WOUND MANAGEMENT
From Giant Steps in Emergency Medicine, sponsored by the American Academy of Emergency Medicine
Joseph R. Lex Jr, MD, Associate Professor, Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA
Educational Objectives
The goal of this program is to improve the management of nonsurgical wounds and decrease risk for infection. After hearing and assimilating this program, the clinician will be better able to:
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1. Assess the need for tetanus booster and antibiotic prophylaxis for patients presenting with nonsurgical wounds. |
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2. Identify foreign objects embedded in wounds. |
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3. Reduce the pain associated with injecting local anesthetic. |
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4. Discuss the importance of irrigation and debridement in managing contaminated wounds. |
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5. Detail the factors that increase risk for infection of nonsurgical wounds. |
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Lex and the planning committee reported nothing to disclose.
Acknowledgments
Dr. Lex was recorded at Giant Steps in Emergency Medicine, sponsored by the American Academy of Emergency Medicine, and held July 16-19, 2008, in San Diego, CA. The Audio-Digest Foundation thanks Dr. Lex and the American Academy of Emergency Medicine for their cooperation in the production of this program.
Minimizing Risk in Wound Care: Part 1
| Background: wounds account for \>10 million visits to emergency department (ED) each year; \>25% of closed malpractice claims against ED physicians involve wound care; treatment goals—avoid infection; achieve acceptable scar |
| Infection rates: stable over last 50 yr; infection generally requires 105 organisms/gram of tissue (most wounds have <103 organisms/gram of tissue); ≈5% of wounds become infected; timing of suturing—previously thought that wounds closed \>6 hr after injury had higher rates of infection; studies show no relationship between timing of suturing (up to 18 hr after injury) and subsequent infection; study with mean time to repair of 24.2 hr showed satisfactory healing (ie, no infection or complications, but study had limited follow-up) in 92% of wounds closed <19 hr and 77% of wounds closed \>19 hr after injury; 95% of wounds on head and face had satisfactory healing, regardless of timing of closure |
Tetanus
| Epidemiology: worldwide, \>250,000 cases annually; associated with \>50% mortality; United States—≈100 cases annually; ≈10% of patients have minor wound or chronic skin lesion; no wound implicated in ≈20% of patients; ≈66% of cases occur in patients \>50 yr of age (likely did not receive vaccine during childhood); antibody titers—study showed that although many older adults do not have protective level of antibodies to tetanus, they exhibit appropriate immune response to exposure (develop antibodies as part of anamnestic response); risk highest among older adults, especially women (many men received tetanus immunization when drafted into military service); tetanus booster recommended for older adults, especially if antibody levels low or immunization history unavailable; unprotective levels of antibodies also more common among individuals with lower levels of education and those born outside United States |
| Tetanus booster: highly effective; antibody levels increase quickly after administration; study showed protective level of antibodies 4 days after booster (regardless of pre-booster level); tetanus bacteria requires 14 to 21 days for incubation; therefore, booster at time of exposure effective; pediatric and adult boosters—combination of tetanus and diphtheria; adult booster has smaller dose of diphtheria toxoid than pediatric version; adults more likely to react to larger dose; children need larger dose to develop immunity |
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Diphtheria: use of combination booster (recommended since 1966) has significantly decreased incidence; isolated outbreaks rare, and mostly have occurred within marginalized populations; significant morbidity and mortality, especially among Native American populations and adults \>60 yr of age |
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Recommendations: Centers for Disease Control and Prevention (CDC) recommends diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine or tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine as routine tetanus booster; Boostrix approved for children 10 to 18 yr of age; Adacel approved for patients 11 to 70 yr of age (not studied in adults \>70 yr of age); health care professionals should receive booster every 2 yr (to prevent becoming carriers of pertussis and infecting patients) |
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Local reaction and allergy: study showed ≈33% of patients develop local edema and tenderness, ≈15% develop fever, and ≈33% develop anaphylactoid reaction (ie, erythema, itching; non-IgE mediated); another study found higher rates, but reporting bias likely; anaphylactic reaction—isolated case reports; true allergy to tetanus toxoid rare |
Foreign Bodies
| Relevance: retained foreign bodies top reason for lawsuits related to wound care |
