The Journal
of Emergency
Medicine,
Vol IO. pp 463-467,
Printed in the USA
1992
Copyright
0 1992 Pergamon
Press Ltd.
A DISPOSABLE EMERGENCY WOUND TREATMENT KIT Richard F. Edlich, MD, PhD, Kendall C. Jones, Jr., MBA, Leslie Buchanan, B.S.N., E.N.P., Raymond G. Morgan, MD, Walter McGregor, MBA, and Harvey N. Himel, MD Department
of Plastic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia Address: Richard F. Edlich, MD, Phc, Department of Plastic Surgery, University of Virginia School of Medicine, Charlottesville, VA 22908
Reprint
0 Abstract - Biomecbanical studies in our laboratory have provided a scientific basis for selecting surgical gloves and instruments, drags, and dressings for traumatic wound treatment. This armamentarium has been incorporated into a disposable emergency wound treatment kit for use in the emergency department. Its upper tray is for wound cleansing, while its lower tray is used for wound closure. A clinical evaluation of the kit by emergency physicians was very favorable because it saved time, eliminating the need to search for and assemble the gloves, instruments, drugs, and dressingsfor wound treatment. Cl Keywords-kit;
management that form the basis for a rational treatment plan for patients with traumatic wounds. An integral part of our comprehensive research program has been biomechanical studies that provide a scientific basis for selecting surgical gloves and instruments, drugs, and dressings for traumatic wound treatment. This armamentarium has been incorporated into a new disposable emergency wound treatment kit (Sorex Medical, Inc., Salt Lake City, UT) for use in the emergency department. The purpose of this report is to describe the components and recommended guidelines for the use of this emergency wound treatment kit. A clinical evaluation of the kit by emergency physicians was very favorable because it saved considerable time, eliminating the need to search for and assemble the gloves, instruments, drugs, and dressings for wound treatment.
wound; disposable INTRODUCTION
Nearly 10 million patients with traumatic wounds are treated annually in emergency departments in the United States. When caring for these wounds, the emergency physicians’ ultimate goal is to restore the physical integrity and function of the injured tissue without infection. Treatment of these wounds involves a series of decisions that determine whether the wound heals by first intention or becomes infected. During the last 25 years, we have performed a large number of clinical and experimental studies that have provided evidence of the influence of these decisions on the ultimate fate of the wound (1). Based on the results of these well designed studies, we have identified principles of emergency wound
DISPOSABLE EMERGENCY WOUND TREATMENT KIT
Our sterilized, disposable emergency wound treatment kit is covered by a heat-sealed, transparent plastic pouch that is opened by applying opposing forces to the unsealed edges. A large package insert can be seen through the transparent bag with an itemized list of the components of the kit. The sterile kit within the transparent pouch is covered by a blue paper drape, which may be aseptically unfolded to reveal two separate trays stacked one upon the other. The upper tray is the wound cleansing tray, while the lower tray is the wound closure tray. Two powder-free, unisized gloves rest on a blue
This research was supported by a generous gift from the Texaco Philanthropic Foundation, White Plains, New York. =
Techniques and Procedures features practical, “how-to” articles of interest to all practicing emergency physicians. This section is coordinated by George Stembuch, MD, Stanford University Medical Center. RECEIVED: 10 December 1991; ACCEPTED: 3 January 1992 0736-4679/92 $5.00 + 00 463
464
R. F. Edlich, K. C. Jones, Jr., L. Buchanan,
underpad on top of the wound cleansing tray (Figure 1) (2). Beneath the underpad is a 4-compartment plastic tray (Figure 2). The right lower compartment contains the anesthesia instrument assembly, which consists of a glass ampule containing 5 mL of 1% lidocaine (Figure 2, No. 4), a 5-mL plastic syringe (Figure 2, No. 5), and three needles (1”-30 gauge, 1.25 fl -27 gauge, 1.5 N-19 gauge) (Figure 2, No. 6) (3). The lower left compartment has a 30-mL plastic syringe (Figure 2, No. 8), while the upper left compartment has two bottles containing 100 mL of 0.9% sodium chloride (Figure 2, No. 9) (4). The central divider has a slot with a 19-gauge, blunt-ended needle (Figure 2, No. 7). The right upper compartment has three separate components. A lOO-mL plastic bottle of Shur-Clens (Clagon Vestal Laboratories, St. Louis, MO) is enclosed in a sterile, heat-sealed foil package (Figure 2, No. 1) (5). The edges of this bag must be opened aseptically by a health care professional to remove the bottle of Shur-Clens. The plastic container of Shur-Clens is clean but not sterile; the Shur-Clens solution is sterile. Shur-Clens is a solution containing 20% poloxymer-188. Beneath the covered Shur-Clens bottle are six 4 x 4” sheets of Optipore sponges (Figure 2, No. 2). Three swabs soaked in 1% povidone iodine enclosed in an aluminum wrap lie under the sponges (Figure 2, No. 3) (6). The lower wound closure tray is covered by powder-free, unisized, surgical gloves enclosed in a paper
R. G. Morgan,
W. McGregor,
l-i. N. Himel
Figure 2. Beneath the underpad is a 4-compartment plastic tray, which is used for wound cleansing. Components: (11 Shur-Glens, [2] six 4 x 4” sheets of Optipore sponges, [3] three swabs soaked in 1% povidone iodine enclosed in an aluminum wrap, [4] a glass ampule containing 5 mL of 1% lidocaine, [5] 5-mL plastic syringe, (61 three needles, [7l 19gauge, blunt-ended needle, [E] 30.mL plastic syringe, and [9] two plastic bottles containing 100 mL of 0.9% sodium chloride.
