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State of the Art:"Wound Care Management in the ED Shirley Lee MD Annual Update in Emergency Medicine 2014

Participant Objectives • Review principles of wound evaluation and management

• Highlight best wound care management practices for wound dressings, topical antibiotics & other modalities

• Review management of complex wounds caused by: bites, burns & high-pressure injection injuries

Wound Care - Why should we care?

• Make up 20% of malpractice claims in Emergency medicine

• 10% of malpractice dollars paid by Emergency physicians

• Often due to inappropriate initial management, leading to significant complications & morbidity

Phases of wound healing •  Hemostasis/coagulation

•  Inflammation

•  Angiogenesis

•  Fibroplasia/fibroproliferation

•  Contraction/scar formation

•  Epitheliazation

•  Scar remodeling

Wound Healing Stages Case 1 • 40 y.o. female

• Tried to break up a fight between her cat and a stray cat that got into her back yard

• Several bites to hand

• What do you want to know?

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Case 1 • PMHx: HTN, NIDDM, migraines

• Meds: Bisoprolol, Glyburide, Fiorinal prn

• Tetanus: 9 yrs ago

• Drug allergies: Penicillin

•  Immunizations UTD for her cat, but unknown for stray, which ran off

Principles of Wound Assessment •  Wound history

•  Injury mechanism

•  Underlying medical history

•  Immunization status

•  Anatomical location

•  Antibiotic coverage

Wound - History & Mechanism •  History - detailed mechanism of injury including TIME of injury Mechanism

provides clue to magnitude of injury (be careful of “it’s nothing” attitude, read EMS and nurse triage notes), eg. occupational exposure, contaminated environments

•  Patient symptoms documented re: paresthesia, loss of sensation, severe pain, FB

•  PMHx - Increased risk of impaired wound healing: DM, obesity, CRF, malnutrition, extremes of age, inherited or congenital connective tissue disorders, immune-compromised, keloid former

•  Immunization status: Td

•  Allergies to antibiotics,latex, local anesthetics

Wound - Anatomical location • Order of laceration occurrence in adults (most to least):

Head and neck (50%), Upper extremities (35%), trunk, lower extremities

•  Important as specific sites more prone to infection eg. lower extremities (decreased regional blood flow)

• Site dictates repair technique for best cosmetic result

• Skin tension and dynamic forces (parallel: face vs perpendicular: legs)

Principles of Wound Management • Examination: r/o FB, nerve tendon, vascular and joint

involvement

• Hemostasis

• Neurovascular exam (BEFORE anesthetics): pallor, cyanosis, cap refill, palpation of pulses distal to wound, motor and sensory function, 2 point discrimination for digital nerves (2-5 mm normal over digits, 7-12 mm over palm)

•  FB - up to 40% missed on initial wound inspection! If any chance of FB in wound, do x-ray

• X-ray - plastic and wood frequently missed, glass is most common retained FB (50%)

Principles of Wound Management •  Preparation

•  Anesthesia and pain meds

•  Sterile technique vs clean nonsterile gloves? (Perelman et al Ann Emerg Med 2004;43:362-70)

•  No hair removal @ wound site as increases infx rate

•  Irrigation - significantly reduces risk of wound infection. Pressure: 5-8 psi with 16-18 gauge catheter to large syringe (60 ml). Sterile vs running tap water

•  Debridement

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Wound Care Basics •  Simple wounds do not require dressings, just antibiotic ointment or

petroleum jelly.

•  Safe to wet wounds before 24-48 hrs

•  Cleaning with soap and water does not interfere with wound healing

•  If closing by delayed primary or secondary closure for contaminated larger or complex wounds, cover with non-adherent dressing and reevaluate on day 4-5 when bacterial counts drop significantly

Postcare Wound Dressings • Gauze is bad!

