Wound management in disaster settings

0.05% Chlorhexidine Gluconate Irrigation in Trauma/Emergency General Surgical Laparotomy Wounds Closure: A Pilot Study

INTRODUCTION

Patients who undergo exploratory laparotomy (EL) in an emergent setting are at higher risk for surgical site infections (SSIs) compared to the elective setting. Packaged Food and Drug Administration-approved 0.05% chlorhexidine gluconate (CHG) irrigation solution reduces SSI rates in nonemergency settings. We hypothesize that the use of 0.05% CHG irrigation solution prior to closure of emergent EL incisions will be associated with lower rates of superficial SSI and allows for increased rates of primary skin closure.

METHODS

A retrospective observational study of all emergent EL whose subcutaneous tissue were irrigated with 0.05% CHG solution to achieve primary wound closure from March 2021 to June 2022 were performed. Patients with active soft-tissue infection of the abdominal wall were excluded. Our primary outcome is rate of primary skin closure following laparotomy. Descriptive statistics, including t-test and chi-square test, were used to compare groups as appropriate. A P value <0.05 was statistically significant.

RESULTS

Sixty-six patients with a median age of 51 y (18-92 y) underwent emergent EL. Primary wound closure is achieved in 98.5% of patients (65/66). Bedside removal of some staples and conversion to wet-to-dry packing changes was required in 27.3% of patients (18/66). We found that most of these were due to fat necrosis. We report no cases of fascial dehiscence.

CONCLUSIONS

In patients undergoing EL, intraoperative irrigation of the subcutaneous tissue with 0.05% CHG solution is a viable option for primary skin closure. Further studies are needed to prospectively evaluate our findings.

Assessment of antimicrobial activity and In Vitro wound healing potential of ZnO nanoparticles synthesized with Capparis spinosa extract

Agents that will accelerate wound healing maintain their clinical importance in all aspects. The aim of this study is to determine the antimicrobial activity of zinc oxide nanoparticles (ZnO NPs) ZnO nanoparticles obtained by green synthesis from Capparis spinosa L. extract and their effect on in vitro wound healing. ZnO NPs were synthesized and characterized using Capparis spinosa L. extract. ZnO NPs were tested against nine ATCC-coded pathogen strains to determine antimicrobial activity. The effects of different doses (0.0390625-20 µg/mL) of NPs on cell viability were determined by MTT assay. The effect of ZnO NPs doses (0.0390625 µg/mL, 0.078125 µg/mL, 0.15625 µg/mL, 0.3125 µg/mL, 0.625 µg/mL, 1.25 µg/mL) that increase proliferation and migration on wound healing was investigated in an in vitro wound experiment. Cell culture medium obtained from the in vitro wound assay was used for biochemical analysis, and plate alcohol-fixed cells were used for immunohistochemical staining. It was determined that NPs formed an inhibition zone against the tested Gram-positive bacteria. The ZnO NPs doses determined in the MTT test provided faster wound closure in in-vitro conditions compared to the DMSO group. Biochemical analyses showed that inflammation and oxidative status decreased, while antioxidant levels increased in ZnO NPs groups. Immunohistochemical analyses showed increased expression levels of Bek/FGFR2, IGF, and TGF-β associated with wound healing. The findings reveal the antimicrobial effect of ZnO nanoparticles obtained using Capparis spinosa L. extract in vitro and their potential applications in wound healing.

Crush syndrome: a review for prehospital providers and emergency clinicians

INTRODUCTION

Disasters and accidents have occurred with increasing frequency in recent years. Primary disasters have the potential to result in mass casualty events involving crush syndrome (CS) and other serious injuries. Prehospital providers and emergency clinicians stand on the front lines of these patients' evaluation and treatment. However, the bulk of our current knowledge, derived from historical data, has remained unchanged for over ten years. In addition, no evidence-based treatment has been established to date.

OBJECTIVE

This narrative review aims to provide a focused overview of, and update on, CS for both prehospital providers and emergency clinicians.

