Wound Management

1
Wound Management

• Andrew Stiell
• U of C Family Medicine R2
• October 1st, 2009

2
Thanks

• Dr Ian Rigby
• Carole Rush

3
Objectives

• Review a few basic topics
• Interactive Game
• Discuss your cases

4
QuizFrom when is the earliest evidence we have
of a surgical technique being done?
5
QuizFrom when is the earliest evidence we have
of a surgical technique being done ?

• 1200s
• 500
• 500 BC
• 1200 BC
• 12 000 BC

6
QuizFrom when is the earliest evidence we have
of a surgical technique being done ?

• 1200s
• 500
• 500 BC
• 1200 BC
• 12 000 BC

7
Trapanation (burr hole)

• 12 000 BC
• Used tools to make hole into skull
• Used to treat trauma, seizure, migraines,
  psychiatric disorder
• 50 survival

8
Skin

• Largest organ in our body
• 16-21 square feet
• 1-4mm thick

9
Skin

• Largest organ in our body
• 16-21 square feet
• 1-4mm thick
• Lots going on (per square inch)
• 650 sweat glands
• 20 blood vessels
• gt1,000 nerve endings

10
Skin - Function

1. Barrier from pathogens

11
Skin - Function

1. Barrier from pathogens
2. Sensation

12
Skin - Function

1. Barrier from pathogens
2. Sensation
3. Heat regulation (radiation, convection,
   conduction)

13
Skin - Function

1. Barrier from pathogens
2. Sensation
3. Heat regulation (radiation, convection,
   conduction)
4. Barrier to fluid loss (evaporation)

14
Skin - Function

1. Barrier from pathogens
2. Sensation
3. Heat regulation (radiation, convection,
   conduction)
4. Barrier to fluid loss (evaporation)
5. Storage (water lipids)

15
Skin - Function

• Barrier from pathogens
• Sensation
• Heat regulation (radiation, convection,
  conduction)
• Barrier to fluid loss (evaporation)
• Storage (water lipids)
• Vitamin D production

16
Skin - Function

1. Barrier from pathogens
2. Sensation
3. Heat regulation (radiation, convection,
   conduction)
4. Barrier to fluid loss (evaporation)
5. Storage (water lipids)
6. Vitamin D production
7. Communication (mood, physical status)

17
Skin - Anatomy
18
Skin - Anatomy
19
Skin- Healing
20
Healing terminology

• Closed
• Open
• Delayed
• Primary intention
• Secondary intention
• Third intention

21
Skin Healing- Open vs Closed

• Closed
• less inflammation
• less contracture
• less scar width
• less future contamination
• Open
• - less chance of infection

22
Skin Healing

• Open or Delayed Closure
• Already infected (by soil, organic matter or
  feces)
• Extensive tissue damage (high-velocity missile
  injuries, explosion injuries of hand or complex
  crush injuries)
• Human Bite wounds
• Animal Bites

23
Skin Healing- Delayed Closure
24
(No Transcript)
25
Some Rules

• In each section go in order starting with the
  lowest question available
• Do not have to answer in the form of a question
• Dr Rigby gets the final say on if answers are
  correct as he is giving out the prize

26
Ooh it burns! Bite Me! Can you feel that? In to the Wild Miscellaneous
100 100 100 100 100
200 200 200 200 200
300 300 300 300 300
400 400 400 400 400
500 500 500 500 End
27
Ooh It Burns! 100
What is the most common age to suffer a burn?
(decade)
28
Ooh It Burns! 100Answer
Ages 0-10 and 20-29
29
Burns

• Most common in ages 1-2 yo 20-29yo
• Males gt Females
• In small children almost all burns are scald
  burns.
• Adults flame burns are most common
• Most common contributing factor is EtOH

30
Burns
31
Burns

• Dont forget child abuse
• Immersion scald burns
• Stocking pattern
• Back of hands feet, buttock and legs
• Accidental
• Spill burns
• Head, trunk, palmer surface of hands feet