•  Dries out wound base, adherent to wound

•  Ideal: semi-occlusive, non-adherent, semi-absorbable dressing to maintain moist, clean environment for 48 hrs while epitheliazation occurs

• Wet-to-dry dressings no benefit over other dressings

•  ? dress wounds at all - Australian study showed 8% infx rate in both non-dressed and dressed wounds

Postcare Wound Dressings • Moisture-retentive wound dressings improve healing by maintaining

prolonged contact of wound bed with wound fluids

•  Hypoxic microenvironment stimulates wound angiogenesis and collage synthesis

•  Decreased infection rate compared to gauze

• Occlusive dressings decrease the pH at wound surface, creating environment inhospital to bacterial growth

•  Decrease pain, reduce scarring, decreased number of dressings/costs

Occlusive Wound Dressings • Films, hydrocolloids, foams & hydrogels

• Films - transparent, adhesive, waterproof

• Best for low levels of exudates as not absorptive

• Joints & hands

Occlusive Wound Dressings •  Hydrocolloids - adhesive, comfortable, semiocclusive, waterproof

dressing

•  Thicker film, moderately absorptive

•  Best for moderate exudate drainage

• Wounds with deeper dermis involvement

•  Leave 7 days until fluid leak

•  Need 2 cm intact dry skin border

•  Form hydrophilic gel to maintain moist environment

Occlusive Wound Dressings • Hydrogels

• Moisture-donating water-based gels available in sheet or tube.

• Nonadhesive requiring secondary dressing to secure

•  Ideal for dry wounds or low levels of exudates

• Marked reduction in wound pain using hydrogel sheets

• Change 1-3 days

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Special Wounds • Auricular hematomas - need pressure dressing to prevent

formation of cauliflower ear deformity

• Oral lacerations - chlorhexidene/oral antiseptics reduce oral bacterial and viral counts. Can also use warm water rinses after all meals.

•  I+D wounds - packing controversial as may delay healing and increase infection rates. Do LIGHT non-adherent packing for limited time of 48 hrs or until granulation tissue has formed

Role of Topical Antibiotics • Antibacterial barrier to facilitate wound repair

• Multiple studies show topical antibiotics significantly decrease bacterial counts in wounds...? clinical benefit

• Not useful for procedurally inflicted wounds eg. removal of lesion

• Bacitracin least allergenic

• Neomycin highly allergenic

• Mupirocin best for MRSA+ve wound

Other wound care facts... • Limited evidence for aloe vera

• Topical steroids impede healing

• Vitamin E, zinc oxide and heparinoid ointments have insufficient evidence for use

• Hydrogen peroxide is bad - causes tissue disruption and impedes wound healing

• Advise sunscreen for at least 1 year to prevent scarring

Pain planning • Often overlooked in wound aftercare plan

• Acetominophen and NSAIDs fine for minor wounds

• Cold compresses or ice works well as analgesic

• Some surgical literature that warmth heals wounds (with special heating devices)

• Narcotics if needed esp with packing involved, painful wounds

Case 1 - Management • Wound swab

•  Local anesthetic & copious wound irrigation

• Hand x-rays

•  ?Labs

•  ? Tetanus / ?Rabies treatment

• Antibiotics

Tetanus recommendations - Adults

Hx of tetanus immunizations Td TIG Td TIG

Fewer than 3 doses Yes No Yes Yes

More than 3 doses

Last dose within 5 yrs No No No No

Last dose within 5-10 yrs No No Yes No

Last dose more than 10 yrs ago Yes No Yes No

Clean minor wounds All other wounds

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Cat bites •  15-50% wound infection rate

•  Acute onset erythema, pain, swelling within hours, serosanguinous drainage 24-48 hrs

•  Low-grade fever, lymphangitis, regional lymphadenitis present 10-20%

•  Local complications: osteomyelitis, tenosynovitis, septic arthritis 40% (due to contamination of bone and joint from sharp slender cat teeth)

•  Prophylactic antibiotics recommended for all cat bites

Pasteurella multocida • Aerobic, gram-neg coccobacilli

• Cat bites also seed P. septica, staph, anaerobes ....

