Management of bad wounds and open fractures (Proceedings)

Practical management of severe wounds and open fractures begins with initial assessment and management. The first priority is the control of severe hemorrhage that may be associated with the injury.

Techniques to Stop Severe External Bleeding

Described in order of preference.

1. Direct pressure: Apply direct pressure by hand over a dressing over the entire bleeding area. In the absence of compress, a bare hand or finger is used. A pad of cloth or gauze (compress) held between the hand and the wound helps control the bleeding by absorbing the blood and allowing it to clot. The compress can be bound in place using bandage material which frees the hands of the first aider for other emergency action. Do not disturb blood clots after they have formed within the compress. If blood soaks through the entire pad, do not remove the pad, but add additional layers of cloth, and continue to direct hand pressure more evenly.

2. Elevation: Unless there is evidence of a fracture, a severely bleeding open wound of the paw or leg can be elevated above the level of the heart. This elevation uses the force of gravity which helps reduce blood pressure in the injured area, thus slowing down hemorrhage. Elevation is more effective in larger animals with log limbs where greater distances from wound to heart are possible. Direct pressure with compress must also be continued to maximize the use of elevation.

3. Pressure on the supplying artery: If external bleeding continues following the use of direct pressure and elevation, application of digital pressure over the main artery supplying the wound can be very successful. Apply pressure to the femoral artery in the groin for severe bleeding of the rear leg; the brachial artery in the inside of the upper front leg for wounds of the front leg. Always supply direct pressure in addition to the pressure point when it is used.

4. Pressure above and below the bleeding wound: This can also be used in conjunction with direct pressure. Pressure above the wound will help control arterial bleeding (bright red, pulsating blood), pressure below the wound will help control venous bleeding (dark, oozing blood).

5. Tourniquet: Use of a tourniquet is dangerous and should only be reserved for a severe life-threatening hemorrhage in a limb you do not expect to save. A wide (2" or greater) piece of cloth should be used to wrap round the limb twice, and a knot is tied. A short stick or similar object is then tied into the knot as well. Twist the stick to tighten the tourniquet until bleeding stops. Secure the stick in place with another piece of cloth and make a written note of the time that it was applied. After application it should not be loosened until in the OR. A pneumatic blood pressure cuff CAN be used without threat of limb loss for up to 2 hours in some cases this is because of the very wide with and it being full of air.

Next Step - Protect, Prevent from Becoming Dehydrated

After the bleeding is controlled the next step is to protect the wound from getting any further contamination and prevent it from becoming dehydrated. This is most commonly done by applying a water or saline soaked dressing onto the wound and a protective bandage applied. Do not remove or disturb the cloth pad or dressing initially placed on the wound as this will cause further dehydration, pain, blood loss and heat. The wound should be "immobilized" using a compressive dressing. Irrigation and cleaning of the wound should follow. Sedation is often required. In severe wounds the addition of a local or regional anesthetic is recommended prior to the irrigation and debridement. An intravenous broad spectrum antibiotic should be give prior to the commencement of the debridement

Open Fracture Management. Splint them where they lie

Use spica splints mad of newspaper if you have any doubt that there could be a fracture associated with the wound. These DO NOT cause a point of stress on the fracture. Most fractures do better and the soft tissues certainly survive better and have less microvascular injury. Sedation is generally required. Truetta even used these splints on open fractures with fair results.

Most fractures can wait for surgery until the patient is stable. However this is not the case with open wounds if at all possible and those involving the skull or spinal cord. Definitive surgery is best done as within hours of the injury.

Management of Penetrating Injuries: From Bites and Bullets and Other Objects

Management Guideline Overview

Just like all injuries, the management of penetrating injury follows the same guidelines and priorities as for general trauma care. Treat the most life threatening problems in priority first and then follow up with those that are limb threatening and then those that are non-limb or life threatening. Start by assessing the scene for safety. Make it safe if it is not. Assess for immediate life-threatening conditions and treat them if they are present. Perform a thorough physical exam and obtain a thorough history. Treat the problems found definitively and complete follow-up care. Document all findings, communications, estimates, agreements, actions well.