32
Ooh It Burns! 200
How do we classify burns?
33
Ooh It Burns! 200 Answer

1. 1st, 2nd, 3rd 4th degree burns
2. Partial vs Full thickness

34
Burns - severity

• 1)Temperature
• 2)Time of exposure
• Capacity to hold heat
• Viscosity
• Clothing

35
Burns - depth

• 1st Degree
• 2nd Degree
• Superficial Partial Thickness
• Deep Partial Thickness
• 3rd Degree
• Full Thickness
• 4th Degree
• -Full Thickness

36
Burns - depth

• 1st Degree
• Minor epithelial damage
• Red, tenderness pain
• No blistering
• Heals over several days
• Eg. sunburns

37
Burns - depth

• 2nd Degree
• Superficial Partial Thickness
• Epidermis and superficial papillary dermis
• Fluid-filled blisters
• Pink, moist, soft and very tender
• Heal in 2-3wks w/o scarring
• Deep Partial Thickness
• Deeper into dermis
• Red blanched white
• Thick walled blisters
• Decreased 2pt discrimination
• Heal in 3-6 wks
• Increased risk of scar

38
Burns - depth

• 3rd Degree
• Full Thickness
• Destroy Epidermis and Dermis
• Capillary network destroyed
• White or leathery
• Numb
• Requires skin grafting
• Eg. Immersion scalds,flames, chemical electrical

39
Burns - depth

• 4th Degree
• Full Thickness destruction of subcutaneous
  tissue
• Involves fascia, muscle bone
• Require extensive debridement and reconstruction
• Eg. Prolonged exposure to immersion scalds,
  burns, chemical and electrical

40
Burn Zones?
41
Burns - Zones

• 1) Coagulation / Necrosis
• Contact with source
• Dead/Dying cells b/c loss of blood flow
• White or charred
• 2) Stasis / Ischemia
• Red and may blanch initially
• _at_ 24hrs no circulation, petechial hemorrhages
• Becomes white as it is necrotic
• 3) Hyperemia
• Blanches, has circulation
• Becomes deep red
• Starts healing at 1 week

42
What should you do if you are out camping, many
hours from help, and your friend suffers a burn?
43
What should you do if you are out camping many
hours from help and your friend suffers a burn?

• A) Do not remove burned clothing
• B) Immerse in cool water x30min
• C) Immerse in cool water x1hr
• D) Cover with dry dressing
• E) A C
• F) B D

44
What should you do if you are out camping many
hours from help and your friend suffers a burn?

• A) Do not remove burned clothing
• B) Immerse in cool water x30min
• C) Immerse in cool water x1hr
• D) Cover with dry dressing
• E) A C
• F) B D

45
Burns-Dressing

• In the field prior to transport
• Remove burned clothing
• Skin washed with cool water
• Immerse in cold water x30min if cannot be
  transported
• gt30 min only cool 9 of TBSA to prevent
  hypothermia
• Do not use ice as it can cause frostbite injury
• Cover with dry dressing

46
Burns-Dressing (in the ED)

• Minor Burns(Outpatients)
• Cleansed with sterile saline
• Blisters?? To pop or not to pop?
• Clean and debride
• If follow up is later (1week)
• Synthetic dressings (Aquacel Ag dressing)
  maintain moist environment
• If follow up is next day
• Strips of sterile fine-mesh gauze soaked in
  saline which are covered by fluffed 4x4 coarse
  gauze
• Flamazine cream
• (Antibacterial ointment is often not used because
  require frequent changes needed)
• F/u at wound clinic 1-3 days for dressing change

47
Burns-Dressing (in the ED)

• Major Burns (Inpatients)
• Cleanse with sterile saline
• Maintain sterile environment
• If waiting for hydrotherapy
• - Cover with clean sheet or towel
• If too unstable for hydrotherapy
• - Plastics will apply Flamazine and gauze
• Debridement of blisters (except palms and soles)
• Aggressive debridement usually deferred unless
  involving joints
• Silver stains the face, therefore polysporin is
  used

