Title: Management of the Traumatic Wound. Not Just ensuring Healing - - PowerPoint PPT Presentation

Name: Dr Amna Hussain Clinical Lead for Minor Trauma Sidra ED

Third QPEM Conference 11-13th of January 2019

Title: Management of the Traumatic

• Wound. Not Just ensuring Healing

I do not have any relevant financial relationship with commercial interest to disclose.

DISCLOSURE

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At the end of the presentation, the attendee will be able to:

Learning Objectives

Formulate a strategy to apply the updated management of prevention of complications Outline the principles of traumatic wound management, incorporating recent research in wound care

Pain

• 1. PAIN. Topical Anesthesia.
• Lidocaine, epinephrine, tetracaine (LET) for an open

wound and mixture of local anesthetics (EMLA/ametop) – good in reducing the pain of local injection-non broken skin.

• EMLA cream as pretreatment before infiltrative local

anesthesia increases patient satisfaction (adults).

• Cochrane review in 2011 regarding efficacy showed

medium to high risk of bias.re efficacy. More low risk bias studies needed.

• Trials on lidocaine putty ongoing-do not distort tissue.

• 1. PAIN. Intradermal Anesthesia
• Lidocaine 1%. Also procaine 1% and bupivacaine 0.25%.

Adding epinephrine 1%-clearer field with less blood loss.

• Can be used on the fingers, toes, or nose.
• Allows higher total doses of anesthetic to be used, increasing

the maximum dose of lidocaine from 4.5 mg/kg to 7mg/kg.

• For children- Inject slowly, warm the medication, use small

needles, avoid large injections in one location, and use distracting vibratory stimulation in the area. Can add 1:10 sodium bicarbonate 8.4%, decreases pain but also shortens time to anesthesia onset.

• 1. PAIN. Nerve Block
• New best practice for performing digital anesthesia.
• Evidence from multiple studies supports use of single

palmar injection in the middle of the proximal phalanx

• ver traditional dual dorsal web space injection.
• The pain of injection found to be no different than in the

dorsal webbing of the finger and requires only one injection instead of two

• 1. PAIN. Wound closure.
• Tissue adhesives and adhesive strips have been shown to

be non inferior to sutures when used appropriately.

• Well-evaluated over the last 20 years and found to be

excellent, less painful or painless alternatives to sutures for the closure of appropriate lacerations.

• Expedite care and improve efficiency in the ED, while

improving patient experience.

• 1. PAIN. Wound Closure
• Suitable lacerations for adhesive:
• low tension (so as not to risk wound dehiscence), do not

require deep-layer sutures, not complicated by hair growth.

• Infection rates and cosmetic comparable with wounds

closed with sutures.

• Staples-Quick, cost-effective. One pediatric prospective,

randomized trial showed staples resulted in shorter procedures at a lower cost with statistically equal outcomes as sutures. Not to be used when CT or MRI may be needed

Preventing Infection

• 2. INFECTION. Irrigation
• Sterile normal saline should be used.
• Antibiotic solution -shown to increase complications compared

to soap!-increase in wound healing failures and dehiscence

• Low-pressure irrigation with a slow, gentle wash. Sufficient for

cleaning simple, non-bite, uncontaminated wounds in vascular area-scalp or face.

• High-pressure irrigation using a 30 mL or larger syringe with 19-

gauge needle -regarded as more effective for removal of debris and reduction in post-repair wound infection.

• Recommendations by wound care experts -25 to 100 mL of

irrigation fluid per cm of laceration

• 2. INFECTION. Timing of wound Closure
• Previously more than 6 hours quoted as increased risk
• f infection. Based on older study from 1995 (Robson et

al) 2014 Quinn et al.

• 2,663 patients treated for traumatic lacerations in three

U.S. EDs

• No difference in the rate of infection for wounds closed

before or after 12 hours from injury.

• Important factors impacting on wound infection-Wound

more than 5cm, Diabetes, Wound below head and neck, contamination of wound.

• 2. INFECTION Prophylactic Antibiotics.
• Prophylactic Antibiotics
• No clear evidence in reduction rate of post-repair infections for

majority of traumatic wounds repaired in the ED –including hand lacerations.

• However, for prophylactic coverage of non-bite lacerations-

beta lactam.

• For plantar puncture wounds -theoretical risk for

Pseudomonas infection, prophylaxis with ciprofloxacin can be considered; however, local antibiotic resistance patterns must be taken into account

• 2. INFECTION: Wound Care
• Non-adherent dressings over the wound - moist, clean

environment for wound healing to take place.

