1、外傷及複雜傷口病患之處理及治療原則,台灣 衛福部 疾病管制署 中區傳染病防治醫療網 王任賢 指揮官,傷口癒合 (Wound Healing),傷口癒合 (Wound Healing),Tissue Injury Coagulation Early Inflammation Late Inflammation Fibroblast Migration / Collagen Synthesis Angiogenesis Epithelialization Remodeling Phase,NEJM 1999,NEJM 1999,NEJM 1999,延遲性的一級癒合 (Delayed Primary
2、 Healing),延遲縫合傷口3至7天，待傷口沒有感染現象再縫合後的癒合。,二級癒合 (Secondary Healing),傷口不縫合，藉肉芽組織形成及表皮新生後的癒合。,表皮新生 (Reepithelialization),傷口癒合完全依靠表皮新生。,Epidemiology:,In USA 10,000,000 annual ER visits Average cost of $200 per patientHollander et al: Wound Registry: Development and Validation. Ann Emerg Med, May 1995.,Caus
3、es of traumatic wounds:,Distribution of traumatic wounds:,Malpractice:,Karcz: Malpractice claims against emergency physicians in Massachusetts; 1975-1993. Am J Emerg Med 1996. wounds claims 19.85%, and 3.15% total expenses ($1,235,597) American College of Emergency Physicians. Foresight Issue 49, Se
4、ptember 2000: Laceration mismanagement & failure to diagnose a retained foreign body is the 2nd most common malpractice claims against emergency physician,What patients want?,Adam: Patient Priorities With Traumatic Lacerations. Am J Emerg Med, October 2000.,Universal Precautions:,CDC published guide
5、lines on use of universal precautions. Use of protective barriers:eg. Gloves/ gowns/ masks/ eyewearWill decrease exposure to infective material.,Gloves:,Use latex free gloves Since March 1999, FDA reported: 2,330 latex allergic reactionsincluding 21 deaths,Surgical gloves during wound repair,Bodiwal
6、a: Surgical gloves during wound repair in the accident and emergency department. Lancet 1982. Randomized 337 patients to gloves or careful hand-washing, no gloves:,Surgical masks during laceration repair,Caliendo: Surgical masks during laceration repair. J Am Coll Emerg Phys 1976. Alternated face ma
7、sk / no mask for 99 wound repairs: Mask: 1 / 47 infected No mask: 0 / 42 infected,Local Anesthesia: 2 main groups,1- Esters(酯類): Cocaine Procaine (Novocain) Benzocaine (Cetacaine) Tetracaine (Pontocaine) Chloroprocaine (Nesacaine),2- Amides(醯胺): Lidocaine (Xylocaine) Mepivacaine (Polocaine, Carbocai
8、ne) Bupivacaine (Marcaine) Etidocaine (Duranest) Prilocaine,Properties of commonly used local anesthetics:,Why Lidocaine?,Less painful Rapid onset Less cardiotoxic Less expensive,Morris: Comparison of pain associated with intradermal and subcutaneous infiltration with various local anesthetic soluti
9、ons. Anesth Analg 1987. 24 volunteers each injected with 5 anesthetic agents and NS visual analog pain scale Etidocaine Bupivacaine Mepivacaine NS Chloroprocaine Lidocaine (least painful),Methods to reduce pain of Lidocaine local infiltration:,1-Small-bore needles 2-Buffered solutions 3-Warmed solut
10、ions 4-Slow rates of injection 5-Injection through wound edges 6-Subcutaneous rather than intradermal injection 7- Pretreatment with topical anesthetics,Skin and Wound preparation:,1- Hair removal 2- Disinfecting the skin 3- Debridement 4- Wound Cleansing and Irrigation 5- Soaking,1- Hair removal: T
11、o shave or not to shave!,Seropian, 1971: 406 clean surgical wounds If shaved pre-op, 3.1% infection rate If depilated, 0.6% infection rateHowell, 1988: 68 scalp lacerations repaired without hair removal (93% within 3 hours of injury), no infection at 5-day follow-up,2- Disinfecting the skin:,An idea
12、l agent does not exist either tissue toxic or poorly bacteriostatic Simple scrub water around wound should be sufficient No studies have demonstrated the impact of cleaning intact skin on infection rate, however it is important to decrease bacterial load to minimize ongoing wound contamination. Avoi
