WOUND MANAGEMENT

Dr. Kenneth DickieRoyal Centre of Plastic Surgery

Epidemiology: Traumatic Wounds

• In USA > 10,000,000 annual ER visits

• Average cost of $200 per patient

• 2 Billion Dollars per year spent on traumatic wounds

Causes of traumatic wounds:

Cause of wound No. of Patients %

Blunt object 42

Sharp object 34

Glass 13

Wood 4

Bite 6

---Human 1

---Dog 3

Other 5

Distribution of traumatic wounds:

Location of Wound No. of Patients (%)

Head and Neck 51

Trunk 2

Upper Extremities 34

Lower Extremities 13

Malpractice:

• Karcz: Malpractice claims against emergency physicians in Massachusetts; 1975-1993. Am J Emerg Med 1996.

wounds claims 19.85%, and 3.15% total expenses ($1,235,597)

• American College of Emergency Physicians. Foresight Issue 49, September 2000: Laceration mismanagement & failure to diagnose a retained foreign body is the 2nd most common malpractice claims against emergency physician

Condition % Claims % Total dollars paid

1- Missed fracture 14 17

2- Wound care 12 8

3- Missed MI 10 24

4- Abdominal pain 9 4

5- Missed meningitis 3.5 8

6- Spinal cord injury 3 8

7- SAH / Stroke 3 6

8- Ectopic pregnancy 2 8

What do patients expect following a traumatic wound?

• Adam: Patient Priorities With Traumatic Lacerations. Am J Emerg Med, October 2000.

 

Aspect of Care All Participants

(n = 679) Facial Lacerations (n = 78)

Other Lacerations (n = 263)

Normal function 28% 27% 26%

Avoiding infection 20% 14% 23%

Cosmetic outcome 17% 33% 14%

Least pain 17% 11% 18%

Length of stay 10% 8% 10%

Compassion 5% 4% 5%

Cost 1% 1% 1%

Days missed 2% 1% 3%

Total 100% 100% 100%

Evaluation:

History:• Mechanism• Time• FB• Medical conditions• Allergies• Tetanus status

Exam:• Size• Location• Contaminants • Neurovascular• Tendons

Universal Precautions:

• CDC published guidelines on use of universal precautions.

• Use of protective barriers:

eg. Gloves/ gowns/ masks/ eyewear

Will decrease exposure to infective material.

Gloves:

• Use latex free gloves

• Since March 1999, FDA reported:

2,330 latex allergic reactions

including 21 deaths

• Bodiwala: Surgical gloves during wound repair in the accident and emergency department. Lancet 1982.

• randomized 337 patients to ‘gloves’ or ‘careful hand-washing, no gloves’:

INFECTION GLOVES NO GLOVES

• None 167 (82.7%) 170 (82.5%)• ‘Mild’ 27 (13.4%) 27 (13.1%)• ‘Severe’ 8 (4.0%) 9 (4.4%)

• Caliendo: Surgical masks during laceration repair. J Am Coll Emerg Phys 1976.

Alternated face mask / no mask for 99 wound repairs:

• Mask: 1 / 47 infected

• No mask: 0 / 42 infected

 

Local Anesthesia: 2 main groups

1-  Esters:• Cocaine • Procaine (Novocain)• Benzocaine (Cetacaine)• Tetracaine (Pontocaine)• Chloroprocaine

(Nesacaine)

2-  Amides:

• Lidocaine (Xylocaine)

• Mepivacaine (Polocaine, Carbocaine)

• Bupivacaine (Marcaine)

• Etidocaine (Duranest)

• Prilocaine

Properties of commonly used local anesthetics:

Agent Class Max. save dose mg/kg

Onset (min)

Duration (hrs)

Procaine Ester 7 2-5 0.25-0.75

Procaine + Epi 9 0.5-1.5

Lidocaine Amide 5 2-5 1-2

Lidocaine + Epi 7 2-4

Bupivacaine Amide 2 2-5 4-8

Bupivacaine + Epi 3 8-16

Why Lidocaine?

• Less painful

• Rapid onset

• Less cardiotoxic

• Less expensive

• Morris: Comparison of pain associated with intradermal and subcutaneous infiltration with various local anesthetic solutions. Anesth Analg 1987.

