Wound Management

1. Wound Management Presenter: Susan Thompson, DO Christiana Care Health Systems Delaware, USA Authors: Susan Thompson, DO; Nicole Y. Ottens, DO; Donald J. Sefcik, DO, MBA

2. Case One A 22 year-old male presents with wounds involving his right hand. He was involved in an altercation at a bar. He grabbed a knife during an attempted stabbing. He has incisions on the palmar aspect of his index, long and ring fingers. - What do you need to consider?

3. Case Two A 42 year-old female presents with a wound on her left forearm. While carrying a letter-opener, she was running to answer a telephone at work and tripped. She stabbed herself. - What do you need to consider?

4. Case Three A 9 year-old female presents with a wound above her left eye sustained during a bicycle accident. - What do you need to consider?

5. Case Four A 14 year-old male presents with a wound to the right thigh. He was bitten by the family pet. - What do you need to consider?

6. Introduction • Open wound injury comprises a significant component of emergency department (ED) workload. • Three major causes are falls up to 1 meter; contact with cutting or piercing objects; or having been struck or collided with. • Most are unintentional and only 3% are due to assault. • 12% - injuries to face, head and upper neck. • 62% - injuries to upper extremities. • 88% of all wound presentations to the ED are repaired and the patient is discharged to home. • Almost 50% referred to general practitioners and specialists for review. • This lecture will cover those wounds that are suitable for repair in the ED.

7. Types of Wounds • Abrasion • Forcible avulsion of skin • Laceration • Simple – usually the result of shearing forces • Avulsion – usually the result of tension forces • Stellate – usually the result of compressive forces • Puncture • Wound is deeper than it is wide • Difficult to explore • Bite

8. Wound Care Principles • Inspection • Preparation • Anesthesia • Closure • Dressings/immobilization • Prophylaxis • Follow-up

9. Clinical Presentation • Initial assessment will direct plan of care for the patient and the wound • What are the injured structures? • How many wounds are present and % of surface area involved? • What is the likely mode of repair? • Will repair need to be delayed for any reason? • What are the likely complications?

10. Clinical Presentation • Important factors of the History: • Time and mechanism of injury • Any pre-hospital intervention • Likelihood of foreign bodies • Tetanus immunization status • PMHx (immunocompromised, diabetes) • Allergies to local anesthetics, antibiotics, etc. • Current medications (warfarin, cytotoxics)

11. Wound Inspection • Is the wound life threatening? • Is it an acute or chronic wound? • What was the timing of the injury? • What was the nature of the injury?

12. Initial Evaluation • General exam • A, B, C’s • Vital signs • Brief head-to-toe examination • Remove any clothing that may restrict examination • Remove constricting rings or other jewelry

13. Initial Examination • Focused local examination • Size and depth of wound • Gross muscle and tendon function • Full range of motion testing • Nervovascular status • Initial cleansing for adequate visualization • This step often requires anesthesia • Rule out deep soft tissue injuries • Tendons • Ligaments • Joint capsules • Neurovascular structures • Fascia/compartments

14. Wound inspection Tendon injuries • An injury to the tendonat the base of a wound may not be apparent in all positions of the limb or body part • The tendon may only be visible when the limb is the position it was at the time of injury • Marked pain with a particular movement of the muscle/tendon may be a clue to the underlying injury and the presence of a tendon injury

15. Wound Inspection Muscle injuries • Note any loss of function • Again, may need analgesia • Determine if fascia is compromised

16. Wound Inspection Foreign bodies (FB) • Depending on mechanism of injury • Penetrating objects (GSW) • Shattered glass • Soil, twigs, leaves • Shrapnel • Broken off needles, etc. • Penetrating FB’s do not always remain local • Consider the course of the FB and the possible structures damaged

17. Wound Inspection Identifying foreign bodies • Direct visualization and removal • Radiographs • Radio-opaque FB’s such as gravel, metal, pencil lead, glass >2mm1 • Place a radio-opaque marker over the wound to assist with location of the FB • Ultrasound • Detect radio-lucent objects larger than 2.5mm • Gas in an open wound makes US less sensitive 1 Lammers R. Foreign bodies in wounds. In: Singer AJ, Hollander JE, eds. Lacerations and acute wounds: an evidence based guide. Philadelphia: FA Davis, 2003;147