| Imaging: radiography—previously believed that only leaded glass visible on radiographs, but all glass (even pieces <0.5 mm) visible, regardless of depth or composition; only ≈15% of wooden foreign bodies visible on x-ray; other imaging modalities—ultrasonography (US) effective at locating splinters, sea urchin spines, and sand; computed tomography (CT) and magnetic resonance imaging (MRI) effective at locating wooden foreign bodies; study compared radiography, xerography, CT, and US; glass visible with all modalities; wood and plastic visible only with US; US gold standard for imaging foreign bodies in soft tissue |
| Other methods of identification: patient reports—study found retained glass fragments in only 15 of 41 patients who believed glass embedded in wound; patient suspicion of retained glass warrants further evaluation, but often incorrect; history—retained foreign body most common with puncture wounds and after motor vehicle accident or stepping on glass; direct observation—study showed glass often present (yet unidentified) in lacerations, even when bottom of wound visible (ie, direct observation often insufficient for identifying glass in wound; x-ray recommended) |
| Retained foreign bodies: study found 7 mo average time to removal; infection developed in 8% of patients; neurapraxia developed in 2% of patients; many patients had been examined previously by physician but foreign body not identified (potential reason for lawsuit) |
| Tendon lacerations: study found no complete ruptures in tendons disrupted up to 95% with early mobilization after injury (but, follow-up limited to 1-2 yr); major lacerations should be corrected when identified, but unidentified lacerations unlikely to result in complete rupture |
Local Anesthetics
| Options: esters—cocaine (rarely used); procaine (eg, Novocain); benzocaine; tetracaine; chloroprocaine; amides— lidocaine; mepivacaine; bupivacaine; prilocaine; levobupivacaine (not available in United States; commonly used in developing countries; levo enantiomer less cardiotoxic; long-acting) |
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Allergy: most patients who report “allergies” to local anesthetics do not have allergic response (immediate or delayed) when challenged; when allergy suspected, 0.5% diphenhydramine injection generally sufficient (except for wounds on face) and results in analgesia for 20 to 30 min; topical anesthetics available for use on face |
| Reducing pain of injection: buffering—pain associated with lidocaine injection partly due to low pH; buffering lidocaine with bicarbonate (1 mL of standard bicarbonate solution to each 10 mL of anesthetic) significantly reduces pain of injection; warming—no effect; needle size—smaller needles hurt less than larger needles; injection—injecting anesthetic slowly (≈10 sec) causes less pain than rapid injection (expansion of soft tissue stimulates pain receptors in skin); injecting into deep tissues hurts less than injecting into superficial tissues (wait ≈2 min to allow anesthetic to take effect before closing wound); injecting into wound edges (rather than into tissue surrounding wound) hurts less and does not increase risk for infection |
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Digits: digital blocks hurt less than injecting directly into digits; digital distraction technique (lightly scratching skin proximal to wound) “distracts” pain receptors and decreases pain; block placed ≈1 cm proximal to bifurcation |
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Duration: lidocaine lasts 30 to 60 min; mepivacaine lasts 45 to 90 min; bupivacaine lasts 120 to 240 min; mixing lidocaine and bupivacaine has no benefit |
Minimizing Risk in Wound Care: Part 2
| Topical anesthetics: combination of tetracaine, adrenaline, and cocaine (TAC)—not approved by Food and Drug Administration (FDA); must be mixed by pharmacist; expensive; contraindicated for use on or near mucosal surfaces (has resulted in seizure and death in children); not recommended by speaker; combination of lidocaine, epinephrine, and tetracaine (LET)—effective 15 to 20 min after application; effective on face and body; question about effect of vasoconstrictors on healing, but does not appear to increase risk for infection (contradictory evidence) |
| Infection control: gloves vs careful hand-washing—no difference in rates of wound infection; use of gloves protects clinician, not patient; nonsterile gloves acceptable (recommended by some studies); mask vs no mask—no difference in rates of wound infection; preoperative shaving—study showed 5-fold increase in postoperative infections; clipping hair acceptable, but shaving causes microtrauma and increased rate of infection; skin disinfection—all agents either toxic to tissues or poorly bacteriostatic; scrubbing around wound with soap and water sufficient; contaminated wounds—debridement critical for preventing infection (removes contaminated and devitalized tissue); delayed primary closure (wound observed for 96 hr; closed if infection does not develop) appropriate for some wounds (\>90% success rate; final scar same as after primary closure) |
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Cleaning wounds: “never put anything in wound that you wouldn’t put in your own eye”; povidone-iodine—1% solution does not decrease tensile strength of wound; powder formulation no longer used; avoid scrub formulation (increases infection when used on fresh wounds); choice of antiseptic—of antiseptics studied, only 0.001% solution of povidone-iodine bacteriostatic without harming fibroblasts; soaking fresh wounds—does not aid healing; study showed soaking in normal saline increased bacterial count; irrigation—decreases bacterial load; relatively high pressures acceptable (do not force bacteria into tissues); 35-mL and 65-mL syringes with 19-gauge needles generate 25 psi; intravenous (IV) bags and plastic bottles (with hole poked using 18-gauge needle) inadequate for generating sufficient irrigation pressure; use of tap water acceptable (does not increase infection rate); if using normal saline solution, discard remainder of bottle after opening (otherwise, contamination likely); facial wounds—irrigation optional for clean wounds (no difference in infection rate); controlling splatter—splatter guards attach to end of syringe |
