acute wounds: lacerations, gsw’s and blasts better acute wound care better patient outcomes better...
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Acute Wounds: Lacerations, GSWs and Blasts Better Acute Wound Care Better Patient Outcomes Better Collaborations John P. Kirby, MD, FACS Director Wound Healing Programs Coursemaster, Surgical Clerkships, ATLS Washington University School of Medicine Slide 2 We stand on the shoulders of giants. Increasing ISS Decreasing CFR : WW2 19% Vietnam 16% and now.8% US Army ISR J of Trauma Vol 75, 2, August Suppl 2013 LT Stuart Hitchcock, MSHS BSN, RN-BC, PhDc Division Officer, Complex Wound & Limb Center National Naval Medical Center, Bethesda Slide 3 Disclosures K30 Program BJH and WUSM Foundations Merck, Inc----research funding for intra-abdominal infections Neumedicines, Inc---research for novel immunomodulation in injury states Musculoskeletal Transplant Foundationresearch in AWR Ethicon, Incresearch in topical hemostasis Cook, Incdeveloping wound infomatics analyses Wendi Gordon Shelist FoundationNF, Surg Infections & WH None of these disclosures represent conflicts of interests for this presentation Slide 4 For Governmental Compliance The information provided is as accurate as possible as of the date indicated. Numbers have been rounded Treatment modalities and preferences vary among surgical services No commercial interests Informational purposes only, not meant to be official recommendations of any government or private entity Slide 5 Important Disclosure to consider Acute & Critical Care Surgery A new practice modelwe have learned from military surgical services. 10 BC ACCS Surgeons 24 X 7 X 365 in house attending coverage for the ED and inpatients 3/day 1/night MOD 36 Bed SICU covered in partnership with Anesthesia with in house attending coverage Multi-Specialty Outpatient Clinic 5 days a week Full teaching service: Students, Residents, Fellows and Nurses: Post Grad Training in CC, ACS, WC Complemented by APNs, Clin RN Specialists, PAs Slide 6 Barnes-Jewish WUSM Acute & Critical Care Surgery Level I Trauma Center Affiliated with St Louis VA (shared with SLU) Wound Care in our group practice >2,000 traumas/yr 24 bed ICU now 36 Bed Allows us to care for a wide variety of wounds Slide 7 What have we learned? Better Acute Care means Better Outcomes Better acute wound care mitigates later chronic wound problems Shared Goal: Treat the WHOLE patient not just the HOLE in patient Paradigms for better acute wound care Lacerations Gun Shot Wounds Burn Wounds SummaryBlast Injuries Slide 8 Acute Management Military has its own and accompanying manuals Multiple society based course offerings ATLS, TEAMS, ABLS, FCCS, FDM Today, wound care is one way to stimulate your thoughts and appetite for the care improvements they represent Slide 9 Primary and Secondary Surveys ABCDEFF: AirwayBreathingCirculation DeficitsExposureFluidsStripem Flipem and Coverem Up! Secondary Survey: Head to Toe physical exam with tubes and fingers in every orifice Follow up ExamsThis is where Wound Care might come in a crucial role: double check to be sure all lacerations, GSWs and injuries are accounted for Slide 10 Keep focused on the Primary Survey Airway has been 1 st for more than 20 years But military experience is moving Bleeding up Stopping exsanguinating hemorrhage may be promoted up the primary survey Whole blood based resuscitation currently only possible in the military 1:1:1 ratiod massive transfusion in civillian Slide 11 Acute Wounds: Lacerations Lacerations Assume contaminated, may not be recommended to be closed v. approximated Tetanus Prophylaxis: Host and Injury Host: prior history of immunization Injury: quantity of Clostridium tetanii innoculation Rusty Nail vs Soil contamination Recommendations Tetanus treatment Slide 12 Double Check on Tetanus 1 Rare, but if missed carries 13% mortality in US care, and 30 50% mortality world wide Complications usually in those not previously immunized, those who do not receive a timely booster or who have an overwhelmingly large innoculum 1. Centers for Disease Control and Prevention tetanus surveillance United States, 2001Y2008. MMWR Morb Mortal Wkly Rep 2011;60:365Y369. Slide 13 Tetanus Treatment 2-4 Consider HTIG in suspected tetanus; tetanus-prone wounds; those with an incomplete primary vaccination series, or unknown vaccination status. A single intramuscular dose of 500 IU suffices. & A protective serum antitoxin antibody level, commonly accepted as 0.01 IU/mL (in vivo) or 0.15 IU/mL (in vitro), makes the diagnosis of tetanus less likely, but not impossible. 2.Biological products. Bacterial vaccines and toxoids; implementation of efficacy review; proposed rule. Fed Regist 1985;50:51002Y51117. 3. Simonsen O, Bentzon M, Heron I. ELISA for the routine determination of antitoxic immunity to tetanus. J Biol Stand 1986;14:231Y239. 