18. Wound Inspection Look for associated injuries • Imaging • Radiographs • Possible underlying fractures • Suspicion of joint involvement • Radio-opaque FB • Ultrasound • Fluid, hematomas in tissues • Vascular structure injuries • Radio-lucent FB

19. Other Considerations • Rabies Risk • Tetanus risk • Unknown tetanus status • “Dirty” wound • Subsequent infection

20. Tetanus Considerations • Clostridium tetani • Anaerobic bacterium • Present in soil and animal feces • 3-21 day incubation period • Bacteria produces toxin in the wound • Toxin causes severe muscle spasm and contraction, convulsions • Death occurs commonly from respiratory failure, rhabdomyolysis and renal failure

21. Tetanus Considerations • Wounds that are prone to Tetanus • Compound fractures • Deep penetrating wounds • Wounds containing foreign bodies • Crush injuries or wounds with extensive tissue damage, burns • Wounds contaminated with soil or horse manure • Wound cleansing delayed more than 3-6 hours • Patients that are prone to Tetanus • Elderly2 • Persons >60 y/o are at a six-fold increased risk of acquiring tetanus than those at any younger age • Having 2 or more prior doses of tetanus toxoid puts one at lower risk for death from tetanus • Tetanus antibody levels decline with age, and only 28% of the population >70 have protective levels 2 National Health and Medical Research Council, the Australian Immunization Handbook, 9th Edn. Canberra: NHMRC, 2008

22. Tetanus Management Tetanus vaccination schedule for acute wound management1 DTP: diptheria, tetanus, pertussis for children before the 8th birthday DT: child diptheria tetanus (CDT) if pertussis is contraindicated Td: adult diptheria tetanus (ADT) for children after their 8th birthday 1 Lammers R., Foreign bodies in wounds. In: Singer, AJ, Hollander, JE, Lacerations and acute wounds: an evidence-based guide. 2009

23. General Principles • Purposes of acute wound repair • Control Bleeding • Promote Healing • Decrease Risk of infection • Minimize scarring

24. General Principles Wound-healing Mechanisms • Wounds never gain more than 80% of the strength of intact skin3 • Three phases of wound healing • Days 1-5, inflammatory phase • No gain in strength of the wound • Days 5-14, fibroplasia and epithelialization • Rapid increase in wound strength • Day 14 onwards, maturation • Production, cross-linking and remodeling of collagen 3 Moy, RL, Lee A, Zalka A. Commonly used suturing techniques in skin surgery. American Family Physician 1991; 44:1625-1634.

25. General Principles • Factors that affect the rate of wound healing • Technical factors of the repair • Anatomic factors • Intrinsic blood supply, location over a joint • Drugs • Steroids, cytotoxics, etc. • Associated conditions and diseases • Diabetes, vitamin C, Zinc deficiency, etc. • General nutritional state of the patient

26. General Principles • When to Repair • Low Risk Wounds • Primary Closure can be done • Extremity wounds can be closed within 6 hours • Torso wounds can be closed within 12 hours • Facial wounds can be closed within 24 hours • High Risk Wounds • Primary closure may not be indicated • Delayed primary closure option • Wound may need to be allowed to heal by secondary or tertiary intention

27. General Principles • When to Consult/Refer • Neurovascular compromise • Tendon or Ligament involvement • Wound characteristics • Wound size • Severe contamination • Open fractures • Amputations • Joint involvement • History of prior wound dehiscence • Cosmetic concerns • Skills of plastic surgeon required • Often this is a later referral and may not be done until healing completion a year later

28. General Principles • Indications for delayed closure • Puncture wounds • Bacteria has been deposited deep into tissues and has high incidence of infection • Thoroughly lavage and allow healing by secondary intention • Wounds unable to be adequately debrided • Contaminated wounds more than 6 hours old • Too much tension in the wound, particularly with crush injury

29. Wound Preparation Methods to minimize risk of infection • Solution • Antiseptic solutions unnecessary4 • Sterile saline or tap water acceptable5 • Irrigation (“The solution to pollution is dilution”) • Copious irrigation decreases infection risk • Sufficient pressure and volume are important • Various techniques have been described • Debridement • Remove foreign bodies, necrotic and nonviable tissue • Dire DJ, Welch AP. A comparison of wound irrigation solution used in the Emergency Department. Annals of Emergency Medicine 1996; 19: 704. • Bansal BC, Weike PA, Perkins SD, Abramo TJ. Tap water irrigation of lacerations. American Journal of Emergency Medicine 2002; 20: 469.

