Wound Care
Key Historical Components[1-3]
Mechanism of wound
Bite
Crush-cause greater de-vitalization of tissue ad more susceptible to infection
Slice
Time of injury
Possible foreign body (5th leading cause of litigation against ed physicians)
Abuse
Associated injuries
Closed head
Underlying fractures
Corneal abrasion
Avulsed tooth
Medications
Allergies
Loss of consciousness
Medical history
Immunosuppressed
Diabetes mellitus
Chronic renal failure
Malnourishment/obesity
Tetanus Status (Redbook guidelines)
Key Physical Exam Components[1, 2]
Must have adequate exposure/light
Location Considerations
Eyebrow
Do not shave hair
Non-absorbable or absorbable
Eyelid
If simple and transverse, repair
If vertical, muscle involvement, lacriminal duct involvement, possible
globe injury, consult ophthalmology
Cheek
Check for underlying structural parotid gland, arterial injury
Ear
If cartilage is involved, call for surgical consult and consider prophylactic
antibiotics
Nose
Must rule out septal hematoma and orbital fracture
If complex, call for consult
Lip
If at the angle or extensive call for consult
Tongue
Usually no repair needed unless large or involving the edge
Buccal Mucosa
Evaluate alveolar margin and teeth
Size
Characterization
Liner, stellate, jagged
Neurologic status of patient
Functional status
Musculoskeletal movements
Neurologic enervation- sensation
Blood flow
Tendon Involvement
Foreign body (see section on exploration of wound)
Key Concepts[1-4]
Minor trauma ~22 pediatrics Emergency Department cases
Lacerations are common ~50/1000 children
Must use barrier protection when evaluating / repairing wounds
Be aware of child’s pain and anxiety as well as parental anxiety
May need
sedation
restraint such as a papoose
parental involvement
Two goals in repair:
avoid infection
provide functions/aesthetically pleasing scar
Wound Types[5]
Clean and Clean-contaminated
Surgical wounds
Contaminated
Most of lacerations
Open wounds
Penetrating wounds
Dirty and infected
Old wound
Foreign body embedded
Devitalized tissue retained
Local Anesthesia
General[3, 4]
Two main classes
Amides
Esters
Allergies
Little cross reactivity between too classes
Usually, patients allergic to preservative from multidose vials, methylparaben
May need to uses single-dose lidocaine, has no preservatives
Alternatives
Diphenhydramine
Must dilute to 1%
Painful injection not modified with buffer
Benzyl alcohol
Topical anesthetic mixtures (Table 1) [1-4]
Location/Uses
Use on face and scalp
Not for use in areas of end-arteriolar circulation
Digit, ear, nose, penis
Must be applied for at least 20 minutes to be efficacious
Usually eliminates need for infiltration with needle/lidocaine
Types
T.A.C.
Consists of
0.5% Tetracaine (ester class)
1:2000 Epinephrine
11.8% Cocaine
Not used secondary to cocaine side effects, abuse potential
L.E.T
Similar efficacy to T.A.C.
Consists of
4% Lidocaine
0.1% Epinephrine
0.5% Tetracaine
EMLA
Eutectic (chemical property ehrtr by the elting point of the
combined product is lower than the single agents) Mixture of
Local Anesthetic
Consists of
Lidocaine, Prilocaine
Very long onset of action (~26>T.A.C.)
