at the time of wounding
– mammalian bites
– human bites
– wounds incurred in submerged bodies of water (eg,
streams, lakes, ponds)
– wounds > 6 - 8 hours

24. Mechanism of Injury
– In 1976, an animal study by Cardany et al
on crush injuries:
– Blunt injuries produced stellate lacerations
with an increased risk of infection compared to
a shearing mechanism
– Subsequent review articles:
– Presence of devitalized tissue in traumatic
wounds increases the risk of wound sepsis

25. Wound Location
– In 1987, Rosenberg et al published a prospective
observational study on the incidence of infection
in 412 paediatric patients
– Infections developed in only 2% of pediatric lacerations
– The rate in the extremity subgroup was 8.5%
– Lammers et al found
– 1.7-3.9% infection rate on the scalp and face wounds
– 5.7-23% rate on the extremities
– Thigh wounds having the highest infection rate — 23%.

26. Wound Location
– Conclusion:
– Highly perfused areas heal well despite higher
inherent bacterial counts
– Face and scalp wounds are at lower risk of
infection

27. – In a cross-sectional study of patients who had traumatic
lacerations, wound characteristics associated with higher
infection rates included:
– jagged wound edges
– stellate shape
– injury deeper than the subcutaneous tissue
– presence of a foreign body
– visible contaminants (ie, dirt and others)
Hollander JE, Singer AJ, Valentine SM, et al. Risk factors for infection in patients
with traumatic lacerations. Acad Emerg Med 2001;8:716–20

28. Who needs
tetanus
prophylaxis?

29. Tetanus Prone Wounds
– Age > 6 hours
– Stellate wound
– Avulsion
– Depth > 1 cm
– Mechanism of injury is a
missile
– Crush
– Burn
– Frostbite
– Signs of infection
– Devitalized tissue
– Contaminants
– dirt, feces, soil, or saliva
– Denervated or ischemic
tissue

31. Tetanus
– Inadequate immunization history or has never been
immunized
– tetanus immune globulin (250 IU) and tetanus toxoid (0.5 mL)
– Minor and uncontaminated wounds
– booster every 10 years
– Contaminated wounds
– booster if the patient has not received tetanus toxoid within 5
years

33. Which
anesthetic
agent is best?

34. Anesthesia
– Most wounds require anesthesia for
proper evaluation and cleaning
– Options include
– local anesthetic injections
– topical anesthetics
– regional anesthesia

35. Local Anesthetics
– Lidocaine
– Rapid onset pain relief
– Duration of action 1-2hrs
– Can distort the local anatomy
– Pain on infiltration reduced by:
– warming of the solution
– buffering by adding 1 cc of sodium bicarbonate to each 9 cc of
lidocaine
– using a small needle (eg, 30-gauge)
– slow infiltration
– injecting through uncontaminated wound margins

36. Local Anesthetics
– Bupivacaine (Marcaine®)
– lasts for 4-8 hours
– pain of infiltration can also be reduced by buffering
– Allergy
– True allergy to local anesthetics is unusual
– Typically involves the anesthetic’s preservative
– In those cases where a true allergy is known or believed to exist, a
drug of the opposite class of local anesthetic is appropriate

38. Topical Anesthetics
– Easy to use
– Do not distorting local anatomy
– Decrease the pain of subsequent
anesthetic injection
– Require time to take effect

40. Local Anesthetic Toxicity

41. Regional Anesthesia
– Blocks the nerve supply to the area of the laceration
– Regional anesthesia preferred to local infiltration in:
– wounds that otherwise would require large, toxic amounts of
local anesthetic
– wounds in which local tissue distortion needs to be avoided
(eg, lips and digits)
– wounds where local infiltration is particularly painful (eg,
plantar surface of the foot)

42. Regional Anesthesia
– Upper extremity: radial, ulnar, median, and digital nerve
blocks
– Lower extremity: sural, posterior tibial, deep, and
superficial peroneal nerve blocks
– Facial: supraorbital, infraorbital, and mental nerve blocks

43. Procedural Sedation
– May be required in cases of extensive wound
repair, especially in children
– The goal is to achieve a depressed level of
consciousness while maintaining a patent
airway

45. Distraction techniques
– Sinha and colleagues found these
techniques to be effective in reducing
situational anxiety in older children and
also in lowering parental perception of
pain distress in younger