• First line Rx: Penicillin

• Alternatives: Amox-Clavulanic acid, cefuroxime, Septra, tetracycline, ciprofloxacin, piperacillin-tazobactam

• NOT effective: Dicloxacillin, Keflex, erythromycin, clindamycin

Case 1 - 36 hours later.... • Vitals: P 118, BP

140/90, T 38.8 Celsius

• Patient c/o of chills and sweats throughout night

• Compliant with antibiotics prescribed

• What are your next management steps?

Case 1 • Labs: WBC 15.3 with left shift

• Blood cultures pending

•  IV Pip/Tazo

• Tylenol for fever

• Pain control

• ?splint hand and forearm

• ?ultrasound / CT/ MRI

• Referral to Plastics immediately for admission / OR

Case 2 • 34 y.o. industrial auto-

painter accidentally injected solvent into his middle finger 9 hours ago, came after his work shift was done

• Came for assessment and WSIB claim

High-pressure injection injuries • Often present as small puncture wound, mainly in hand

• Usually occur accidentally with cleaning up project or when stabilizing something (resulting in injury to non-dominant hand)

• Products injected: water, paint, solvents, thinners, hydraulic oil and fluid

• Morbidity affected by: site of injection, type, amount, pressure and viscosity of injected material

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Solvents & Paint thinners"Solvents & Paint thinners

Lower viscosity = more spread in tissue

Nondistensible tissue (fingers) = increased tissue pressure = compartment-like syndrome

X-ray findings • distribution of radiopaque

densities (paint) or subcutaneous air from water or air injection

• require urgent hand surgeon referral for debridement, as amputation rate can be up to 50% if >6 hours after time of injury

Which of these materials was used to treat wounds by ancient wound healers?

• a) plants

• b) spit

• c) feces

• d) radiation

Case 3 • 46 y.o. male cleaning out gas stove at work

• Opened door to clean, and large explosion occurred with flash burn to face

• Small room with minimal ventilation

• Brought to resusc

• Vitals: BP 130/85 P 115 RR 24

• A+O x 3

Depth of burn and size • Dependent on: - temperature -

heat capacity of causative agent - duration of exposure - skin thickness

• Burn depth classification: First, Second, Third degree

Burn types

Electrical Thermal Chemical

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Classification of Burn Depth

First degree Second degree Third degree

Cause Sun, hot liquids, brief flash burn

Hot liquids, flash or flame

Flame, prolonged contact with hot liquid or hot object, electricity,

chemical

Color Pink or red Pink or mottled red

Dark brown, charred, translucent with visible thrombosed veins,

pearly white

Surface Dry Moist, weeping blisters Dry and inelastic

Classification of Burn Depth

First degree Second degree Third degree

Sensation Painful Very painful Anesthetic

Depth Epidermis Epidermis and portions of dermis

Epidermis, dermis and possibly deep structures

Time to heal A few days One or more

weeks Heals by contraction

Burn size - Percentage TBSA

•  Rule of nines

•  Lund-Browder or Berkow chart

•  Rule of hands: patient’s hand (palm & fingers) = 1% BSA

•  Important for assessing fluid requirements and transfer criteria

•  More than 20% BSA require IV fluid resuscitation

Case 3 • ABCs: inhalation injury ruled out

• Saline soaked gauze applied to burn

• Patient had artificial eye made of porcelain, which resulted in significant intraorbit eye burn, requiring immediate removal

• Socket irrigated with Morgan lens to cool thermal injury

•  Td given, pain meds, consult to burn unit & ophthamology

Case 3 • Burn debrided of dead tissue

• Topical antibiotic applied: bacitracin

• Burn treated in open fashion (no gauze), as impossible to maintain dressings on face

• Patient d/c with advice to reapply cream to face frequently

• F/U with burn unit and opthamology

Burn dressing overview •  Topical antimicrobials:

•  Silver sulfadiazine - excellent for gram-negative organisms, mostly for large burns

•  Smaller burns - bacitracin and neomycin adequate with moist dressings

•  Non-adherent dressing (eg Adaptic) + gauze on top held in place with elastic dressing (ace bandage, burn net)

•  Superficial partial-thickness burn: Biobrane (outer silicone layer and inner layer of collagen-impregnated nylon mesh)

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Questions?