Kurt Ortwig NP NorthShore University Health System Department of Emergency Medicine

Kurt Ortwig NP NorthShore University Health System Department of Emergency Medicine

Overview How many wound pts seek care for wound repairs in the US? What is the average age of the pt with lacerations in the US? What gender? Average laceration length? What % of wounds become contaminated?

Most common area of lacerations Scalp & Face: 51% Upper extremities: 34% (i.e. fingers) Lower extremities: 13% (i.e. toes) Trunk and back less likely to be involved in wound injury Trott, TT. (2012). Wounds and Lacerations.

Complications Infection 3.5-6.3% of lacerations become infected High risk for infection: Bite wounds Lower extremity lacerations Retained foreign material Children have a much lower risk for infection (1.2%)

Hand Injuries: Highest number of malpractice claims

3 Goals of Wound Repair Eliminate Complications Restore Function Reduce Scaring Howshealth.com

Anatomy of Skin Epidermis Basal Layer Keratinized or horny layer Dermis Papillary Dermis Reticular dermis Subcutaneous tissue www.hughston.com

Anatomy of Skin Trott, TT. (2012). Wounds and Lacerations

Anatomy of Skin Scf.usc.edu

Skin Alterations with Age Aging: Flattening f dermoepidermal junction Decrease in thickness of deep dermal papillae Reduction in vascularity/nutrient supply Decreased sub-q fat Decreased tensile strength Resulting in increased tearing of skin with sutures

Wound Healing Initial stage of Bleeding (Hemostasis) Enzyme release Proliferation of PMN, Platelets, Macrophage, RBCs Inflammatory Phase: (6hrs to 3 days) Granulocyte Activity Fibrin layer, macrophage release, granulocyte counts increase, early fibroblasts and collagen formation, epithelial cell growth Epithelial Cell Growth Epithelial growth begins within 12 hours Neovascularization New vessels grow within 3-7 days Collagen formation New Collagen fibrils form by day 2 and peak between day 5 and 10 Skin Remodeling Note : Slight eversion helps wound heal Inverted edges delays healing

Timeline: Wound Healing Hemostasis: Clotting, platelet aggregation, vasoconstriction (0-10 minutes) Inflammatory phase (wound is cleaned): compliment activation, granulocyte activation (12-24 hours) Epithelialization: New epithelial growth and formation 12-48 hours months to mature Neovascularization new vessel formation (Day3, peaks at day 7, stabilizes by day 21, months for maturity) Collagen synthesis new collagen fibrils. (Day 2, peak synthesis by day 7, greatest collagen mass by week 3) Wound Contraction and remodeling scar remodeling (several months to 1 year)

Skin Tension Lines Static Tension Commonly called Langer Lines Lacerations parallel to lines are less likely to create widened scars Dynamic Tension Kraissl s Lines - wrinkles Forces created by underlying pull of muscles in any given body area

Repair of Static Tension Typical laceration along a Langer Line Parallel repair Wounds retracted >5mm subject to strong static tension, tend to leave scar

Wound Healing Suturing Aligns epithelial cells next to each other Collagen formation occurs under the epithelial cells, catalyzed by normal inflammation Promotes wound healing Epithelialization occurs Constriction of wound

Suturing Promotes healing by: Eliminating dead space/realigning tissue plane Apposing and holding skin edges until they have healed Healing by first intention

Timing of Wound Repair Controversial: Sooner the repair the least chance of infection Clean wounds may be repaired up to 12-24 hours after lacerations Wounds that have a high risk of infection should be closed within 6 hours: Contamination Locations w/poor vascular supply Immunocompromised patients

Puncture wounds Deeper than they are wide Difficult to explore Infection rate of 6-10% Tetanus prone Higher risk for abscess formation, especially if through a rubbery sole of a shoe X-ray to exclude FB Plantar puncture wounds through rubber soles high risk for pseudomonas (Cipro or Levofloxicin)

Simple puncture wounds Caused by clean objects (needle, tacks, staple, etc) Pt presents within 24 hours of injury No evidence of retained foreign material Wounds edges are clean and non devitalized Puncture site is not indurated or overly tender to palpation Tx: Skin cleansing, antibiotic ointment, band-aid Pt educated on S&S of infection

