外伤及复杂伤口病患之处理及治疗原则

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

(WoundHealing)傷口癒合

(WoundHealing)TissueInjuryCoagulationEarlyInflammationLateInflammationFibroblastMigration/CollagenSynthesisAngiogenesisEpithelializationRemodelingPhaseNEJM1999NEJM1999NEJM1999傷口癒合分類

(TypeofWoundHealing)一級癒合(Primaryhealing)延遲性的一級癒合(Delayedprimaryhealing)二級癒合(Secondaryhealing)表皮新生(Reepithelialization)一級癒合

(PrimaryHealing)直接縫合傷口後的癒合。延遲性的一級癒合

(DelayedPrimaryHealing)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

(SecondaryHealing)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:InUSA>10,000,000annualERvisitsAveragecostof$200perpatientHollanderetal:WoundRegistry:DevelopmentandValidation.AnnEmergMed,May1995.Causesoftraumaticwounds:

CauseofwoundNo.ofPatients%Bluntobject42Sharpobject34Glass13Wood4Bite6Human1Dog3Others5Distributionoftraumaticwounds:LocationofWound

No.ofPatients(%)

HeadandNeck

51Trunk2UpperExtremities

34LowerExtremities13Malpractice:Karcz:

MalpracticeclaimsagainstemergencyphysiciansinMassachusetts;1975-1993.AmJEmergMed1996.

woundsclaims19.85%,and3.15%totalexpenses($1,235,597)AmericanCollegeofEmergencyPhysicians.ForesightIssue49,September2000:Lacerationmismanagement&failuretodiagnosearetainedforeignbodyisthe2ndmostcommonmalpracticeclaimsagainstemergencyphysician

Condition%Claims%Totaldollarspaid1-Missedfracture14172-Woundcare1283-MissedMI10244-Abdominalpain945-Missedmeningitis3.586-Spinalcordinjury387-SAH/Stroke368-Ectopicpregnancy

28Whatpatientswant?

Adam:PatientPrioritiesWithTraumaticLacerations.

AmJEmergMed,October2000.AspectofCareAllParticipants

(n=679)FacialLacerations(n=78)OtherLacerations(n=263)Normalfunction28%27%26%Avoidinginfection20%14%23%Cosmeticoutcome17%33%14%Leastpain17%11%18%Lengthofstay10%8%10%Compassion5%4%5%Cost1%1%1%Daysmissed2%1%3%Total100%100%100%UniversalPrecautions:CDCpublishedguidelinesonuseofuniversalprecautions.Useofprotectivebarriers:eg.Gloves/gowns/masks/eyewearWilldecreaseexposuretoinfectivematerial.Gloves:UselatexfreeglovesSinceMarch1999,FDAreported:2,330latexallergicreactionsincluding21deathsSurgicalglovesduringwoundrepairBodiwala:Surgicalglovesduringwoundrepairintheaccidentandemergencydepartment.Lancet1982.Randomized337patientsto‘gloves’or‘carefulhand-washing,nogloves’:

InfectionGlovesNoglovesNone167(82.7%)170(82.5%)Mild27(13.4%)27(13.1%)Severe8(4.0%)9(4.4%)SurgicalmasksduringlacerationrepairCaliendo:Surgicalmasksduringlacerationrepair.JAmCollEmergPhys1976.Alternatedfacemask/nomaskfor99woundrepairs:Mask:1/47infectedNomask:0/42infected

LocalAnesthesia:2maingroups

1-

Esters(酯類):CocaineProcaine(Novocain)Benzocaine(Cetacaine)Tetracaine(Pontocaine)Chloroprocaine(Nesacaine)

2-

Amides(醯胺):Lidocaine(Xylocaine)Mepivacaine(Polocaine,Carbocaine)Bupivacaine(Marcaine)Etidocaine(Duranest)Prilocaine

Propertiesofcommonlyusedlocalanesthetics:AgentClassMax.savedosemg/kgOnset(min)Duration(hrs)ProcaineEster72-50.25-0.75Procaine+Epi90.5-1.5LidocaineAmide52-51-2Lidocaine+Epi72-4BupivacaineAmide22-54-8Bupivacaine+Epi38-16WhyLidocaine?