• 24 volunteers• each injected with 5 anesthetic agents and NS• visual analog pain scale• Etidocaine> Bupivacaine> Mepivacaine> NS>

Chloroprocaine> Lidocaine (least painful) 

Methods to reduce pain of Lidocaine local infiltration:

• 1-Small-bore needles

• 2-Buffered solutions

• 3-Warmed solutions

• 4-Slow rates of injection

• 5-Injection through wound edges

• 6-Subcutaneous rather than intradermal injection

• 7- Pretreatment with topical anesthetics

1-Small-bore needles:

Edlich, 1988:

• 30-gauge hurts less than a 27-gauge

• 27-gauge hurts less than a 25-gauge, etc.

2-Buffered solutions:

• with sodium bicarbonate at a ratio of 1:10

• change in the pH of the anesthetic solution does not increase wound infection rates

• No compromise to anesthesia effect

Studies on buffered lidocaine:

Study Number Pain score

McKay, 1987 24 Volunteers Reduced

Christoph, 1988 25 Volunteers Reduced

Bartfield, 1990 91 Patients No Difference

Orlinsky, 1992 61 Patients Reduced

Brogan, 1995 45 Patients Reduced

Fatovich, 1999 135 Adults + 136 children

No Difference

3-Warmed solutions:

Study Number Temp. (°C)

Pain score

Brogan, 1995 45 Patients 20 vs 37.6 Reduced

Martin, 1996 40 Volunteers 20 vs 37 Reduced

Colaric, 1998 20 Volunteers 20 vs 37 Reduced

Warming and Buffering have synergistic effect:

Mader, 1994 and Bartfield, 1995: Effect of warming and buffering on pain of Lidocaine infiltration.

• Warming and Buffering have synergistic effect in reducing pain

• Temp. used 40 and 38.9 °C vs room temp.

4-Slow rates of injection: Study Number Injection

Rate Pain score

Krause, 1997

29 Volunteers 0.1ml/sec vs 1ml/sec

Reduced with slow rate

Scarfone, 1998

42 patients 1ml/5sec vs 1ml/30sec

Reduced with slow rate

5-Injection through wound edges:

Study Number Pain score

Kelly, 1994 81 patients Reduced

Bartfield, 1998 63 patients Reduced

6-Subcutaneous rather than intradermal injection:

7- Pretreatment with topical anesthetics:

Study Number Agent Pain score

Bartfield, 1995 54 Patients Lidocaine Reduced

Bartfield, 1996 57 Patients Tetracaine Reduced

8- Digital / Regional nerve block:

• A critical skill for all ED physicians

• Save time

• Decrease possibility of systemic toxicity

• Less painful than local infiltration

• Do not cause the volume-related tissue distortion

Topical Anesthetic instead of local:

TAC: • Tetracaine – 25 cc of 2% solution• Adrenalin – 50 cc of a 1:1000 solution• Cocaine – 11.8 gm Pryor, 1980 and Hegenbarth, 1990: • topical TAC vs lidocaine infiltration, in laceration

repair• No significant difference in anesthetic efficacy

TAC:

Down sides are:• Not reliable when used below the head• Tissue toxic, Case reports of death and seizures• Corneal damage• Intense vasoconstriction avoid in digits, nose, pinna

and penis• Must be mixed by hospital pharmacist• Not approved by FDA• Expensive – up to $35 / dose

LAT, LET, or XAP:

• Lidocaine – 15cc of 2% viscous

• Adrenaline – 7.5cc of 1:1000 topical

• Tetracaine – 7.5cc of 2% topical

• Ernst-1995, Blackburn-1995, Ernst-1997: showed effective anesthesia if left in place for 15 to 20 minutes

• Schilling-1995 and Amy-1995: As efficacious as TAC

• $5 / dose

• Much less potential for significant toxicity

Lidocaine with Epinephrine:

• In animal models, there is theoretic concern for increased risk of wound infection

• Tissue ischemia and necrosis if injected in digits

Skin and Wound preparation:

• 1- Hair removal

• 2- Disinfecting the skin

• 3- Debridement

• 4-Wound Cleansing and Irrigation

• 5-Soaking

1- Hair removal:To shave or not to shave!