wallet (Figure 3, No. 1). A blue underpad, a nonfenestrated paper drape, and a fenestrated cloth drape lie beneath the gloves (Figure 3, No. 2). The wound closure tray has three compartments (Figure 4). The right compartment of the tray has 5 surgical instruments: straight Iris scissors (Figure 4, No. I), a Webster needle holder (Figure 4, No. 2), a scalpel handle with attached number 15 scalpel blade (Figure 4, No. 3), Adsen forceps with teeth (Figure 4, No. 4), and a curved Mosquito hemostat (Figure 4, No. 5) (7). The left lower compartment contains ten 4 x 4” gauze sponges (Figure 4, No. 6). The left upper compartment has a 3 x 4” Telfa pad (Kendall Healthcare Products, Co., Mansfield, MA) (Figure 4, No. 9), Bacitracin ointment (Figure 4, No. 7), and a roll of plastic, transparent tape (Figure 4, No. 8). GUIDELINES
Figure 1. Two powder-free, unislzed gloves [2] on a blue underpad [l] on top of the wound cfeanelng tray.
FOR USE
The treatment of wounds can be divided into two distinct phases: wound cleansing and wound closure. The emergency physician must use aseptic technique wearing cap, mask, and powder-free gloves.
465
Disposable Wound Treatment Kit
Figure 3. The lower wound closure tray is covered by powder-free, unlrlzed surgical gloves encloeed in a paper wallet [l]. A blue underpad, a nonfenestrated paper drape, and a fenestrated cloth drape lie beneath the gloves [2].
3. Anesthetizethe woundbeforecleansing. 4. Withdraw 5 mL of lolo lidocaine using the 19gaugeneedleattachedto the 5-mL syringe. 5. Usethe 30-gaugeneedlefor infiltration anesthesia or the 27-gaugeneedlefor regionalnerveblock. 6. Cleansethe contaminatedwounds by high pressure,syringeirrigation. The 30-mLsyringewith its 19-gaugeblunt endedneedleshouldbe positioned perpendicularto and as close as possibleto the wound surface.By manually applying maximum pressureto the syringebarrel, 200 mL of 0.9% sodiumchlorideis deliveredto wound surfaceat a pressureof approximately9 psi. Splashingof the irritant from the woundcanbeminimizedby holding a 4 x 4” gauzespongenear the blunt-ended needle. 7. Wash the irrigated wound with the Optipore sponges,soakedin Shur-Clens. 8. Using the swab sticks, apply 1% povidoneiodine to intact skin only. 9. Remove underlying underpad, wound cleansing tray, and surgicalgloves. WoundClosure
WoundCleansing 1. Don powder-freesurgicalgloves. 2. Placeblue underpadbeneaththe wound anatomic site.
