1. A 20 year old healthy male lacerated his hand while
cutting carrots in a nearby kitchen 12 hours prior. He thought the wound would "heal on it's own", but unfortunately it continues to bleed and he is
"unable to work like this."
He has a 3 cm "V shaped" laceration over
lateral surface of his left index finger (non-domminant hand) between the PIP
and MCP joints. No joint or tendon involvement is apparent. He has normal
vascular, motor, and sensory exam.
What would you use to suture the wound?
 |
 Comments:
"research
states there is little difference between clean and sterile - patients don't
like it tho."
"I
would offer loose approximation. It also depends on if the wound is actively
bleeding. If I did close the wound I would use clean gloves."
"not
because it's necessary, just because that seems to be the standard way it's
done at --- - may be time to rethink that"
"probably
not necessary to use the sterile gloves, but why not?"
|
2. How would you irrigate this wound?
  |
3. What would you use to repair this laceration?
  |
Comments: 5.0 nylon |
4. Would you recommend using topical antibiotics on
the wound?
 |
Comments:
"yes, i don't recommend for most wounds, but because i'm leaving it open, then yes."
5. When would you recommend suture removal?
 |
Comments
"I also use a removable splint for fingers to help with reducing movement, particularly around joints."
"I would recommend 10 - 14 days if the lac involved a joint but I'm assuming this one doesn't."
"7-10 days"
6. A 55 year old diabetic smoker presents with a tender area of fullness in the gluteal region. There does not appear to be rectal or anal involvement. The area of fullness appears to extend 5cm diameter. The pt is notably uncomfortable with any pressure to the area but otherwise denies fevers/chills and appears non-toxic.
How would you evaluate this infection prior to
I and D?
 |
Comments:
"I would only use ultrasound if there was a question as to whether or not this was an abscess and/or where I should incise it."
"I could also do a rectal exam."
"depending on US i may ct and consult"
"It depends on if there is any gas in the sound on if I would consider a CT for perineal involvement"
7. Once you have evacuated the pustular drainage would you irrigate the wound?
 |
 |
8. Once the incision and drainage is complete, you
would
 Comments: "I know packing the wound is old school and that the loop drain is the latest recommendation. Fortunately, I haven't had to I&D a large enough abscess recently. And I would only recommend that the patient "return" to the ED for packing / loop removal if they can't get in to see their PMD in time." Thanks for your participation. |
“It has
been said, 'time heals all wounds.' I do not agree. The wounds remain. In time,
the mind, protecting its sanity, covers them with scar tissue and the pain
lessens. But it is never gone.”
-Rose Kennedy
Some thoughts on Question 4 (topical antibiotics pros/cons):
ReplyDeleteThe literature suggests that rates of infection are diminished with the use of topical antibiotics: http://www.ncbi.nlm.nih.gov/pubmed/7606610
In a survey of the literature there was not enough evidence to recommend against it:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1756323/pdf/v019p00556.pdf
That being said, we are seeing higher rates of contact allergy to bacitracin (neomycin has always been considered an allergen but rates of bacitracin contact allergy seem to have increased.)
"Reporting on data from 1998 to 2000, the Mayo Clinic Contact Dermatitis Group reported bacitracin to be 8th most common allergen with 8.7% of 1,321 patients patch testing positive.39 During the same time period, the North American Contact Dermatitis Group reported bacitracin to be the 9th most common allergen by revealing a positive patch test result in 9.2% of 5,812 patients tested between 1998 and 2000, which was a significant increase from 1.5% and 7.8% of positive reactions in patients tested from 1989 to 1990 and 1992 to 1994, respectively. Furthermore, in another study, of 858 (8.5%) of patients studied between 1995 and 2001 had clinically relevant positive patch test results to bacitracin.
More comments and questions regarding abscess care:
ReplyDeleteHere is the main article I was referencing regarding the need for packing:
http://www.ncbi.nlm.nih.gov/pubmed/19388915
http://bestbets.org/bets/bet.php?id=272
Also interesting regarding provider practice variability:
http://www.ncbi.nlm.nih.gov/pubmed/23447753
And here is the loop drainage info:
http://www.acep.org/Clinical---Practice-Management/Novel-Technique-Improved-Skin-Abscess-Drainage/
https://vimeo.com/19580472
Emerg Med J. 2014 Feb;31(2):96-100. doi: 10.1136/emermed-2012-202143. Epub 2013 Jan 12.
ReplyDeleteTraumatic lacerations: what are the risks for infection and has the 'golden period' of laceration care disappeared?
Quinn JV1, Polevoi SK, Kohn MA.
Author information
Abstract
OBJECTIVE:
To determine risk factors associated with infection and traumatic lacerations and to see if a relationship exists between infection and time to wound closure after injury.
METHODS:
Consecutive patients presenting with traumatic lacerations at three diverse emergency departments were prospectively enrolled and 27 variables were collected at the time of treatment. Patients were followed for 30 days to determine the development of a wound infection and desire for scar revision.
RESULTS:
2663 patients completed follow-up and 69 (2.6%, 95% CI 2.0% to 3.3%) developed infection. Infected wounds were more likely to receive a worse cosmetic rating and more likely to be considered for scar revision (RR 2.6, 95% CI 1.7 to 3.9). People with diabetes (RR 2.70, 95% CI 1.1 to 6.5), lower extremity lacerations (RR 4.1, 95% CI 2.5 to 6.8), contaminated lacerations (RR 2.0, 95% CI 1.2 to 3.4) and lacerations greater than 5 cm (RR 2.9, 95% CI 1.6 to 5.2) were more likely to develop an infection. There were no differences in the infection rates for lacerations closed before 3% (95% CI 2.3% to 3.8%) or after 1.2% (95% CI 0.03% to 6.4%) 12 h.
CONCLUSIONS:
Diabetes, wound contamination, length greater than 5 cm and location on the lower extremity are important risk factors for wound infection. Time from injury to wound closure is not as important as previously thought. Improvements in irrigation and decontamination over the past 30 years may have led to this change in outcome.
KEYWORDS:
Wounds, Wounds, Research, Wounds, Treatment