Seropian, 1971: • 406 clean surgical wounds• If shaved pre-op, 3.1% infection rate• If depilated, 0.6% infection rate  Howell, 1988: • 68 scalp lacerations repaired without hair removal

(93% within 3 hours of injury), no infection at 5-day follow-up

2- Disinfecting the skin:

• An ‘ideal agent’ does not exist – either tissue toxic or poorly bacteriostatic

• Simple scrub water around wound should be sufficient

• No studies have demonstrated the impact of cleaning intact skin on infection rate, however it is important to decrease bacterial load to minimize ongoing wound contamination.

• Avoid mechanical scrubbing unless heavily contaminated (increase inflammation in animal data)

Solution Antimicrobial activity

Mechanism of action

Uses Tissue toxicity

N. Saline - Washing action Cleanse surrounding skin /

irrigation -

Povidine-iodine 10%, 1% + Germicide Cleanse surrounding skin, ?

Irrigation contaminated wounds +

Chlorhexidine 1%, 0.1% + Bacteriostatic

Cleanse surrounding skin +

Hydrogen Peroxide + Bactericidal Cleanse contaminated wounds +

Hexachlorophene + Bacteriostatic Cleanse surrounding skin +

Nonionic detergents - Wound

cleanser Wound cleanser -

3- Debridement:

• Devitalized soft tissue acts as a culture medium promoting bacterial growth

• Inhibits leukocyte phagocytosis of bacteria and subsequent kill

• Anaerobic environment within the devitalized tissue may also limit leukocyte function

Dhingra V: Periphral Dissemination of Bacteria in Contaminated Wounds: Role of Devitalized tissue: Evaluation of Therapeutic Measures. Surgery, 1976.

• Animal study, devitalized wounds contaminated with 3 Bacteria, treated with NS jet irrigation or debridement at 2, 4, 6 hr

• Debridement more effective in reducing bacteria count and infection rate

4-Wound Cleansing and Irrigation:

• Decreasing wound contamination and hence infection, "the solution to pollution is dilution."

• Indications

• Methods

• Pressure

• Solution

• Volume

• Side effects

1- Indications:

• Any contaminated or bite wounds• Animal and human studies demonstrate irrigation lowers

infection rates in contaminated wounds Hollander JE et al: Irrigation in facial and scalp lacerations:

Does it alter outcome? Ann Emerg Med 1998.  • 1,923 patients 1,090 patients received saline irrigation, and

833 patients did not• Nonbite, noncontaminated facial skin or scalp lacerations who

presented less than 6 hours• No difference in wound infection rate or cosmetic appearance

2- Methods:

• Bulb syringe• IV bag +/- pressure cuff• Syringe and needle• Jet lavage

3- Pressure:

• lack of clinical studies • recommend irrigation pressures in the range of 5 to 8

psi • High-pressure irrigation is defined as more than 8 psi

(use of a 30- to 60-mL syringe and a 18-20 gauge needle)

• Animal studies: Rodeheaver, 1975 & Stevenson, 1976, high-pressure irrigation reduce both bacterial wound counts and wound infection rates

4- Solution:

Ideal solution must be:

• Not toxic to tissues

• Does not increase rate of infection

• Does not delay healing

• Does not reduce tensile strength of wound healing

• Inexpensive

Dire DJ: A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990.

• 531 patients were randomized into 3 groups, and irrigated with:

• NS, 1% PI, or pluronic F-68• No difference in wound infection rate • NS has the lowest cost

Lineaweaver: Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg, 1985.

• 1% povidone-iodine• 3% hydrogen peroxide • 0.25% acetic acid• 0.5% sodium hypochlorite• assayed in vitro using cultures of human fibroblasts

and Staphylococcus aureus• All agents tested killed 100 percent of exposed

fibroblasts

Then he looked at different dilutions…

• …povidone-iodine 0.01, 0.001, 0.0001%

• …sodium hypochlorite 0.05, 0.005, 0.0005%

• …hydrogen peroxide 3.0, 0.3, 0.03, 0.003%

• …acetic acid 0.25, 0.025, 0.0025%

• ONLY antiseptic not harmful to fibroblasts yet still bacteriostatic was Povidone iodine 0.001%

Moscati: Comparison of normal saline with tap water for wound irrigation. Am J Emerg Med 1998.  