Not useful in wound repair
Lidocaine
Preparations
1% = 10 mg/ml
blocks pain
2%= 20 mg/ml
blocks pain and pressure
With epinephrine,
Increase duration
hemostasis
Not for use in areas of end-arteriolar circulation
Digit, ear, nose, penis
Maximum Doses
No Epi = 3-4 mg/kg
With Epi = 5-7 mg/kg
Techniques for Pain reduction
Use long, fine-gauge needle
Slow injection speed
Combine with 8.4% (1 mEq/ml) NaHCO3
Use 10:1 dilution
Shelf life = 1week
Warm solution to 40-42
Entry sites
Though wound-- thought to reduce pain
Through skin
Inject into subcutaneous tissue
Wound Preparation[1-4]
Sterile vs. Clean
Use of sterile gloves is standard practice though may be unnecessary
Hair
Shaving increases infection risk as follicles harbor bacteria
May cut hair if necessary
Avoid cutting eye brow hair
Hair acts as guide
May grow back abnormally
Non-Viable Tissue
Must be removed
Irrigation/Cleansing
“The most important step” Marty Belson, MD
Wound infection
Rare ~1-3% of wounds
Can be severe
Bites, complex, lower extremity, or long wounds (>3 cm) have increased
risk
Key factors for effective irrigation
Velocity/Pressure – 5- 8 psi
Puncture saline bottle with 18gauge needle
Use 60-cc syringe with 18 gauge angiocath
Too much pressure damages tissue
Volume ~50-100 ml solution / cm of laceration
Solutions
Normal Saline
Best choice
Easily obtained
Tap Water
If no saline, a safe and efficacious alternative
1% Povidone-Iodine solution
Controversial-some say retards wound healing when used in
wound
Use on peripheral edges before injection with lidocaine, sutures, or
staples
Surfactant Cleansers (ie: Shur-Cleans)
Not antimicrobial
Help lift bacteria from wound
When used with sponge may minimize pain
Good for deep, contaminated wounds
Exploration
Probe wound with finger/sterile q-tip
Palpate for foreign body/fracture
Check for tendon involvement
Check for teeth in lip lacerations
Suture
Technique Tips[1]
“Approximation not strangulation” Marty Belson, MD
Wound Edge Eversion
Enter the skin at 90-degree angle
Keep suture loop as deep as the distance across wound
Minimize Tension
Deep Sutures
Close dead space
Absorbable suture
Begin and end stitch at bottom of the wound
More Sutures
Ok in vascular areas
Limit number with poor blood supply
Undermining
Releases dermis/superficial fascia
Allows approximation with less force
Dog Ears
Avoid when possible
If occur, extend the wound at 45 degree angle
Vermillion Border
Place 1st suture for proper alignment
For Wound Eversion
Mattress Sutures
Excellent Review by Zuber
http://www.aafp.org/afp/20021215/2231.pdf
Types
Braided – more reactivity, greater risk of infection
Monofilament – less reactivity, less risk of infection
Non-Absorbable (Table 2)
Retain tensile strength
Relatively non-reactive
Meant for outer layer
Examples:
Nylon – general purpose, good grip
Silk – general purpose, braided, good grip
Prolene – general purpose, monofilament, good for hair
Absorbable (Table 3)
Closure below the epidermis
Longer lasting sutures should be place deep
Deep sutures
Should be placed whenever possible
Decrease dead space
Relieve skin tension
Improve cosmetic outcome
Do not place in adipose tissue
May be used to close outer layer
Face, scalp
Use fast gut (gut with more infection, but monofilament/sythetic last
longer)
Tissue Adhesive[3, 4, 6]
2-Octylcyanoacrylate-Dermabond
Polymerize with thin layers of water on skin to form bond
Meant to replace 5-0 and smaller sutures
Has antibacterial effect
Has plasticizers to allow flexibility
Cosmetic results equal to suturing
Overall, less cost than sutures
Location/Wound Types
Dry
Well-opposed wound edges
Short wounds (<6-8 cm)
Low tension (≤ between wound edges)
Straight to curvilinear wounds
Wounds that do not cross joints or creases, unless plan to immobilize joint
Face, extremities, torso and even scalp-if area dry
Contraindications
Jagged or stellate lacerations
Bites, puncture or crush wounds
Contaminated wounds
Mucosal surface
Axillae/perineum
Advantages
Faster repair time
Less pain, only topical anesthetics necessary, no needles
Better acceptance by patients
Water-resistant covering
Equal wound strength at 7 days
No suture removal
Application
Prepare wound in standard fashion
Place deep sutures for wide wounds
