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Wound Repair Part 1 - Wound Prep

Brian Lin, MD and Zack Shinar, MD
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09:45
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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01:20

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EM:RAP 2017 March Written Summary 580 KB - PDF

Sterile gloves, sterile saline, betadine prep… are any of them essential in wound preparation? We used to think so, but it seems like nothing is sacred. Wound experts Brian Lin and Jonathan Kantor give their laceration repair tips and personal practices (which may deviate from what you learned in training).

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Ian L., Dr -

Those sterile bags can be clumsy and 10 ml Sterile Saline Plastic Ampoules that come in 50s are better .
Apply gently .
Good that immunocompetency was mentioned the diabetic elderly in the nursing home who has fallen on the road and has some gravel in the wound .

Brian L. -

great point Ian! thanks, BWL

Michelle S. PA-C -

I work in wound care and emergency medicine. I have been doing wounds for 11 years. I am struggling with the thought of using chlorhexidine on a clean laceration. The cytotoxic effects could be pretty devastating to the healing process, especially for an elderly patient with fragile skin. Even the thought of chlorhexidine on a fairly dirty wound makes me cringe. Can the speaker discuss why they would choose this over something like Prontosan (combination of Polyhexanide and Betaine) or Shur-Clens? Clearly cost is some issue but, if studies show there is not a lot of difference in healing between saline, water, chlorexidine and the others and chlorexidine is cyto-toxic, why not choose the tissue safe cleanser in a clean lac? I appreciate your input and feedback. Thank you.

Brian L. -

Michelle, thanks so much for listening and for this opportunity to comment. Due to editing of the segment you didn't get to hear all of my thoughts on this issue, so I will share some of them here.
Firstly, and I am sure Dr. Kantor would agree, I wouldn't suggest actually rubbing chlorhexidine (or any other bactericidal agent) within a wound. I agree with you, it would likely be (at least in theory) detrimental for wound healing. I would suggest using this agent around the margins of a wound on intact skin, but not within, so as to prevent introduction of more bacteria within the wound (such as when you drive the suture needle in to the surrounding skin).
In truth, I don’t strongly favor chlorhexidine over betadine. On any given day, I am more likely to use whatever is readily available. This is because, as Dr. Kantor said, there is no evidence that one is better than the other--and due to the low baseline rates of wound infection, such a study will likely never be generated. I do tend to favor chlorhexidine simply for the sake of convenience: when the repair is done, I don’t have to deal with the extra step of going back to remove the unsightly orange betadine from the wound (which can sometimes put the sutures at risk for dehiscence).
Finally, to address your questions regarding these specialty products, I can’t say I personally have any experience with them. My quick scan of the literature surrounding these products certainly doesn’t have me convinced they are any better and I imagine they are probably more expensive. However, it once again boils down to a simple issue: availability. I am guessing most pit docs and PAs in the ER setting don’t stock Prontosan in their wound carts, but correct me if I am wrong.

Great questions by the way. You certainly know your stuff!

Mike M. -

There seems to be a presumption that some type of chemical solution (chlorhex, betadine, etc) is necessary for wound cleansing. As far as I know there is no data to support this, and one can certainly imagine ways that these cyto-toxic agents could cause harm. What the available data does support is irrigation with tap water (PMID: 18254034 , PMID: 23325896). I'm a fan of keeping things simple. More is not always better, and I don't think that we should be promoting the use of these agents as part of routine wound care.

Brian L. -

Thanks for the comment. I agree. While I still prefer to use some type of antibacterial agent in my wound prep (force of habit I suppose?) I try to ensure to keep it on the skin surface adjacent to the wound rather than within the wound itself, where cytotoxicity is a relevant concern.

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Crashing Slowly Full episode audio for MD edition 238:10 min - 332 MB - M4AEM:RAP 2017 March German Edition Deutsche 73:21 min - 101 MB - MP3EM:RAP 2017 March Spanish Edition Español 89:05 min - 122 MB - MP3EM:RAP 2017 March Aussie Edition Australian 16:33 min - 23 MB - MP3EM:RAP 2017 March French Edition Français 25:15 min - 35 MB - MP3EM:RAP 2017 March Canadian Edition Canadian 28:50 min - 40 MB - MP3EM:RAP 2017 March Board Review Answers 262 KB - PDFEM:RAP 2017 March Board Review Questions 218 KB - PDFEM:RAP 2017 March MP3 Files 316 MB - ZIPEM:RAP 2017 March Written Summary 580 KB - PDF

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