CUTTING EDGE WOUND CARE

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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

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Wound Care Outline

• General Principles
• Wound Evaluation
• Anesthesia
• Wound Preparation
• Suturing and Adhesives
• Antibiotics
• Conscious Sedation

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Wound Care

• Over 11 million lacerations per year treated in
  EDs
• Over 2 billion spent on wound care per year
• Goals of Wound Care
• avoid infection and achieve a functional and
  aesthetically pleasing scar

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Wound Care

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

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Outpatient Wound PreparationA 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
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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
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Evaluation of the Patient

• Allergies anesthetics, latex, tape
• Tetanus
• Td TIG
• Uncertain or lt 3 doses Yes No/Yes
• gt 3 doses
• Last dose within 5 yrs No No
• Last dose 5 - 10 yrs No No
• Last dose gt 10 yrs Yes No

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Evaluation of the Laceration

• Mechanism
• laceration vs crush
• Neurovascular exam
• Tendon injury
• Examine for foreign bodies

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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 FBs
• sensitivity 95 -98, specificity 89 to 98
• Computed Tomography
• most useful in identifying objects and location
• expensive, increased radiation dose

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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

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Anesthesia of the Laceration

• Agent Trade Class Conc
  Dose Onset Duration
• Procaine Novocaine Ester 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

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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

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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

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Anesthesia of the Laceration

• Topical Anesthesia
• TAC
• LET
• EMLA

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Anesthesia of the Laceration
Schilling, Ann Emerg Med, 1995
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Wound Anesthesia

• Randomized, Controlled Trial of the Use of Music
  During Laceration Repair

Menegazzi, Ann Emerg Med, 1991
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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

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Wound Preparation

• Soaking
• 3 treatment groups
• Tx Group Bacterial 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

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Wound Preparation

• Lammers, Ann Emerg Med, 1990

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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

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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

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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

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Berk, Ann Emerg Med, 1988
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Wound Closure

• Nonabsorbable sutures
• retain most of their tensile strength longer than
  60 days
• relatively nonreactive
• appropriate for skin closure
• Suture Knot Tensile Tissue Reactivity
  Workability
• Nylon (Ethilon) Good Good Minimal Good
• Polypropylene Least Best Least Fair
• Silk Best Least Most Best

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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
• Suture Knot Tensile Security
  Tissue 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

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Wound Closure

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Selected Indications for Antibiotics in Traumatic
Wounds

• Delay in wound cleansing and repair gt 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

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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

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Antibiotics

• Prophylactic Antibiotics for Dog Bite Wounds
• Parenteral antibiotics Oral antibiotics
• Cefazolin Dicloxacillin
• Nafcillin Cephalexin
• Oxacillin
• Erythromycin
• 1999 ACEP Clinical Policy

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Antibiotics

• Prophylactic Antibiotics for Cat Bite Wounds
• Parenteral antibiotics Oral antibiotics
• Pen G Pen VK
• Ampicillin Amoxicillin
• Cefuroxime Cefuroxime axetil
• Ceftriaxone Cefixime
• Tetracycline Erythromycin
• 1999 ACEP Clinical Policy

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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

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Antibiotics

• Antibiotics for Human Bite Wounds
• Parenteral antibiotics Oral antibiotics
• Pen G Pen VK
• Cefuroxime Dicloxacillin
• Ceftriaxone Augmentin
• Cephalexin
• 1999 ACEP Clinical Policy

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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

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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

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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

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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

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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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