48
Burns - fluids

• Why do we have such big fluid losses?
• 1) Increased evaporation b/c loss
  semi-impermiable barrier
• 2) Systemic inflammatory causing vessels to have
  increased permeability
• -Fluid gets pushed in to burned tissues
• 3)Tissue destruction causes capillary
  permeability
• Fluid gets goes in to adjacent tissue to the burn
  wound

49
Ooh It Burns! 300
Name 2 criteria for burn referral/transfer?
50
Ooh It Burns! 300 Answer
Transfer Guidelines for Patients with Severe
Burns Any burn gt10 of BSA in pts lt10 or
gt50 Burns involving gt20 of total BSA in any
patient Full-thickness burns involving gt5 of
total BSA Significant burns of hands, face, feet,
genitalia, perineum, or major joints Significant
electrical injury Significant chemical
injury Significant inhalation injury, trauma, co
morbidities
51
Burns-disposition

• Admission Guidelines
• Any partial-thickness burn injury involving
  10-20 of BSA in adults (gt10 or lt50years of age)
• Any partial-thickness burn involving 5-10 of BSA
  in patients lt 10 year of age
• Transfer Guidelines for Patients with Severe
  Burns
• Any burn gt10 of BSA in pts lt10 or gt50
• Burns involving gt20 of total BSA in any patient
• Full-thickness burns involving gt5 of total BSA
• Significant burns of hands, face, feet,
  genitalia, perineum, or major joints
• Significant electrical injury
• Significant chemical injury
• Significant inhalation injury, trauma, co
  morbidities

52
Burns-disposition

• Consider Admission
• - Younger or older patients
• - gt10 burns
• - Full Thickness burns
• - Important areas
• - hand, face, feet, genitalia, perineum, joints
• - Other injuries( electrical, chemical,
  inhalation, trauma)
• Others can be managed with outpatient follow up

53
Ooh It Burns! 400
Name a household product you can use to remove
this burn substance?
54
Ooh It Burns! 400 Answer

• Tar Burns
• 1)Commercial products ()
• 2)Butter
• 3)Baby Oil
• 4)Sunflower Oil

55
(No Transcript)
56
Ooh It Burns! 500
What is the indication for escharotomy in the ED?
57
Ooh It Burns! 500 Answer
Full thickness circumferential burns with
decreased distal perfusion or increased
compartment pressure.
58
Which patients are candidates for Escharotomy?

• Full-thickness circumferential and
  near-circumferential skin burns result in the
  formation of a tough, inelastic mass of burnt
  tissue (eschar)

59
Which patients are candidates for Escharotomy?

• Full-thickness circumferential and
  near-circumferential skin burns result in the
  formation of a tough, inelastic mass of burnt
  tissue (eschar)
• Upper Lower Extremities, Neck, Torso, Abdomen

60
Upper and Lower Limb

• Monitor compartment pressure (30mmHg) and distal
  perfusion
• Main reason for poor perfusion is volume
  depletion
• Need a period of 3-8hrs for edema to develop

61
Upper and Lower Limb

• Use scalpel electrical cautery
• Cut down to subcutaneous fat
• Release in pressure is felt along with a pop
• 1cm to each side of burn
• Extend across joints

62
Upper and Lower Limb

• Continue to thenar and hypothenar eminences
• Continue to little toe and great toe

63
Upper and Lower Limb

• Lateral and medial sides of finger
• Consider hand specialist because of high risk of
  injuring neurovascular bundle

64
Neck

• Edema compresses airway
• Tight neck eschar draws neck into flexion
• Posterior or Laterally to avoid vascular
  structures

65
Chest

• Can restrict respiratory excursion
• Anterior Axillary lines
• Clavicles to costal margin
• Transverse lines

