WOUND CARE AND REPAIR
FARAS ABUZEYAD, MD.
Epidemiology:
In USA > 10,000,000 annual ER visits
Average cost of $200 per patient
Hollander et
al: Wound Registry:
Development and Validation. Ann Emerg
Med, May 1995.
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
Others 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 patients want?
Adam: PatientPriorities With Traumatic
Lacerations. Am J Emerg Med, October
2000.
Aspect of Care All Participants Facial Other
(n = 679) Lacerations (n Lacerations
= 78) (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: Exam:
• Mechanism • Size
• Time • Location
• FB • Contaminants
• Medical conditions • Neurovascular
• Allergies • Tendons
• Tetanus status
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: 2- Amides:
Cocaine Lidocaine (Xylocaine)
Procaine (Novocain) Mepivacaine (Polocaine,
Carbocaine)
Benzocaine
(Cetacaine) Bupivacaine (Marcaine)
Etidocaine (Duranest)
Tetracaine
(Pontocaine) Prilocaine
Chloroprocaine
(Nesacaine)
Properties of commonly used local anesthetics:
Agent Class Max. save Onset Duration
dose mg/kg (min) (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 No Difference
children
3-Warmed solutions:
Study Number Temp. Pain score
(°C)
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 Pain score
Rate
Krause, 29 Volunteers 0.1ml/sec vs Reduced
1997 1ml/sec with slow
rate
Scarfone, 42 patients 1ml/5sec vs Reduced
1998 1ml/30sec 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 Epinepkrine:
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 Mechanism of Uses Tissue
activity action toxicity
N. Saline Washing action Cleanse surrounding skin /
- -
irrigation
Povidine-iodine 10%, Germicide Cleanse surrounding skin, ?
1% + +
Irrigation contaminated wounds
Chlorhexidine 1%, Bacteriostatic
0.1% + Cleanse surrounding skin +
Bactericidal Cleanse contaminated wounds
Hydrogen Peroxide + +
Cleanse surrounding skin
Hexachlorophene + Bacteriostatic +
Wound Wound cleanser
Nonionic detergents - -
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 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 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 Wound Tissue Workability
Security Tensile Reactivity
Strength
Nylon Good Good Minimal Good
(Ethilon)
Polypropylene Least Best Least Fair
(Prolene)
Silk Best Least Most Best
Absorbable suture:
Material Knot Wound Security Tissue
Security Strength (d) Reactivity
Surgical gut Poor Fair 5-7 Most
Chromic gut Fair Fair 10-14 Most
Polyglactin (Vicryl) Good Good 30 Minimal
Polyglycolic acid Best Good 30 Minimal
(Dexon)
Polydioxanone Fair Best 45-60 Least
(PDS)
Polyglyconate Fair Best 45-60 Least
(Maxon)
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 ( 60yrs F: 59, M: 71
1979
Scher, 1985 Rural Elderly 29
Pai, 1988 Urban 34-60 yrs, all 5
Females
Stair, 1989 ER > 65 yrs 9.7
Alagappan, ER > 65 yrs 50
1996
Recommendations for tetanus prophylaxis:
History of Tetanus Td TIG Td TIG
Immunization
Uncertain or 10 y Yes No Yes No
Infection Rate:
Galvin, 1976 4.8%
Gosnold, 1977 4.9%
Rutherford, 1980 7.0%
Buchanan, 1981 10.0%
Baker 1990 1.2%
3 doses
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 PVD
Contaminated or DM
devitalized wounds Lymphedema
High risk sites eg. Foot Indwelling prosthetic
Immunocompromised device
Risk for infective Extensive soft tissue
endocarditis injury
Intraoral through and Deep puncture wounds
through lacerations
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