Approximate edges
Decrease tension
Approximate dry wound edges with fingers or forceps or assistant
Apply thin layer, wait 15 seconds and repeat for at least 4 layers
Keep wound approximated for additional 30-60 to allow complete drying
Caveats/Tips
Place wound in horizontal plane to help control run off
Use gauze to protect the eye if wound on face/forehead
May place pt in slight Trendelenberg position to help prevent run off into eye
Polymerization is an exothermic reaction and will feel hot
May place steri-strips first to help approximate wound
Do not allow into wound
There is a 10 second ‘grace’ period in which it can be removed easily
If eyelids sealed together, use copious amounts ophthalmologic ointment, eyelid
should open in 24 hours
Octylcyanoacrylate is used for corneal perforations and is safe to the eye—but
very poor form to have to test this out
Limitations
Dehiscence is most common complication 1-5
Wound strength is 10-15% less on first day than sutures
Children tend to pick at bond
Discharge instructions
May bath and get wound wet
Manufacturer recommends against swimming
Do not place petroleum based ointments on bond
Should begin to flake off in 5-10 days
Eithcon demonstration
http://www.jnjgateway.com/home.jhtml?loc=USENG&page=viewContent&contentId=edea000100011411&parentId=fc0de00100001307
Staples[2, 7]
General
Produce equivalent cosmetic results
In pediatric patients, use in scalp lacerations
In trauma, can be used for rapid closure
Advantages
Faster than sutures, ~5-7 times
Shown to be cost saving
Decreased inflammatory response
Decrease wound width
Decrease wound closure time
Decreased tissue strangulation
Disadvantages
Increased discomfort on removal
Closure not as exact as suture
Adhesive Tapes
Less reactive
Not recommended for primary closure
Require adhesive adjunct
i.e. benzoin
increases induration/infection
toxic to actual wound
Dressing[3, 4]
Dressing should remain dry 24-48 hours
Patients should inspect, clean and redress wound
Apply antimicrobial ointment for at least 3 day
Human and Animal Bites[1, 4, 8]
For all animal bites
Call Poison Control 404-616-9000
Have parents contact their county animal control
In general, prophylactic antibiotics recommended for
Immunosuppressed
Risk for infective endocarditis
Contaminated wounds
Cat bites
Usually deep puncture
Should not be closed
Give prophylactic antibiotics, i.e.: Augmentin
Dog Bites
At least 350,000 dog bite/year in pediatric population
Most are from family or neighbor’s dog
Usually more open
Bacteria
Aerobic
Pasteurella multocida
Staphylococcus aureus
Anaerobic
Bacteroides fragilis
Veillonea parvula
Highly vascular areas less likely to become infected
Recent wounds <6 hours can be close without prophylactic antibiotics
Rabies Virus (See tables 7 and 8)
Rare in domesticated animals, usually from bats, raccoons, etc
Non-provoked attacks are higher risk than provoked
Need 10 quarantine
If unknown animal or very high risk, immunization within 48 of bite
Immunize with vaccine and immunoglobin
Human Bites
Give prophylactic antibiotics, i.e. Augmentin
May close if able to cleanse/irrigate
Discharge Instruction
Elevate and immobilize
Reevaluate in 24-48 hours especially for hand bites
When can wounds be closured[1, 3]
Depends on location, level of contamination and time elapsed
General rule, 6-12 hours
Clean face wound, up to 24 hours
Contaminated hand or foot wound should not be repaired after 3 hours
Antibiotics[4]
Prophylactic antibiotics recommended for
Immunosuppressed
Risk for infective endocarditis
Contaminated wounds
Violation of ear cartilage
Crush injuries
Penetrating bone, joints, tendons
Old wounds, especially in hands or lower extremities
Through and through oral mucosa lacerations
Otherwise, no efficacy in minor wounds
Tetanus[9]
Mostly a disease of older Americans.
For CDC Guidelines see Table 6
Documentation
Must document procedures
For Example
“L.E.T. place on wound. After 20 minutes wound irrigated with 250 cc NS under high pressure.
Wound probed with no recovery of FB. Periphery of wound cleaned with betadine. Wound
infiltrated with 3 cc of 1% Lidocaine. 3 5-0 Vicryl deep sutures place. 4 5-0 Prolene sutures
place on outer layer. Patient tolerated well.”