66
Abdomen

• Can result in abdominal compartment syndrome
• Extend incisions from thorax

67
Bite Me! 100
What type of animal bite is responsible for the
most ER visits?
68
Bite Me! 100 Answer
Dog
69
Dog Bites

• Make up 0.4 of ER visits
• 60-90 of bite related visits

70
Dog Bites

• Make up 0.4 of ER visits
• 60-90 of bite related visits
• Most frequent victims
• Children young adults
• Males gt Females
• In North America 80 of bites are from family or
  neighbors dog
• In developing countries more likely to be stray
  dogs

71
Dog Bites

• Approximately 10 deaths /year in the US
• Most commonly involves
• Pit Bulls
• Rottweilers
• German Shepherds
• 2 attacks require hospitalization (usually for
  surgical repair)

72
Dog Bites

• Lots of pressure but not sharp
• Superficial crush injuries
• Damages skin and muscle

73
Dog Bites

• Usually involves extremity
• Can involve face, neck and scalp in children
• lt 2 years old can perforate cranium

74
Dog Bites

• Infection rate 5-10
• (non-bite laceration 3-7)
• Hand Bites 12-30
• Face bites 1-5

75
Dog Bite Infection

• Species
• Staph Aureus
• Alpha Beta Strep
• Capnocytophaga Canimorsus
• Klebsiella
• Bacillus subtilis
• Pseudomonas
• Enterobacteriaceae
• Bacteroides
• Fusobacterium
• Peptostreptoccocus
• Actinomyces

76
Capnocytophaga canimorsus(formerly dyscgonic
fermenter 2)

• Can cause overwhelming sepsis in 2-3 days of bite
• Normal flora of dogs
• 30-70 mortality in immunocomprimised

77
Bite Me! 200
Which household animal bite has the highest rate
of infection? And what is the most responsible
bacteria?
78
Bite Me! 200 Answer
Cat Pasturella Multicida
79
Cat Bites

• Up to 15 of bites that present to ER
• Most commonly puncture wounds
• More likely to penetrate and effect tendons,
  joints and bone

80
Cat Bites

• High rate of infection
• 30-50
• 24 require admission
• Most commonly in hand

81
Cat Bites

• Pasteurella Multicida
• - 70-90 of cats
• - scratches and bites
• Can develop in to cellulitis within 24hrs

82
Cat Bites

• Pasteurella Multicida
• - 70-90 of cats
• - scratches and bites
• Can develop in to cellulitis within 24hrs
• Also in dogs, lions, wolves and cougars

83
Bite Me! 300
Name a body part that is at higher risk for
infection from a bite?
84
Bite Me! 300 Answer
-Hand -Below knee -Through and through in the
mouth -Over joint
85
Managing bites

• Factors
• Species of animal
• Location
• Type
• Co-morbidities

86
High Risk Bites
High Risk Low Risk
Species -Cats -Human -Primate -Pig -Dog -Rodent
Location -Hand -Below knee -Through and through in the mouth -Over joint -Face -Scalp -Mucosa
87
High Risk Bites
High Risk Low Risk
Type -Puncture Extensive Crush Contaminated Old gt12hr -Large -Superficial -Clean -Recent
Co-morbidities -Elderly -DM -Prosthetic Valve -Asplenic -EtOH -Steroids
88
Who needs Abx?
89
Who needs Abx?

• Dogs only if high risk factor
• Cats All bites
• Humans Hands high risk
• Rodent No
• Self Inflicted Mucosa if through through

90
Abx of choice

• Dogs ( most other animals)
• Amox-Clavulanate
• Doxycycline
• Cats
• Amox-Clavulanate
• Doxycycline
• Humans
• Amox-Clavulanate
• Doxycycline

91
Bite Me! 400
Where on the body would you consider suturing a
cat bite?
92
Bite Me! 400 Answer
Face
93
Who to Suture?
94
Who to Suture?