• Help contain drainage and minimize dried crust formation.
• Not been proven to prevent bacterial contamination,
• Avoid immersing the wound in water until the wound has closed

and the sutures are removed but getting wound wet not shown to increase risk of infection

• Tissue adhesives and adhesive strips cannot get wet, or they

will lose their strength.

Scarring

• 3. SCARRING.

Common Question “Will it scar doctor?” Correct Answer “Well yes, it’s a break in the skin but we will be careful to minimize it”

• Hypertrophic scars -hard, red or pink, raised scars, elevated

but remaining within the limits of the original wound. May regress over time.

• Keloids raised, reddish-purple, nodular scars, harder than

hypertrophic scars, invading adjacent tissue extending beyond the margins of the original wound, and rarely regressing over

• time. Common in darker skinned people.
• Can prevent hypertrophy with good wound closure, no

evidence that keloid formation can be prevented.

• SCARRING. Absorbable or non absorbable?

Suture Choice

• Absorbable sutures- convenient –do not require follow up

for removal.

• Previous belief that enzymatic process responsible for

suture dissolution will leave a visible mark.

• Newer research shows no increase in adverse

appearance when used properly

• Cosmetic outcomes for absorbable and non absorbable
• ptions generally are equivalent.

• 3. SCARRING. Sub speciality follow up?
• Specialty consultation is not always available eg in a

remote environment or late at night.

• Complex facial lacerations warrant referral or consult.
• Study of facial laceration repair - satisfaction scores were

similar between wounds repaired by plastic surgeons and those repaired by ED physicians.

• A subset of females and parents of small children preferred

plastic surgeon repair-bias because of patient awareness

• f provider specialty.
• Dermatology referral - scar management, laser surgery and

pharmacologic management once the wound has healed.

Take home messages No “Golden Hour” of wound repair- especially of head and face. Up to 19 hours is no greater risk of infection than before if no clinical evidence of infection. Topical anesthetics reduce pain of local infiltration-important in children, but increase ED stay. Effective irrigation if contaminated wound to help prevent infection . Prophylactic antibiotics in high risk contaminated wounds only Scarring can be minimized but may still be present

References

• Childs DR, Murthy AS. Overview of wound healing and management. Surg Clin North

Am 2017;97:189-207.

• Hamer ML, Robson MC, Krizek TJ, Southwick WO. Quantatative bacterial analysis of

comparative wound irrigations. Ann Surg 1975;181:819-822.

• Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: What are the risks for infection

and has the ‘golden period’ of laceration care disappeared? Emerg Med J 2014;31:96- 100.

• Ali S, McGrath T, Drendel AL. An evidence-based approach to minimizing acute

procedural pain in the emergency department and beyond. Pediatr Emerg Care 2016;32:36-42; quiz 43-44.

• Singer AJ, Stark MJ. Pretreatment of lacerations with lidocaine, epinephrine, and

tetracaine at triage: A randomized double-blind trial. Acad Emerg Med 2000;7:751-756.

References

• Sanders JE. Pediatric wound care and management in the emergency department. Pediatr Emerg Med

Pract 2017;14:1-24.

• Al Youha S, Lalonde DH. Update/review: Changing of use of local anesthesia in the hand. Plast

Reconstr Surg Glob Open 2014;2:e150.

• Mattick A, Clegg G, Beattie T, Ahmad T. A randomised, controlled trial comparing a tissue adhesive (2-
• ctylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Emerg Med J

2002;19:405-407.

• Wilbur L, Seupaul R. Evidence-based emergency medicine. Are tissue adhesives an acceptable

alternative for simple lacerations? Ann Emerg Med 2011;58:373-374.

• Forsch RT, Little SH, Williams C. Laceration repair: A practical approach. Am Fam Physician

2017;95:628-636.

• Khan AN, Dayan PS, Miller S, et al. Cosmetic outcome of scalp wound closure with staples in the

pediatric emergency department: A prospective, randomized trial. Pediatr Emerg Care 2002;18:171- 173.

• Prevaldi C, Paolillo C, Locatelli C, et al. Management of traumatic wounds in the emergency

department: Position paper from the Academy of Emergency Medicine and Care (AcEMC) and the World Society of Emergency Surgery (WSES). World J Emerg Surg 2016;11:30.

THANK YOU