LesspainfulRapidonsetLesscardiotoxicLessexpensiveMorris:Comparisonofpainassociatedwithintradermalandsubcutaneousinfiltrationwithvariouslocalanestheticsolutions.AnesthAnalg1987.24volunteerseachinjectedwith5anestheticagentsandNSvisualanalogpainscaleEtidocaine>Bupivacaine>Mepivacaine>NS>Chloroprocaine>Lidocaine(leastpainful)

MethodstoreducepainofLidocainelocalinfiltration:

1-Small-boreneedles2-Bufferedsolutions3-Warmedsolutions4-Slowratesofinjection5-Injectionthroughwoundedges6-Subcutaneousratherthanintradermalinjection7-PretreatmentwithtopicalanestheticsSkinandWoundpreparation:1-Hairremoval2-Disinfectingtheskin3-Debridement4-WoundCleansingandIrrigation5-Soaking

1-Hairremoval:

Toshaveornottoshave!Seropian,1971:

406cleansurgicalwoundsIfshavedpre-op,3.1%infectionrateIfdepilated,0.6%infectionrate

Howell,1988:

68scalplacerationsrepairedwithouthairremoval(93%within3hoursofinjury),noinfectionat5-dayfollow-up2-Disinfectingtheskin:

An‘idealagent’doesnotexist–eithertissuetoxicorpoorlybacteriostaticSimplescrubwateraroundwoundshouldbesufficientNostudieshavedemonstratedtheimpactofcleaningintactskinoninfectionrate,howeveritisimportanttodecreasebacterialloadtominimizeongoingwoundcontamination.Avoidmechanicalscrubbingunlessheavilycontaminated(increaseinflammationinanimaldata)SolutionAntimicrobialactivityMechanismofactionUsesTissuetoxicityN.Saline-WashingactionCleansesurroundingskin/irrigation-Povidine-iodine10%,1%+GermicideCleansesurroundingskin,?Irrigationcontaminatedwounds+Chlorhexidine1%,0.1%+BacteriostaticCleansesurroundingskin+HydrogenPeroxide+BactericidalCleansecontaminatedwounds+Hexachlorophene+BacteriostaticCleansesurroundingskin+Nonionicdetergents-WoundcleanserWoundcleanser-3-Debridement:DevitalizedsofttissueactsasaculturemediumpromotingbacterialgrowthInhibitsleukocytephagocytosisofbacteriaandsubsequentkillAnaerobicenvironmentwithinthedevitalizedtissuemayalsolimitleukocytefunction

DhingraV:PeriphralDisseminationofBacteriainContaminatedWounds:RoleofDevitalizedtissue:EvaluationofTherapeuticMeasures.Surgery,1976.Animalstudy,devitalizedwoundscontaminatedwith3Bacteria,treatedwithNSjetirrigationordebridementat2,4,6hrDebridementmoreeffectiveinreducingbacteriacountandinfectionrate4-WoundCleansingandIrrigation:

Decreasingwoundcontaminationandhenceinfection,"thesolutiontopollutionisdilution."IndicationsMethodsPressureSolutionVolumeSideeffects1-Indications:AnycontaminatedorbitewoundsAnimalandhumanstudiesdemonstrateirrigationlowersinfectionratesincontaminatedwounds

HollanderJEetal:Irrigationinfacialandscalplacerations:Doesitalteroutcome?AnnEmergMed1998.

1,923patients1,090patientsreceivedsalineirrigation,and833patientsdidnotNonbite,noncontaminatedfacialskinorscalplacerationswhopresentedlessthan6hoursNodifferenceinwoundinfectionrateorcosmeticappearance2-Methods:BulbsyringeIVbag+/-pressurecuffSyringeandneedleJetlavage3-Pressure:

lackofclinicalstudiesrecommendirrigationpressuresintherangeof5to8psiHigh-pressureirrigationisdefinedasmorethan8psi(useofa30-to60-mLsyringeanda18-20gaugeneedle)Animalstudies:Rodeheaver,1975&Stevenson,1976,high-pressureirrigationreducebothbacterialwoundcountsandwoundinfectionrates4-Solution:

Idealsolutionmustbe:NottoxictotissuesDoesnotincreaserateofinfectionDoesnotdelayhealingDoesnotreducetensilestrengthofwoundhealingInexpensive