46. How much
prep is
necessary?

47. Sterile Gloves
– A prospective, randomized, multicenter trial evaluating the use of
sterile versus nonsterile gloves in laceration repair showed:
– No difference in rate of infection
– Another randomized study by Perelam et al reproduced similar
results
– Traditional medical teaching and CDC guidelines continue to
recommend the use of sterile technique during laceration repair

48. Skin Disinfection
– A standard in the operating room
– The Cochrane review found there was
insufficient research to draw meaningful
conclusions regarding the use of antiseptic
solutions around traumatic surface wounds
before closure

49. Hair Removal
– Seropian and Reynolds showed that:
– Infection risk increased from 0.6% to 5.6% when hair was
shaved from a wound compared with removal by a topical hair
remover
– A prospective study of surgical wounds by Cruse reported
that:
– 0.9% infection rate with no shaving
– 2.4% with shaving
– The use of clippers is not associated with any increased risk of
infection

50. Debridement
– All wounds should be explored and debrided of
devitalized tissue or containments
– Balance tissue loss versus function
– Necrotic tissue
– Creates a nidus for infection
– Obstructs re-epithelialization and wound contraction

51. Foreign Bodies
– Foreign bodies
– Test and directly visualize the function and
stability of associated structures (ie, tendons and
ligaments)
– Eighty to 90% of foreign bodies are
detected by radiograph

52. Foreign Bodies
– Radiographs may not detect organic foreign bodies
– wood splinters and vegetable matter
– Ultrasound
– CT is the modality of choice for the detection of foreign
bodies when other techniques have failed

53. Wound Exploration
– Indications for removal:
– Reactive material- wood and vegetable material
– Contaminated material
– Clothing
– Foreign body in the foot
– Impingement of neurovascular structures
– Impairment of function
– Easy to remove

54. Irrigation:
how much is
enough?

55. Irrigation pressure
– In 1975, Rodeheaver
– Irrigation at 15 psi removed 85% of bacterial contamination
from a wound
– Low pressure (1 psi) removed only 49%
– The recommended irrigation pressure is 5 to 8 psi
– Use a 30- to 60-mL syringe and a 19-gauge needle or splash
shield
– Saline bag inside a pressure cuff inflated to 400 mm Hg and
connected to intravenous tubing with a 19-gauge angiocath

57. Irrigation
– In a study comparing different amounts of irrigation (250
cm3, 500 cm3, and 1000 cm3), the incidence of infection
was related inversely to the amount of irrigation
– Recommendation:
– 50 mL to 100 mL of irrigant per centimeter of laceration
– The more contaminated the wound, the greater the amount of
irrigant required for proper wound preparation

58. – Hollander and colleagues found irrigation did not make a
difference in clean, non-contaminated facial and scalp
lacerations

59. Povidone-iodine
– A randomized prospective study of irrigation with dilute (1%)
povidone iodine and scrubbing with the same
– Reduce wound infections in one study of human subject
– Study flawed as 20% of participants lost completely to follow up
– 35% of the remainder having follow-up only by phone
– An animal study by Howell et al showed:
– 1% povidone-iodine irrigation significantly reduced the bacterial
count of streptococcal-inoculated wounds, but not those
inoculated with Staphylococcus.

60. Povidone-iodine
– Other studies have been performed that show little
toxicity from 1% Betadine®
– Made by diluting standard 10% povidone-iodine solution by
1:10)
– The use of 1% Betadine® for wound irrigation therefore
remains indeterminate
– It does not appear to worsen outcome
– Very limited supporting evidence for any advantages over the
simpler use of water or saline

61. Tap Water
– Animal studies have shown that tap water is as effective
as sterile saline in reducing wound infection and bacterial
counts
– A small double-blind study comparing tap water to sterile
saline, in simple lacerations less than 8 hrs old, irrigated
with 500 cc of solution at high pressure:
– No significant difference in wound infection rates

62. Tap Water
– The Cochrane review database stated that, although
evidence is limited, there is no difference in wound
infection rates with the use of tap water as an irrigation
fluid, provided the water is potable
– Benefits
– Low cost
– Immediate availability

63. Other Irrigation Fluids
– Hydrogen peroxide- tissue toxic and
poorly bactericidal
– Detergents- tissue toxic in animal
studies