There are also other important management decisions that must be made that are specific to the penetrating trauma itself. It was stated in the past that every traumatic event that penetrated the skin should undergo operative exploration and repair. However we know today that this old rule (started before the widespread use of broad spectrum antibiotics ) is no longer applicable.

Today a "selective management" concept of handling penetrating wounds is recommended and is based on the following criteria:

1. careful assessment (physical exam, radiographs, ultrasound, lab indices, and monitoring),

2. knowledge of the mechanism of injury, forces involved, and physiologic consequences,

3. knowledge of anatomy involved or possibly involved,

4. past clinical experience with the management of the various types of penetrating injuries,

5. owners financial commitment,

6. facility and staff abilities,

7. other concurrent medical conditions the pet has.

Initial Assessment and Treatment

If the animal is now brought to your hospital scan the patient quickly for injury including all surfaces. If external bleeding, a sucking wound in the neck or chest is noted a compressive or triangular occlusive dressing should be applied respectively. Impaled objects should be stabilized with a dressing if applicable. They should not be removed unless 1. they are thought to be interfering with the movement of air in the airway; 2. they are continuing to create lacerating trauma due to continuous movement that can not be controlled; 3. they are endangering the staff (rare).

The wounds should be assessed closely. Clip the area around the wound and note the wound's location, size, shape, the presence of air or subcutaneous emphysema, the amount of separation of the skin from the underlying tissues, surrounding skin color, the presence of crepitus, pain, and deformity. Cover large open wounds with a water soluble jelly and dress them to keep them clean. Place an antibiotic or antiseptic cream over smaller holes and surrounding areas. Its important to form a protective barrier over the penetrated skin as soon as possible to prevent further contamination with bacteria; particularly with "hospital" entrenched microflora and enteric organisms from the patient. Decisions are then made as to the care options available. Options are based on the animal's overall condition, the wound (mechanism of injury, location, severity), finances available, equipment and help available, and past experience.

Specific Management Recommendations

General Wound Management - Wounds that do not show signs of deeper tissue disruption, hemorrhage or sucking air are able to be treated conservatively initially as previously mentioned. Simple clipping, gentle cleaning, and dressing are all that is required. All should be treated with broad spectrum antibiotics . It is recommended NOT to use Baytril or other quinolones as a first line broad spectrum antibiotic in most cases. They should be reserved for serious infections and not for prophylaxis except when penetration may involve the brain , sinus, or spinal canal. First generation cephalosporins are otherwise recommended. If the wounds are very severe these are best started intravenously (e.g., cephazolin 40 mg/kg the first dose then 20 mg/kg thereafter Q 6 hr.). Begin the antibiotic coverage BEFORE the would is debrided by at least 30 minutes if possible. If the oral cavity, upper airway, or GI intact is involved then metronidazole at 7 mg/kg IV Tid is added. Aminoglycosides are reserved for those cases involving significant gi contamination. Gentamycin is given at 5 mg/kg IV or IM Sid and coursed for 3-5 days.

Bite Wound Management - Small skin holes caused by teeth with the muscle intact and no separation of the skin from underlying tissues warrants in some cases only cleaning the area and placing the patient on broad spectrum antibiotics. If tissues under the skin are separated from the skin, fat exits the holes , or subcutaneous tissues feels disrupted then exploration is highly warranted. No cases ever should the wound be simply flushed with saline and sutured closed.

The bite wound minimally is left open to drain. Lacerations and avulsion defects are covered with water soluble jelly, the entire area is clipped and scrubbed and formal exploration of the deeper tissues accomplished. If the skin surrounding the wound is separated from underlying tissue the exploratory incision should encompass this entire area unless special methods are utilized to allow for thorough visual exam without complete exposure (involving high intensity fiberoptic headlight or endoscopic equipment). Upon wide exposure all devitalized fat and muscle should be removed. This needs to be aggressively done. If the thoracic, abdominal or other cavities (calvarium, sinus, joint, spinal canal) are penetrated surgical exploration of those cavities, and debridement, repair, and irrigation are done as needed.

