Wound Management

Local Anesthetics

3-5 mg/kg of Lidocaine s epi

5-7 mg/kg of Lido c epi

Lidocaine will last 20-30 min in infiltration and 30-120 minutes for blocks

1cc Bicarb for 9cc 1%, less for 2%

 

2-3 mg/kg of bupi s epi (1 cc/kg of .25%)

3-4 mg/kg of bupi c epi

Bupi will last ~4 times longer than lidocaine

Use 0.1 cc for 20 cc of Bupi

 

1 meq/cc Bicarb (Cardiac Syringe)=8.4%

 

To add epi to above:

Concentration should be 1:100,000=

10 mcg/cc

For 50 cc vial, add 500 mcg or 0.5 cc of 1:1000

 

Lido and Bupi are amides (as are any with i in first part of name)

Multi-dose vials have a preservative which can be allergenic

Benzyl alcohol .9% with epi 1:100,000 is alternative in lido allergic (JEM 21:4)

Benadryl also works great, but you must dilute from vial which is 4% to 1%

 

Digital block using flexor tendon sheath

Insert into tendon at distal palmar crease without a syringe.

Flex and extend finger, should see needle swinging widely

Attach syringe and inject, if there is resistance withdraw slightly

 

 

 

You know that 1% lidocaine contains epinephrine at 1:100,000 (you’ve seen this on the bottle). You also have epi for sub-Q at 1:1000.

Hmm. What does 1:100,000 mean? 1:1000? For that matter what does 1% mean? Why didn’t someone teach me this in medical school?

Don’t panic, it is really easy. Start with the realization that ‘percent’ (%) is equal to 1:100, just nobody writes it that way. Then realize that each of these ratios represents grams per cubic centimeters (or mls). So:

1% = 1:100 = 1 gram per 100 cc = 1000 mg/100cc = 10 mg/cc (standard lidocaine for infusion concentration)

1:1000 = 1 gram per 1000 cc = 1000 mg/1000 cc = 1 mg/cc (epi for sub-Q)

1:100,000 – 1 gram per 100,000 cc = 1000mg/100,000 cc = 0.01 mg/cc

You also note (with increasing excitement as you realize how simple this is!) that the bottle of 1% plain lido is a 30cc bottle.

So: 0.01 mg/cc times 30 cc equals 0.3 mg. Since you have epinephrine at 1 mg/cc, you can draw up 0.3 cc of this solution (use a tuberculin syringe) and add it to the lidocaine jar. Viola! You now have 1% lidocaine with epinephrine 1:100,000!! You are so slick.

Bier Block

Signs of systemic toxicity include:  metallic taste, perioral numbness, ringing in ears, twitching of face, convulsions

 

Bier block procedure

Prior to the procedure, patients were given written information on the procedure, and informed consent was obtained. The technique of Bier block used at the WHCC is identical to that described in the emergency medicine literature,1 with the exception that the injured arm is simply elevated for 2 minutes before cuff inflation rather than exsanguinated. The insertion of an IV line in the unaffected arm was discretionary. The upper arm was wrapped with cast felt padding before the application of the pneumatic cuff, to reduce the risk of pinching or bruising. A 0.5% solution of lidocaine in a dose of 1.5–3 mg/kg was used, according to physician preference. Local anesthetic was slowly injected through an indwelling cannula and the patient was advised that the arm would tingle and feel warm (or cold) and that the skin would become mottled. The cannula was removed immediately after injection of the anesthetic, and bleeding was prevented by using a small (22-guage or smaller) catheter and by holding pressure on the site for several minutes after the cannula was removed. The risk of cuff leak was minimized by using an anesthetic injection site at least 10 cm distal to the cuff and inflating the cuff to at least 250 mm Hg, regardless of patient age. A second (distal) cuff was available, and was usually only employed if the procedure took longer than anticipated, resulting in discomfort at the proximal cuff site. The arm was typically anesthetized and appropriate for reduction at 15–20 minutes post injection. The Bier block and reduction were performed by the attending primary care physician. Bier block guidelines at WHCC stipulate that the pneumatic cuff must be inflated to at least 100 mm Hg above the patient’s systolic pressure for a minimum of 30 minutes and no longer than 90 minutes. The cuff was deflated using a “deflation/re-inflation” technique to reduce the risk of a significant IV bolus of lidocaine reaching the central circulation, whereby for 3 cycles the cuff is deflated for 5 seconds and then re-inflated for 1 minute. In 2004 a mini-C-Arm (General Electric OEC) was obtained by WHCC. Post-reduction radiographs were routinely obtained, either before or after cuff deflation at the attending primary care physician’s discretion (depending on the confidence of reduction success).

