HIGH RISK WOUNDS: CLINICAL PEARLS

Mayo 90th Annual Clinical Reviews

1

Eric T. Boie MD, FAAEM Consultant, Department of Emergency Medicine Assistant Program Director, Mayo Emergency Medicine Residency Mayo Clinic - Rochester

DISCLOSURES

• None

OBJECTIVES At the end of this presentation participants should be able to :

1) Detail current best practices for laceration management

2) Identify key clinical features and management of 4 high-risk wounds commonly seen in practice

3) Outline a rational approach for a) antibiotics and b) surgical consultation in high-risk wounds

4) Describe 1 new controversy/old myth for each entity discussed

WHY IS THIS IMPORTANT? Primary: “The Needs of the Patient Come First”

Secondary: “High Risk” not only from a medical standpoint but from a malpractice standpoint.

Traumatic wounds make up only 5.4% of ED visits, but account for 24% of malpractice litigation. (1)

PRETEST – HIGH RISK WOUNDS Question 1: A 30 year-old healthy male presents with an uncomplicated finger laceration from a utility knife.

What intervention is most effective in reducing the likelihood of infection?

a) Prophylactic antibiotics

b) Irrigation

c) Soaking

d) Use of sterile gloves courtesy safetytooltopics.com

PRETEST – HIGH RISK WOUNDS Question 1: A 30 year-old healthy male presents with an uncomplicated finger laceration from a utility knife.

What intervention is most effective in reducing the likelihood of infection?

a) Prophylactic antibiotics

b) Irrigation

c) Soaking

d) Use of sterile gloves courtesy safetytooltopics.com

PRETEST – HIGH RISK WOUNDS

Question 2: A 50 year-old diabetic male presents a swollen, erythematous index finger. He holds it in flexion and has pain on extension and upon palpation over the palmar aspect of the finger.

What is the most appropriate management?

a) Oral antibiotics and next day recheck

b) Send to the ED for IV antibiotics

c) Splinting, anti-inflammatories and next day recheck

d) Send to the ED for surgical evaluation

PRETEST – HIGH RISK WOUNDS

Question 2: A 50 year-old diabetic male presents a swollen, erythematous index finger. He holds it in flexion and has pain on extension and upon palpation over the palmar aspect of the finger.

What is the most appropriate management?

a) Oral antibiotics and next day recheck

b) Send to the ED for IV antibiotics

c) Splinting, anti-inflammatories and next day recheck

d) Send to the ED for surgical evaluation

PRETEST: HIGH RISK WOUNDS Question 3: A 21 year-old male presents with a laceration over his 2nd MCP joint 2 hours after punching another guy in the mouth.

Which of the following is NOT an appropriate part of management?

a) Dismiss on prophylactic cephalexin

b) Plain radiograph for fracture or foreign body

c) Exploration for joint or tendon involvement

d) Irrigation with tap water

Courtesy Ohio State Univeristy , Department of Emegency Medicine

PRETEST: HIGH RISK WOUNDS Question 3: A 21 year-old male presents with a laceration over his 2nd MCP joint 2 hours after punching another guy in the mouth.

Which of the following is NOT an appropriate part of management?

a) Dismiss on prophylactic cephalexin

b) Plain radiograph for fracture or foreign body

c) Exploration for joint or tendon involvement

d) Irrigation with tap water

Courtesy Ohio State Univeristy , Department of Emegency Medicine

PRETEST – HIGH RISK WOUNDS Question 4: A 73 year-old female presents 12 hours after being bitten by her cat on the hand with redness, swelling, and lymphangitis.

The most likely causative agent of her soft tissue infection is:

a) Eikenella corrodens

b) Staphylococcus aureus

c) Pasturella multocida

d) Captnocytophagia canimorsus

(courtesy Howcast.com 2013)

PRETEST – HIGH RISK WOUNDS Question 4: A 73 year-old female presents 12 hours after being bitten by her cat on the hand with redness, swelling, and lymphangitis.

The most likely causative agent of her soft tissue infection is:

a) Eikenella corrodens

b) Staphylococcus aureus

c) Pasturella multocida

d) Captnocytophagia canimorsus

(courtesy Howcast.com 2013)

PRETEST – HIGH RISK WOUNDS Question 5: A healthy 25 year-old construction worker presents with a plantar puncture wound after stepping on a nail that came through his work boot.