4. Borrow R, Balmer P, Roper MH. Tetanus update 2006. In: Immunization,Vaccines and Biologicals (Immunological Basis for Immunization Series; Module 3). Geneva: World Health Organization; 2006: 1Y35. Slide 14 Tetanus: A Review Nice review article Ataro, Mushatt, et. Al in J. Of the Southern Medical Association, Vol 614, 2011 Slide 15 Assess, Clean and Dress Assessment Association with deeper structure injury Connective tissue Arteries Veins Nerves Lymphatics Cavities: Peritoneal, joint capsules Document Position, Length, Width, Depth, peri- wound: Essentially the same as a Pressure Ulcer Slide 16 Assess & Clean I assess the wound from outside in: Evaluate and Treat the WHOLE patient not just the HOLE in the patient See the location of the wound and begin with the whole patient, look fore and aft Pulses, range of motion Allows me to think about what might be at depth or behind or associated structures Now you look at the wound Slide 17 Basic Vascular Exam Dorsalis pedis pulse was weakly/faintly palpable This really means. The doppler ultrasound was somewhere else Everyone should be familiar with a basic Ankle Brachial Index: ABI Slide 18 Ankle Brachial Index Take the systolic blood pressure in each arm, select the higher of the two Take the systolic blood pressure above the ankle and below any injury Ankle value is the numerator of the two Ration should be > 1.0, ratios less than that and sometimes greater reflect injury or disease This gives a value that can be tracked (like the GCS for an extremity) Slide 19 Clean Water, normal saline, antibiotic with saline Simple irrigation Pulse lavage Combination of lavage, low energy pulse lavage, high energy lavage-debridement Sharp debridement Combinations Hard to show value in antibiotic solution(s) Slide 20 Clean, debride, and stabilize Slide 21 J. Of Trauma Infection Prevention and Control in Deployed Military Medical Treatment Facilities Duane R. Hospenthal, MD, PhD, FACP, FIDSA, Andrew D. Green, MB, BS, FRCPath, FFPH, FFTravMed, RCPS, DTM&H, Helen K. Crouch, RN, MPH, CIC, Judith F. English, MSN, RN, CIC, Jane Pool, MS, RN, CIC, Heather C. Yun, MD, FACP, Clinton K. Murray, MD, FACP, FIDSA Prevention of Combat-Related Infections Guidelines Panel Slide 22 Journal of Trauma Prevention of Combat-Related Infections Guidelines Panel All wounds and all patients should be assumed to be contaminated Universal Precautions Good clinical practice guidelines Immediate treatment for healing Mitigating later pathogenic and resistant bacteria Slide 23 Personal Practice Habits NS lavage with low pressure pulse lavage, no high pressure to avoid driving debris Small surface areaslavage with ultrasound Local lidocaine gels and soaks, regional anesthetic blocks over general First dressing often iodine based antimicrobialbut for hemostasis, not for antimicrobial Tissue approximation over complete closure OCT antibiotic ointment/xeroform early then Collagen based/foam protective dressings Common NPWT use Slide 24 Gunshot Wounds = GSWs Wound Care stresses examination of the whole person: treat the whole not the just the hole GSWs are a microcosm of many wounding mechanisms Lets combine acute care with wound care Slide 25 GSW 101 A gunshot wound is the hole in the surface of the body from the projectile, not the trajectory Count the wounds and then posit on the trajectories One gunshot yields two GSWs or one GSW and one retained bullet Number of holes plus bullets should be an even number unless shot before (increasingly common)_ The severity of the gunshot is largely determined by the transfer of Kinetic Energy to the body of the patient KE = MV 2 Mass v. Velocity Slide 26 Elephant gun v Assault Rifle Stopping Power 1916 Mauser KE = Mass X VELOCITY 2 Contemporary M16 Large projectile Heavy Mass for stopping power Fewer rounds carried Single action Smaller rounds, but more rounds Automaticevery man gets a machine gun >1000 feet / sec Sound barrier, sonic boom Potential space behind projectile Slide 27 High Velocity Projectile has a blast zone trailing behind it Injury from not only penetration of the projectile But from KE transferred Larger soft tissue injuries Slide 28 50 cal to leg Traumatic Wound Slide 29 Number of holes (GSWs) plus number of bullets must be an even number If not You are missing a hole or You are missing a bullet or You are miss identifying a graze or a fragmentation Or the patient has been shot before Note we now leave bullets IN Just double checking holes plus bullets pays off Now sometimes the holes plus bullets are impossible to track = an exploratory laparotomy or laparoscopy Slide 30 Clean, debride, and stabilize Slide 31 GSWs are usually left open They can be simply cleaned They can be packed with an iodoform gauze packing strip or normal saline wet to moist This may keep them being observed This may keep them openespecially for long tracts this may be beneficial They should be changed 1 2 times q 24 hours GSWs can assist us with their blast effects Slide 32 GSWs v. Lacerations A knife will cut or puncture with very little transfer of energyless damage to see on CT, more need for careful examinat