• lacerations were made on each animal and inoculated with standardized concentrations of Staph. aureus

• irrigation with 250 cc of either NS from a sterile syringe or water from a tap

• no difference in bacterial count in 2 groups

Lammers:Bacterial counts in experimental, contaminated crush wounds irrigated with various concentrations of cefazolin and penicillin. Richard Lammers, American Journal of Emergency Medicine, January 2001.

• An animal bite wound model was created• inoculated with 0.4 mL of a standard bacterial solution • each wound was scrubbed for 30 seconds with 20% poloxamer

188 and then irrigated with 100 mL of one of 4 solutions: NS(control); cefazolin + penicillin G (LD); CZ + PCN (ID); and CZ + PCN (HD)

• No differences in the bacterial counts or infection rates

Kaczmarek, 1982: Cultured open bottles of saline irrigating solution

• 36/169 1000cc bottles were contaminated

• 16/105 500cc bottles were contaminated

 

Brown, 1985: Approximately one in five of the opened bottles use for irrigation were contaminated

4- Volume:

• Irrigation volume not studied

• use 50 mL to 100 mL of irrigant per cm of laceration

5- Side effects:

• Increase tissue inflammation (very high pressure irrigation), but benefit outweigh risk

• Splatter (use your hand or plastic shield)

5- Soaking: Lammers: Effect of povidone-iodine and saline soaking on

bacterial counts in acute, traumatic contaminated wounds. Ann Emerg Med, 1990.

• Contaminated traumatic wounds within 12 hours of injury • 33 wounds randomized into: soaking in either 1% PI, NS, or covered with dry gauze

(control) for 10 min.• Bacterial counts not changed in PI + control groups, but

increased in NS group • Infection rate: PI=12.5% (1/8), control= 12.5% (1/8),

NS=71% (5/7)

Foreign Bodies:

• Glass, metal, and gravel are Radiopaque

• Wooden objects and some aluminum products are radiolucent

• Glass is accurately visualized on 2-view radiographs if it is 2 mm or larger

• and gravel if it is 1 mm or larger

Wound Closure:

• Time

• Delayed primary closure

• Options

• Suturing method

Time:

• The Golden Period: the time interval from injury to laceration closure and the risk of subsequent infection, (is highly variable)

• Morgan WJ: The delayed treatment of wounds of the hand and forearm under antibiotic cover. Br J Surg 1980.  

• 300 hand and forearm lacerations• closed < 4hr had infection rate 7% • closed > 4hr had infection rate 21% 

Berk WA: Evaluation of the "golden period" for wound repair: 204 Cases from a third world emergency department. Ann Emerg Med 1988.

• evaluation in a third-world country - 204 patients • <19 hours to repair 92% satisfactory healing• >19 hours to repair 77% satisfactory healing• Exception: head and face lacerations had 95.5%

satisfactory healing, regardless of time 

• Baker: The management and outcome of lacerations in urban children. Ann Emerg Med 1990.

• 2,834 pediatric patients

• No difference in infection rate for lacerations closed less than or more than 6hrs

Delayed primary wound closure:

• High risk wounds that are contaminated or contain devitalized tissue

• Wound is initially cleansed and debrided

• Covered with gauze and left undisturbed for 4 to 5 days

• If the wound is uninfected at the end of the waiting period, it is closed with sutures or skin tapes

Dimick, 1988: Delayed Primary Closure

Wound left open for 4 or 5 days until edema subsides, no sign of infection, and all debris and exudates removed

• >90% success rate in closure without infection

• Final scar as same as primary closure

Options:

• Nonabsobable suture

• Absorbable suture

• Tissue adhesive

• Adhesive tapes

• Staples

Nonabsobable suture:

Material Knot Security

Wound Tensile Strength

Tissue Reactivity

Workability

Nylon (Ethilon)

Good Good Minimal Good

Polypropylene (Prolene)

Least Best Least Fair

Silk Best Least Most Best

 Absorbable suture:

Material Knot Security

Wound Strength

Security(d)