Table 1. Local Anesthetic Choices Modified from [3]
Drug
Trade Name Class Concentration
(%)
Procaine
Novocaine
Ester
0.5-1.0
Procaine with
epinephrine
Lidocaine
Xylocaine
Amide 0.5-2.0
Lidocaine with
epinephrine
Bupivacaine
Marcaine
Amide 0.125-0.25
Bupivacaine
with epinephrine
Maximal Dose
(mg/kg)
7
9
Onset
(min
2-5
Duration
(hours)
0.25-0.75
0.5-1.5
4.5
7
2-5
1-2
2-4
2
3
2-5
4-8
8-16
Table 2. Non-Absorbable Suture Characteristics Modified from [3, 5]
Suture Material Type
Knot Security Tensile
Tissue
Strength Reactivity
Nylon (Ethilon) Monofilament Good
Good
Minimal
Polypropylene Monofilament Least
Best
Least
(Prolene)
Silk
Braided
Best
Least
Most
Visibility
Workability
Black
Blue
Good
Fair
Black
Best
Table 3. Absorbable Suture Characteristics modified from [3, 5]
Suture Material Type
Knot
Wound Tensile Security
Security
Strength
*(days)
Surgical gut
Monofilament Poor
Fair
5-7
Tissue
Reactivity
Most
Chromic gut
Monofilament
Fair
Fair
10-14
Most
Polyglactin
(Vicryl)
Polyglycolic
acid (Dexon)
Polydioxanone
(PDS)
Polyglyconate
(Maxon)
Poliglecaprone
25 (monocryl)
Braided
Good
Good
30
Minimal
Monofilament
Best
Good
30
Minimal
Monofilament
Fair
Best
45-60
Least
Monofilament
Fair
Best
45-60
Least
Monofilament
Good
Good
7
Minimal
*Retention of 50% of tensile stength
Visibility
Yellow/ta
n or blue
dyed
Brown or
blue dyed
Violet
Violet or
blue
undyed
Table 4 Suture Removal Times[1-3, 10]
Location
Days
Eyelid
2-3
Face/Scalp
5
Neck
3-4
Scalp
5-7
Upper Extremities
8-10
Lower Extremities
8-10
Trunk/Back
10-12
Joints/Extensor surface hands 14
Horizontal Mattress
4-6
Vertical Mattress
4-6
Table 5 Choice of size and Type Based on Location [2]
Location
Size
Type
Face and Eyelid
6-0
Non-absorbable or Absorbable
Forehead and Scalp
5-0
Non-absorbable
Trunk and Extremities
4-0 or 5-0
Non-absorbable
Large Joints and Thick Skin
3-0 or 4-0
Non-absorbable
Oral Mucosa
3-0 or 4-0
Non-absorbable
Table 6 Summary guide to tetanus prophylaxis in routine wound management, 1991[9]
Clean, minor wounds
All other wounds *
History of adsorbed
tetanus toxoid (doses)
Unknown or < 3
3 or More‡
Td†
TIG
Td†
TIG
Yes
No∫
No
No
Yes
Yes
No
* Such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva;
puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns
and frostbite.
†For children <7 years old; DTP (DT, if pertussis vaccine is contraindicated) is
preferred to tetanus toxoid alone. For persons >= 7 years of age, Td is preferred to
tetanus toxoid alone.
‡ If only three doses of fluid toxoid have been received, then a fourth dose of toxoid,
preferably an adsorbed toxoid, should be given.
∫Yes, if >10 years since last dose.
Yes, if >5 years since last dose. (More frequent boosters are not needed and can
accentuate side effects).
Table 7 Rabies postexposure prophylaxis guide---- United States,1999[11]
Animal type
Evaluation and disposition Postexposure prophylaxis
of animal
recommendations
Dogs, cats, and ferrets
Healthy and available for
Persons should not begin prophylaxis
10 days observation
unless animal shows clinical signs of
rabies
Rabid or suspected rabid
.* Immediately vaccinate. Consult
Unknown (e.g.,escaped)
public health officials
Skunks, raccoons, foxes
Regarded as rabid unless
Consider immediate vaccination
and most other carnivores; animal proven negative by
bats
laboratory tests+
Livestock,small
Consider individually
Consult public health officials. Bites
rodents,lagomorphs
of squirrels, hamsters, guinea
(rabbits and hares), large
pigs,gerbils,chipmunks,rats,mice,other
rodents (woodchucks and
small rodents,rabbits,and hares almost
beavers), and other
never require antirabies postexposure
mammals
prophylaxis
* During the 10-day observation period, begin postexposure prophylaxis at the first sign of rabies
in a dog, cat, or ferret that has bitten someone. If the animal exhibits clinical signs of rabies, it
should be euthanized immediately and tested
+ The animal should be euthanized and tested as soon as possible. Holding for observation is not
recommended. Discontinue vaccine if immunofluorescence test results of the animal are negative
Table 8 Rabies postexposure prophylaxis schedule -- United States,1999[11]
Vaccination status
Treatment
Regimen*
Not previously vaccinated
Wound cleansing
All postexposure treatment
should begin with immediate
thorough cleansing of all
wounds with soap and water.