Massive gastrointestinal rupture and contamination cases – These should not have the abdomen closed. All other cavities, following irrigation and drying are closed. Suction drains are placed where dead space is present if the use of compression dressings can not be used effectively. Sil-Med and other silicone multiholed suction drains and collapsible reservoirs are recommended to be used. But home-made multiholed catheters and continuous evacuation systems made from syringes with plungers held out with a pin can also be used. Gravity assisted passive drains are acceptable where they can be covered and not at great risk for significant contamination which may lead to ascending infection. Wounds are closed with minimal monofilament absorbable subcutaneous sutures used to bring the deeper tissues together. Skin closure may include near far-far-near or vertical mattress patterns that help close the subdermal and subcutaneous layers.

Gunshot Wound Management - All penetrations should be carefully examined to attempt to determine trajectory and the type of missile, and energy imparted to estimate the possible damage caused. In cases were financial constraints are not a problem most all cases should receive radiographs and a planned exploration based on clinical signs and suspicions for deeper injury. Bullets passing through the chest may be handled conservatively in approximately 50% of the cases Those involving hemorrhage are begun with diagnosis centesis, chest tube placement, and continuous suction drainage. Counterpressure of 20 mmHg can be helpful for controlling or slowing bleeding. Blood loss may require transfusion, autotransfusion, and exploration if hemorrhage continues or clinical signs worsen. Bullet injuries involving the abdominal cavity warrant exploration early in the course. Serosal patching of repaired visceral organ injuries is recommended. Wounds involving other tissues are managed as described for bite wounds. Debridement and irrigation are recommended in most cases except for shallow and low velocity bullets. This includes shot from shotgun injury with wide patterns, provided no clinical signs or radiographic evidence of deeper penetration into abdomen, etc. is observed.

Impalement Wound Management - The area and cavity involved are explored before the impaled object is removed. For example an arrow penetrating the chest and abdomen should be left in place until both the chest and abdomen are opened on the midline and removal is done under direct visualization of all the structures involved. If the object is tamponading hemorrhage or leakage of gastrointestinal tract contents, occlusion by vascular clamp or Rummel loop should be performed before the object is removed. Management is otherwise similar to bite wounds.

Summary

The tenets I subscribe to regarding the emergency management of severe wounds and open fractures can be summarized in 15 statements (see below). Some of these are old and well proven by their use in many thousands of wounds while others have only come to be realized over the last few years. Some overlap. These are what I believe and are probably not shared by all trauma surgeons but by following them I have had success that I do not think otherwise possible and by teaching them to others I hope others will also realize success in the management of the truly most severe cases in practice.

Tenets of Emergency Management of Wound and Open Fractures

1. The first priority is yourself: Consider all patients with traumatic wounds as having human blood contamination until proven otherwise. Therefore always put on gloves before the patient is touched and use caution. Use Universal Precautions as outlined by OSHA regarding BSI (body substance isolation) precautions (see references).

2. The second priority is providing good assessment of the entire patient and to provide adequate oxygenation, ventilation and circulation and to control major bleeding. The best way to stop bleeding initially is with direct pressure done by hand or with a pneumatic pressure cuff inflated proximal to the wound if possible. Some cases may require immediate surgery to cross-clamp bleeding vessels. Until that time so not let up pressure.

3. Wounds should be kept clean and moist with sterile saline soaked sponges applied from the very beginning of emergency care. Most infections in fresh wounds or surgical wounds come from the hospital environment therefore protect the wound with a temporary sterile towel "bandage" as soon as the patient is seen, even before the patient is placed on an exam table if possible. Wounds covered immediately and kept moist with a saline dressing are associated with significantly less nosicomial infections.

4. Impaled objects should be removed only under controlled surgical conditions with exposure of the deeper tissues involved. The only exceptions are if the object is obstructing the patient's airway or the object prevents transport and medical care..

5. All wounds involving injury below the skin should be widely clipped, thoroughly explored, debrided as necessary, and lavaged extensively. They should not be closed if they can not be debrided completely clean within 6 hours of the injury or can not be removed en toto. Small punctures should be opened and gently irrigated and inspected. They should be left open to ensure drainage Irrigation fluids should not be forced.

6. Debridement of all contaminated and devitalized tissue and copious irrigation are accomplished as soon as possible. If gross contamination is still present following these the wound should never be closed. Rather the wound is packed open with wet saline gauze sponges. This is followed by a dry dressing. Wet-to-dry dressings are changed daily. The wound can generally be closed on day 3-6 when a good granulating tissue bed is present (delayed primary closure) so long as it can be done without much tension.

