The Use of Multiple Negative Pressure Wound Therapy Modalities to Help Manage Extensive Wounds Caused by a Crush/Sheer Injury

In 2014, the World Health Organization estimated that 5.8 million people die of injuries worldwide, which is a small proportion of the number of people injured.^1,2 Traumatic injuries can be classified as being caused by blunt trauma, penetrating trauma, crush injury, blast injury, burns, degloving injury, and animal bites. These wounds vary greatly in their severity—from soft tissue injuries to extending to the bone and internal organs.

Managing extensive wounds caused by crush/sheer injury can require several treatment modalities to effectively treat and ultimately heal the wounds. Negative pressure wound therapy (NPWT) has been utilized for many years to achieve wound healing at a quicker rate. With the addition of instillation wound therapy, wounds can be treated and closed even sooner, resulting in greater patient satisfaction as well as decreased cost.²

By using NPWT as an intervention in wound care, clinicians have the opportunity to facilitate wound healing. The device applies negative pressure to the wound bed, which increases tension to the tissue and capillary blood flow. Granulation tissue and the growth of new blood vessels are the result of this application. This therapy also is thought to reduce the bacterial burden in the wound by removing wound exudate that contains enzymes that are involved in inflammation and decreasing edema.³

While standard NPWT has been used for many years and found to be very effective in healing wounds, the addition of the instillation of fluids and allowing them to dwell for a specific time in the wound bed is increasingly being used with much success.¹ Negative pressure wound therapy with instillation and dwell time (NPWTi-d) may help manage bacterial bioburden by removing exudate and cleansing the wound bed.

In this report, the author presents a complex case in which 2 distinct NPWT modalities were instrumental in helping manage extensive wounds resulting from extreme crushing/sheering forces.

This is the case of a 22-year-old male, who was in his normal state of health at the time of the vehicular run-over accident. During a college celebration, the patient fell off a parade float and was run over by the next float in the parade. The injuries were severe and life-threatening, so the patient was rushed to the local hospital and stabilized. From there, the patient was flown by helicopter to a level 1 trauma center where he underwent emergency surgery to evaluate and repair the most life-threatening injuries and to assess for internal bleeding The patient’s injuries included multiple facial fractures and lacerations, bilateral acetabular fractures, superior and inferior pubic rami fractures, left sacral fracture, left compartment syndrome, and degloving injury of the scrotum and perineum with distraction of the testicles from the scrotum (Figure 1).

Initially, treatment focused on stabilization. The plastic surgery service was consulted as well as vascular surgery, orthopedic surgery, an ear nose and throat specialist, and the trauma service. At 3 days post injury, the patient underwent open reduction and internal fixation of the left parasymphyseal fracture, left muscle flap for coverage of the exposed femoral artery patch, and a diverting colostomy due to the exposed perineum (Figure 2). At 10 days post injury, the patient was taken back to the operating room for debridement of the necrotic and infected pubic bones bilaterally, placement of the right rectus abdominus pedicle muscle flap for coverage of the left groin, scrotal debridement, and pouching of the right testicle in the upper right thigh (Figure 3). Negative pressure wound therapy was applied to maintain the integrity of the tissue after this debridement and changed every 3 days, most of the time in the operating room.

The patient developed wound complications, including increased white blood cell count and fever, indicating a possible wound infection, which would be potentially life-threatening in this already compromised patient. At approximately 32 days post injury, the decision was made by the plastic surgeons to apply NPWTi-d (V.A.C. VERAFLO Therapy; 3M + KCI) (Figure 4). The device was applied by intermittently instilling 60 mL of normal saline with a 10-minute dwell time, followed by negative pressure at -125 mm Hg for 3.5 hours; NPWTi-d was applied for 11 days with dressing changes every 2 to 3 days.

At approximately 41 days post injury, the patient’s surgeons determined the wounds were ready for grafting. The patient underwent split-thickness skin grafts to the left thigh, perineum, right thigh, and right arm (Figure 5). Traditional NPWT (V.A.C Therapy; 3M + KCI) then was applied using a special 4-chamber pump because there were multiple wounds to cover. The NPWT dressing served as a bolster to achieve adherence of the skin grafts. At 49 days post injury, NPWT was discontinued, and Polymem WIC Silver (Ferris Mfg. Corp.) dressing was applied on all skin graft sites. The dressing was changed daily at the patient’s bedside until discharged to a rehabilitation facility at 80 days post injury.

Due to the extent of the injuries and major life alterations that they caused, the patient struggled emotionally with the fear of possibly not being able to walk, hesitations involving body image issues, and concerns over the whole recovery process. The patient’s parents were very involved in their son’s care regimen, especially learning to care for the colostomy. The patient became depressed, not wanting to eat or engage in conversation. The psychology service was consulted, and the patient was prescribed an anti-depressant that helped improve mood and change his outlook on life—the patient realized that if the patient was going to get better, he had to want to get better.

The patient achieved full recovery after spending almost 4 months in the hospital and a rehabilitation facility. The patient has resumed all activities of daily living (Figure 6).

Individuals sustaining life-threatening injuries are a challenge to any health care team. This patient survived his injuries due to the multitude of wound modalities used in his care. This case demonstrates the efficacy of using NPWTi-d. When used with other modalities, NPWTi-d can be successful in treating severe life-threatening injuries. The solution used for irrigation in this case was normal saline; however there are other solutions that can be utilized.⁴ This case demonstrates that normal saline can be very effective and less cost prohibitive.

In the literature, it has been reported that patients who were treated with NPWTi-d have an increased chance of secondary wound closure, less time in the hospital, and faster healing rates than those treated with just NPWT.⁵

There are many options available to the surgeon for the treatment of traumatic injuries. Negative pressure wound therapy has been proven to be beneficial by decreasing the number of dressing changes and reducing pain.⁵ By combining treatment modalities, patients who have undergone complex trauma can be saved and returned to their activities of daily living.

Note: The author would like to acknowledge Tamara Morehouse, BSN, RN, CWCN (Barnes- Jewish Hospital), and Ida Fox, MD (Plastic Surgery, Barnes-Jewish Hospital), for their contribution in the management of this patient's injuries as well as their work in coauthoring a poster related to this case study, which was presented at the 2018 Symposium on Advanced Wound Care in Las Vegas, Nevada.

Author: Terri Reed, BSN, RN, CWON

Affiliation: Barnes-Jewish Hospital, Wound/Ostomy, St. Louis, MO

Correspondence: Terri Reed, BSN, RN, CWON, Wound/Ostomy RN, Barnes-Jewish Hospital, Wound/Ostomy, #1 Barnes-Jewish Hospital Plaza, St. Louis, MO 63110; terri.reed@BJC.org or reedterri@sbcglobal.net

Disclosure: The author discloses no financial or other conflicts of interest.