Puncture Wound

Puncture with retained material Wound edges appear shredded, contaminated Puncture instrument is old, rusty, dirty, sock or shoe remnant in wound c/o tenderness to site Present >48 hours after injury Tx: Anesthetize; clean and explore wound, debride and remove any devitalized tissue and foreign material, close by secondary intention; antibiotic ointment and dressing; Abx effective against G+ org; follow-up in 48 hours

Puncture wound w/ complication

Infected puncture wound Pt C/O deep foot pain S&S of infection X-ray for FB; bone injury; gas pockets Most common organisms for puncture wounds: Staph Aureus, Staph epidermis and Strep Cover with Abx for gram + orgs Tx with 1 st generation cephalosporin (Ancef); ampicillin/sulbactim (Unasyn) or clindamycin (for allergic pts) P. Aeruginosa associated with postpuncture osteomyolitis caused from rubber soled shoe puncture. Tx: ABOVE abx PLUS add an aminoglycoside, CBC, sed rate, X-rays

Infection

Organisms Most common organism: Strep pyogenes and staph aureus in >90% cases Increased incidence of CA-MRSA Soil involved injuries may have gram negative and Clostridium organisms Salt water: Vibro vulnificus Fresh water lakes, pools: Aeromonas hydrophilia Puncture Wounds: Pseudomonas Trott, TT. 2012. Wounds and Injuries

Guidelines for Antibiotic Use Older wounds > 8 hours (hand and foot); >24 hours (face); >12 hours other sites Highly contaminated wounds Crush injuries Suspected CA-MRSA contamination: (HIV; incarceration; previous MRSA; athletes, veterinarians; indigents; children) Wounds requiring extensive debridement; extensive contamination Wounds over cartilage or involving tendons, bone, joints Puncture wounds through rubbery shoes GSW through clothing Pts with circulatory compromise; Diabetes; CV/Valve disease; Immunocompromised; immunosuppressed CV Disease/Valve disease Orthopedic implants Mammalian bites Trott,TT. 2012. Wounds and Lacerations

Antibiotic Use: Bites Mouth contains high bacterial counts Cat (60-80% risk of infection) May suture if no puncture wounds and <12 hours old Dog (<6% risk of infection) Non-infected dog bites, <12 hours old can be sutured Human bites May suture if no puncture wounds and <12 hours old Risk Factors for infection by bites: Location: Hand, wrist, foot, over large joints, through and through oral bites, scalp or face in infants Pt Hx: >50 years old or have a Dx: alcoholism, asplenia, DM, PVD, chronic steroid use, prosthetic heart valves or joints Species: Large cat, domestic cat, human, primates and pigs

Guidelines for Empirical Abx use for mammalian bite infections Cat, Dog, Human Adults: Ampicillin/sulbactim 1.5-3G IV q 6 hrs Ceftriaxone 1G IV q 12 hrs plus metronidazole 500 mg q 8 hrs TMP/SMX 4-10 mg/kg (TMP) IV q 12 hrs plus clindamycin 600 mg IV q 8 h Children (1-12 yo) Ampicillin/sulbactim 50mg/kg IV q 12 hrs plus clindamycin 7.5mg/kg IV q 8 hrs TMP/SMX 2-3 mg/kg (TMP) IV q 12 hrs plus clindamycin 7.5 mg/kg IV q 8 h Trott, TT. (2012) Wounds and Lacerations

Tetanus Hx in US: 2009 =19 cases and2 deaths CDC, 2011

History of Td (doses) Clean, Minor Wounds All other wounds* Tdap or Td TIG Tdap or Td TIG Unknown or <3 Yes No Yes Yes > 3 doses No** No 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 younger than 7 years of age, DTaP is recommended; if pertussis vaccine is contraindicated, DT is given. For persons 7 9 years of age, Td is recommended. For persons >10 years, Tdap is preferred to Td if the patient has never received Tdap and has no contraindication to pertussis vaccine. For persons 7 years of age or older, if Tdap is not available or not indicated because of age, Td is preferred to TT. TIG is human tetanus immune globulin. Equine tetanus antitoxin should be used when TIG is not available. If only three doses of fluid toxoid have been received, a fourth dose of toxoid, preferably an adsorbed toxoid, should be given. Although licensed, fluid tetanus toxoid is rarely used. ** Yes, if it has been 10 years or longer since the last dose. Yes, if it has been 5 years or