• Dog All (/- hand feet)
• Cats Face only
• Rodent All
• Monkey No
• Human All except hands
• Self inflicted Mucosa All

95
Treatment

• With delayed closure keep moist with saline
  dressing
• Bites of the hand or over joints should be
  immobilized with a bulky soft dressing or splint
• F/U in 1-3 days
• Dont forget tetanus

96
Bite Me! 500
What illnesses can result from a bite from this
guy?
97
Bite Me! 500 Answer

• Tick
• Lymes Disease
• Rocky Mountain Spotted Fever

98
Ticks

• Found in the Canadian Rockies
• Found on trees and ground
• Like hair and moist areas

99
Lymes Disease

• Signs/Symptoms
• Circular/target rash
• Fatigue
• Chills/Fever
• H/A
• Muscle Joint Aches
• Late Meningitis, loss of muscle tone, arthritis
• Tx Doxycycline, Amoxicillin, Cefuroxime

100
Rocky Mountain Spotted Fever

• Signs/Symptoms
• Fever
• N/V, decreased appetite
• Severe H/A
• Muscle pain
• Abdo pain
• _at_2-5 days
• Maculopapular rash
• Petechial rash
• (starting in extremities)
• Later can affect all organ systems
• Tx Doxycycline

101
Can you feel that? 100
How much 1 lidocaine without Epi can you give a
70kg man?
102
Can you feel that? 100 Answer
31.5ml 4.5mg/kg 315 mg _at_10mg/ml 31.5ml (35ml
if using 5mg/kg)
103
Anesthesia
30ml
_____
15ml
50ml
____
(25ml)
104
Can you feel that? 200
Name two CNS symptoms you can get from lidocaine
overdose?
105
Can you feel that? 200 Answer
Overdose CNS - Lightheadedness - Visual
disturbances - Headache - Perioral
tingling -Numbness of tongue - Sedation -
Decreased concentration - Dysarthria -
Tinnitus - Metallic taste - Muscular
twitching, tremors - Seizures - Coma
106
Anesthesia

• Overdose
• CNS - Lightheadedness
• - Visual disturbances
• - Headache
• - Perioral tingling
• -Numbness of tongue
• - Sedation
• - Decreased concentration
• - Dysarthria
• - Tinnitus
• - Metallic taste
• - Muscular twitching, tremors
• - Seizures
• - Coma

107
Can you feel that? 300
Name a cardiac finding from lidocaine overdose?
108
Can you feel that? 300 Answer
Overdose Cardio - Increased risk Conduction
problems - Negative Inotropic -
Vasoconstriction followed by vasodilation -
Widened PR - Widened QRS - Sinus Tachy -
Sinus Arrest - AV dissociation
109
Anesthesia

• Overdose
• Cardio - Increased risk Conduction problems
• - Negative Inotropic
• - Vasoconstriction followed by vasodilation
• - Widened PR
• - Widened QRS
• - Sinus Tachy
• - Sinus Arrest
• - AV dissociation
• - Avoid in WPW

110
Can you feel that? 400
What is the treatment for lidocaine related
cardiac arrest?
111
Can you feel that? 400 Answer
Intralipid (Fat-emulsion, TPN)
112
Lidocaine Toxicity

• Treatment
• - Monitored bed
• - Oxygenation
• - Seizing Diazepam, Thiopental
• (not Phenytoin)
• Succ Intubation
• - Cardiac IV fluids, Pressors, ACLS
• - Intralipid (tx cardiac arrest prevention)
• 20 Fat Emulsion
• 1.5ml/kg bolus
• then 0.25ml/kg/min x60min
• increase if hypotensive

113
Can you feel that? 500
What do you do if a patient tells you they have a
lidocaine allergy?
114
Can you feel that? 500 Answer
Ask them more questions
115
Local Anesthetic Allergies

• True local anesthetic allergies are rare
• Two types of caines
• Esters procaine, tetracaine, benzocaine
• Amides Lidocaine, bupivacaine
• No cross reactivity between the two
• But multidose lidocaine uses an Ester
  preservative (methylparaben)

116
Local Anesthetic Allergies

• - So what are your options when you seriously
  suspect a lidocaine allergy?