DireDJ:Acomparisonofwoundirrigationsolutionsusedintheemergencydepartment.AnnEmergMed1990.531patientswererandomizedinto3groups,andirrigatedwith:NS,1%PI,orpluronicF-68Nodifferenceinwoundinfectionrate

NShasthelowestcost

Lineaweaver:Cellularandbacterialtoxicitiesoftopicalantimicrobials.PlastReconstrSurg,1985.1%povidone-iodine3%hydrogenperoxide0.25%aceticacid0.5%sodiumhypochloriteassayedinvitrousingculturesofhumanfibroblastsandStaphylococcusaureusAllagentstestedkilled100percentofexposedfibroblasts

Thenhe

lookedatdifferentdilutions……povidone-iodine0.01,0.001,0.0001%…sodiumhypochlorite0.05,0.005,0.0005%…hydrogenperoxide3.0,0.3,0.03,0.003%…aceticacid0.25,0.025,0.0025%ONLYantisepticnotharmfultofibroblastsyetstillbacteriostaticwasPovidoneiodine0.001%

Moscati:Comparisonofnormalsalinewithtapwaterforwoundirrigation.AmJEmergMed1998.

lacerationsweremadeoneachanimalandinoculatedwithstandardizedconcentrationsofStaph.aureusirrigationwith250ccofeitherNSfromasterilesyringeorwaterfromatapnodifferenceinbacterialcountin2groups

Kaczmarek,1982:Culturedopenbottlesofsalineirrigatingsolution36/1691000ccbottleswerecontaminated16/105500ccbottleswerecontaminated

Brown,1985:

Approximatelyoneinfiveoftheopenedbottlesuseforirrigationwerecontaminated

Lammers:Bacterialcountsinexperimental,contaminatedcrushwoundsirrigatedwithvariousconcentrationsofcefazolinandpenicillin.RichardLammers,AmericanJournalofEmergencyMedicine,January2001.Ananimalbitewoundmodelwascreatedinoculatedwith0.4mLofastandardbacterialsolutioneachwoundwasscrubbedfor30secondswith20%poloxamer188andthenirrigatedwith100mLofoneof4solutions:NS(control);cefazolin+penicillinG(LD);CZ+PCN(ID);andCZ+PCN(HD)Nodifferencesinthebacterialcountsorinfectionrates4-Volume:Irrigationvolumenotstudieduse50mLto100mLofirrigantpercmoflaceration5-Sideeffects:Increasetissueinflammation(veryhighpressureirrigation),butbenefitoutweighrisk5-Soaking:

Lammers:Effectofpovidone-iodineandsalinesoakingonbacterialcountsinacute,traumaticcontaminatedwounds.AnnEmergMed,1990.Contaminatedtraumaticwoundswithin12hoursofinjury33woundsrandomizedinto:soakingineither1%PI,NS,orcoveredwithdrygauze(control)for10min.BacterialcountsnotchangedinPI+controlgroups,butincreasedinNSgroup

Infectionrate:PI=12.5%(1/8),control=12.5%(1/8),NS=71%(5/7)ForeignBodies:Glass,metal,andgravelareRadiopaqueWoodenobjectsandsomealuminumproductsareradiolucentGlassisaccuratelyvisualizedon2-viewradiographsifitis2mmorlargerandgravelifitis1mmorlarger

WoundClosure:

TimeDelayedprimaryclosureOptionsSuturingmethodTime:TheGoldenPeriod:thetimeintervalfrominjurytolacerationclosureandtheriskofsubsequentinfection,(ishighlyvariable)MorganWJ:Thedelayedtreatmentofwoundsofthehandandforearmunderantibioticcover.BrJSurg1980.

