New developments may ease wound management
There are several new developments on the horizon for wound care," says Alexander Trott, MD, professor of emergency medicine at the University of Cincinnati College of Medicine (OH). Here are several to watch for in your ED:
Wound adhesives. In the near future, it won’t be necessary to use sutures to proximate wound edges—they will be "glued" together with adhesives. "You avoid causing punctures from the sutures, and it doesn’t require anesthetizing the wound in order to suture it closed," says Robert Herr, MD, MBA, FACEP, former corporate chairman of emergency medicine for FHP International and currently an emergency medicine consultant based in Salt Lake City, UT. "However, the wound still may require anesthesia prior to irrigation."
Although not yet approved by the FDA, in the coming months wound adhesives will probably affect the management of one-third of lacerations seen in the ED, says Trott. Instead of being sutured or stapled, wounds can be "glued" together, eliminating the need for anesthetic and suture removal, he explains.
However, use will be limited to wounds with clean, straight edges less than 5 cm long. "You can’t use them for jagged or deep wounds, wounds over joints, or contaminated wounds with a lot of dirt in them, but in the near future there will be products that will overcome these limitations," says Trott.
Absorbable sutures. "This essentially obviates the need for suture removal," says Herr. "It’s especially useful in areas which are tough to take stitches out of, such as ears or the digits of the hand." The substance can be used in almost every circumstance that regular sutures are used for skin, and eliminates the need for a follow-up visit to remove stitches.
New cleansers. Most EDs are using Betadine for invasive procedures, such as chest tubes, while SureCleanse is used to clean wounds, says Barbara Birmingham, RN, MSN, clinical coordinator for trauma and burns service for University of Alabama at Birmingham. "You can wash the patient’s skin with it, and you don’t have to worry about rinsing all of it off, because it doesn’t cause any tissue damage," she notes.
Syringes with splash guards. An injector needle with a little dome over it can protect you from getting splashed in the eye, says Birmingham. "There have been cases where nurses have been splashed in the face with bodily fluids and ended up with hepatitis, so it’s a good idea to use these when fluid is splashing," she stresses.
One wound irrigation device, Zerowet Splashield, offers protection from both contaminated splash and needlesticks. Recently, the manufacturer’s Klenazlac system, which facilitates removing and replacing of the Zerowet Splashield, was developed for infection-prone wounds that require hundreds of ccs of irrigation.
Numbing substances. This is used to anesthetize the skin in place of injecting local anesthetic. "It can be placed on the skin with occlusion to get it to absorb and is the equivalent to an anesthetic numbing the skin," says Herr. "However, the drawback is it causes inflammation in open wounds." The substance is useful next to an open wound, or for starting IVs through intact skin.
Hyperbaric medicine. The treatment requires the use of a hyperbaric oxygen chamber, and requires the patient to breathe 100% oxygen under pressures greater than one ATA. "If someone comes in with infected wound, especially if immunocompromised to begin with, they can be referred for hyperbaric treatment for enhanced healing of the wound," says Herr.
The treatment can speed healing of wounds including second and third degree thermal burns, gas gangrene, crush injuries, acute traumatic ischemias, open fractures, frostbite, and necrotizing soft tissue infections, says Ralph Nussbaum, DO, medical director of the Utah Center for Wound Healing and Hyperbaric Medicine.
Reductions in the need for skin grafting procedures, days on ventilators, and mortality rates have all been demonstrated when adjunctive hyperbaric oxygen therapy is incorporated into the treatment of burn patients, according to Nussbaum. "Estimates show that total cost of care may be reduced up to 75% with certain types of traumatic wounds," he adds.