DISCUSSION

CS is a severe systemic manifestation of trauma and ischemia involving soft tissue, principally skeletal muscle, due to prolonged crushing of tissues. Among earthquake survivors, the reported incidence of CS is 2-15%, and mortality is reported to be up to 48%. Patients with CS can develop cardiac failure, kidney dysfunction, shock, systemic inflammation, and sepsis. In addition, late presentations include life-threatening systemic effects such as hypovolemic shock, hyperkalemia, metabolic acidosis, and disseminated intravascular coagulation. Immediately beginning treatment is the single most important factor in reducing the mortality of disaster-situation CS. In order to reduce complications from CS, early, aggressive resuscitation is recommended in prehospital settings, ideally even before extrication. However, in large-scale natural disasters, it is difficult to diagnose CS, and to reach and start treatments such as continuous administration of massive amounts of fluid, diuresis, and hemodialysis, on time. This may lead to delayed diagnosis of, and high on-site mortality from, CS. To overcome these challenges, new diagnostic and therapeutic modalities in the CS animal model have recently been advanced.

CONCLUSIONS

Patient outcomes can be optimized by ensuring that prehospital providers and emergency clinicians maintain a comprehensive understanding of CS. The field is poised to undergo significant advances in coming years, given recent developments in what is considered possible both technologically and surgically; this only serves to further emphasize the importance of the field, and the need for ongoing research.

Use of chitosan wound dressing for the treatment of surgical site infection: a case report

Surgical site infections (SSIs) are treated using topical antiseptics and systemic antibiotics, but some cases are unresponsive to such regimens. This case study reports the effective healing of an SSI by a chitosan wound dressing (MaxioCel; Axio Biosolutions Private Limited, India) in a 63-year-old female patient. The patient presented with an infected, hard-to-heal wound in the abdominal region, developed after a hernia surgery, and was initially treated with standard procedures. However, due to the continuous progression of infection, a highly absorbent, bioactive microfibre dressing was selected for the treatment and was continued for two months with alternate-day dressing changes. After 60 days of treatment, wound healing was observed, along with remission from the infection, as well as reduction in exudate level and pain. The use of chitosan wound dressing in management of hard-to-heal infected wounds provides efficient remission of SSI and a faster healing rate.

Rescue Robots for the Urban Earthquake Environment

Robotics have important applications in the field of disaster medical rescue. The deployment of urban rescue robots at the earthquake site can help shorten response time, improve rescue efficiency and keep rescue personnel away from danger. This discussion introduces the performance of some robots in actual rescue scenarios, focuses on the current research status of robots that can provide medical assistance, and analyzes the merits and shortcomings of each system. Based on existing studies, the limitations and development directions of urban rescue robots are also discussed.

Application of berberine-loaded albumin nanoparticles in infections of traumatic wounds

In recent years, the morbidity of infections in traumatic wounds has been on the increase. There are not many kinds of drugs for clinical treatment of infections, and their efficacy and safety are limited. Plant antimicrobial drugs are increasingly popular in mainstream medicine due to the challenges of traditional antibiotics abuse. Berberine has a scavenging effect on infections, however, berberine was restricted from using as a drug preparation with poor stability and bioavailability. Due to the low toxicity of nanoparticles, the green-synthetic, size-controlled approach of nanoparticles has been paid more attention. Therefore, based on the intermolecular disulfide bond network platform built earlier, we designed and developed a strategy to assemble molecular bovine serum albumin into large-sized nanostructures through the reconstructed intermolecular disulfide bond and hydrophobic interaction, and berberine with poor water solubility was encapsulated in it. Nanoassembly with bovine serum albumin increased biostability of berberine and significantly improved its activity against Staphylococcus Aureus (S.aureus) activity, which gives some new insights into the preparation and development of anti-infectives for Chinese medicine.

Decontamination of Surgical Instruments for Safe Wound Care Surgeries in Disasters: What are the Options? A Scoping Review

International guidelines stipulate that autoclavation is necessary to sterilize surgical equipment. World Health Organization (WHO) guidelines for decontamination of medical devices require four levels of decontamination: cleaning, low- and high-level disinfection, as well as sterilization. Following disasters, there is a substantial need for wound care surgery. This requires prompt availability of a significant volume of instruments that are adequately decontaminated. Ideally, they should be sterilized using an autoclave, but due to the resource-limited field context, this may be impossible. The aim of this study was therefore to identify whether there are portable and less resource-demanding techniques to decontaminate surgical instruments for safe wound care surgery in disasters. A scoping review was chosen, and searches were performed in three scientific databases, grey literature, and included data from organizations and journals. Articles were scanned for decontamination techniques feasible for use in the resource-scarce disaster setting given that: they achieved at least high-level disinfected instruments, were portable, and did not require electricity. A total of 401 articles were reviewed, yielding 13 articles for inclusion. The study identified three techniques: pressure cooking, boiling, and liquid chemical immersion, all achieving either sterilized or high-level disinfected instruments. It was concluded that besides autoclaves, there are less resource-demanding decontamination techniques available for safe wound surgery in disasters. This study provides systematic information to guide optimal standard setting for sterilization of surgical material in resource-limited disaster settings.