| Wound closure: running stitches—faster than interrupted stitches; if stitch “pops,” wound may open; no differences in infection rate or final scar; closing “dead space”—subcutaneous absorbable sutures increase inflammation and risk for infection in nonsurgical wounds; correct suturing technique, using appropriate needle and suture material, sufficient to close dead space; staples—study of scalp lacerations (without anesthetic) found no difference in rates of infection when closing wound with staples or sutures; faster wound closure with staples; patients preferred staples; adhesive closures (eg, Steri Strips)—preparing skin (eg, defatting skin; applying benzoin) does not affect outcome; especially useful in older adults with fragile skin; tissue glues—several commercial formulations available; all derivatives of cyanoacrylate; result in same effective closure as sutures or staples |
| Hand washing: alcohol hand sanitizers less drying than soap and water; some contain softeners but leave residue on hands; effective against most pathogens (including methicillin-resistant Staphylococcus aureus and HIV), except Clostridium difficile |
| Antibiotic creams: do not decrease rate of infection (silver sulfadiazine cream may increase rate); useful for preventing dressing from sticking to wound |
| Dressing maintenance: keeping sutured wounds covered \>24 hr does not decrease infection rate (instruct patient to remove dressing when convenient, after 24 hr); acceptable to get sutures wet (eg, to wash hair), but caution patients about scrubbing stitches; speaker suggests refraining from swimming for 24 hr after wound closed (fibroblasts sufficiently cover wound by 24 hr) |
| Antibiotic prophylaxis: hand lacerations at same risk for infection as those on other parts of body (≈5%); oral antibiotics do not decrease infection rate; human bites—study showed increased risk for infection, but no patients required admission to hospital or IV antibiotic, or had serious infections or complications; puncture wounds to feet— patient factors that increase risk for infection include diabetes and vasculopathies (ie, predisposed to infections in general); retained foreign body increases risk; for patients presenting ≤24 hr after injury, carefully examine wound for retained material and trim epidermal flap (antibiotics not indicated); patients who present \>24 hr after injury typically do so because of infection (treat as appropriate); tetanus booster not always necessary (bacteria live in soil and feces, not rusty metal); intraoral lacerations—antibiotics generally not necessary |
| Summary: acceptable to suture fresh wounds up to 18 hr after injury (clean wounds may be sutured up to 4 days later); all glass visible on x-ray; Tdap recommended whenever tetanus booster needed; avoid cleaning wounds with solutions that damage tissue; avoid shaving hair around wound; acceptable to use tap water to irrigate wounds; nonsterile clean gloves acceptable to wear when closing wounds; avoid buried sutures; running stitches acceptable when appropriate; topical antibiotics do not affect outcome (avoid silver sulfadiazine); acceptable to get stitches wet; prophylactic antibiotics generally not helpful |
Suggested Reading
Alagappan K et al: Immunologic response to tetanus toxoid in geriatric patients. Ann Emerg Med 30:459, 1997; Blankenship RB, Baker T: Imaging modalities in wounds and superficial skin infections. Emerg Med Clin North Am 25:2223, 2007; Bodiwala GG, George TK: Surgical gloves during wound repair in the accident-and-emergency department. Lancet 2(8289):91, 1982; Durani P, Leaper D: Povidone-iodine: use in hand disinfection, skin preparation and antiseptic irrigation. Int Wound J 5:376, 2008; Gaufberg SV et al: Expanding the use of topical anesthesia in wound management: sequential layered application of topical lidocaine with epinephrine. Am J Emerg Med 25:379, 2007; Graham DD Jr: Ultrasound in the emergency department: detection of wooden foreign bodies in the soft tissues. J Emerg Med 22:75, 2002; Hirschmann JV: Topical and oral antibiotics in wound care. Cutis 82(2Suppl 2):18, 2008; Hoel T et al: Combined diphtheria-tetanus-pertussis vaccine for tetanus-prone wound management in adults. Eur J Emerg Med 13:67, 2006; Hollander JE et al: Irrigation in facial and scalp lacerations: does it alter outcome? Ann Emerg Med 31:73, 1998; Lineaweaver W et al: Neutrophil delivery to wounds of the upper and lower extremities. Arch Surg 120:430, 1985; Lloyd JD et al: Closure techniques. Emerg Med Clin North Am 25:73, 2007; Martin JR et al: The effect of local anesthetics on bacterial proliferation: TAC versus lidocaine. Ann Emerg Med 19:987, 1990; Moscati RM et al: A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med 14:404, 2007; Singer AJ et al: In vivo study of wound bursting strength and compliance of topical skin adhesives. Acad Emerg Med Oct 20, 2008 [Epub ahead of print]; Talan DA et al: Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med 43:305, 2004.
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