Tetanus, Diphtheria, Pertussis (Tdap) Tdap Licensed in 2005 First vaccine to protect against tetanus, diphtheria, pertussis Vaccine given to children under 7 yo Periodic boosters required as immunity can fade over time Contraindicated for Pts who have already had Tdap Td within past 2 years Adults over 65 yo Children 7-9 yo Latex allergy Already received a booster of Tdap No known allergy to Tdap Not immunized in past 10 years No hx of seizures, Guillian Barre or other neurologic problems Pregnant Who gets Tdap Adolescents 11-18 who received DTaP or DPT as children and did not get a booster and have not received a dose of Td in past 5 years Adolescents who have already gotten a booster dose of Td should get a dose of Tdap as well, should wait at least 5 years between Td and Tdap Adolescents who did not get scheduled doses as children Adults aged 19-64 should substitute one dose of Tdap, Td should be used for later boosters Td if >64 yo Children <7yo administer DTaP and refer to pediatrician Children 7-9:give Td and refer to pediatrician

Anesthesia

Preparing the Patient Fully explain procedure Provide a comfortable environment Suggest patient lie down Have patient relax Allow parent in room Universal precautions

Anesthesia Lidocaine (1 or 2%) - will not damage tissues. Short acting (onset 1-2 minutes, duration 0.5 hrs, low cardiotoxicity) Bupivicaine (0.5%) - will not damage tissues, longer duration (onset 5-10 minutes, duration 4-6 hours, higher cardiotoxicity) Diphenhydramine may be used for the rare patient that is allergic to local anesthetic agent Preferable to inject through intact skin at the periphery (injecting through contaminated wounds increases chances of infection)

Anesthesia Using epinephrine w/the anesthetic: Vasoconstricting agent Allows a lower dose of anesthetic to be administered Prolongs the duration of action Controls local bleeding Contraindicated in areas with end arterioles: Fingers, toes, penis, tip of nose (controversial see (controversial see Garcia-Gubern, Colon-Rolon, & Bond, 2010)

Local Anesthetics Injectable

Local Anesthesia Use a 25-27 gauge needle Inject small amount slowly into deep dermal subcutaneous tissue and slowly inject as the needle is withdrawn Inject into subdermal region Superficial injections are more painful and create wheals Instill slowly to decrease pain

Anesthesia Topical Anesthesia (TAC/LET/TAL) No discomfort, no tissue swelling, intense vasoconstriction Cannot be used in lacerations in ear, penis, digits (d/t compromised vascularity) Works well to the face, poorly to elsewhere. May have to offset with additional lidocaine for complete anesthesia. Does not work well if laceration needs revision or subcutaneous sutures are required. Consider lidocaine injection over topical if child becomes distraught over topical.

Wound Assessment

Assessing the wound History to establish possibility of foreign material Mechanism of injury Type of instrument that caused injury Assess site, size and depth X-ray all glass related wounds Tetanus

Assessment Health Hx: Conditions that affect healing: Steroid therapy Immobility Diabetes Cancer Vascular compromise Age (very old, very young) Obesity Chronic Renal Failure

Predictors of Poor Wound Outcomes Multivariate analysis on factors responsible for poor wound outcomes: Tissue trauma Extremity wound location Wider wounds Electrocautery use Poor wound apposition

Drugs Associated with Poor Healing Outcomes Corticosteroids Anticoagulants NSAIDS Colchicine Antineoplastic

Wound Assessment Inspect wound under bright light Explore to assess depth and presence of damage to underlying muscle, tendons, vessels and nerves Detailed neurovascular exam documented before anesthesia and closure Assess perfusion by palpation of pulses and presence of capillary refill distal to the injury Detailed motor exam, two point discrimination, flexor and extensor tendons If tendon, vessel or nerve repair is needed refer to MD for closure

Wound Closure

Types of Closure Primary Intention Suture Secondary Intention Granulation and epithelialization Tertiary Intention Healed by secondary intention and then debrided and closed after 4-5 day period

Indications for closure. Primary Closure Clean, minimally contaminated Less than 6-8 hours old Secondary Closure Noncosmetic animal bites Abscess cavities Ulcers Tertiary Closure Contaminated Crush injury Singer, Quinn, Thode et al. (2002).Determinants of poor outcome after laceration and surgical incision repair. Plast Reconstr Surg, 110:429-35

Suture Material

Suture Material Become familiar w/your kit Become familiar with the choice of suture material: Absorbable Non-absorbable Biological Synthetic Monofilament/multifilament