13、d mechanical scrubbing unless heavily contaminated (increase inflammation in animal data),3- Debridement:,Devitalized soft tissue acts as a culture medium promoting bacterial growth Inhibits leukocyte phagocytosis of bacteria and subsequent kill Anaerobic environment within the devitalized tissue ma
14、y also limit leukocyte function,Dhingra V: Periphral Dissemination of Bacteria in Contaminated Wounds: Role of Devitalized tissue: Evaluation of Therapeutic Measures. Surgery, 1976. Animal study, devitalized wounds contaminated with 3 Bacteria, treated with NS jet irrigation or debridement at 2, 4,
15、6 hr Debridement more effective in reducing bacteria count and infection rate,4-Wound Cleansing and Irrigation:,Decreasing wound contamination and hence infection, “the solution to pollution is dilution.“ Indications Methods Pressure Solution Volume Side effects,1- Indications:,Any contaminated or b
16、ite wounds Animal and human studies demonstrate irrigation lowers infection rates in contaminated wounds Hollander JE et al: Irrigation in facial and scalp lacerations: Does it alter outcome? Ann Emerg Med 1998. 1,923 patients 1,090 patients received saline irrigation, and 833 patients did not Nonbi
17、te, noncontaminated facial skin or scalp lacerations who presented less than 6 hours No difference in wound infection rate orcosmetic appearance,2- Methods:,Bulb syringe IV bag +/- pressure cuff Syringe and needle Jet lavage,3- Pressure:,lack of clinical studies recommend irrigation pressures in the
18、 range of 5 to 8 psi High-pressure irrigation is defined as more than 8 psi (use of a 30- to 60-mL syringe and a 18-20 gauge needle) Animal studies: Rodeheaver, 1975 & Stevenson, 1976, high-pressure irrigation reduce both bacterial wound counts and wound infection rates,4- Solution:,Ideal solution m
19、ust be: Not toxic to tissues Does not increase rate of infection Does not delay healing Does not reduce tensile strength of wound healing Inexpensive,Dire DJ: A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990. 531 patients were randomized into 3 groups,
20、and irrigated with: NS, 1% PI, or pluronic F-68 No difference in wound infection rate NS has the lowest cost,Lineaweaver: Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg, 1985. 1% povidone-iodine 3% hydrogen peroxide 0.25% acetic acid 0.5% sodium hypochlorite assayed
21、 in vitro using cultures of human fibroblasts and Staphylococcus aureus All agents tested killed 100 percent of exposed fibroblasts,Then he looked at different dilutions povidone-iodine 0.01, 0.001, 0.0001% sodium hypochlorite 0.05, 0.005, 0.0005% hydrogen peroxide 3.0, 0.3, 0.03, 0.003% acetic acid
22、 0.25, 0.025, 0.0025% ONLY antiseptic not harmful to fibroblasts yet still bacteriostatic was Povidone iodine 0.001%,Moscati: Comparison of normal saline with tap water for wound irrigation. Am J Emerg Med 1998. lacerations were made on each animal and inoculated with standardized concentrations of
23、Staph. aureus irrigation with 250 cc of either NS from a sterile syringe or water from a tap no difference in bacterial count in 2 groups,Kaczmarek, 1982: Cultured open bottles of saline irrigating solution 36/169 1000cc bottles were contaminated 16/105 500cc bottles were contaminatedBrown, 1985: Ap
24、proximately one in five of the opened bottles use for irrigation were contaminated,Lammers: Bacterial counts in experimental, contaminated crush wounds irrigated with various concentrations of cefazolin and penicillin. Richard Lammers, American Journal of Emergency Medicine, January 2001. An animal
25、bite wound model was created inoculated with 0.4 mL of a standard bacterial solution each wound was scrubbed for 30 seconds with 20% poloxamer 188 and then irrigated with 100 mL of one of 4 solutions: NS(control); cefazolin + penicillin G (LD); CZ + PCN (ID); and CZ + PCN (HD) No differences in the