64. When should
antibiotics be
prescribed?

65. Antibiotics
– Multiple studies since the 1970’s have shown no benefit to
the use of antibiotics in incised, clean, early traumatic
wounds in non-immunocompromised hosts
– After performing a meta-analysis of randomized trials of
prophylactic antibiotics for simple non-bite wounds,
Cummings and Del Beccaro concluded that there is no
evidence to support the routine use of prophylactic
antibiotics in simple lacerations

66. Indications for Prophylactic
Antibiotics
– Open joint or fractures associated with the
wound
– Human, dog, cat bites
– Intraoral lacerations
– Immunocompromised patients
– Heavily contaminated wounds
– Prosthetic devices
– Patients in need of endocarditis prophylaxis

67. What
material
reigns
supreme?

68. Material
–Sutures
–Staples
–Tissue adhesives
–Adhesive tapes

69. Sutures
– Suture material and technique dependent on:
– type of wound
– location
– mechanical stress
– infection risk

70. Sutures
– Percutaneous sutures with nonabsorbable suture
material are used for low- to medium- tension wounds

71. Sutures
– Natural fibers (eg, silk)
– more reactive than synthetic fibers
– have a higher incidence of wound infection in
contaminated wounds
– should be avoided in most cases

72. Sutures
– Dermal Sutures
– placed to reduce wound tension, aid closure,
reduce wound dead space, and reduce
hematoma formation
– Synthetic absorbable suture material
preferred
– Increase the risk of infection in animal studies
– Has not been shown to increase infection in
clean wounds

73. Suture Selection
– Face
– Scalp
– Chest
– Back
– Abdomen
– Joints
– Extremities
– Oral
– 5-0 to 6-0
– 3-0 to 5-0
– 3-0 to 4-0
– 3-0 to 4-0
– 3-0 to 4-0
– 3-0 to 4-0
– 4-0 to 5-0
– 3-0 to 5-0 absorbable

74. Staples
– A cosmetically acceptable alternative to sutures for:
– the closure of scalp lacerations
– closure of linear perpendicular lacerations of the trunk or
extremities
– Avoid uneven or overlapping wound edges
– Staples vs sutures
– Staples provide more rapid wound repair
– Have a lower rate of reactivity and infection
– Unable to provide a meticulous closure
– More painful process of removal

75. Octyl cyanoacrylate
(Dermabond®)
– Forms a plastic adhesive bond on initial
application approaching 50% of the
strength of 5-0 suture material
– Numerous studies and a Cochrane review
report comparable cosmetic outcomes
compared to standard suturing

76. Octyl cyanoacrylate
(Dermabond®)
– Placed 5.7 minutes quicker on average than sutures
– Less painful
– Small increase in rate of dehiscence for glued wounds
compared to suture closure

77. Adhesive Tapes (Steri-
StripsTM)
– The least reactive of all closure techniques
– Adhesive tapes:
– Equal to staples in cosmesis
– Pose less risk of infection than either staples or sutures

78. Adhesive Tapes (Steri-
StripsTM)
– The lowest tensile strength of any wound closure
device highest failure rates
– When used with complete coating of the skin surface with
liquid adhesive has the highest degree of adherence
– 10 days have similar or superior tensile strength to that of
wounds closed with sutures

79. Wound
Aftercare

80. After Wound Care
– Cover wounds with a non-adherent dressing for 24 to 48
hours
– After dressing removed, clean 3-4 times a day to minimize
coagulum between wound edges
– Recommend 6 months of a sun-blocking agent

81. After Wound Care
– Tissue adhesives will slough off over 5 to 10 days with
wound epithelialization
– Sutures and staples- removal after 7 days
– Facial sutures- 3 to 5 days to avoid formation of sinus
tracts
– Sutures over joints- 10 to 14 days and be splinted in
position of function for up to 10 days

82. Summary
– The emergency physician needs knowledge of basic
wound physiology along with host and wound factors
affecting healing
– Although many options are available for wound closure,
the choice of closure needs to be appropriate for the
wound
– The ultimate goal is to obtain the ideal functional and
cosmetic result without complications

83. References
– Wound Mangement; Emerg Med Clin N Am 25 (2007)
873–899
– Wound Care: Modern evidence in treatment of man’s age-
old injuries
– Essential of Wound Management