Tissue Reactivity

Surgical gut Poor Fair 5-7 Most

Chromic gut Fair Fair 10-14 Most

Polyglactin (Vicryl) Good Good 30 Minimal

Polyglycolic acid (Dexon)

Best Good 30 Minimal

Polydioxanone (PDS)

Fair Best 45-60 Least

Polyglyconate (Maxon)

Fair Best 45-60 Least

Tissue adhesive:

• N-butyl-2-cyanoacrylate, Histoacryl blue (HAB), GluStitch

• First described in 1949 and first used medically in 1959

• Antibacterial effect

• Cost $5 per single-use ampule

• Reduction in cost (Canadian $) per patient of switching from nondissolving sutures $49.60

• S. Mizrahi: Use of Tissue Adhesives in the Repair of Lacerations in Children. Journal of Pediatric Surgery,April, 1988.

• 1500 pediatric patients with simple laceration in ED, closed with HAB

• Infection 1.8%

• Dehiscence 0.6%

Tissue adhesive:

• Octylcyanoacrylate (OCA), or Dermabond

• Approved by FDA in 1998

• Antibacterial effect

• Cost $25 per single-use ampule • Greater strength than HAB

Which laceration?

• Short (< 6-8 cm)

• Low tension (< 0.5 cm gap)

• Clean edged

• Straight to curvilinear wounds that do not cross joints or creases

Contraindications:

• Jagged or 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)

Advantages of Adhesive vs Sutures:

• Faster repair time

• Less painful

• Eliminate the risk for needle sticks

• Antibacterial effect

• Does not require removal of sutures

Study Material No. Cosmetic outcome

Time (min)

Complications

Simon, 1996

HAB vs Suture

61 2 months- same 7 vs 17 1 infection (HAB)

Simon, 1997

HAB vs Suture

61 2 months/ 1yr - same

_ _

Quinn, 1997

OCA vs Suture

130 3 months- same 3.6 vs 12.4 Infection: 0 vs1 Dehiscence: 3 vs 1

Singer, 1998

OCA vs Suture

124 3 months- same 5.9 vs 10 1 infection + 2 dehiscence (OCA)

Osmond, 1999

OCA vs HAB

94 3 months- same 0 2 dehiscence (HAB)

Adhesive tapes:

• Seldom recommended for wound closure in the ED

• Require the use of adhesive adjuncts (eg, tincture of benzoin)

• May be used with tissue adhesive or after suture removal to decrease tension

Staples: • Consider staples for linear lacerations not involving the face or

other cosmetically sensitive areas• Frequently used for scalp, trunk, or extrimities lacerations. • Optimally, two operators perform this procedure

Brickman KR: Evaluation of skin stapling for wound closure in the emergency department. Ann Emerg Med 1989;18:1122-1125.

• 87 ER patients with 87 lacerations (2/3 scalp, trunk, and extremities)

• 65% closed in 30 seconds using staples• No infections

John T. Kanegaye: • 88 child with scalp lacerations, nonabsorbable suture

vs staples• Shorter overall times for wound care and closure: 395

vs 752 sec• Total cost based on equipment and physician time:

$23.55 vs $38.51• F/U rate 91%, with no cosmetic or infectious

complications in either group

Suturing methods:

• Simple interrupted

• Simple running

• Horizontal mattress

• Vertical mattress

• Running subcuticular (intradermal)

Simple Interrupted:

• Most common

• Easy to master

• Can adjust tension with each suture

• Stellate, multiple components, or directions wound

Simple Running:

• Minimize time of suture repair

• Even distribution of tension

• Low-tension, simple linear wounds

• Removed within 7 days to avoid suture marks

• Optimal suture material is nonabsorbable

Horizontal Mattress:

• Cause wound edges eversion

• Single layer closure with significant tension

• Decrease repair time, less knots required

• Need delayed suture removal, so risk of suture marks

Vertical Mattress:

• High-tension wounds

• Prone to skin suture marks if left in too long

Running Subcuticular (Intradermal):

• Best for areas where cosmetic result is of utmost importance

• Time-consuming

• Difficult to master

• Low tension wounds

• Absorbable suture

McLean, 1980:

• 51 patients with continuous, running

• 54 patients with interrupted stitch

• Two infections in each group

 

Topical AB:

Dire DJ: Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med, 1995.  