300handandforearmlacerationsclosed<4hrhadinfectionrate7%closed>4hrhadinfectionrate21%

BerkWA:Evaluationofthe"goldenperiod"forwoundrepair:204Casesfromathirdworldemergencydepartment.AnnEmergMed1988.evaluationinathird-worldcountry-204patients<19hourstorepair:92%satisfactoryhealing>19hourstorepair:77%satisfactoryhealingException:headandfacelacerationshad95.5%satisfactoryhealing,regardlessoftime

Baker:Themanagementandoutcomeoflacerationsinurbanchildren.AnnEmergMed1990.2,834pediatricpatientsNo

differenceininfectionrateforlacerationsclosedlessthanormorethan6hrs

Delayedprimarywoundclosure:

Highriskwoundsthatarecontaminatedorcontaindevitalizedtissue

WoundisinitiallycleansedanddebridedCoveredwithgauzeandleftundisturbedfor4to5daysIfthewoundisuninfectedattheendofthewaitingperiod,itisclosedwithsuturesorskintapes

Dimick,1988:DelayedPrimaryClosure

Woundleftopenfor4or5daysuntiledemasubsides,nosignofinfection,andalldebrisandexudatesremoved>90%successrateinclosurewithoutinfectionFinalscarassameasprimaryclosureTopicalAB:

DireDJ:Prospectiveevaluationoftopicalantibioticsforpreventinginfectionsinuncomplicatedsoft-tissuewoundsrepairedintheED.AcadEmergMed,1995.

prospective,randomized,double-blinded,placebo-controlled(426Lacerations)Bacitracin-5.5%infection(6/109)Neosporin-4.5%infection(5/110)Silvadene-12.1%infection(12/99)Placebo–4.9%infection(5/101)Dressing:

Chrintz,1989:1202patientswithcleanwoundsDressingoffat24hours-4.7%infectionDressingoffatsutureremoval-4.9%

Goldberg,1981:100patientswithsuturedscalplacerationsallowedtowashhair

withnoinfectionorwounddisruption

Noe,1988:100patientswithsurgicalexcisionofskinlesionsallowedtobathenextday

withnoinfectionorwounddisruptionTetanus:Morethan250,000casesannuallyworldwidewith50%mortality100casesannuallyinUSAAbout10%inpatientswithminorwoundorchronicskinlesionIn20%ofcases,nowoundimplicated2/3ofcasesinpatientsoverage50StudySettingAge%NoProtectiveABRuben,1978NursingHomeElderly49Crossley,1979Urban>60yrsF:59,M:71Scher,1985RuralElderly29Pai,1988Urban34-60yrs,allFemales5Stair,1989ER>65yrs9.7Alagappan,1996ER>65yrs50Recommendationsfortetanusprophylaxis:

HistoryofTetanusImmunizationTdTIGUncertainor<3dosesYesYesLastdosewithin5yNoNoLastdose5-10yYesNoLastdose>10yYesNoInfectionRate:Galvin,1976 4.8%Gosnold,1977 4.9%Rutherford,1980 7.0%Buchanan,1981`10.0%Baker19901.2%ProphylacticAntibiotics:

BitewoundsContaminatedordevitalizedwoundsHighrisksiteseg.FootImmunocompromisedRiskforinfectiveendocarditisIntraoralthroughandthroughlacerationsPVDDMLymphedemaIndwellingprostheticdeviceExtensivesofttissueinjuryDeeppuncturewoundsProphylacticAntibiotics:Amoxicillin/ClavulinKeflexErythromycinrecommendedcourseis3to5daysAntibioticTherapy:

CummingsP:Antibioticstopreventinfectionofsimplewounds:Ametaanalysisofrandomizedstudies.AmJEmergMed1995.7randomizedtrials(1,734patients)AssignedpatientstoABorcontrolPatientstreatedwithABslightlyhigherinfectionrateLevelofTrainingandRateofInfection:

Adam:LevelofTraining,WoundCarePractices,andInfectionRates,AmericanJEmerg.Med,May1995.Woundswereevaluatedin1,163patientsMedicalstudents0/60(0%);Allresident17/547(3.1%)Physicianassistants11/305(3.6%)Attendingphysicians14/251(5.6%)

LevelofTrainingandCosmeticoutcome:

Adam:AssociationofTraininglevelandShort-termCosmeticApperanceofRepairedLacerations,AcademicEmerg.Med,April1996.Retrospectivestudy,552patients%achievingoptimalcosmeticscoreMedicalstudent50%R154%R266%R368%Physicianassistance70%Attendingphysician66%TreatmentofcSSTIFDAClassificationofSSTIsUncomplicatedSuperficialinfections,suchasSimpleabscessesImpetiginouslesionsFurunclesCellulitisCanbetreatedbysurgicalincisionaloneComplicatedDeepsofttissueRequiressignificantsurgicalinterventionInfectedulcersInfectedburnsMajorabscessesSignificantunderlyingdiseasestate,whichcomplicatesresponse

totreatmentFDA=USFoodandDrugAdministration;SSTI=skinandsofttissueinfection.AMajorSurgicalSiteInfection

isaCatastrophe!FromLewisKaplan,MD.Reprintedwithpermissionofauthor.FactorsLeadingtoDiabeticFootInfection1.ArmstrongDGetal.DiabetesTechnolTher.2004;6:167–177.2.LipskyBAetal.ClinInfectDis.2004;39:885–910.IschemiaImpairedhealing1Poorperfusionofoxygen,nutrients,antibiotics1Autonomic

Dry/crackedskin1Sensory

Inabilitytodetecttrauma1Motor

Abnormalbiomechanics2Polymorphonuclear

dysfunction1,2Diabetic

FootInfectionNeuropathyImmunopathyAngiopathyGramStainofPolymicrobial(AerobicandAnaerobic)DiabeticWoundInfectionMicrobesandChronicWoundsAllchronicwoundsarecontaminatedbybacteria.Woundhealingoccursinthepresenceofbacteria.Itisnotthepresenceoforganismsbuttheirinteractionwiththepatientthatdeterminestheirinfluenceonwoundhealing.Definitions

Woundcontamination:thepresenceofnon-replicatingorganismsinthewound.Woundcolonization:thepresenceofreplicatingmicroorganismsadherenttothewoundintheabsenceofinjurytothehost.WoundInfection:thepresenceofreplicatingmicroorganismswithinawoundthatcausehostinjury.MicrobiologyofWoundsThemicrobialflorainwoundsappeartochangeovertime.Earlyacutewound;Normalskinflorapredominate.S.aureus,andBeta-hemolyticStreptococcussoonfollow.(GroupBStreptococcusandS.aureusarecommonorganismsfoundindiabeticfootulcers)MicrobiologyofWoundsAfterabout4weeksFacultativeanaerobicgramnegativerodswillcolonizethewound.Mostcommonones=Proteus,E.coli,andKlebsiella.Asthewounddeteriorates

deeperstructuresareaffected.Anaerobesbecomemorecommon.Oftentimesinfectionsarepolymicrobial(4-5).MicrobiologyofWoundsInsummary:earlychronicwoundscontainmostlygram-positiveorganisms.Woundsofseveralmonthsdurationwithdeepstructureinvolvementwillhaveonaverage4-5microbialpathogens,includinganaerobes(seemoregram-negativeorganisms).Howdoyouknowwhenawoundisinfected?Thiscanbeverydifficult.Acontinuumexistsbetweenwhenpathogenscolonizethewoundandthenstarttocausedamage.Thereisnoabsolutelyfoolprooflaboratorytestthatwillaidinthisdiagnosis.Howdoyouknowwhenawoundisinfected?Onefeatureiscommontoallinfectedchronicwounds;Thefailureofthewoundtohealandprogressivedeteriorationofthewound.Unfortunately,woundinfectionsarenottheonlyreasonsforpoorwoundhealing.Howdoyouknowwhenanulcerisinfected?Thetypicalfeaturesofwoundinfections:increasedexudateincreasedswellingincreasederythemaincreasedpainincreasedlocaltemperaturePeriwoundcellulitis,ascendinginfection,changeinappearanceofgranulationtissue(discoloration,pronetobleed,highlyfriable).141microbesisolatedfrom93diabeticfootulcerStudydoneonsyrianpopulationpresentedinSDAsept2003B.hammadMDandH.JammalMDRelativeDistributionofBacteria

FromSuperficialtoDeepInfectionsStaphylococcusStreptococcusGram-negativeBacilliAnaerobesSuperficialinfectionDeepinfectionNicholsRL,etal.ClinInfectDis.2001;33(suppl2):S84-S93.Methicillin-ResistantS.aureus