7. Primary or delayed closure of traumatic wounds following debridement should be completed with non-absorbable monofilament sutures in an interrupted vertical mattress pattern or a near far -far near pattern avoiding the placement of any subcutaneous sutures. If subcutaneous sutures are used to take the tension off the skin closure layer or ligations are needed to be done use the smallest monofilament absorbable or non absorbable material that is easy to work with such as 3-0 or 4-0 polypropylene.

8. Dead space should be treated with closed suction drains or compression bandages. Sutures placed can not obliterate dead space – only compartmentalize it. Penrose drains should be used in clean wounds only if the exposed end and wound can be covered completely with a sterile compressive dressing.

9. Unstable fractures and luxations should be splinted as soon as possible: "Splint them where they lay". Bubble wrap works well as a light weight Robert Jones Dressing and newspaper can be used effectively for spica splints. Transporting on a flat rigid object like a board can accomplish "emergency splinting" of the entire patient as well as any obvious fracture and is recommended as a first aid procedure as well as intra-hospital .

10. Wounds and fractures are painful and patients always should be treated with analgesics. Local and regional anesthesia, analgesia and sedation should be not be hesitated to be used as needed. Epidural anesthesia and analgesia is a very effective way to manage pain and catheters provide a very good means of managing wound and fracture pain.

11. Open joints and fractures should be thoroughly debrided and irrigated as soon a comfortably possible. With the use of local, regional or epidural anesthesia this can be accomplished within hours of the injury in most cases in even the more unstable cases.

12. Systemic broad spectrum antibiotics do not take the place of good wound debridement and irrigation but are recommended to be started before the debridement is begun and continued a minimum of 48-72 hours.

13. In severe wounds the importance of enteral nutritional support is a key to the prevention of infection that is just as important as good debridement, irrigation, and broad-spectrum antibiotics. This should be started within hours of the injury.

14. Rest and immobilize the wound, fracture or luxation with compressive dressings to prevent postoperative swelling. In open unstable injuries use external fixation devices (pins and clamps) to allow dressing changes and wound care without loosing immobilization is recommended.

15. Ancillary treatment methods that help assure good oxygenation and blood flow to the injured tissues have a place and should be used: These include the oral administration of pentoxyfline which helps improve red cell flexibility; physical therapy (massage, passive range of motion exercises, etc.), hyperbaric oxygen treatments, and even the local application of leeches in distal extremity injuries that have much venous congestion.

16. Other complementary treatment aids in the healing of wounds include the very effective and scientifically proven use of hyperbaric oxygen, either at low or high pressures, and giving one to two times per day. Cold laser, photonic therapy, Pulse Signal Therapy have been found also effective in the healing of wounds, including those that are contaminated or infected.

Case Illustration: Louie

A case recently presented to our hospital will severe to illustrate many of these tenants:

Louie is a 10 year old Yellow Labrador that was presented to the emergency service after being presumably stuck by a motor vehicle. The owner stated that Louie had been discovered on the side of the road by a passer-by. He was found laying in the snow and had a puddle of blood next to him. He was unable to rise on his real legs. His left rear limb had an easily recognizable severe wound and fracture with much soft tissue injury. The leg was in an abnormal position. The owner placed him on a board and into his truck and immediately brought him to the service. This acted to "splint the entire patient" not only the severely injured limb (Tenet No 9).

Gloves were put on by the emergency team (Tenet No.1) and a sterile towel was applied around the open wound immediately before he was carried on the board into the hospital (Tenet No 3) Assuming significant injury and shock flow – by oxygen was delivered to his face while assessment was being performed. A team member was also preparing to place an intravenous catheter, pull blood for lab analysis, and begin Plasmalyte at a moderate rate. As this was accomplished a thorough assessment protocol was begun to be carried out (Tenet No. 2):

• A primary survey or evaluation was done and revealed the following:

• LOC (level of consciousness) = alert but quite

• Airway = patent

• Breathing = normal breathing pattern and rate, breaths sounds heard bilaterally

• Cardiovascular = membrane color pink, pulses slightly fast but easily palpable,

• Capillary refill time 2 sec, Jugular vein filling time 4 seconds with volume slight,

• Heart tones adequate and no murmurs or gallop or arrhythmia, rate same as pulse

• Disability = sensation present in all four extremities on toe pinch

• Everything else on a quick visual assessment = no obvious external bleeding

• Vitals Signs recorded:

• HR 140, RR 30, BP 120/80, rectal temp 100, weight estimated to be approx. 40-45 Kg.