Go to source: CAEP – Canadian Association of Emergency Physicians |

A review (Emerg Med J 2013;30:214-217)

 

LET

LET Application Instructions. Use 1-3 cc of LET (works best if blood and debris are removed from wound). Gel Apply to wound and wound edges with a cotton-tip applicator. The wound is NOT covered (as it is with solution). The LET is usually effective in 20 min, at which time skin around the wound appears blanched, due to the epinephrine’s effects. The gel should be removed prior to suturing. LET gel anesthesia lasts about 45-60 min after it is removed from the wound.

Solution Paint solution onto wound and wound edges with cotton-tip applicator. Then apply a cotton ball saturated with LET to the wound. Immunocompromised status The LET is usually effective in 20 min, at which time skin around the wound appears blanched, due to the epinephrine’s effects. *Source: Adapted from: Kennedy RM, Luhmann JD. The “ouchless emergency department” getting closer: Advances in decreasing distresss during painful procedures in the emergency department. Paediatr Clin North Am. 1999;46:1215. See Reference 224.

 

Tetanus Prophylaxis in Wound Repair

 

Laceration Repair

No Gloves Necessary

816 patients, no increased infection rate (Annals 2004, 43:3, p.362)

 

Irrigation

Restudy proving tap water is as good as sterile (Acad Emerg Med 2007;14:404)

Dermabond

To simplify glue administration, one

can draw up the glue into a 1 ml tuberculin syringe, after first puncturing

the vial with finger pressure, as if the vial were to be used. The needle of

the tuberculin syringe is passed through the cotton pledget at the tip of

the vial, and the purplish glue is drawn from vial to syringe. The vial and

needle are then discarded, and the needle replaced with a 24 gauge plastic

intravenous catheter.

 

If gentle separation of the lashes is not possible, application of liberal mineral oil/petroleum jelly may allow for mechanical lysis of the adhesions within minutes.  If this is still not successful, the application of mineral oil/petroleum jelly under pressure patching overnight will frequently allow for separation upon recheck the next day.  Some recommend patches soaked in normal saline.

 

put tegaderm over eye

 

 

Photo courtesy of Dr. Hagop Afarian (UCSF-Fresno)

Tissue adhesives for wound closure often seem to intentionally make a bee-line straight for high-risk areas such as the eye. To avoid inadvertent application of the tissue adhesive, Dr. Hagop Afarian (UCSF-Fresno) utilizes a transparent tegaderm tape with an oval cut out of the center to provide a protective barrier. Immediately after application of the tissue adhesive, the tegaderm can be carefully peeled off to reveal a still-drying, well-circumscribed aliquot of glue over the wound. Be sure that the wound is dry, and the edges are well-apposed prior to tissue adhesive application.

 

advanced gluing techniques

Hair Apposition Technique

(Annals 2002 40:1)

Suturing

Always place needle holder between two ends, wrap around towards other end, and then pull ends towards opposite sides

Subcuticular Technique

 

Ring Removal

Can use dremmel multipro c high speed tungsten carbide cutting disc at maximum rpm with piece of splint under ring. (J. Emerg Med 20:3)

Stapling

Stapling can be used for trunk and extremity wounds as well as scalp. (Annals EM 18:10, 1989. p. 1122 JB-P)

 

Dog Ears

Elderly

Consider taping alone or tape parallel to the wound edges and suture through the tape.