30. Wound Preparation • Essential to remove all contaminants, foreign bodies and devitalized tissue prior to closure • Universal precautions • Be aware of latex allergy • Powder-free gloves6 • Powders, starches in the wound will delay healing and produce granulomas 6 Ellis H. Hazards from surgical gloves. Annals of the Royal College of Surgeons of England 2007; 79:161-163

31. Wound Preparation • Hair can be removed by clipping 1-2cm above the skin with scissors • Shaving with a razor is associated with an increased infection rate • Scalp wounds closed without prior hair removal heal with no increase in infection7 7 Howell JM, Morgan JA,. Scalp lacerations repair without prior hair removal. American Journal of Emergency Medicine 1988; 6:7.

32. Wound Anesthesia • Proper cleansing and closure of wounds requires adequate anesthesia • General anesthesia only occasionally indicated • Extensive or multiple wounds • Requiring lengthy debridement/scrubbing • When local infiltration would require more than the safe dose of local anesthetic

33. Wound Anesthesia Anesthetic Agent Examples • Procaine • Lidocaine • Bupivicaine • Each of these combined w/epinepherine Anesthetic Techniques • Topical • Local infiltration • Regional / nerve blocks • Intra-articular anesthesia • Hematoma blocks • General anesthesia

34. Wound Anesthesia Agents • Lidocaine 1 or 2% • Onset: 2-5 minutes • Duration: 1-2 hours • Maximum dose: 4.5 mg/kg • Bupivicaine 0.25 or 0.5% • Onset: 8-12 minutes • Duration: 4-8 hours • Maximum dose: 2 mg/kg • Because of lack of clinical trials, bupivicaine not recommended for children <12, however it is commonly used without problems in children 8 McGhee DL. Anesthetic and analgesic techniques. Roberts and Hedges, Clinical Procedures in Emergency Medicine. 5th edn. 2010: 490-491

35. Wound Anesthesia Agents • Addition of Epinepherine to local anesthetic • Advantages • Provides hemostasis • Prolongs duration of action of the anesthetic agent • Slows absorption; allows increased dose • Increases level of blockade • Disadvantages • Increased infection; impairs host defenses • Delays wound healing • Do not use in areas with terminal arteries • Toxicity – catecholamine reaction

36. Wound Anesthesia Techniques • Topical application • Helpful with pediatric patients, small wounds, and/or prior to injections of anesthetic agents • Ingredients: • Lidocaine 4%, epinepherinebitartrate 0.1%, tetracaine 0.5%, sodium metabisulfate • Application instructions: • Apply 1-3 ml to laceration with cotton swab • Secure remainder of dose using gauze • Tape for 20-30 minutes • Do not exceed 4mg/kg of lidocaine (up to 280mg) • Lidocaine 4% is 40 mg/ml (7ml = 280 mg)

37. Wound Anesthesia Techniques • Local Infiltration • Infiltration of agent around and into the wound • Considered quicker and safer than regional or general anesthesia • Can provide local hemostasis • A relatively large dose of drug needed to anesthetize certain wounds8 • Can distort the tissues 8 McGhee DL. Anesthetic and analgesic techniques. Roberts and Hedges, Clinical Procedures in Emergency Medicine. 5th edn. 2010: 490-491

38. Wound Anesthesia Techniques • Regional nerve block • Infiltration at a site proximal to the wound • Nerve exit site that innervates the wound area • Can anesthetize a large area with a small amount of agent • Less distortion to the wound area • Less risk of infection • Depends on operator skill and comfort with procedure