117
Local Anesthetic Allergies

• So what are your options when you seriously
  suspect a lidocaine allergy?
• 1) Switch to Ester
• 2) Use Single-dose vial lidocaine or cardiac
  lidocaine
• Test dose of 0.1ml intradermally
• Observe x 30min
• 3) Diphenhydramine (Benadryl)(1) can provide
  analgesia
• 1 mL of the standard solution (50mg/ml) to 4 mL
  of sterile saline

118
In to the Wild 100
Can you name two animals that carry rabies?
119
In to the Wild 100 Answer
Dogs Cats Foxes Bats Raccoons Skunks
120
Rabies

• 40-70,000 human deaths per year in 3rd world
• Very rare in North America
• Prior to vaccination program 1947 there were
  40/year in the US now as little as 3.
• Dogs are most common carrier in 3rd world
  countries, but in Canada it is the fox.

121
Rabies

• Strain and Animal carriers vary throughout North
  America

122
In to the Wild 200
VIDEO JEOPARDY
10yo boy is bit by his neighbors dog, does he
need rabies prophylaxis? And why or why not?
123
In to the Wild 200 Answer
He does not. The dog had every right to bite
him. (assuming the dog can be watched for 10 days)
124
Rabies -suspicious characters

• Rabid dogs will die in lt 8 days of becoming ill.
  (average 3days)
• Transmit once they secrete virus in their saliva
• Usually ill when secreting virus, but can be
  delay in becoming ill
• BitegtgtScratch

125
Rabies -suspicious characters

• Dogs
• Aggressive
• Ataxia
• Irritability
• Anorexia
• Lethargy
• Excessive salivation
• Unprovoked bite
• Cats
• Aggressive
• or irritable
• Wild Animals
• Unusual behavior (nocturnal animal walking
  through downtown in the day)

126
Rabies -clinical presentation

• Can incubate for 30-90 days
• Initially (non-specific)
• H/A, fever, runny nose, myalgias, GI
• Agitation, anxiety
• Paresthesia, pain, severe itching
• After days to weeks progress to full-blown rabies

127
Rabies -clinical presentation

• Can incubate for 30-90 days
• Initially (non-specific)
• H/A, fever, runny nose, myalgias, GI
• Agitation, anxiety
• Paresthesia, pain, severe itching
• After days to weeks progress to full-blown rabies

128
Rabies -clinical presentation

• Furious
• Agitation, hydrophobia, extreme irritability,
  hallucinations, seizures, ataxia
• Dumb
• Prominent limb weakness
• Progress to confusion followed by coma then death
  in about 1 week
• No effective treatment exists

129
Case Report CDC

• April 26, 2007, a patient from rural Alberta,
  Canada died after 9 weeks in an ICU from
  encephalitis caused by rabies virus variant
  associated with silver-haired bats
• August 2006 bitten by bat on his left shoulder
  while sleeping.
• February 14, 2007 sudden onset left shoulder
  pain and hand weakness
• February 21, 2007 weakness, anorexia, dysphagia,
  irritability
• February 23, 2007 Left arm myoclonus,
  inspiratory spasms followed by high fever,
  hypoxia and decreased LOC
• Transferred to ICU
• February 26, 2007 family revealed he was bitten
  by bat 6months earlier
• Underwent treatment x9weeks before passing away
  April 26th

130
Rabies

• Who needs Post-Exposure-Prophylaxis?

131
Rabies

• Who needs Post-Exposure-Prophylaxis?
• Depends on
• Type of exposure
• Location of incident
• Species
• Availability of animal

132
Animal Evaluation of Animal Postexposure Prophylaxis Recommendations
Dogs, Cats Healthy available x10days Only if animal develops signs
Dogs, Cats Rabid or suspect Immediate vaccination
Dogs, Cats Unknown Consult Public Health
Skunks, raccoons, foxes, carnivores, bats Consider rabid unless proven negative by lab Consider immediate vaccination
Livestock, small rodents (squirrels, hamsters, gerbils, chipmunks, rats, mice, rabbits, large rodents Consider individually Almost never need prophylaxis, Consult Public Health
133
Post Exposure Prophylaxis

