ABSTRACT
SUMMARY:
Acute Wound Care
Contents Bibliography:
Page:
Title:
4 Hollander, J.
E. and A. J. Singer (1999). "Laceration management." Ann Emerg Med 34(3):
356-67.
Rodeheaver, G. T., D. Pettry, et al. (1975). "Wound
cleansing by high pressure irrigation." Surg Gynecol Obstet 141(3):
357-62.
All traumatic wounds are
contaminated to some degree by both soil and bacteria. Specific infection
potentiating factors in soil impair the defenses of the tissue and invite
infection. These factors are small in size and resist removal by low pressure
irrigation. The efficiency of wound irrigation is markedly improved by
delivering the irrigant to the wound under continuous high pressure. Irrigation
of the wound with saline solution delivered at 15 pounds per square inch removed
84.8 per cent of the soil infection potentiating factors from the wound. The
residual infection potentiating factors remaining in the wound did not
significantly impair tissue defenses. On the basis of these experimental
studies, clinical studies are now being initiated to test the therapeutic value
of high pressure irrigation in traumatic wounds in humans.
Hollander, J. E. and A. J. Singer (1999). "Laceration
management." Ann Emerg Med 34(3): 356-67.
In 1996, almost 11 million
lacerations were treated in emergency departments throughout the United States.
Although most lacerations heal without sequelae regardless of management,
mismanagement may result in wound infections, prolonged convalescence, unsightly
and dysfunctional scars, and, rarely, mortality. The goals of wound management
are simple: avoid infection and achieve a functional and aesthetically pleasing
scar. Recent US Food and Drug Administration approval of tissue adhesives has
significantly expanded clinicians' wound closure options and improved patient
care. We review the general principles of wound care and expand on the use of
tissue adhesives for laceration repair.
Singer, A. J., J. E. Hollander, et al. (1994). "Pressure
dynamics of various irrigation techniques commonly used in the emergency
department." Ann Emerg Med 24(1): 36-40.
STUDY OBJECTIVE: To evaluate
the pressure dynamics of common irrigation techniques used in the treatment of
traumatic wounds. DESIGN: Matched experimental trial. PARTICIPANTS: Ten male
volunteers. INTERVENTIONS: Pressure curves were obtained while performing manual
irrigation with 250-mL boluses of normal saline with 19-gauge needles on 35-mL
syringes, 19-gauge needles on 65-mL syringes, IV bags pierced with 19- gauge
needles, and plastic bottles pierced with 19-gauge needles. Measurements also
were obtained using an IV bag with tubing attached to either a 19-gauge or
16-gauge needle within a pressure cuff inflated to 400 mm Hg. RESULTS: Median
peak pressures were 35 lb/in.2 (psi)(range, 25 to 40 psi) and 27.5 psi (range,
15 to 40 psi) using a 35-mL syringe and a 65-mL syringe, respectively. Median
peak pressures with the IV bag and plastic bottle were 4 psi (range, 2 to 5.5
psi) and 2.3 psi (range, 1.2 to 4.5 psi), respectively. The IV bag in a pressure
cuff generated pressures of 6 to 10 psi and 4 to 6 psi using 19-gauge and 16-
gauge needles, respectively. CONCLUSION: Both 35-mL and 65-mL syringes with a
19-gauge needle are effective in performing high-pressure irrigation in the
range of 25 to 35 psi. The use of IV bags and plastic bottles should be
discouraged when high-pressure irrigation is required.
Pigman, E. C., D. B. Karch, et al. (1993). "Splatter
during jet irrigation cleansing of a wound model: a comparison of three
inexpensive devices." Ann Emerg Med 22(10): 1563-7.
STUDY
OBJECTIVE: Pressurized jet irrigation is commonly used to cleanse traumatic
wounds but results in splatter of blood, a biohazard. Three inexpensive
irrigation devices were compared to assess the degree of splatter produced: a
1.25-in. 18-gauge angiocath, an Irrijet Irrigation System with a 12.7-cm splash
shield, and a Zerowet Splashield held directly against the wound (Zerowet-C) and
held 4 to 10 cm from the wound, an incorrect technique (Zerowet-I). DESIGN: A
standard laceration was created in pieces of beef. This wound model was placed 1
m from the floor. Paper grid sheets were placed on the irrigator's face and
chest. Six grid sheets were suspended at the 9:00, 12:00, and 3:00 positions 1 m
from the wound model and 1 and 1.5 m from the floor to simulate exposure to
nearby individuals. Two grid sheets were placed flat on the floor, at the 10:30
and 1:30 positions, 1 m from the base of the wound model stand. The study area
was contained in a 3 x 2 x 2 m plastic sheet enclosure to prevent air drafts.
INTERVENTION: Ten irrigations were performed with the angiocath, Irrijet,
Zerowet-I, and Zerowet-C. Each run used 200 mL methylene blue solution delivered
with a 50-mL syringe by one-hand pressure. The methylene blue splatter on each
of the grids was counted by size (diameter, less than 1 mm, more than 1 mm and
less than 5 mm, more than 5 mm and less than 10 mm, and more than 10 mm).