Preparation and Characterization of Antibacterial Porcine Acellular Dermal Matrices with High Performance

Infection is a common complication in the process of wound management. An ideal wound dressing is supposed to reduce or even prevent the infection while promoting wound healing. A porcine acellular dermal matrix (pADM) has been already used as a wound dressing in clinic due to its capacity to accelerate wound healing. However, not only is pure pADM not antibacterial, its mechanical properties are poor. In this study, an antibacterial pADM with good performance was prepared by adding two natural products as modifiers, quercetin (QCT) and tea tree oil (TTO). The result of Fourier-transform infrared (FTIR) proved that the addition of modifiers did not break the natural triple-helical structure of collagen. Meanwhile, the results of differential scanning calorimetry (DSC), thermogravimetric analysis (TG), mechanic experiment, and enzymatic degradation demonstrated that pADM handled with QCT and TTO (termed QCT-TTO-pADM) had better thermal stability, mechanical strength, and resistance to enzymatic degradation than pADM. Meanwhile, QCT-TTO-pADM had excellent antibacterial activity and showed an antibacterial rate of over 80%. Furthermore, in the cytocompatibility analysis, QCT-TTO-pADM had no side effects on the adhesion, growth, and proliferation of fibroblasts. QCT-TTO-pADM could even accelerate wound healing more efficiently than pADM and glutaraldehyde-modified pADM (GA-pADM). In conclusion, QCT-TTO-pADM was a potential antibacterial wound dressing with good performance.

The Ethical Triage and Management Guidelines of the Entrapped and Mangled Extremity in Resource Scarce Environments: A Systematic Literature Review

OBJECTIVE

A systematic literature review (SLR) was performed to elucidate the current triage and treatment of an entrapped or mangled extremity in resource scarce environments (RSEs).

METHODS

A lead researcher followed the search strategy following inclusion and exclusion criteria. A first reviewer (FR) was randomly assigned sources. One of the 2 lead researchers was the second reviewer (SR). Each determined the level of evidence (LOE) and quality of evidence (QE) from each source. Any differing opinions between the FR and SR were discussed between them, and if differing opinions remained, then a third reviewer (the other lead researcher) discussed the article until a consensus was reached. The final opinion of each article was entered for analysis.

RESULTS

Fifty-eight (58) articles were entered into the final study. There was 1 study determined to be LOE 1, 29 LOE 2, and 28 LOE 3, with 15 determined to achieve QE 1, 37 QE 2, and 6 QE 3.

CONCLUSION

This SLR showed that there is a lack of studies producing strong evidence to support the triage and treatment of the mangled extremity in RSE. Therefore, a Delphi process is suggested to adapt and modify current civilian and military triage and treatment guidelines to the RSE.

Hurricane Harvey Aftermath

Natural disasters, such as hurricanes and severe flooding, pose a threat of increased skin and soft-tissue infections, especially in the event of open fractures and wading through the waters. The purpose of this case study is to present a complex patient sustaining trauma resulting in an open bimalleolar fracture, multiple wounds, and exposure to a variety of water-borne pathogens during Hurricane Harvey in Houston, Texas, in 2017. He underwent multiple incision and drainage procedures, tissue cultures, and placement of antibiotic beads, with an application of external fixation to the left ankle. Several unique multidrug-resistant water-borne pathogens were identified, including Aeromonas hydrophila, Pseudomonas fluorescens/putida, and Serratia marcescens. Once the soft-tissue envelope was restored and infection cleared, a full-thickness rotational flap with tissue expansion was performed. Ultimate reconstruction was delayed several weeks and final left ankle open reduction and internal fixation was performed following antimicrobial treatment with split-thickness skin autograft and wound vacuum-assisted closure application. The patient was discharged after 28 days with no further complications. In instances such as these, all caretakers coming into contact with the patient should be aware of the potential risks of the possible infectious diseases and management to optimize the recovery following hydrologic disasters.