26、bacterial counts or infection rates,4- Volume:,Irrigation volume not studied use 50 mL to 100 mL of irrigant per cm of laceration,5- Side effects:,Increase tissue inflammation (very high pressure irrigation), but benefit outweigh risk,5- Soaking:,Lammers: Effect of povidone-iodine and saline soaking
27、 on bacterial counts in acute, traumatic contaminated wounds. Ann Emerg Med, 1990. Contaminated traumatic wounds within 12 hours of injury 33 wounds randomized into:soaking in either 1% PI, NS, or covered with dry gauze (control) for 10 min. Bacterial counts not changed in PI + control groups, but i
28、ncreased in NS group Infection rate: PI=12.5% (1/8), control= 12.5% (1/8), NS=71% (5/7),Foreign Bodies:,Glass, metal, and gravel are Radiopaque Wooden objects and some aluminum products are radiolucent Glass is accurately visualized on 2-view radiographs if it is 2 mm or larger and gravel if it is 1
29、 mm or larger,Wound Closure:,Time Delayed primary closure Options Suturing method,Time:,The Golden Period: the time interval from injury to laceration closure and the risk of subsequent infection, (is highly variable) Morgan WJ: The delayed treatment of wounds of the hand and forearm under antibioti
30、c cover. Br J Surg 1980. 300 hand and forearm lacerations closed 4hr had infection rate 21%,Berk WA: Evaluation of the “golden period“ for wound repair: 204 Cases from a third world emergency department. Ann Emerg Med 1988. evaluation in a third-world country - 204 patients 19 hours to repair: 77% s
31、atisfactory healing Exception: head and face lacerations had 95.5% satisfactory healing, regardless of time,Baker: The management and outcome of lacerations in urban children. Ann Emerg Med 1990. 2,834 pediatric patients No difference in infection rate for lacerations closed less than or more than 6
32、hrs,Delayed primary wound closure:,High risk wounds that are contaminated or contain devitalized tissue Wound is initially cleansed and debrided Covered with gauze and left undisturbed for 4 to 5 days If the wound is uninfected at the end of the waiting period, it is closed with sutures or skin tape
33、s,Dimick, 1988: Delayed Primary ClosureWound left open for 4 or 5 days until edema subsides, no sign of infection, and all debris and exudates removed 90% success rate in closure without infection Final scar as same as primary closure,Topical AB:,Dire DJ: Prospective evaluation of topical antibiotic
34、s for preventing infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med, 1995. prospective, randomized, double-blinded, placebo-controlled (426 Lacerations) Bacitracin - 5.5% infection (6/109) Neosporin - 4.5% infection (5/110) Silvadene - 12.1% infection (12/99) Placebo 4
35、.9% infection (5/101),Dressing:,Chrintz, 1989: 1202 patients with clean wounds Dressing off at 24 hours - 4.7% infection Dressing off at suture removal - 4.9%Goldberg, 1981: 100 patients with sutured scalp lacerations allowed to wash hair with no infection or wound disruptionNoe, 1988: 100 patients
36、with surgical excision of skin lesions allowed to bathe next day with no infection or wound disruption,Tetanus:,More than 250,000 cases annually worldwide with 50% mortality 100 cases annually in USA About 10% in patients with minor wound or chronic skin lesion In 20% of cases, no wound implicated 2
37、/3 of cases in patients over age 50,Recommendations for tetanus prophylaxis:,Infection Rate:,Galvin, 1976 4.8% Gosnold, 1977 4.9% Rutherford, 1980 7.0% Buchanan, 1981 10.0% Baker 1990 1.2%,Prophylactic Antibiotics:,Bite wounds Contaminated or devitalized wounds High risk sites eg. Foot Immunocomprom
38、ised Risk for infective endocarditis Intraoral through and through lacerations,PVD DM Lymphedema Indwelling prosthetic device Extensive soft tissue injury Deep puncture wounds,Prophylactic Antibiotics:,Amoxicillin/Clavulin Keflex Erythromycin recommended course is 3 to 5 days,Antibiotic Therapy:,Cum