(MRSA)andDiabeticFootInfectionsInalargemulticentertrialinpatientswithdiabeticfootinfection1:11%of473specimenswereMRSAOftheMRSAspecimens,only13%werepureMRSAcultures15%ofpatientsgrew>1StaphylococcusspeciesInanothermulticentertrialinpatientswithdiabeticfootinfection,MRSAwasisolatedfrom25/361patients(7%)2MRSAisisolatedinbothinpatientandcommunitysettings3

MRSAisolationisassociatedwith2:PreviousantibiotictherapyWorseclinicaloutcomes1.CitronDMetal.Bacteriologyofdiabeticfootinfections(DFI):1640isolatesfrom473specimens[abstract].IDSA;2005.2.LipskyBAetal.ClinInfectDis.2004;38:17–24.3.LipskyBAetal.ClinInfectDis.2004;39:885–904.MRSA-AnincreasingproblemRetrospectiveanalysisof63swabsfrominfectedfootulcerGram+aerobic84.2%staph.Au.79%30.2%MRSANotrelatedtopriorantibioticusage

(dangandal.diab.med.20;2:159feb2003)InapriorstudyMRSAisassociatedwithpreviousantibiotictreatment

(tentolourisandal.diab.med.16;9:767sep1999)

MSSA(n=18)*

MRSA(n=12)*

Characteristics

Age 57.4(41–72)years 56.8(40–75)yearsDurationofDM 10.4(6.4–17.1)years 11.2(7.1–18)yearsNeuropathiculcers 50.0% 58.3% Ulcerarea 2.74(0.25–7.2)cm2 2.64(0.16–10.5)cm2Numberoforganisms 0.8(0–2) 1.1(0–3) HbA1c 9.0%

0.5% 8.9%

0.7%Creatinine 165.4

42.1mmol/L 148.8

13.8mmol/LCourse

Timetohealing 17.8(8–24)weeks 35.4(19–64)weeks†Amputations 2 2 *Resultsareshownasmean(range)ormean

SEM.†Statisticallysignificant(P=.03).ImpactofMRSAandMSSAinaDiabeticFootClinicTentolourisNetal.DiabetMed.1999;16:767-771.MRSASurgicalSiteInfectionConsequencesInmultivariableanalysis,MRSASSIwasassociatedwithSignificantlyhighermortalityrate(P=0.003)Significantlyincreasedhospitalcharges(P=0.03)Increasedlengthofstay(P=0.11)PatientsDyingMeanChargesPerCaseHospitalStayPostInfectionMRSAN=12120.7%$118,41422daysMSSAN=1656.7%$73,16513.2daysS.aureusBacteremiainSurgicalPatientsGottliebGS,etal.JAmCollSurg.2000;190:50-57.23.6%ofpatientsdevelopedSABpostoperatively33%developedasecondarycomplication

(endocarditisormetastaticfoci)Attributablemortalitywas11%PatientswithpostoperativeSABhadundergone27cardiothoracicprocedures15abdominalprocedures9neurosurgicalprocedures9orthopedicproceduresoramputations13miscellaneousproceduresSourceofS.aureusBacteremiainSurgicalPatientsPresumedSourceofBacteremian(%)Primarysurgicalwoundinfection49(67)Intravascularcatheter12(16)Post-operativepneumonia4(5.5)Other(biliarydrains,etc)6(8.2)Unknown2(2.7)AdaptedfromGottliebGS,etal.JAmCollSurg.2000;190:50-57.CommonCSSSIswithpolymicrobialcharacterDiabeticfootSurgicalwoundinfectionRadiationdermatitisMajortraumaDeepneckinfectionNecrotizingfasciitisAntimicrobialsCurrentlyAvailableforMRSAInfections—2008VancomycinLinezolidDaptomycinTigecyclineMinocyclineClindamycinSulfamethoxazole/TrimethoprimFluoroquinolonesRifampinAminoglycosidesGapsInEmpiricAgentsSpectrumsClassMRSAGram-FermentersESBLsP.aeruginosaAnaerobesPip/Tazo-++-++++++-++++++Imipenem/Meropenem-++-+++++++-+++++Ertapanem-++-++++++-+++FQs-+-+++++-++++-++ESC(Extended-spectrumceph)-++-+++-+-+++Tygacil+++++-++++++-+++1.GrazianiALeta