 

Delayed Primary

place fine mesh gauze

wrap in compressive dressing

bring back in 72 hours

 

Figure 3. Technique For Closing Avulsion Of Gingival Mucosal Tissue.

 

The technique to close this injury is shown. The sutures are brought around the teeth and through the avulsed tissue flap (insets).

Used with permission from: Trott A. Special Anatomic Sites. In: Weimer R, Cochran A, eds. Wounds and Lacerations: Emergency Care and Closure. St Louis, MO: Mosby-Year Book; 1991:172. Figure 1.

 

Technique For Closing Avulsion Of Gingival Mucosal Tissue When A Needle Cannot Be Passed Between The Teeth.

 

The technique of flossing the suture material through the teeth in cases in which the needle cannot be passed between the teeth because of tight interproximal contacts: A. Pass needle through facial tissue then floss through teeth. B. Pass needle through palatal tissue. C. Pass needle through palatal tissue again and floss through teeth. D. Tie suture on facial aspect.

Used with permission from: Trott A. Special Anatomic Sites. In: Weimer R, Cochran A, eds. Wounds and Lacerations: Emergency Care and Closure. St Louis, MO: Mosby-Year Book; 1991:172. Figure 2

 

 

 

ABX Prophylaxis

Immunosuppressed states

Joint Replacement

Extensor Tendons

Plastics Level Facial Closure

Academic Emergency Medicine Volume 11, Number 5 561-562, © 2004 Society for Academic Emergency Medicine Single- vs. Double-layer Closure for Facial Lacerations Adam J. Singer, Janet Gulla, Michele Hein, Scott Marchini, Stuart Chale and Balvantray P. Arora Stony Brook University: Stony Brook, NY ABSTRACT OBJECTIVE: To compare cosmetic outcome of facial lacerations closed with single or double layer of sutures. METHODS:Design—RCT. Setting—University-based ED, annual census 75,000. Subjects—ED patients > 1 yr with non-gaping (width < 10 mm), linear, facial lacerations. Interventions—Following standard wound preparation, lacerations were randomized to closure with single layer of simple interrupted 6/0 polypropylene sutures or double layer of simple interrupted 6/0 polypropylene plus inverted deep dermal 5/0 polyglactin sutures. Masked Outcomes—Duration of closure; 5-10-day wound infection rates; 90-day patient- and practitioner-assigned cosmetic scores (100-mm VAS from 0 [worst] to 100 [best]); percentage of wounds with optimal wound evaluation score (WES) of 6/6 at 90 days; and scar width at 90 days. Data Analysis—Outcomes were compared with chi-square and t-tests. A sample of 60 patients had 90% power to detect a 17-mm difference in cosmetic VAS scores. RESULTS: 60 patients were randomized to single- (30) or double (30)-layer closure. Mean age (SD) was 18.7 years (20.3); 15% were female. Mean (SD) laceration length and width were 2.5 (2.8) cm and 3.1 (1.9) mm, respectively. Groups were similar in baseline patient and wound characteristics. Length of single-layer closure was 6 minutes shorter (95% CI, 1-11 minutes) than double-layer closure. There were no infections in either group. 90-day follow-up rates were 89% and 97% for single- and double-layer closure groups, respectively. There were no between-group differences in patient (mean difference 1.4 mm [95% CI, –5.6 to 4.4]) or practitioner (mean difference 3.2 mm [95% CI, –3.2 to 9.6]) VAS scores. All patients in both groups received optimal WES scores of 6. Scar widths were similar at 90 days (mean difference 0.16 mm [95% CI, –0.4 to 0.15]). CONCLUSIONS: Single-layer closure of non-gaping facial lacerations is faster than double-layer closure. Cosmetic outcomes and scar widths are similar in sutured wounds whether or not deep dermal sutures are used.