Leaving Contaminated Trauma Laparotomy Wounds Open Reduces Wound Infections But Does Not Add Value

BACKGROUND

The incidence of surgical site infection (SSI) has become a key quality indicator following clean and clean/contaminated surgical procedures. In contrast, contaminated and dirty wounds have garnered little attention with this quality metric because of the expected higher complication incidence. We hypothesized that wound management strategies in this high-risk population vary significantly and might not add value to the overall care.

MATERIALS AND METHODS

This is a retrospective, observational study of trauma patients who underwent an exploratory laparotomy at an urban, academic, level 1 trauma center from 2014 to 2016. Deaths before hospital discharge were excluded. Wounds were classified using the Centers for Disease Control and Prevention definition on review of the operative reports. SSI was determined by review of the medical record, also per Centers for Disease Control and Prevention definition. Wound management strategies were categorized as either primary skin closure or closure by secondary intention. Outcomes were compared using Chi square or Kruskal-Wallis test.

RESULTS

There were 128 patients who met study criteria. Fifty-five (42.9%) wounds were left open to close by secondary intention. In the wounds that were closed primarily (n = 73), eight (10.9%) developed an SSI. There were significant differences in the average length of stay (25.0 versus 11.6 d, P = 0.032), number of office visits (3.0 versus 1.8, P = 0.008), and time from last laparotomy to the last wound care office visit (112.8 versus 57.4, P = 0.012) between patients who were treated with secondary intention closure compared to those closed primarily who did not suffer from SSI.

CONCLUSIONS

There is significant incidence of SSI in contaminated and dirty traumatic abdominal wounds; however, wound management strategies vary widely within this cohort. Closure by secondary intention requires significantly more resource utilization. Isolating risk factors for SSI may allow additional patients to undergo primary skin closure and avoid the morbidity of closure by secondary intention.

The relationship between timing of admission to a hospital and severity of injuries following 2005 Pakistan earthquake

PURPOSE

The objective of this study was to establish the relationship between the timing of admission to a hospital and the severity of injuries following an earthquake.

METHODS

It was a retrospective chart review of injured patients admitted to a tertiary care teaching hospital following the 2005 Pakistan earthquake. Age, gender, injury severity score, type of injuries, complications, operations, hospital stay and mortality were studied and compared at different time intervals using SPSS.

RESULTS

Most injuries were musculoskeletal [145 (59%)] vs. all other injuries, including minor lacerations [103 (41%)], but the percentage of non-musculoskeletal injuries was higher within 24 h (67% vs. 53% respectively, p = 0.4). Injury severity score (25 ± 10 vs. 16 ± 9, p=0.01), multiple injuries [73% vs. 45%, p=0.05] and crush syndrome [20% vs. 03%, p = 0.02] were significantly higher in patients admitted within 24 h. More patients with head and neck injuries were admitted within 24 h (27% vs. 18%, p = 0.4). Patients admitted within 24 h had higher complication rates (67% vs. 32%, P = 0.01) as well as mean operative procedures (2.8 ± 1.9 vs. 1.9 ± 1.9, p= 0.08).

CONCLUSION

Our study showed that patients admitted to a hospital within 24 h following an earthquake had more severe injuries and higher complication rate than those admitted after 24 h.

Global emergency medicine: a review of the literature from 2014

OBJECTIVES

The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a worldwide audience of academics and clinical practitioners.

METHODS

This year 6,376 articles written in six languages were identified by our search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the gray literature. A total of 477 articles were deemed appropriate by at least one reviewer and approved by the editor for formal scoring of overall quality and importance.

RESULTS

Of the 477 articles that met our predetermined inclusion criteria, 63% were categorized as emergency care in resource-limited settings, 13% as EM development, and 23% as disaster and humanitarian response. Twenty-five articles received scores of 17.5 or higher and were selected for formal summary and critique. Inter-rater reliability for two reviewers using our scoring system was good, with an intraclass correlation coefficient of 0.657 (95% confidence interval = 0.589 to 0.713). Studies and reviews focusing on infectious diseases, trauma, and the diagnosis and treatment of diseases common in resource-limited settings represented the majority of articles selected for final review.

CONCLUSIONS

In 2014, there were fewer total articles, but a slightly higher absolute number of articles screening in for formal scoring, when compared to the 2013 review. The number of EM development articles decreased, while the number of disaster and humanitarian response articles increased. As in prior years, the majority of articles focused on infectious diseases and trauma.