WOUND MANAGEMENT

RV. M . OLLERO MD Emergency Department Fatima University Medical Center

WOUND MANAGEMENT
Course Description
focuses on didactic knowledge and techniques necessary for the optimal repair of traumatic lacerations

Objectives
understand and be able to perform techiques useful in basic and intermediate laceration repair
stellate, v-shaped & parallel injuries intradermal stitches use of tissue glue

How and with what should lacerations be cleaned?

It is common practice to use a variety of materials and techniques to prepare outpatient wounds for definitive care Emergency physicians use:
soaking disparate methods of irrigation variety of solutions
hydrogen peroxide - to prepare lacerations for closure
some of these methods may be harmful to host tissue others have not been proven effective

What solutions should I use to clean wound surfaces?

Hydrogen Peroxide Chlorhexidine (Hibiclens ) Povidone Iodine Solution (Betadine ) Nonionic surfactants (Poloxamer 188 and Pluronic F-68)

Hydrogen Peroxide
kills fibroblasts hemolyzes erythrocytes occludes local microvasculature

(Branemark PI:J Bone Joint Surg;1967 and Lineweaver W:Arch Surg;1985)

Chlorhexidine (Hibiclens )
Toxic to tissue defenses R (Edlich RF:Ann Emerg Med;1988) Less effective against gram negatives than povidone iodine Activity against viruses not known May cause permanent corneal damage

Povidone Iodine Solution (Betadine )

Effective against R gram positives, gram negatives, fungi, and viruses 10% povidone iodine (1% iodine)
toxic if applied directly to wound margins

1% povidone iodine is probably not clinically toxic to wounds 1% POVIDONE IODINE KILLS STAPH AUREUS MORE QUICKLY THAN 10% POVIDONE IODINE
(Berkelman RL: J Clin Microbiol;1982)

1% and 0.1% povidone iodine killed 100% of S. aureus at 15 seconds in vitro, whereas it took 10% povodone iodine 60 seconds to do the same. This difference may be more pronounced in tissue

Povidone Iodine Solution (Betadine )

Keep in mind that scrub solutions are fine for intact skin injurious to wound surfaces

Nonionic surfactants (Poloxamer 188 and Pluronic F- 68)

emulsify wound debris non toxic to host tissues have no intrinsic antimicrobial activity

Nonionic surfactants (Poloxamer 188 and Pluronic F- 68)

induces degranulation of PMNs increases superoxide concentrations in vitro (Ingram DA:Am J Pathol;1992) clinical effect on wounds is unknown

Nonionic surfactants (Poloxamer 188 and Pluronic F- 68)

useful in scrubbing debris from contaminated wounds with micropore sponges do not kill bacteria

How should I clean wound surfaces?

Irrigation Scrubbing Debridement

Irrigation
most effective method of cleaning traumatic wounds
In an animal study (Stevenson TR: JACEP;1976)

normal saline through a 35 mL syringe and a 19 G needle

significantly decreased wound bacterial counts and infection rates

35 mL & 12 mL connected to 19 G needles produce similar psi low pressure, high volume irrigation method (Lavage)
not as effective as the aforementioned techniques
all wounds were treated 45 minutes after wounding needles were held as close to the wounds as possible

Irrigation
compared 1% povidone iodine, normal saline, and poloxamer 188 as irrigants in outpatient traumatic wounds
no difference among infection rates no unirrigated controls and wounds were scrubbed with a nonionic surfactant before irrigation.(Dire DJ:Ann Emerg Med;1990)

Miscellaneous irrigation techniques

Irrigating from a plastic bottle, an IV bag or an IV bag with a pressure cuff
do not generate adequate psi relative to the irrigation technique described above (Singer, AJEM, 1994)

Irrigation
optimal volume of irrigant has not been determined 60 mL per cm of wound length as a guideline
not been tested experimentally

best approach is to treat the wound based on its appearance reserve high pressure systems (above 20 psi)
grossly contaminated wounds inadequately cleansed with standard methods

Irrigation
Interestingly, there is recent animal evidence (Haws M, Ann Plast Surg,1994)
vitamin A applied to wound surfaces 10 minutes before repair
increases breaking strength and tensile strength in steroid-treated rats

This is not to imply this practice should be extended to humans yet

Scrubbing
Gentle scrubbing of wound surfaces with saline soaked gauze prolonged the effective period for antibiotics in an animal experiment
(Edlich RF:Am J Surg;1971)

scrubbing wound surfaces with a coarse, bristleladen brush may injure tissue scrubbing with a micropore sponge and nonionic surfactant is an acceptable alternative detergents injure tissue