39. Types of Wound Closure Chemical Adhesives • Useful on small, linear, dry wounds under low tension • Topical antibacterial ointments can affect integrity • Non-toxic, however avoid getting into the eye Wound Tape (Steri-strips) • Paper tape reinforced with rayon • Easy to apply, good with fragile skin • Most useful with small, linear, low tension, dry wounds • Adherence may be improved by the application of adhesive adjuncts (tincture of benzoin) • Do not get into the wound, can be very painful and potentiate infection • Tape and staples have lower rates of infection than closure with conventional sutures

40. Types of Wound Closure Staples • Rapidly and easily applied • Cause less tissue reactivity • On appropriately chosen wounds, cosmetic results comparable to sutures • Must be removed with an appropriate device Sutures • Multiple decisions regarding suture type, size and suturing techniques need to be made • Provide more precision for delicate skin • Able to close multiple layers of tissue and complicated wounds and lacerations

41. Suture Types Absorbable • Maintain tensile strength for less than 60 days • Polyglactin (Vicryl); polyglycolic acid (Dexon) Non-absorbable • Maintain tensile strength for longer than 60 days • Silk • Good tensile strength • Increased infection rate and tissue reactivity • Nylon (Ethilon; Dermalon); Polypropylene (Prolene; Surgilene) • Good tensile strength • Less reactivity and infection • Require more knots to secure

42. Suture Size Guidelines (the larger the number the smaller the diameter) • Face: 5-0 or 6-0 • Scalp: 4-0 or 5-0 • Hands: 4-0 or 5-0 • Trunk: 3-0 or 4-0 • Feet: 3-0 or 4-0 • High tension areas: 3-0 or 4-0 • Ex. over joints

43. Suturing Techniques Overview • Goal is to align tissues vertically • EVERT tissue margins • Minimize tension • Line up anatomical landmarks • If you don’t like a stitch, take it out • Learn how to appropriately do instrument ties • First tie (throw) is a double loop • Second tie (throw) completes the first square knot

44. Suturing Techniques Subcutaneous layer closure • absorbable suture material necessary • Goal is to approximate the wound deeply • Work from the bottom to top • Suture knots should be at the bottom of the wound

45. Suturing Techniques Skin Closure • Simple interrupted • Most commonly used • Each stitch placed individually • Place equal distance apart • Distance varies by body part • 2-3mm on face; 5mm to 10mm on torso • Close wound by repeatedly bisecting • Avoid the “dog ear”

46. Suturing Techniques Skin Closure • Continuous (running) • Begin at one end of wound and rather than cutting the suture after the knot is made, continue to loop through wound • Advantage: fewer knots (weak points of stitches); even tension distribution • Disadvantage: if suture breaks, entire run may unravel • No increase in wound strength with use of running sutures9 9 McClean NR, Fyfe AH, Flint EF, et al. Comparison of skin closure using sontinuous and interrupted nylon sutures. British Journal of Sugery. 1999; 67: 633-635

47. Suturing Techniques Skin Closure • Mattress • Variations of interrupted stitches • Vertical mattress • Used to evert edges with a natural tendency to roll inward • Horizontal mattress • Redistributes tension on deeper wounds and everts wound edges

48. Wound Follow-up Prophylactic Antibiotics • Literature is controversial • If initiated – the sooner the better • Ideally the first dose given intravenously prior to wound closure • Indications include: • Grossly contaminated wounds • Open fractures • Human and animal bite wounds • Immunocompromised patients • Patients with prostheses

49. Suture Removal Scalp: 7-10 days Face: 3-5 days Trunk: 7-14 days Extremities: 7-14 days • Near joints • Flexor aspect: 7-10 days • Extensor aspect: 10-14 days With immunocompromised patient consider delaying suture removal

50. Dressings • Dressings and subsequent wound care are as important as the initial closure technique • Nonadherent dressing and gauze wrap • Wound should remain moist • Should not be immersed or soaked • Initial dressing should ideally remain on until suture removal • Change if its ability to absorb fluid is exceeded • If not possible, dressing may be removed 24 hours after wound closure, bathed or showered and dabbed dry • Contaminated wounds should be re-evaluated at 48 hours post-closure