Secondary survey or evaluation revealed normal findings until the caudal one-half of he body was reached. There where numerous superficial abrasions noted on the caudal abdominal skin in the inguinal region. The left rear limb had a large degloving injury and open fracture luxation at the distal end of the tibia and there was much displacement. There was a large area wound involving the medial aspect of the left thigh. The nail bed of the foot was squeezed and sensation of the pinch was acknowledges by the dog. The foot was obviously swollen but some pink color was present in each of the nail beds. There was obvious contamination with road debris throughout the wound. Bowel sounds were not heard on auscultation. There was no pain or distension of the abdomen. There was a small amount of blood at the tip of the prepuce. The ureteral meatus was the source of the hemorrhage. Rectal exam was unremarkable. Pain was elicited when the right hip was manipulated. The owner was asked about any possible allergies, when the dog was last fed, any past history of illness or surgery, on any medications and answers recorded.

For the sake of brevity only the most pertinent aspects of care as outlined in the tenants listed above will be described from here on.

Emergency care of the wound-fracture consisted of the following:

The wounds were initially covered with saline soaked sponges (Tenet No.3) while intravenous enrofloxacin (10 mg /kg), metronidazole (7 mg/kg) and cefazolin (40 mg/kg) was administered (Tenet No.12 ). Sedation (hydromorphone 0.15 mg/kg and acepromazine 0.001 mg/kg) was provided intravenously following continued fluid support and the wounds were wrapped with more sterile towels and "trauma radiographs" (lateral films of the neck, chest, abdomen, pelvic region) were taken. This revealed a severely displaced fracture luxation of the left tibial-tarsal joint (Figs 1) and a right coxofemoral craniodorsal luxation (Figs 2). The wounds were then initially irrigated and debrided of all gross contamination easily visible (Tenet 6). The wounds were dressed with wet saline dressings and no attempt at closure was done (Tenet 5). Bubble wrap was used over a dry dressing of 4x4 gauze and brown cling to make a light weight Robert Jones dressing that would provide some stability to the fracture luxation ( Tenet 9) Analgesia was provided as needed with intravenous hydromorphone and a 100 mcg fentanyl patch was applied to the right distal extremity. (Tenet 10 and 11). A urinary catheter was placed and gross hematuria was noted. Continued monitoring in the ICU was done and 400 mg of pentoxyfline was begun orally bid as well as twice a day hyperbaric oxygen treatments. He initially received 100 % oxygen at 15 psi for an hour each treatment in a stainless steel chamber (Oxytec, Inc.). He then was treated with 40% oxygen at 4.4 psi for an hour each treatment. This was done using a collapsible and portable hyperbaric chamber (Animal Hyperbarics, Inc.)( Fig 3). (Tenet 15). More definitive wound care and surgery was performed the following day.

Under general anesthesia (ketamine, diazapam, isoflurane, hydromorphone, glycopyrolate) and continuous positive pressure ventilatory support with a mechanical ventilator) an epidural catheter was placed to provide epidural anesthesia with lidocaine, bupivicaine, hydromorphone. Louie was taken to surgery after clipping and preparation of the limbs (Tenet 11). The coxofemoral luxation was repaired by open reduction and internal fixation as attempts at closed reduction had failed. The left rear limb was then suspended and surgical preparation completed using chloroxynolol 3% (Technicare). The wound was debrided and irrigated (Fig 4). A fiberoptic surgical head-light was used to increase illumination which facilitated the cleaning and debridement process (Fig 5). Replacement of the medial collateral ligament was completed with three screws, washers, and No. 5 Ethibond (a braided polyester fiber suture) to simulate the long and short collateral ligaments (Aron, Purinton 1985). A type 2 external fixature was applied for stabilization of the entire joint (Tenet 14).(Clark 1997) (Fig 6). Penrose drains were inserted through the posterior aspect of the wound to increase drainage ability where a pocket between skin deep fascia has formed (Tenet 8) and saline dressings applied for wound coverage. Two leeches were applied to the toes to assist with venous congestion and to help prevent microvascular thormbosis and a sterile dressing applied. During the entire 6 hours of surgery for adequate analgesia and anesthesia the isoflurane inhalational concentration required was able to be maintained below 0.5-0.7 % due to the use of the epidural catheter. Postoperative radiographs were completed which revealed the implanted screws and washers and the reduced luxation of the tibial-talar joint (Fig 7) and the reduced coxofemoral joint with the two screws used to anchor the supporting Ethibond suture. (Tomlinson 1997) During and immediately after surgery hematocrit, total plasma protein, blood glucose, and venous blood gases were monitored. At the conclusion of the surgery because of the drop of hematocrit below 20 % and a total plasma protein below 4.5 g/dl a unit (500 ml) of stored whole blood was administered.