What is most important in his care from a risk management standpoint?

a) Plain radiographs

b) Dismissal on cephalexin

c) Dismissal on ciprofloxacin

d) Provider educating the patient courtesy footdoctorscolorado.com

PRETEST – HIGH RISK WOUNDS Question 5: A healthy 25 year-old construction worker presents with a plantar puncture wound after stepping on a nail that came through his work boot.

What is most important in his care from a risk management standpoint?

a) Plain radiographs

b) Dismissal on cephalexin

c) Dismissal on ciprofloxacin

d) Provider educating the patient courtesy footdoctorscolorado.com

CASE 1: HAND LACERATION

Key Features of Management

1. DO EXAMINE to full depth, dry field, full range of motion

- Tendon/tendon sheath

- Joint/Joint capsule

- Foreign body**

2. DO ASSESS for digital nerve injury (2 point)

CASE 1: HAND LACERATION

3. DO DECONTAMINATE wound IRRIGATION

4. DO provide tetanus and/or rabies vaccines when appropriate

5. DO CONSIDER wound type and location and host factors when considering prophylactic antibiotics

Key Features of Management (continued)

IRRIGATION Most beneficial preventing infection and optimizing wound healing (2,3)

Physical decontamination with pressure

- 5-8 PSI (4)

- 16-19 gauge catheter on 35-65 ml syringe

Saline and Tap Water equally safe and effective (5,6)

**AVOID SOAKING (3)

**AVOID DETERGENTS/IODINE in wound (2)

PROPHYLACTIC ANTIBIOTICS: WHO GETS THEM?

• Two high-risk features (1)

Wound

Host

• Antibiotics are NOT valuable in simple, uncomplicated wounds (7)

WOUNDS CHARACTERISTICS AND RISK OF INFECTION

High Risk • Tears, crush, or puncture

• Stellate

• Bites

• Contaminated (feces, soil)

• Foreign body

• Deep structure exposure

• Extremities (hand)

Low Risk

• Linear

• Well vascularized (head, neck, scalp)

HOST FEATURES AND RISK OF INFECTION

High

• Elderly (>65)

• Diabetes

• Vascular Disease

• Immunocompromised

Low • Age <65

• No comorbid illness

NEW CONTROVERSIES AND OLD MYTHS

STERILE GLOVES REQUIRED…likely not (2)

- latex free

- no powder

AGE of WOUND has major impact on infection rate …..maybe not

Zehtabchi et.al., 2012 (8)

- no golden period

- no evidence that increased wound age increases infection risk

LACERATION TAKE-HOMES

Thorough exam

Wound prep key – IRRIGATION

Antibiotics for high risk wounds/patients only

Take time to educate your patient

Best Newer Article

Pevaldi, et. al Management of Traumatic Wounds in the ED, World Journal of Surgery, 2016

CASE 2: PYOGENIC FLEXOR TENOSYNOVITIS (PFT)

LambDW, HooperG, Color Guide Hand Conditions, 1994

KEY CLINICAL FEATURES: PFT

• Puncture wound to palmar finger – flexor crease, 2-5 days prior to presentation (9)

• Diabetics, immune compromised greater risk (10)

KEY CLINICAL FEATURES: PFT

1) uniform, symmetric swelling of the digit*

2) digit held in flexion

3) tenderness along entire tendon sheath

4) pain on passive extension**

Tenosynovitis is a clinical diagnosis (11)

All 4 present in just over half of cases (9)

KANAVEL’S SIGNS (1925)

PFT: MANAGEMENT • EARLY SURGICAL CONSULATION

• IV antibiotic therapy

• Bacteriology: Staph aureus (40-75%), other Staph and Strep species

• PCN plus first generation cephalosporin OR beta-lactamase inhibitor

• Treatment delay = adhesions, necrosis, spreading infection

PFT: WHAT’S NEW?