Debridement
Devitalized tissue (crush injuries) are a honeycomb of dead tissue and red blood cells S. aureus
most common cause of wound infection grows aggressively in and on blood

Conservatively removing devitalized tissue helps prevent infection avoid debridement on the face and cosmetically sensitive areas

Wound Coagulum
proteinaceous coagulum forms in traumatic lacerations one to three hours after wounding
(Rodeheaver G:Am J Surg;1974 and Edlich RF:Am J Surg;1973)

theorized - coagulum coats pyogenic bacteria and protects them from antimicrobials treating wounds with topical proteolytic enzymes prolongs the window of effectiveness of antibiotics (Rodeheaver G:Am J Surg;1974 )

Wound Coagulum
gently scrub lacerations that are older than three hours remove proteinaceous coagulum that protects bacteria from antibiosis

Wound Coagulum
parenteral antimicrobial delivery early in treatment may be warranted early antimicrobial delivery
lower wound bacterial counts more effectively than later treatment consider the fact that it takes longer for an oral cephalosporin to get to wounded tissue than it does for an IV or IM dose (about one hour IM)

Identifying Soft Tissue Foreign Bodies

Complications of retained foreign bodies
inflammation or infection Pain Dysfunction Osteomyelitis angiosarcoma.

Inert foreign bodies may not need to be removed Vegetative matter, cloth fibers, clay soil and organic matter
very reactive pyogenic substances

Indications for Bullet Removal

It is very rare that surgery is performed solely for the purposes of bullet removal Retained bullets rare cause complications and surgical attempts to find and remove these bullets usually cause more harm than good, if they are even successful

Indications for bullet removal

Just under the skin, and residing in a pressure area where the bullet is painful when the patient sits or lies down Visibly bulging beneath the skin and causing cosmetic distress In a joint space In the globe of the eye In a vessel lumen causing ischaemia or with the risk of embolisation to the heart, lungs or peripheral vessles

Indications for bullet removal

Impinging on a nerve or nerve root and causing pain Localised abscess formation (usually due to dirt or clothing fragments entrained by the bullet) Required for forensic investigation and the patient and physician are in full agreement that the removal will not result in increased pain, suffering, complications or injury and both agree to the removal Documented elevated lead levels, usually in a child and occurring several months after injury (extremely rare)

Identifying Soft Tissue Foreign Bodies

History:
FBs wider than 4.5 mm may push epidermis into the wound and cause infection or a cyst Nail punctures through shoes or socks may cause Pseudomonas sp. osteomelitis. Consider a retained soft tissue foreign body in patients with indolent or persistent infection

Identifying Soft Tissue Foreign Bodies

Physical Exam:
Examine wound with a gloved finger or instrument if possible Be careful about gloved fingers in the wound if there are sharp foreign bodies present Well localized, sharp pain on skin palpation increases the risk of a retained foreign body

Identifying Soft Tissue Foreign Bodies

Diagnostic Modalities
Plain Radiography Xeroradiography Ultrasound Computed Tomography

Plain Radiography
Metal, bone, teeth, pencil, graphite some plastics, glass and gravel can be identified Underpenetrated (soft tissue) films may be more useful than standard degrees of tissue penetration Virtually all glass FBs are visible at 2 mm, but only 61% are seen at the 0.5 mm size Wood splinters, thorns, cactus spines and vegetable matter may not be seen on plain xrays, especially 48 hours after wounding

Xeroradiography
Seldom available to emergency physicians expensive and 20 times the radiation dose of standard x-rays does not identify isodense FBs

Ultrasound
Detects differences in acoustical impedance Detects vegetative FBs invisible on plain x-rays or xeroradiographs Sensitivity 95% to 98% specificity 89% to 98% 7.5 MHz transducer identifies FBs from a few millimeters to 3 cm in depth

Computed Tomography
Most useful in:
identifying objects approximating size determining relationship to other structures

Disadvantages:
cost radiation dose degree of patient cooperation (children)

Techniques of Laceration Closure

Knot Tying Simple Closures and Needle Control Intradermal Technique Vertical Mattress Suture Bevelled Lacerations Parallel Lacerations Corner Stitches Tissue Glue

Knot Tying
Instrument Tie with Surgeon's Knot: Advantates
better knot security after first throw less slippage as the wound is approximated during tying

Two hand ties may be necessary for ligation of bleeding vessels and usually require an assistant to hold the hemostat and display the tie

Simple Closures and Needle Control

Wound Edge Eversion
avoid wound margin inversion minimize scarring

Wound Edge Eversion

needle should approach the skin at a right or 90 angle "palm" the needle driver
needle is released using gentle pressure on the needle driver with the thenar eminence