Other clues for parotid injury include saliva leaking from the wound and/or blood seen coming from the duct opening (Stenson’s duct) inside the cheek at the level of the upper second molar. The three branches of the trigeminal nerve (supraorbital, infraorbital, and mental nerves) provide sensation to the face, and intact sensation on the face also should be documented. Facial nerve integrity can be established only by testing (and documenting) the function of all five branches. (See Facial Nerve Injury below.) In summary, if the patient can lift the forehead/brow, open/shut the eyes, move the lips in a smile or frown, and have contraction of the platysma when shrugging shoulders, the facial nerve is intact. Patients unable to cooperate with testing due to head injury or intoxication are likely to be admitted or observed until their mental status clears, but if discharged from the ED, one must remember to test and document nerve function before discharge. This easily can be overlooked when the patient’s stay extends beyond the first physician’s shift.

Clues to diagnosis start with a high index of suspicion in any laceration between the tragus and the mid-cheek. Remember that one also should consider the diagnosis with fractures of the mandible or zygomatic arch.30

The next step is to thoroughly examine any wound on the cheek to see if the duct is visible in the wound. Then one should milk the parotid gland and look for blood at Stenson’s duct, located just inside the cheek at the level of the upper second molar.

 

Lacerations located lateral to a vertical line running through the lateral canthus of the eye and involving any of the branches of the facial nerve generally are considered for microscopic repair of the transected nerve tissue with 8.0 or 9.0 nylon epineural simple suture. Nerve injuries that result from lacerations medial to this line generally are not considered repairable, owing to the small caliber of the nerve. Figure 4. Facial Nerve and Parotid Gland: Note that the parotid duct lies roughly along a line drawn from the tragus to the mid upper lip. It enters the oral cavity along a line from the pupil to the mental nerve. The facial nerve divides into five main branches inside the parotid gland. Any laceration of the parotid gland or duct mandates an exam for facial nerve injury.

 

 

peridex 0.12 % 15 cc swish 30 sec and then spit

Head Bandage

Use kling, then take two 10-15 cm pieces of umbical tape thread a piece at each ear with hemostat and then tie.

Trott 3rd Edition of Emergency Wound Care

 

Hemostasis-all bleeding but minor oozing should be controlled before wound repair

Anesthesia-a pain free repair is essential

Irrigation-Most important step for reducing infection

Exploration-in a bloodless field with good light/exposure

Remove  devitalized or contaminated tissue-spare as much good skin as possible, but debride it all

Tissue preservation-Do not excise tissue, tack it down, it will allow the plastics folks to have a palette to work with later.

Closure Tension-wound edges should just barely touch. use undermining or deep stitches to avoid having to smash the edges against each other

Deep sutures-use as few as possible

tissue hadling-always be gentle

Wound infection-the most important dose of abx is the one given IV as soon as the patient arrives

Dressings-wounds heal best wet

 

Suture Material

Vicryl Rapide is irradiated polyglactin-910. Dissolves in 7 days; may be used for lac repair without stitch removal.

ear dressing

 

for delayed primary closure

give 4-5 days of antibiotics, then bring pt back, debride and close

can use chromic gut to close scalps, even better is vicryl rapide

 

erythema 5-10mm from abscess or wound edge is normal, beyond is cellulitis

 

Dermabond, etc.