Bedside Ultrasound may aid diagnosis

courtesy Western Journal of Emergency Medicine 2015

PFT: TAKE HOMES Early recognition clinical diagnosis

Prompt referral for surgical evaluation

Antibiotics

• IV not PO

• Broad coverage – first generation cephalosporin alone NOT adequate

• Best Article: Clark, Common Acute Hand Infections, American Family Physician, 2003

CASE 3: “FIGHT BITE” – CLENCHED FIST INJURY

LambDW, HooperG, Color Guide Hand Conditions, 1994

FIGHT BITE: KEY FEATURES • Small, but high risk wound

• Hand anatomy = structures close to the surface

• tendon

• nerve

• joint

• bone

• MCP joint most common – teeth

penetrate tendon sheath/joint capsule in 67% of cases (12)

• Polymicrobial: Staph, Strep, GNR, Eikinella corrodens, anaerobes

Courtesy Bing images

FIGHT BITE: KEYS IN MANAGEMENT

• Careful wound evaluation

• Plain Radiographs – fracture, foreign body, air in joint space

• Copious irrigation

• Low threshold for referral if deep structures involved

FIGHT BITE: KEYS IN MANAGEMENT

• Provide Prophylactic Antibiotics

• AVOID mono-treatment with cephalexin, dicloxacillin, and erythromycin. Poor activity against Eikenella

• Amoxicillin-clavulanate is agent of choice

• Avoid suturing

• Recheck in 24 hours

(10)

FIGHT BITE: TAKE HOMES Appreciate the high incidence of underlying structure

involvement

Early referral for deep structure involvement or active infection

Appropriate antibiotic prophylaxis – NOT cephalexin alone

Patient education

Best New Article: Kennedy et.al. Human and other Mammalian Bite Injuries of the Hand: Evaluation and Management, Journal of the American Academy of Orthopedic Surgeons, 2015 (12)

CASE 4: CAT BITE

courtesy www.eplasty.com and Nocera NF et.al. Rutgers Department of Surgery

CATS ARE THE WORST!

courtesy allthebestpets.com

CAT BITES Epidemiology (13)

• 5-15% of all bites (dogs = 80-90%)

• adult women

• 2/3 to hand

Virulence (14)

• Up to 80% of cat bites get infected (20% for dogs)

• 37% required hospital admission

• 12% required surgery

CAT BITES • Paturella Multicoda (15)

• Most common organism infection after cats

• Gram negative coccobacillus

• Rapid onset infection (12 hours)

• Intense erythema and swelling

• Poorly responsive to cephalexin, dicloxacillin, and erythromycin

courtesy Partners Infectious Disease Images

CAT BITES: KEYS TO MANAGEMENT

• Wound evaluation and decontamination

• Radiographs (broken teeth, boney injury)

• Prophylactic antibiotics for ALL cat bites – All are high risk (13)

• Amoxicillin-clavulanate 875/125mg BID

• 3-7 days of therapy

• doxycycline, ciprofloxacin plus clindamycin, penicillin plus dicloxacillin are alternatives

• Tetanus and rabies as indicated

• If infection already present, IV antibiotics and admission for most

WHAT’S NEW IN BITES?

What about antibiotic prophylaxis in the MRSA era?

Ogden et al 2012, Journal of Pediatric Infectious Disease

• Most cultures grew Pasturella species

• MSSA and Streptococcus in remainder

• No MRSA isolates

Conclusion: Currently no evidence to support covering for MRSA in bite wounds (16)

CAT BITE: TAKE HOMES

Cats are the worst!

Prophylaxis for all cat bites – drug of choice amoxicillin-clavulanate

13% in bite study did not get appropriate antibiotic for bite! (16)

IV antibiotics and admission for infected bites

• Best Article : Ellis and Ellis, Dog and Cat Bites, American Family Physician, August 2014. (13)

CASE 5: PLANTAR PUNCTURE WOUND

PLANTAR PUNCTURE WOUNDS • 90% involve stepping on a nail – occupational (17)

• Management is controversial, not evidence based

• Very real complications in 5-10% (18)

• Cellulitis

• Pseudomonas osteomyelitis (2-4 weeks post injury), metatarsal heads greatest risk

• Even following all best practices, complications will occur

• Patient education paramount!