If available,a virucidal agent
such as a povidone-iodine
solution should be used to
irrigate the wounds
RIG
Administer 20 IU/kg body
weight. If anatomically
feasible,the full dose should
be infiltrated around the
wounds(s) and any remaining
volume should be
administered IM at an
anatomical site distant from
vaccine administration.
Also,RIG should not be
administered in the same
syringe as vaccine. Because
RIG might partially suppress
Vaccine
Previously vaccinated@
Wound cleansing
active production of
antibody,no more than the
recommended dose should be
given.
HDCV,RVA,or PCEC 1.0
mL,IM (deltoid area+),one
each on days 0&,3,7,14,and 28
All postexposure treatment
should begin with immediate
thorough cleansing of all
wounds with soap and water.
If available,a virucidal agent
such as a povidone-iodine
solution should be used to
irrigate the wounds
RIG
RIG should not be given
Vaccine
HDCV,RVA,or PCEC 1.0
mL,IM (deltoid area+),one
each on days 0&,3
HDCV=human diploid cell vaccine; PCEC=purified chick embryo cell vaccine; RIG=rabies
immune globulin; RVA=rabies vaccine adsorbed; IM, intramuscular.
* These regimens are applicable for all age groups, including children.
+ The deltoid area is the only acceptable site of vaccination for adults and older children. For
younger children, the outer aspect of the thigh may be used. Vaccine should never be administered in the gluteal area.
& Day 0 is the day the first dose of vaccine is administered.
@ Any person with a history of preexposure vaccination with HDCV, RVA or PCEC; prior
postex-posure prophylaxis with HDCV, RVA, or PCEC; or previous vaccination with any other
type of rabies vaccine and a documented history of antibody response to the prior vaccination.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Belson, M., Pediatric Sedation and Wound Care.
Selbst, S.M. and M. Attia, Minor Trauma--Lacerations, in The Textbook of Pediatric
Emergency Medicine, G. Fleisher, Editor. 2000, Lippincott Williams & WIlkins:
Philadelphia. p. 1479-1494.
Hollander, J.E. and A.J. Singer, Laceration Management. Annals of Emergency Medcine,
1999. 34(3): p. 356-397.
Knapp, J., Updates in wound management for the pediatrician. Pediatr Clin North Am,
1999. 46(6): p. 1201-1213.
Anonymous, Wound Closure Manual: Ethicon.
Bruns, T.B. and J.M. Worthington, Using tissue adhesive for wound repair: a practical
guide to dermabond. American Family Physician, 2000. 61(5): p. 1383-8.
Kanegaye, J.T., et al., Comparison of skin stapling devices and standard sutures for
pediatric scalp lacerations: a randomized study of cost and time benefits. J Pediatr, 1997.
130(5): p. 808-13.
Presutti, J., Prevention and treatment of dog bites. American Family Physician, 2001. 63:
p. 1567-72,1573-4.
Diptheria, tetnus and pertussis: recommendations for vaccine use and other preventive
measures. Recommendations of theAdvisory Committee on Immunization Practices
(ACIP). Morbidity and Mortality Weekly Report, 1991. 40((RR-10)): p. 1-28.
Zuber, T.J., The mattress sutures: vertical, horizontal and corner stich. American Family
Physician, 2002. 66(12): p. 2231-2236.
Human rabies prevention--United States. Morbidity and Mortality Weekly Report, 1999.
48((RR-1)): p. 1-21.