Intradermal Technique
used to eliminate dynamic or static wound tension before skin closure to improve cosmesis subcutaneous vicryl stitches increases wound inflammation & risk of infection (Mehta
PA, Ann Emerg Med, 1996)

technique involves the dermis and superficial subcutaneous tissues

close dead space when appropriate to prevent hematomas, seromas & wound sepsis

Intradermal Technique
first bite starts deep in the wound and exits through the dermis, usually on the side of the operator next bite on the opposite side of the wound exits at the base of the wound very important to take symmetrical bites on either side of the laceration ensure that both ends of the suture material exit throught same side of the loop formed by the stitch (i.e., Before tying)
ensures the knot will fall into the wound and not rest near the wound surfacecausing a cosmetic problem

Vertical Mattress Suture

areas where skin is lax and might fall, or invert into the wound margin
elbow dorsum of hand

helpful in achieving wound margin eversion

Vertical Mattress Suture

larger bite is first taken about 1.5 cm from the wound margin on either side bites are smaller on the return
1-2 mm from the wound margin

Bevelled Lacerations
bites are taken equidistant from the wound margin
over riding of the skin surfaces
increased shadow accentuated scar

more shallow side

bite should be taken closer to the wound margin and relatively more shallow

on the other side of the wound

take a deeper bite farther from the wound margin

technique allows for wound approximation without over riding of wound edges

Parallel Lacerations
close each laceration with simple stitches alternate sutures from wound to wound so they are not next to one another
increased skin tension and wound distortion

place stitches close to wound margins

effect on the adjacent laceration is minimized

Parallel Lacerations
Another approach half buried horizontal mattress technique through both lacerations
technically difficult requires a great deal of practice and experience

Parallel lacerations that are close to one another and coapt easily may be taped

Corner Stitches
tips of V-shaped lacerations tacked down
half buried horizontal mattress

bite through the flap is too near the tip

tissue necrosis

bite too far back on the flap

tip of the flap to fall into the wound

alternative approach
simple stitch through the flap

Tissue Glue (Quinn, 1993): Butyl-2cyanoacrylate

chemically similar - "super glue" used to close simple wounds in Germany, Israel and Canada This compound is not FDA approved for this purpose but probably soon will be used in the United States substance has bacteriostatic activity against streprococci and staphylococci (Eiferman,1983)

Tissue Glue:Butyl-2-cyanoacrylate
have similar tensile strength compared to sutured lacerations 2-3 weeks post wounding lacerations closed with cyanoacrylate have significantly lower tensile strength at 3-4 days compared to sutured wounds (Bresnahan, Ann Emerg Med, 1995) New cyanoacrylates (e.g., octylcyanoacrylate) are in development that may improve the tensile strength (Quinn, Acad Emerg Med, 1996)

Tissue Glue: Butyl-2-cyanoacrylate

Procedure:
used for lacerations with low static or dynamic wound tension approximate the wound edges
make sure the surface is dry

apply just enough glue to close the wound glue begins to set within three seconds on a dry surface
Most studies have been done with simple facial wounds

Tissue Glue: Butyl-2-cyanoacrylate

Advantages Speed and diminished need for analgesia or sedation
one study in the Ophthalmology literature infers this substance is bacteriostatic

Tissue Glue: Butyl-2-cyanoacrylate

Disadvantages: Apparently only stays in place for about seven days

Can I leave wounds open?

Yes.

DELAYED PRIMARY CLOSURE (DPC)

technique of leaving a contaminated laceration open for 3-5 days quantity of pyogenic bacteria in wounded tissue is one determinant of infection
wound bacterial counts fall in open wounds, reaching their nadir at 96 hours

bacterial counts fall about 1 to 1.5 log(10) units per gram of tissue over 12 hours leaving wounds open for 3-5 days
lowers bacterial counts lowers chance of wound sepsis

DELAYED PRIMARY CLOSURE (DPC)

Indications:
grossly contaminated wound that can not be cleaned adequately non-facial lacerations that are too old for closure

DELAYED PRIMARY CLOSURE (DPC)

An Effective Technique:
Clean the wound as you normally would (i.e., Scrubbing, irrigation, and debridement) Apply a damp, sterile layer of fine mesh gauze to all wound surfaces, followed by a bulky dressing Antimicrobials may be indicated for these patients to lower wound bacterial counts wound should be reassessed 3-5 days later
Remove the gauze (which has since dried and will "autodebride" the wound surface) and any devitalized tissue that is extant Suture the wound as you normally would if there are no signs of infection