1. Debridedevitalized,tissueusingthe No. 15scalpel blade. 2. Stop bleedingby applying direct pressureto a 4 x 4” spongecoveringthe wound. Stop persistent bleedingeitherby electrocoagulationof the bleeding vessel,or by ligaturewith a synthetic,absorbable, braidedsuture. 3 Approximate wound edgeswith monofilament, nonabsorbable,synthetic sutures attached to a beveledconventionalcutting edgesurgicalneedle (8). For wounds subjectedto strong, static skin tensions,approximatethe quadrantsof the wound with interrupted dermal, absorbable sutures attachedto a compoundcurve, cutting-edgeneedle (9). 4. Sutureline careof facial woundsis accomplished with Bacitracinointment. In other anatomicsites, the Telfa pad dressingshould cover the wound and be attachedto the skin with tape. CLINICAL
Figure 4. The wound closure tray has three compartments. Componenk [1] straight Iris 8cis8or8, [2] Webster needle holder, [3] a aoalpel handle with attached No. 15 scalpel blade, [4] Adsen forceps with teeth, [51 curved mosquito hemostat, [fl 10 4 x 4” gauze sponges, m Bacitnxln ointment, [S] plastic, transparent tape, and [Q] 3 x 4” Telfa pad.
TRIAL
Five different board certified emergencyphysicians evaluatedthe wound treatment kit. All expressed considerablesatisfactionwith the designand componentsof the kit. They consideredthe major advantageof the kit that it savedtime, eliminatingthe need
R. F. Edlich, K. C. Jones, Jr., L. Buchanan, R. G. Morgan, W. McGregor, H. N. Himel
466
to search for and assemble the gloves, instruments, drugs, and dressings for wound treatment. The only limitation noted in their clinical trial was the powderfree unisized glove for physicians with small hands. In these instances, the physician selected sized powder-free gloves for wound treatment.
DISCUSSION Our clinical experience with this wound treatment kit has been very gratifying. Its most important benefit is that it saves considerable time, eliminating the need to assemble the surgical gloves, instruments, drugs, and dressing used in wound treatment. Needles with their attached sutures were not added to the kit because their selection must be individualized to each specific wound. However, we have simplified the selection and ordering of sutures and needles by recommending only five different types for use in wound closure (Table 1). Beveled, conventional cutting edge needles attached to 5-O polypropylene sutures are used for percutaneous sutures in facial lacerations (8). Larger diameter beveled, conventional cutting edge needles attached to 4-O polypropylene sutures are used for percutaneous sutures in other anatomic sites. Approximation of the dermis of a facial laceration subjected to strong static skin tensions is accomplished with compound curved reversed cutting edge needles swaged to 5-O polyglactin 910 sutures (9). Larger diameter polyglactin 910 sutures (4-O) swaged to the same compound curved needles are used for interrupted dermal closure in lacerations in other anatomic sites subjected to strong static skin tensions. A taper point needle (RBI) attached to a 4-O polyglactin 910 suture is used for ligating bleeding vessels unresponsive to direct pressure. The swages of these cutting edge and taper point needles are produced by laser drilling, rather than by creating a channel. Depending on the anatomic sites, the appropriate swaged needles and sutures are added to the wound treatment tray. Our wound treatment is becoming one of several
important adjuncts to wound treatment. We routinely photograph each wound using the Polaroid Close-Up System (Cambridge, MA). This system, equipped with a new color Auto-Film Camera Body (X8-59), is one of the most convenient close up systems. It produces brilliant color prints in minutes, which we attach to the medical record. These photographs of the wound provide important documentation of the injuries, support reasonable claims for professional reimbursement, and facilitate referral to a plastic surgeon for follow-up evaluation. Magnification has become an essential part of wound repair and all emergency physicians should be comfortable in the use of magnification loupes. Gne has to operate using magnification loupes to appreciate how destructive even our precise and careful attempts of surgery are on delicate tissues. Fortunately, magnification loupes give us a decided advantage to minimize operative trauma. With a 2.5 x magnification, emergency physicians uniformly prefer a Keplerian lens system over that of a Galilean lens system (10). The advantages of the Keplerian lens are its increased field of view and its brighter and clearer peripheral image. The Keplerian lens system allows the physician to visualize the exquisite details of the wound configuration and its biomechanical properties, and to perform wound closure using microsurgical techniques. Surgical repair of extremity lacerations must be performed in a bloodless field, by a tourniquet and Esmarch bandage. This flat, disposable rubber Esmarch bandage is wrapped first around the digits before proceeding to wrap the entire arm or leg. A sterile, disposable tourniquet is used, which helps prevent the risk of cross-contamination. The tourniquet must be calibrated, at least daily, and preferably before each case. The inflatable tourniquet should be approximately 20% wider than the diameter of the limb on which it is used. The tourniquet’s pneumatic cuff is applied snugly and as close to either the axilla or inguinal region as possible. The limb is elevated and wrapped from distal to proximal with the disposable, sterile Esmarch ban-
