Dirty Wounds Christopher M. Ziebell, MD, FACEP
Types Fresh Water Salt Water Bites Cats Humans Dogs and other mammals
Freshwater Trauma
Recognize this finger?
Lindsey Lohan
Microbiology Usual suspects: Staph, strep, etc. Unique suspects: AEEVM Aeromonas species Edwardsiella tarda Erysipelothrix rhusiopathiae Vibria vulnificus Mycobacterium marinum
Fresh Water Aeromonas
Aeromonas Causes cellulitis, abscesses, and necrotizing infections Often ß-lactam resistant People with liver disease, cancer more susceptible
Aeromonas Fluroquinolones 3 rd Generation Cephalosporins Bactrim and Tetracyclines may be effective, but resistance is showing up.
Mycobacterium marinum Papules Eblows Knees Dorsum hands/feet Ulcerate and scar
Salt Water
Vibrio vulnificus Salt Water
Erysipelothrix sp.
Erysipelothrix Common in fishermen and seafood workers who suffer minor trauma while handling contaminated shrimp, crab, or fish.
Water injury treatment Wound Care Copious Irrigation OR Washout
Water injury treatment Hospitalize Liver failure Cancer Immunosuppression Clinical signs of systemic infection
Water injury treatment Empiric Treatment 1st Generation cephalosporin OR Clinda PLUS Levofloxacin PLUS Flagyl OR Doxy
Bite Wounds
The Animals Cats People Dogs and other mammals
Cat bites
Cat Bites 89% are provoked More common in females and adults In addition to usual suspects Bartonella henselae (cat scratch fever) Long skinny teeth allow inoculation of germs into deeper tissue, including periosteum
Cat bite
People
Human Bites Eikenella corrodens (gram neg anaerobe) Infecting organism in 7-27% of human infected human bites
Fight Bites
Fight Bites Includes self-inflicted bites in nail biters, thumb sucker, and mentally ill Includes skin flora and mouth flora
Dogs and other Mammals More often non-provoked More common in males and children May cause more mechanical trauma Broken bones Penetrating skull trauma
Workup of Bites No cultures if no infection If infection Wound cultures Aerobic and anaerobic Blood cultures Aerobic and anaerobic
Workup of Bites X-ray Deep wounds warrant evaluation Bone injury Joint injury Foreign body
Workup of Bites Ultrasound Abscess Foreign body Bone injury
Workup of Bites CT Dog bites to the head can penetrate the skull
Treatment ABCs of trauma Direct Pressure to bleeding wounds Neurovascular assessment of affected area
Treatment Wound care Meticulous wound care for abrasions/lacerations
Treatment Deep punctures Trim superficial devitalized tissue Remove foreign bodies or gross contamination Superficial irrigation, avoiding high pressure irrigation Avoid removal of deep tissue (coring)
Primary Closure Treatment Do not close:» Crush injuries» Puncture wounds» Bites to the hands or feet» Wounds more than 12 hours old» Cat or human bites, except to the face» Bite wounds on compromised persons» Immunocompromised» Splenectomy» Venous stasis» DM
Treatment Delayed Closure Cleans wound on day 1 Debride wound on day 1 Close wound after 72 hours
Prophylaxis Antibiotics Tetanus Rabies Viral
Prophylaxis Antibiotics» Deep puncture wounds» Significant wounds with crush injury» Compromised vascular or lymphatic structures» Wounds in hands, genitalia, face, or in close proximity to bone or joint» Wounds requiring closure» Bite wounds on compromised persons» Immunocompromised» Splenectomy» Venous stasis» DM
Prophylaxis Tetanus Vaccine for anyone with broken skin not up to date Immune globulin for those who have never been vaccinated
Prophylaxis Rabies Complex decision making based upon the type of animal. See guidance at: http://www.cdc.gov/rabies/exposure/index.html
Prophylaxis Viral HBig and Hep B vaccine if the biter is positive and victim not immune Transmission of HIV and Hep C is considered very low risk
Treatment of Infected Bites Remove sutures Gram stain, aerobic and anaerobic culture of drainage Blood cultures Consult surgeon for significant infection I&D abscesses Empiric antibiotics based on organisms as described earlier
And Don t Forget PTSD Especially for children