• Scrub wound with soap and water followed by a
  virucidal agent (eg. Povidone-iodine)
• Within 3 hours
• Swab wound
• Human Rabies Immunoglobulin (HRIG) (20IU/kg)
• Into and around the wound remainder IM
• Human diploid cell vaccine (HDCV) 1ml IM
• - days 0,3,7,14,28
• If previously vaccinated, No HRIG HDCV 1ml
  IM
• -days 0 and 3

134
In to the Wild 300
35yo male comes in after a 35day hike in Nepal.
What does he have?
135
In to the Wild 300 Answer
Frostbite
136
Frostbite

• Ears, nose, cheeks, chin, fingers toes
• Sensory deficiency
• Complete Anesthesia
• Pain with reperfusion
• Dull ache becomes throbbing _at_ 48-72hrs
• Can last weeks to months

137
In to the Wild 400
How do you classify frostbite?
138
In to the Wild 400 Answer
1st, 2nd, 3rd and 4th degree
139
Frostbite - classification

• Superficial
• -1st Degree
• -central pallor
• -anesthesia
• -2nd Degree
• blisters with clear/milky fluid
• Surrounding edema erythema within 24hrs

140
Frostbite - classification

• Deep
• -3rd Degree
• - hemorrhagic blisters
• - develops black eschar (weeks)
• -4th Degree
• Involves muscle and bone
• Complete tissue necrosis

141
In to the Wild 500
You have been winter camping with your friend who
forgot his gloves. After a couple of days you
notice his hand look like this, what do you do?
142
In to the Wild 500 Answer
It will depend.
143
Frostbite - management

• In the field
• - Get to warm area ASAP
• - Do not rewarm if possibility they will
  refreeze
• - Place in warm (not hot water) or against body
• - Do not rub

144
Frostbite - management

• In the ED
• 1) Rewarm
• -waterbath 40-42C
• -15-30min
• -analgesic!

145
Frostbite - management

• In the ED
• 2) Dressing
• - Dry
• - Elevate
• - Apply sterile dressing
• -nonadherent gauze
• - Blisters
• - Drain vs aspirate vs nothing
• - consider tPA
• - possible life altering amputation
• - no contraindications to tPA

146
Frostbite - management

• In the ED
• 3) Disposition
• - contact plastic surgery
• -ongoing wound care
• -escharotomy
• -fasciotomy
• -amputation
• - Abx if evidence of infxn
• - Topical Aloe
• - Pain medication

147
Miscellaneous 100
Name two ways you could repair this laceration
148
Miscellaneous 100 Answer
1) Trim hair and suture 2) Staples 3) Use hair to
tie across wound 4) Hair apposition technique
149
Hair Apposition TechniqueOng M, et al. A
randomized controlled trial comparing the hair
apposition technique with tissue glue to standard
suturing laceration (HAT study), Annals of
Emergency Med, Vol 40, Issue 1, July 2002

• Linear lacerations, lt10cm
• Hair length gt3cm

150
Hair Apposition TechniqueOng M, et al. A
randomized controlled trial comparing the hair
apposition technique with tissue glue to standard
suturing laceration (HAT study), Annals of
Emergency Med, Vol 40, Issue 1, July 2002

• Linear lacerations, lt10cm
• Hair length gt3cm
• Results
• Less scarring
• Lower pain scores
• Less wound breakdown
• Quicker! (5min vs 15min)

151
Miscellaneous 200
35yo Female, recently moved from Winnipeg, has
not seen a doctor for 15years. Comes to ER after
cutting her finger while cooking. You suture her
up her laceration. Is there anything else you
want to do before she leaves?
152
Miscellaneous 200 Answer
Tetanus Toxoid (Td)
153
Tetanus
154
Tetanus in Canada
155
Tetanus (Lockjaw)

• Signs/Symptoms
• Acute onset
• Hypertonia
• /or painful muscular contractions
• Usually jaw and neck
• Generalized muscle spasms
• No apparent medical cause