39、mings P: Antibiotics to prevent infection of simple wounds: A metaanalysis of randomized studies. Am J Emerg Med 1995. 7 randomized trials (1,734 patients) Assigned patients to AB or control Patients treated with AB slightly higher infection rate,Level of Training and Rate of Infection:,Adam: Level
40、of Training, Wound Care Practices, and Infection Rates, American J Emerg. Med, May 1995. Wounds were evaluated in 1,163 patients Medical students 0/60 (0%); All resident 17/547 (3.1%) Physician assistants 11/305 (3.6%) Attending physicians 14/251 (5.6%),Level of Training and Cosmetic outcome:,Adam:
41、Association of Training level and Short-term Cosmetic Apperance of Repaired Lacerations, Academic Emerg. Med, April 1996. Retrospective study, 552 patients % achieving optimal cosmetic score Medical student 50% R1 54% R2 66% R3 68% Physician assistance 70% Attending physician 66%,Treatment of cSSTI,
42、FDA Classification of SSTIs,Uncomplicated Superficial infections, such as Simple abscesses Impetiginous lesions Furuncles Cellulitis Can be treated by surgical incision alone,Complicated Deep soft tissue Requires significant surgical intervention Infected ulcers Infected burns Major abscesses Signif
43、icant underlying disease state, which complicates response to treatment,FDA=US Food and Drug Administration; SSTI=skin and soft tissue infection.,A Major Surgical Site Infection is a Catastrophe!,From Lewis Kaplan, MD. Reprinted with permission of author.,Factors Leading to Diabetic Foot Infection,1
44、. Armstrong DG et al. Diabetes Technol Ther. 2004;6:167177. 2. Lipsky BA et al. Clin Infect Dis. 2004;39:885910.,Ischemia Impaired healing1 Poor perfusion of oxygen, nutrients, antibiotics1,Autonomic Dry/cracked skin1 Sensory Inability to detect trauma1 Motor Abnormal biomechanics2,Polymorphonuclear
45、 dysfunction1,2,Diabetic Foot Infection,Neuropathy,Immunopathy,Angiopathy,Gram Stain of Polymicrobial (Aerobic and Anaerobic) Diabetic Wound Infection,Microbes and Chronic Wounds,All chronic wounds are contaminated by bacteria. Wound healing occurs in the presence of bacteria. It is not the presence
46、 of organisms but their interaction with the patient that determines their influence on wound healing.,Definitions,Wound contamination: the presence of non-replicating organisms in the wound. Wound colonization: the presence of replicating microorganisms adherent to the wound in the absence of injur
47、y to the host. Wound Infection: the presence of replicating microorganisms within a wound that cause host injury.,Microbiology of Wounds,The microbial flora in wounds appear to change over time. Early acute wound; Normal skin flora predominate. S. aureus, and Beta-hemolytic Streptococcus soon follow
48、. (Group B Streptococcus and S. aureus are common organisms found in diabetic foot ulcers),Microbiology of Wounds,After about 4 weeks Facultative anaerobic gram negative rods will colonize the wound. Most common ones= Proteus, E. coli, and Klebsiella. As the wound deteriorates deeper structures are
49、affected. Anaerobes become more common. Oftentimes infections are polymicrobial (4-5).,Microbiology of Wounds,In summary: early chronic wounds contain mostly gram-positive organisms. Wounds of several months duration with deep structure involvement will have on average 4-5 microbial pathogens, including anaerobes (see more gram-negative organisms).,How do you know when a wound is infected?,This can be very difficult. A continuum exists between when pathogens colonize the wound and then start to cause damage. There is no absolutely foolproof laboratory test that will aid in this diagnosis.,