Types of Suture Absorbable Non-absorbable Natural- digested by body enzymes catgut Synthetic- hydrolyzed by the body tissues Decreased reaction Vicryl, monocryl, polydioxanone Exterior skin closure Must be removed Silk, stainless wire, nylon, polyester, propylene Nylon: Ethilon Propylene: Prolene

Suture Material (cont.) Trends: Less silk May cause tissue reaction Preference for synthetic monofilament (nylon or polypropylene ) Inert and gentle on tissues

Suture Materials (cont.) Diameter of suture material : Smaller the number, the larger the suture Most frequently used sized for small simple wounds are 3/0- large, 6/0- fine Guide for choosing suture: Trunk/lower limbs: 3/0 Scalp: 3/0, 4/0 Upper limbs & Most wounds: 4/0 Face: 5/0, 6/0 (Decrease one size for children)

Choosing needle size Most suture needles are curved w/triangular tip Referred to as cutting or reverse cutting needles depending on the placement of the apex of the triangular tip on the inside or outside of the needle curvature. The reverse cutting needle is particularly strong and resistant to bending

Suture Needles

Choosing needle size Recommend precision point cutting needles Penetrate skin more readily than needles without precision points

Instrument handling http://www.midwiferytoday.com/enews/graphics/suture-video.jpg

Preparation Sterile/clean equipment Wound cleaning Allow patient to assist Use running water Shave area if danger of hair entering wound, clippers preferred Razors may increase infection rates Never shave eyebrows Drape wound with sterile towels

Wound Cleansing Use warm sterile saline to clean Use a broad-spectrum antiseptic solution around wound edges, being careful not to allow the solution to enter the wound Flush out small particles of dirt, use a 35-65 ml syringe and a 16-19 g catheter syringe for irrigation If extensive debridement is needed refer to MD for closure

Wound Irrigation Cochrane Databased Systematic Review Major factor in decreasing bacterial counts in wounds is amount of irrigation Tap water irrigation just as effective as sterile saline Tap water may be associated with decreased rates of infection Irrigation pressure should be between 8-31 psi - Too much pressure can cause tissue trauma (20-60 ml syringe w/18-19 g needle) Fernandez & Griffith. (2008). Water for wound cleansing Cochrane Database Syst Rev, 2008 (1): CD003861.

Cleaning/Irrigating Wound

Comments on Wound Exploration, FB, and Wound Edge Revision Stones and glass have a distinctive clinking feeling when blind probed When in doubt xray When in doubt and considering doubling down: US Epi/tourniquets and assistance for deep wounds. Use the back of the pick ups to hold back adipose Careful consideration to grabbing blindly Scissors are the easiest to master wound edge revision Scalpel wound edge revision

Before and after

Wound Closure Begin by looking for the mirrored pattern to match wound edges Accurate closure occurs by placing the initial sutures at strategic points along the wound If laceration is V-shaped begin at the point of the V-flap If laceration is linear, begin in the middle

Wound Closure Technique Hold needle holder by placing the thumb and ring finger in the rings with the index finger on the hinge of the blades Grasp needle in the holder on its flattened area, about a third of the way along its length from the suture material

Interrupted Sutures Easier than continuous If suture is placed incorrectly, it is easier to replace one suture Alternate sutures can be removed (e.g.. face or infected wound) Suture removal simple and less painful Easier to achieve accurate alignment of wound edges

Wound Closure Technique (cont.) Support the wound edge with the tissue forceps and insert the needle 5mm from the edge of the round at right angles to the skin This will facilitate an eversion of the wound edges which creates a good apposition without excessive tension

Wound Closure Technique (cont.) Rotate the wrist to move the needle gently through the tissue following the natural curve of the needle Pull the sutures through the tissue until a short tail remains at the initial skin entry site Insert into the adjacent wound edge (do not traverse both wound edges with one bite of the needle) Tie

Suturing

Instrument ties www.affinityhealth.org

Wound Closure Technique (cont.) Tying the knot: Hold the needle holder paralleled to the skin Grasp the needle end of the suture Make two clockwise loops around the needle holder Grasp the tail with the needle holder and pull it through the loop, setting the throw