• prospective, randomized, double-blinded, placebo-controlled (426 Lacerations)

• Bacitracin - 5.5% infection (6/109)

• Neosporin - 4.5% infection (5/110)

• Silvadene - 12.1% infection (12/99)

• Placebo – 4.9% infection (5/101)

Dressing: Chrintz, 1989: 1202 patients with clean wounds• Dressing off at 24 hours - 4.7% infection• Dressing off at suture removal - 4.9%

Goldberg, 1981: 100 patients with sutured scalp lacerations allowed to wash hair with no infection or wound disruption

Noe, 1988: 100 patients with surgical excision of

skin lesions allowed to bathe next day with no infection or wound disruption

Tetanus:

• More than 250,000 cases annually worldwide with 50% mortality

• 100 cases annually in USA

• About 10% in patients with minor wound or chronic skin lesion

• In 20% of cases, no wound implicated

• 2/3 of cases in patients over age 50

Study Setting Age % No Protective AB

Ruben, 1978 Nursing Home

Elderly 49

Crossley, 1979

Urban > 60yrs F: 59, M: 71

Scher, 1985 Rural Elderly 29

Pai, 1988 Urban 34-60 yrs, all Females

5

Stair, 1989 ER > 65 yrs 9.7

Alagappan, 1996

ER > 65 yrs 50

Recommendations for tetanus prophylaxis:

History of Tetanus Immunization

Td TIG Td TIG

Uncertain or <3 doses Yes No Yes Yes

Last dose within 5 y No No No No

Last dose 5-10 y No No Yes No

Last dose >10 y Yes No Yes No

3 doses

Infection Rate:

• Galvin, 1976 4.8%

• Gosnold, 1977 4.9%

• Rutherford, 1980 7.0%

• Buchanan, 1981 10.0%

• Baker 1990 1.2%

Antibiotic Therapy:

Cummings P: Antibiotics to prevent infection of simple wounds: A metaanalysis of randomized studies. Am J Emerg Med 1995.

• 7 randomized trials (1,734 patients)

• Assigned patients to AB or control

• Patients treated with AB slightly higher infection rate

Prophylactic Antibiotics:

• Bite wounds

• Contaminated or devitalized wounds

• High risk sites eg. Foot

• Immunocompromised

• Risk for infective endocarditis

• Intraoral through and through lacerations

• PVD

• DM

• Lymphedema

• Indwelling prosthetic device

• Extensive soft tissue injury

• Deep puncture wounds

Prophylactic Antibiotics:

• Amoxicillin, Clavulin

• Keflex

• Erythromycin

• recommended course is 3 to 5 days

Level of Training and Rate of Infection:

Adam: Level of Training, Wound Care Practices, and Infection Rates, American J Emerg. Med, May 1995.

• Wounds were evaluated in 1,163 patients

• Medical students 0/60 (0%);

• All resident 17/547 (3.1%)

• Physician assistants 11/305 (3.6%)

• Attending physicians 14/251 (5.6%)

Level of Training and Cosmetic outcome:

Adam: Association of Training level and Short-term Cosmetic Apperance of Repaired Lacerations, Academic Emerg. Med, April 1996.

• Retrospective study, 552 patients• % achieving optimal cosmetic score• Medical student 50%• R1 54%• R2 66%• R3 68%• Physician assistance 70%• Attending physician 66%

Points to Take Home:

• Laceration mismanagement & failure to Dx. FB is 2nd most common malpractice

• Be aware of different methods to reduce pain from Lidocaine infiltration

• In contaminated wounds with devitalized tissues debride and irrigate

• You have a wide options for wound closure• Always check tetanus status• AB only for high risk wounds

If you have any questions, feel free to contact Dr. Kenneth Dickie at royalcentreofplasticsurgery.com

Stay In Touch

Twitter: @RCPSurgeryTwitter Personal: @DrKennethDickie

Google+: plus.google.com/+RoyalcentreofplasticsurgeryinBarrie/Google+ Personal: plus.google.com/+DrKennethDickieBarrie

or Call Us at 705-726-2800