RESULTS: There was significantly less splatter onto the irrigator's face and
chest with Irrijet, Zerowet-I, and Zerowet-C. No facial splatter occurred with
Zerowet-C. There was significantly less splatter at the 9:00 and 12:00 positions
at both heights, and on the floor with Irrijet, Zerowet-I, and Zerowet-C. Less
significant splatter difference was noted at the 3:00 position. CONCLUSION:
Irrijet, Zerowet-I, and Zerowet-C were superior to the angiocath in preventing
splatter during this wound model irrigation. The correct use of Zerowet
(Zerowet-C) was particularly effective in preventing splatter onto the
irrigator's face.
Anglen, J. O. (2001). "Wound irrigation in musculoskeletal
injury." J Am Acad Orthop Surg 9(4): 219-26.
Wound irrigation to remove
debris and lessen bacterial contamination is an essential component of open
fracture care. However, considerable practice variation exists in the details of
technique. Volume is an important factor; increased volume improves wound
cleansing to a point, but the optimal volume is unknown. High-pressure flow has
been shown to remove more bacteria and debris and to lower the rate of wound
infection compared with low-pressure irrigation, although recent in vitro and
animal studies suggest that it may also damage bone. Pulsatile flow has not been
demonstrated to increase efficacy. Antiseptic additives can kill bacteria in the
wound, but host-tissue toxicities limit their use. Animal and clinical studies
of the use of antiseptics in contaminated wounds have yielded conflicting
outcomes. Antibiotic irrigation has been effective in experimental studies in
some types of animal wounds, but human clinical data are unconvincing due to
poor study design. There are few animal or clinical studies of musculoskeletal
wounds. Detergent irrigation aims to remove, rather than kill, bacteria and has
shown promise in animal models of the complex contaminated musculoskeletal
wound.
Hollander, J. E., A. J. Singer, et al. (2001). "Risk
factors for infection in patients with traumatic lacerations." Acad Emerg
Med 8(7): 716-20.
BACKGROUND:
Most of our knowledge of laceration management comes from studies in animal
models or patients with closure of sterile postoperative surgical incisions.
Traumatic laceration management has not been well studied. OBJECTIVE: To
determine which characteristics of traumatic lacerations were associated with
the development of wound infection. METHODS: A cross-sectional study of
consecutive patients with traumatic lacerations repaired over a four-year period
was conducted. Structured closed-question data sheets were prospectively
completed at the time of laceration repair and suture removal. Infection was
determined at the time of suture removal. Multivariate modeling was used to
determine the adjusted odds ratio (OR) of infection. RESULTS: Five thousand five
hundred twenty-one patients were enrolled; 195 patients developed an infection
(3.5%). An increased likelihood of wound infection was associated with age
(adjusted OR per year, 1.01; 95% CI = 1.0 to 1.02); history of diabetes mellitus
(adjusted OR 6.7; 95% CI = 1.7 to 26.4); laceration width (adjusted OR 1.05 per
mm; 95% CI = 1.02 to 1.08); and presence of foreign body (adjusted OR 2.6; 95%
CI = 1.3 to 5.2). Laceration location on the head/neck was associated with a
decreased risk of infection (adjusted OR 0.28; 95% CI = 0.18 to 0.45).
CONCLUSIONS: Both patient and wound characteristics of traumatic lacerations
have an influence on the likelihood of infection. This knowledge may be valuable
for determining whether various methods of wound cleansing, debridement, and
repair can improve the outcome of patients with traumatic
lacerations.
McDonald, W. S. and L. S. Nichter (1994). "Debridement of
bacterial and particulate-contaminated wounds." Ann Plast Surg 33(2):
142-7.
Debridement of contaminated
wounds is an essential component of uncomplicated wound healing. Efficient
techniques should be capable of removing bacteria as well as foreign matter
because of the well-known ability of foreign bodies to potentiate infection. We
have compared the ability of current debridement techniques with the relatively
new ultrasound debridement to clean wounds contaminated with bacteria and
particulate matter. In part I, we prepared dorsal wounds on 15 Sprague- Dawley
rats, and 20 mg of Montmorillonite clay soil fraction, a well- known
infection-potentiating factor, was placed in each wound. Animals were randomly
assigned to one of three treatment groups: ultrasound debridement, soaking, and
irrigation. The amount of clay removed from each wound was measured. In part II,
48 Sprague-Dawley rats were given a standard wound and inoculated with a
subinfective dose of Staphylococcus aureus bacteria and 10 mg of Montmorillonite
clay particles. Each rat was randomly assigned to a debridement technique--
soaking, scrubbing, high-pressure irrigation, and ultrasound--and was examined
after 7 days for inflammatory responses. Results of part I demonstrated that
ultrasound debridement and irrigation remove statistically equal amounts of clay
(p < 0.05). In part II, we found that high-pressure irrigation and ultrasound
debridement effectively treat contaminated wounds (gross infection, p < 0.05;
wound induration, p < 0.0001; bacteria counts, p < 0.002). This study
presents ultrasound debridement as effective treatment of contaminated
wounds.