The patient was admitted back to the intensive care unit with monitoring of ECG, BP, vital signs, urine output and receiving nasal-pharyngeal oxygen. The only new complication noted in the immediate post operative period was the development of paroxsymal unifocal venticular tachycardia that resolved with 36 hours following surgery. The previously noted hematuria gradually cleared up spontaneously over a period f a few days. Louie remained comfortable and received enteral nutritional support (Tenet 14) and analgesia via his epidural catheter and fentanyl patch (Tenet 10). Physical therapy (Tenet 15) and tender loving nursing care in the ICU and daily dressing changes (Tenet 6) were performed. Approximately 5 medical grade leeches (LEECHES USA) were applied to his foot daily to decrease edema and help maintain microcirculation in the distal extremity. (Fig 8). The injury had essentially caused a 360 degree degloving injury with 270 degrees being an anatomic degloving with loss of all the skin and subcutaneous tissues. The caudal portion of the limb had a complete physiologic degloving as the skin and subcutaneous tissues had pulled away completely from the deeper structures. Because of this the lymphatics draining the toes were literally destroyed and the consequence was significant edema formation. The leeches significantly helped with the reduction of the edema until full thickness grafting was able to be accomplished.

Ten days following the injury Louie underwent a full-thickness mesh grafting with skin taken from his left flank. The graft was applied to the lateral aspect of the hock. Petroleum impregnated gauze was applied following Bacitracin ointment application. This was followed by a sterile layer of 4x4 gauze pads and then cast padding and cling gauze. Seed graphs were applied to the medial side of the wound at various stages following the full-thickness grafting. Dressings were continued to be changed every two to three days as needed. The KE apparatus remained in place for one month after its application to provide support for the skin wound that were healing (Fig 9). One week following the removal of the KE apparatus the wounds were almost completely closed with only small areas between the seed grafts were still open (Fig 10). Due to deep crusty snow his owner was using a boot to protect the graft sites. (Fig 11). Louie was using his leg quite well and his owner was quite pleased.

This case illustrates many of the multiple tenets I have come to follow that are involved with the emergency care and management of serious wounds and open fractures. It also provides insight to the use of hyperbaric oxygen and leeches for the treatment of microvascularly compromised tissues.

References

Aron DN, Purinton PT: Replacement of the collateral ligaments of the canine tarsaocrural joint: a proposed technique. Vet Surg. 14:178-184, 1985

Clark GN: Malleolar shearing injuries treated by double ligament replacement. In Current Techniques in Small Animal Surgery, ed M J Bojrab, GW Ellison, B Slocum, Williams and Wilkins, 1997

Feliciano D, Moore E, Mattox K:

Trauma , Appleton & Lange, Stamford, Connecticut. 1996

Jain KK: Textbook of Hyperbaric Medicine 2nd Revised Edition Hogrefe & Huber Publishers, Seattle 1996

Tomlinson JL: Reduction of coxofemoral luxations. In Current Techniques in Small Animal Surgery, ed M J Bojrab, GW Ellison, B Slocum, Williams and Wilkins, 1997

Peacock E E, Van Winkle W: Surgery and Biology of Wound Repair WB Saunders, Philadelphia. 1970

Waldron DR, Trevor P: Management of Superficial Skin Wounds in Textbook of Small Animal Surgery Second Edition WB Saunders Co, Philadelphia. 1993