156
Tetanus Immunization

• Children tetanus toxoid_at_ 2m,4m,6m,18m 4-6y
• Adults Series of 3 Td over 10 to 20 months
• Everyone should have booster q10 years
• If going traveling to high risk country and
  gt5years since booster

157
Tetanus Prophylaxis (Canadian Immunization Guide
2006)
Clean Wound, Minor wound
-Uncertain - lt3 doses - gt 10 years since booster Tetanus Toxoid (Td)
gt3 doses booster lt 10years Nothing
158
Tetanus Prophylaxis (Canadian Immunization Guide
2006)
Tetanus-Prone Wound
-Uncertain - lt3 doses Tetanus Toxoid (Td) Tetanus Immune Globulin (TIg)
gt 5years since booster Tetanus Toxoid (Td)
gt3 doses booster lt 5years Nothing
159
Miscellaneous 300
ID 69yo Male, who says he has never seen a
doctor in his life Comes to ER after he was
working in the loft of his barn when he slipped,
fell forward cutting his arm on a nail and landed
in the pig pen. What tetanus vaccines will he
need?
160
Miscellaneous 300 Answer
Tetanus Toxoid (Td) Tetanus Immune Globulin
(TIg)
161
Tetanus Prophylaxis (Canadian Immunization Guide
2006)
Clean Wound, Minor wound
-Uncertain - lt3 doses - gt 10 years since booster Tetanus Toxoid (Td)
gt3 doses booster lt 10years Nothing
162
Tetanus Prophylaxis (Canadian Immunization Guide
2006)
Tetanus-Prone Wound
-Uncertain - lt3 doses Tetanus Toxoid (Td) Tetanus Immune Globulin (TIg)
gt 5years since booster Tetanus Toxoid (Td)
gt3 doses booster lt 5years Nothing
163
Miscellaneous 400
ID 52 yo male, HIV, who is up to date with all
his immunizations (last tetanus 4years
ago). Comes to ER after suffering a work related
crush injury to his left arm that is contaminated
with soil. What tetanus vaccines will he need?
164
Miscellaneous 400 Answer
Tetanus Toxoid (Td) Tetanus Immune Globulin
(TIg)
165
Tetanus Prophylaxis (Canadian Immunization Guide
2006)

• HIV patients with Tetanus-Prone Wounds
• Always receive Tetanus Immune Globulin (TIg) in
  addition to tetanus toxoid regardless of the time
  since the last booster

166
Miscellaneous 500
167
Miscellaneous 500 Answer
168
Thanks
169
References

• Edlich RF, Thacker JG, Rodeheaver GT, et al A
  Manual for Wound Closure. St. Paul, MN, M
  Medical Surgical Products, 1979
• Ong M, et al. A randomized controlled trial
  comparing the hair apposition technique with
  tissue glue to standard suturing laceration (HAT
  study), Annals of Emergency Med, Vol 40, Issue 1,
  July 2002
• Current Opinion in AnaesthesiologyOctober 2009 -
  Volume 22 - Issue 5 - p 667-671doi
  10.1097/ACO.0b013e32832eb93fRegional anaesthesia
  Edited by Bernadette VeeringLipid resuscitation
  for local anesthetic toxicity is it really
  lifesaving?Leskiw, Ulana Weinberg, Guy L
• www.Uptodate.com
• Rosens Emergency Medicine Concepts and clinical
  Practice, 6th ed.
• www.emedicine.com
• www.cdc.gov

170
Anesthesia
Max Concentration 70kg pts
Lidocaine
1 without Epi 3-5 mg/kg 10mg/ml 35ml
2withOUT Epi 3-5 mg/kg 20mg/ml 17.5ml
1 WITH Epi 5-7 mg/kg 10mg/ml 49ml
2 WITH Epi 5-7 mg/kg 20mg/ml 24.5ml
Marcaine
withOUT Epi 2.5mg/kg
WITH Epi 3.5mg/kg