Wound Closure Technique (cont.) Tying the knot (cont.) Follow this by a single, anticlockwise throw looping around the needle holder and squaring the knot by moving the needle holder to the opposite side of the wound A third throw of one loop for monofilaments, the first and third throws should comprise two loops) Note each successive throw is looped around the forceps in the opposite direction All knots should be on the same side of the wound

Wound Closure Technique (cont.) Suture is then cut free from knot Leave tail of about 5mm before beginning next insertion Dispose of all sharps

Types of Sutures Simple interrupted Vertical mattress Horizontal mattress Running sutures Corner Subcutaneous

Simple Interrupted

Simple Interrupted Suture

Running Suture

Continuous Suture

sarajevojepii.up.pt

Vertical Mattress

Horizontal Mattress

Corner / flap Repair

Flap Repair

Stellate Lacerations

Thoughts on Complex Wounds Smaller needles with thin diameter are easier to manipulate for Stallete lacerations Prolene slides through tissue easier then ethilon. Corner sutures get above the apex of the angle

Sub-q layered wound repairs Layered repairs Vicryl and Nylon

Subcutaneous SUB Q

SQ Suturing

Tips and Tricks to SQ Sutures Using smooth pickups, grab the very edge of the wound edge, pull up and away from center of wound Place needle at the base of the wound and insert needle into tissue towards pick ups. Goal is to have needle come just under pick ups. If you hit the pickups with needle, walk the needle under the pickups.

Tips continued Do not saw the knot in place, need smooth consistent pressure to seat knot. When cutting the excess suture material, pull upwards and while maintaining traction, slide the scissors down the suture material until you encounter the knot and cut. Avoid puckering of the tissue.

Vermillion Boarder

Complicated wounds Contraindication to suturing Deep wounds requiring closing by secondary intention Some facial wounds will need a plastic surgeon Full thickness lacerations to the lip require suturing in layers Lacerations to eyes needs a thorough assessment to ensure no injury to eye or lid Areas where scare contraction will lead to unsightly appearance.

Special Considerations Never shave hair of the eyebrow

Special Considerations Wound on chins of children will require suturing rather than steri-strips because drool will cause the strips to come off Wounds of the inner mouth heal well without suture, unless they are gaping Salt water mouth washes cleanse the wound and reduce chance of bacterial contamination

Special Considerations Pre-tibial flap lacerations Poor vascular supply Attempts to align the wound edges for primary union causes tension on the flap edges leading to necrosis These wounds are not suited to suturing

High Risk Wounds Do not suture any wound that has a high risk for contamination (infection) Human bite wound > 6 hours old Dog bite wounds may be sutured if they are cleansed meticulously Wounds caused by high pressure equipment and crush injuries Susceptible to tissue swelling, necrosis and infection

4 most common mistakes in ED malpractice cases Failure to order tests (i.e.. X-ray for foreign body) Inadequate H&P (i.e. tendon exam) Misinterpretation of tests (i.e.. X-ray interpretation) Failure to obtain a consultation (i.e. hand consult)

Common Mistakes Sutures too tight Does not allow for normal wound swelling Induce vascular compromise of wound edges Necrosis Delayed healing Poor cosmetic result Sutures too loose Fails to bring wound edges together Wound gapes Sutures may fall out

Common Mistakes Wound edges overlapping (inverted) Interferes with wound healing May dehisce Causes a ridge effect, scar Sutures too close to wound edge Likely to pull out

Dressing Purpose is to protect wound from further trauma Some choose dressings for aesthetic reasons Dressing type depends upon: individual assessment of wound wound site pt. needs environmental factors

Dressing Face: No dressing Avoid clot formation which will foster scar growth Dap peroxide to any clot forming along suture lines every 6 hours Due to excellent blood supply to face and scalp, facial healing is excellent Other wounds: Cover wounds with absorbent dressing for 24-72 hours Check wound daily for any signs of infection Redness Pain Swelling Drainage After initial protective dressing, wound may be open to air Select dressing that will allow the patient to return to work in a safe manner

Suture Removal Suture Removal Guide Adult Child Facial Wounds 5 days 5 days Scalp wounds 7-10 days 7-10 days Arm/hand wounds 7-10 days 7-10 days Lower limb or joint wounds 10-14 days 7-10 days

Tips and Tricks Use the natural skin folds and lines to guide you to wound approximation Adhesive strips can be used to approximate wound prior to suturing Skin adhesive to delicate flaps that will necrosis or to tack down edges for better approximation Skin adhesive to secure sutures from curious kids