DISCUSSION Cyanoacrylate adhesives were invented by Dr Harry Coover ofKodak Laboratories when he was trying to make clear plasticsuitable for gunsights.1 These were methyl-2-cyanoacrylate andwere found to be tremendously strong. These and similar short chain cyanoacrylates experienced commercial success and became generally known as “superglues”. In the 1950s and 60s, methyl-2-cyanoacrylateadhesive was used to bond skin and control bleeding in open wounds. Disposable cyanoacrylate sprays were used to control haemorrhage in the Vietnam War. However, it became apparentthat methyl-2-cyanoacrylate provokes acute and chronic tissuereaction. They also cause histotoxicity because of the exothermicnature of the polymerisation reaction of these short chain cyanoacrylates. Furthermore, they generate local high concentrations of breakdown products, which include formaldehyde and alkylcyanoacetate.2 As a result, compounds were developed that were more compatible with human tissue. These used monomers with longer alkyl chains, which owing to their slower degradation, cause less histotoxicity. These are used for wound closure and embolisation. They canalso be used as dressings for burns, minor cuts, abrasions andmouth ulcers. They have been shown to provide a waterproof antimicrobialbarrier and improve epithelialisation and wound healing.3

They are, therefore, quite different from superglues and muchmore expensive to produce.

Proper use of cyanoacrylate tissue adhesives for wound closure:

 

• 1 Wound should be in horizontal plane to prevent run-off.
• 2Wound should be clean and dry, haemostasis essential.
• 3 Woundedges opposed with only minimal tension.
• 4 Deep dermal suturesmay be necessary to take tension off woundedges.
• 5 Adhesiveapplied to opposed edges to act as bridge acrosswound.
• 6Do not get adhesive into wound.
• 7 Do not tell patient youare using superglue.

Go to source: Case of the month: Honey I glued the kids: tissue adhesives are not the same as “superglue” — Cascarini and Kumar 24 (3): 228 — Emergency Medicine Journal

 

Stopping the Bleeding (from James Adams Lecture)

Methylcellulose

Gelfoam

From skin gelatin

Absorbable

4-6 weeks

Liquefies in 2-5 days in nose, rectum

Serves as a scaffold for coagulation

Oxidized Regenerated Cellulose

Surgicel

Johnson and Johnson

Binds platelets and chemically precipitates fibrin.

Cannot be mixed with thrombin

Microfibrillar collagen:

decellularized bovine source

Avitene

Stimulates platelet adherence

Stops venous ooze

active part of the clotting cascade

Absorbed 90 days

About $50

Collagen

Not likely to be useful for pumping arterial hemorrhage

Apply to the site of bleeding with pressure

Easily removed after hemostasis is achieved

When direct pressure does not work: Options

Thrombin (Thrombostat)

Bovine Thrombin, 5000u or 10,000 u

Cleaves fibrinogen to fibrin

Positive feedback to coagulation cascade

Mix powder with CaCl and spray

Can mix with gelfoam, not surgicel

Thrombin + Gelfoam + CaCL

Glynns Glue

Thrombin for cleavage/activation

Gelfoam as a matrix

CaCl

Sucralfate for adherence

Mix and pack

Fibrin ‘glue’

Tiseel, Baxter.

FDA approved 1998

Concentrated fibrinogen with factor VIII

Thrombin and Calcium

Aprotinin to prevent clot dissolution

Takes time to prepare

Tisseel

Baxter

Bovine Thrombin and CaCl

Human Fibrinogen and Factor VIII

Aprotinin for antifibrinolytic activity

Special heating and mixing

Applied through simultaneous spray or mist of the 2 syringes

Fibrin ‘glue’

1940s: fibrinogen (in cryoprecipitate) and thrombin were combined during surgical

procedures

1960s: concentrated fibrinogen developed

Good for diffuse oozing, needle punctures, lymphatic leaks, diffuse parenchymal organ

injury.

Used for hemostasis and adhesion

Fibrin ‘glue’

Liver and spleen lacerations

Dental extractions in hemophiliacs

Hemostasis at cannulation sites and vascular grafts.

Sealing dural leaks

Bone, lung, tissues

 

Abscess Drainage

Superior Cluneal Nerve Block for Buttocks Abscess Drainage (J Emerg Med 2010;39(1):83)