Table 1. Needle and Suture Speciftcation Suture Type’
Point Geometry
Curvature Type
Diameter mm
PC1 PC3 PS4C PS4C RBI
beveled, oonventlonal cutting edge beveled, conventional cutting edge reversed cutting edge reverse cutting edge taper point
single radius single radius compound curved compound curved single radius
0.35 0.43 0.43 0.43 0.45
‘Ethion,
Inc., !Somerville,
NJ
Length mm
Type
Size
13.0 16.2 15.8 15.8 17.5
PdyProw~~ polyprodene polygkwtin910 potyglactin910 polyglactin 910
5-O 44 4-O
467
Disposable Wound Treatment Kit
dage to exsanguinate blood from the extremity prior to inflation of the tourniquet. It seems rational to relate the tourniquet pressure to the patient’s systolic blood pressure. It is recommended that the tourniquet pressure be 70 torr above the patient’s systolic blood pressure (11). Slightly greater pressures are recommended for a person with a particularly obese or muscular extremity. The safe duration of tourniquet ischemia is approximately 2 hours. However, most patients can tolerate this pressure for only 20 minutes without complaining of pain. Dictation of an operative record of wound treatment is an important part of comprehensive wound care. The operative note should address each of the technical considerations of wound repair. The process of dictating the operative record should be made considerably easier by the computer-voice recognition technology (12). Appropriate tetanus prophylaxis should be instituted and updated on the paC&t’s computerized medical record (13).
CONCLUSION An integral part of our comprehensive research program has been biomechanical studies that provide a scientific basis for selecting surgical gloves and instruments, drugs, and dressings for traumatic wound treatment. This armamentarium has been incorporated into a new disposable wound treatment kit for use in the emergency department. Its upper tray is for wound cleansing, while its lower tray is used for wound closure. This wound cleansing kit has 19 component parts. A clinical evaluation of the kit by emergency physicians was very favorable because it saved time, eliminating the need to search for and assemble the gloves and instruments, drugs, and dressings for wound treatmqFt,It has been concluded that this wound treatment Kit is another important part of a comprehensive wound treatment program that allows wound healing to progress without infection and with the most aesthetically pleasing scar.
REFERENCES 1. Edlich RF, Rodeheaver GT, Morgan F, Berman DE, Thacker JG. Principles of emergency wound management. Ann Emerg Med. 1988;17:1284-302. 2. Villasenor RA, Harris DF II, Barron GJ, Krasnow M, Saiz JJ. Powderfree surgical gloves. Ophthalmic Surg. 1984;15:241-3. 3. Edlich RF. Smith JF. Maver NE. et al. Performance of discosable needlk syringe s&teds for l&al anesthesia. J Emerg h;led. 1987;5:83-90. 4. Stevenson TR, Thacker JG, Rodeheaver GT, Bachetta C, Edgerton MT, Edlich RF. Cleansing the traumatic wound by high pressure syringe irrigation. J Am Co11 Emerg Phys. 1976;s: 17-21. 5. Bryant CA, Rodeheaver GT, Reem EM, Nichter LS, Kenney JG, Edlich RF. Search for a non-toxic surgical scrub solution for periorbital laceration. Ann Emerg Med. 1984;13:317-21. 6. Edlich RF, Custer J, Madden J, Dajani AS, Rogers W, Wangensteen OH. Studies in management of the contaminated wound; 3: assessment of the effectiveness of irrigation with antiseptic agents. Am J Surg. 1969;118:21-30.
7. Frances EH III, Towler MA, Moody FP, et al. Mechanical performance of disposable surgical needle holders. J Emerg Med. 1992;10:63-70. 8. Kaulbach HC, Towler MA, McClelland WA, et al. A beveled, conventional cutting edge surgical needle: a new innovation in wound closure. J Emerg Med. 1990,8:253-63. 9. Abidin MR, Becker DG, Paley RD. et al. A new compound curved needle for intradermal suture closure. J Emerg Med. 1989;7:441-4. 10. Doctor A, Cutler PV, Westwater JJ, et al. Emergency medicine magnifying loupes. J Emerg Med. 1989;7:321-7. 11. Sanders R. The tourniquet: instrument or weapon?. Hand. 1973;5:119-23. 12. Zimmer CA, Devlin PM, Werner JL, et al. Adaptive communication systems for patients with mobility disorders. J Burn Care Rehab. 1991;12:354-60. 13. Colley JW, Hoar MG, De.tmer DE, Edlich RF. Computerized medical record for Virginia. In preparation.