PLANTAR PUNCTURE WOUND: KEYS TO MANAGEMENT

• Attentive and thorough exam – foreign body

• Radiographs if foreign body expected

• Clean site to extent possible

• avoid aggressive surgical coring

• remove any foreign body/material

• Never close

• Non weight-bearing for 48 hours

PLANTAR PUNCTURE WOUND MYTHS

Prophylactic ciprofloxacin is effective in preventing Pseudomonas osteomyelitis - FALSE

Prophylactic anti-streptococcal/anti-staphylococcal coverage is indicated in all plantar puncture wounds - FALSE

No indication for prophylactic antibiotics except in high risk hosts (17,18)

PLANTAR PUNCTURE WOUNDS: TAKE HOMES

Attentive, thorough wound evaluation and good patient education are key

Evaluate for foreign body

Reserve antibiotics for high risk hosts or patients who already demonstrate infection

Best Article: Roberts JR, Stepping on a Nail: Some Rational Guidelines, Roberts Practical Guide to Common Medical Emergencies, Lippincott- Raven. 1996.

THANK YOU!

BIBLIOGRAPHY 1. Prevaldi C, Paolillo C, Locatelli C, et al: Management of traumatic

wounds in the Emergency Department: Position paper from the Academy of Emergency Medicine and Care (AcEMC) and the World Society of Emergency Surgery (WSES). WJES 2016; 11:30-5.

2. DeBoard RH, Rondeau DF, Kang CS, et al: Principles of basic wound evaluation and management in the emergency department. Emerg Med Clin N Am 2007; 25:23-39.

3. Nicks BA, Ayello EA, Woo K, et al: Acute wound management: Revisiting the approach to assessment, irrigation, and closure considerations. Int J Emerg Med 2010; 3:399-407.

4. Howell JM, Chisholm CD: Outpatient wound preparation and care: A national survey. Ann Emerg Med 1992; 21:976-81.

5. Valente JH, Forti RJ, Freundlich LF, et al: Wound irrigation in children: Saline solution or tap water? Ann Emerg Med 2003; 41:609-16.

6. Bansal BC, Wiebe RA, Perkins SD, et al: Tap water for irrigation of lacerations. Am J Emerge Med 2002; 20(5):469-472.

7. Roodsari GS, Zahedi F, Zehtabchi S: The risk of wound infection after simple hand laceration. World J Emerg Med 2015; 6(1):44-7.

8. Zehtabchi S, Tan A, Yadav K, et al: The impact of wound age on the infection rate of simple lacerations repaired in the emergency department. Injury, Int J Care Injured 2012; 43:1793-8.

9. Draeger RW, Bynum DK, Jr.: Flexor tendon sheath infections of the hand. J Am Acad Orthop Surg 2012; 20:373-82.

10. Clark DC: Common acute hand infections. Am Fam Physician 2003; 68(11):2167-76.

11. Barry RL, Adams NS, Martin MD: Pyogenic (suppurative) flexor tenosynovitis: Assessment and management. Interesting Case Series. www.ePlasty.com; February 12, 2016.

12. Kennedy SA, Stoll LE, Lauder AS: Human and other mammalian bite injuries of the hand: Evaluation and management. J Am Acad Orthop Surg 2015; 23:47-57.

13. Ellis R, Ellis C: Dog and cat bites. Am Fam Physician 2014; 90(4):239-43.

14. Howell RD, Sapienza A: The management of domestic animal bites to the hand. Bull Hosp Jt Dis 2015; 73(2):156-60.

15. Aziz H, Rhee P, Pandit V, et al: The current concepts in management of animal (dog, cat, snake, scorpion) and human bite wounds. J Trauma Acute Care Surg 2015; 78(3):641-48.

16. Ogden RK Jr., Hedican EB, Stach LM, et al: Antibiotic management of animal bites in children during the methicillin-resistant Staphylococcus aureus era. J Pediatric Infect Dis Soc 2013; 2(4):379-81.

17. McDevitt J, Gillespie M: Managing acute plantar puncture wounds. Emergency Nurse 2008; 16(5):30-6.

18. Roberts JR: Stepping on a nail: Some rational guidelines. In Roberts’ Practical Guide to Common Medical Emergencies (pp 9-13). Philadelphia, PA: Lippincott-Raven.