wound care in er.ppt
TRANSCRIPT
Wound ManagementWound Managementin EDin ED
Wound ManagementWound Managementin EDin ED
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• 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
• Regional anesthetics
Methods to reduce pain of Lidocaine local 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
Topical anesthesia
• TAC (tetracaine, 0.25-0.5%; adrenaline, 0.025-0.05%; 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 8-12-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
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• 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
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 RCTs Glue is the wound closure method of choice in recent
lacerations to the face in children
Glue me• 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
(high-moisture 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 HistoryClean Minor
WoundsAll Other Wounds
< 3 doses in primary series
TdTd + TIG
Primary 3 Series Completed
Last < 5 years ago NillNill
Last > 5 years ago and < 10
NillTd
Last > 10 years ago TdTd
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 platelet-derived 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 :1. Emerg Med Clin N Am 21 20032. EM practice Mar. 20053. Sum search: multiple data base search.4. BestBETS website