Présentation à l'INCAM Bruxelles - Prise en charge des plaies sur le versant infectieux

1. Basic principles of
acute and
traumatic wounds
care
Dr Arnaud DEPIL DUVAL
Chef de service – Urgences Evreux - Vernon

2. Mylan makes no claim or warranty of, and is
not responsible for, any medical, scientific or
other information that may be disseminated
through this presentation

3. Dr Arnaud Depil Duval - Urgences Evreux Vernon

4. Infectious risk
Dr Arnaud Depil Duval - Urgences Evreux Vernon

5. Risk?
• Each wound is
colonized
• But not infected

6. Protection
• Don’t bring more germs
• Use protective equipments
• Clean but not sterile
• Don’t forget the mask (especially
doctors…)

7. Cleaning and
detersion
• Abundant washing for fragments, germs,
etc
• Soaking is not indicated
• Kamolz LP, Wild T. Wound bed preparation: The
impact of debridement and wound cleansing. Wound
med 2013; 1:44-50
• No evidence of superiority of saline
solution compared to controlled tap water
• Fernandez R, Griffiths R. Water for wounds cleansing.
Cochrane Database Syst Rev 2012; 2:cd003861

8. Antisepsis
• No benefits with antisepsis
• Khan MN, Naqvi AH (2006) Antiseptics, iodine, povidone iodine and
traumatic wound cleansing. J Tissue Viability 16:6–10
• Ghafouri HB, Zare M, Bazrafshan A, Abazarian N, Ramim T. Randomized
controlled trial of povidoneiodine to reduce simple traumatic wound
infections in the emergency department. Injury 2016; 47:1913-8
• Antisepsis only required for pre-incision
• Evidence-based richtlijn voor de behandeling van wonden met een
acute etiologie in de ketenzorg

9. Water is better
• Sterile water not superior to tap
water
• Fernandez R, Griffiths R. Water for wounds
cleansing. Cochrane Database Syst Rev 2012;
2:cd003861
• Moscati RM, Mayrose J, Reardon RF, Janicke
DM, Jehle DV. A multicenter comparison of
tap water versus sterile saline for wound
irrigation. Acad Emerg Med 2007; 14:404-9.
• With soap
• Instead after suture…

10. Waiting for
exploration
• Maintained in a humid environment
with a compress soaked in water
• Economic excision and as complete
as possible of contused tissues, dead
or doomed to necrosis as well as the
evacuation of foreign bodies
• Under local or regional anesthesia
Dr Arnaud Depil Duval - Urgences Evreux Vernon

11. Suture
• No demonstrated association
between closure time and risk of
infection
• Quinn JV, Polevoi SK, Kohn MA. Traumatic
lacerations: what are the risks for infection
and has the 'golden period' of laceration care
disappeared? Emerg Med J 2014; 31:96-100
• Head up to 24h
• Berk WA, Osbourne DD, Taylor DD. Evaluation of
the 'golden period' for wound repair: 204 cases
from a Third World emergency department. Ann
Emerg Med 1988; 17:496-500
• Control after 48h

12. Antibiotherapy
• No skin specimen
• No indication for local antibiotic therapy
• Antibiotherapy to evaluate only if:
• Clinical signs of regional or systemic infection
• Late management (beyond 24 hours)
• Important or deep bacterial inoculum
• Difficulty of access to effective washing
• Particular location
• Risk about medical status of patient
• Unsatisfactory trimming
• Systematic if bite

13. Antibiotherapy
Absence of local or general infectious signs
Heavily soiled wound
Amoxicillin + clavulanic acid 1 g / 8 hours per os
If penicillin allergy
Pristinamycin 1 g / 8 hrs PO
Or Clindamycin 600 mg / 8 hr
Or Cotrimoxazole 800 mg / 160 mg / 12 hrs PO
5 days
Local ischemic terrain
Other situations No antibiotics
Presence of local inflammatory signs
Erythema / induration
peri-lesional <5 cm
even in the presence of pus
AND
no general sign
No antibiotic therapy
EXCEPT local ischemic terrain : antibiotherapy
Erythema / induration
peri-lesional> 5 cm
or
lymphangite
or
general signs
Absence of gravity
Antibiotherapy
7 days
Presence of severity criteria
local (crepitus, necrosis) or general
Immediate hospitalization
and urgent surgical opinion and infectiologist

14. Bites

15. Bites
• 30 to 50% infections
• <12h : Pasteurella multocida

16. Germs
Dr Arnaud Depil Duval - Urgences Evreux Vernon
Source Germs Diseases / incubation times
Dog and cat Pasteurella multocida
Aerobic bacteria (streptocoques, Staphylococcus aureus,
Caonocytophaga canimorsus, Eikenella corrodens)
and anaerobia (Prevotella, Fusobacterium, Veillonella,
Peptostreptococcus), Bartonella henselae (only cat), Rhabdovirus
Pasteurellosis / <24 h
Pyogenic infections / 2 days
Disease of cat's claws / 3 to 15
days
Rage / 15 to 90 days (or even
years)
Rat and
other
rodents
Pasteurella multocida
Streptobacillus moniliformis
Spirillum minus
Leptospira
Pasteurellosis / <24 h
Streptobacillary
sodoku
leptospirosis
Human Aerobic bacteria (streptocoques, Staphylococcus aureus,
Caonocytophaga canimorsus, Eikenella corrodens)
and anaerobia (Prevotella, Fusobacterium, Veillonella,
Peptostreptococcus)
Pyogenic infections / 2 days
HIV infections, HCV, HBV

17. Animal bites
(mammalians)
• If less accessible to abundant
washing
• Left open
• Drained by a greasy dressing for
a secondary closure (j4-j5)
• If absence of infectious sign
• In other cases, suture possible,
with follow-up in the first days
Dr Arnaud Depil Duval - Urgences Evreux Vernon

18. Antibiotherapy animal bites (mammalians)
Absence of local or general infectious signs
Absence of local or general
infectious signs
Amoxicillin + clavulanic acid 1 g / 8 hours per os
If penicillin allergy :
Doxycycline 100 mg / 12 hrs PO
If contraindicated cyclines AND penicillin allergy :
Pristinamycin 1 g / 8 hrs PO
Or Clindamycin 600 mg / 8 hr
Or Cotrimoxazole 800 mg / 160 mg / 12 hrs PO
5 days
Presence of local
inflammatory signs 5 days and more

19. Tetanos

20. Tetanos
Quick Test
Tetanos quick test only
if non-up-to-date
vaccination AND wound
with tetanos risk

21. Tetanos, rage and virus
Dr Arnaud Depil Duval - Urgences Evreux Vernon
Type of wound vaccinations up to date vaccinations non up to date
Minor, clean No injection
Specify the date of the next
reminder
Immediate administration of a vaccine dose (0.5 mL
intramuscular or deep subcutaneous) containing tetanus
valence.
Propose if necessary an update program and specify the
date of the next reminder
Major (extended, penetrating,
with foreign body or treated
late) or likely to have been
contaminated by telluric germs
No injection
Specify the date of the next
reminder
In one arm, human tetanus immunoglobulin, 250 IU.
In the thigh for children <3 years or <15 kg
In the other arm, administering a dose of anti-tetanus
vaccine (or prescription)
Propose if necessary an update program and specify the
date of the next reminder

22. Take home messages
• Don’t need sterile gloves only
clean
• Tap water is better
• No demonstrated association
between closure time and risk of
infection
• Indications for antibiotics
• Don’t forget tetanus vaccination