The Limited Access Dressing for Damage Control in Trauma Patients

Abstract: The leeching effects of the Limited Access Dressing (LAD) effectively controls infection, reduces edema, promotes earlier physiotherapy, and helps to control secondary damage to trauma cases, which results in faster wound bed preparation, reconstruction, and quicker rehabilitation. The following is a case series of 20 consecutive patients treated with LAD without specific controls. In eight cases bone was exposed, in three cases tendon was exposed, in two cases both bone and tendon were exposed, and in one case an injured brachial artery was exposed. Methods. After saline wash, the LAD with intermittent negative pressure was applied (30 minutes negative pressure, 3.5-hour rest period). Wound debridement and physiotherapy were started on day 1 as necessary. Second stage elective procedure was done after healthy granulation tissue had covered exposed tendon, bone, and vessels. A split-thickness skin graft (SSG) was then applied to cover the wound. Results. Excellent graft take (> 99%) was seen in 18 of the 20 cases where skin grafting was done under LAD. The time taken to prepare the wound for resurfacing (after skin grafting) was less than 6 weeks in the majority (16/18) of cases. Post discharge physiotherapy to achieve maximum possible mobilization in upper extremity (10/20) cases was less than 6 weeks in most cases (6/10). The average cost of treatment was Rs. 16071.00 (US $365). Conclusion. LAD is an effective tool for damage control in trauma cases.

  Early surgical treatment of poly-trauma has not always been advocated. It was believed that the poly-traumatized patient did not have the physiological reserve to withstand prolonged operations. Extended operative procedures during the early phase of multiple trauma recovery were associated with adverse outcomes. In response, the concept of damage control in trauma patients was developed in the 1990s. The damage control methodology is characterized by primary, rapid, and temporary stabilization of patient’s general and local condition. Secondary definitive management follows once the acute phase of systemic recovery has passed.¹   Although this approach is especially adaptable to the patient with acute and complex trauma, it is also applicable to a wide variety of other non-traumatic surgical encounters. A surgeon facing a complex surgical challenge has three philosophical concepts at his or her disposal: 1) avoidance, 2) aggressive attempts at complete reversal or control of the condition, and 3) temporizing maneuvers.² The concept of initial temporary control using Limited Access Dressing (LAD) with a staged definitive approach at a later date as an elective procedure for a patient with extensive wounds (including burns) has many benefits. LAD combines the principles of moist wound healing and topical negative pressure dressing along with a provision of an additional port (12-14 Fr tube) for manipulating the wound environment without the need to change the dressing.³

Methods

  The following uncontrolled case series presents 20 consecutive patients treated with LAD within 24 hours of traumatic extremity injury (crush/avulsion/degloving/blast) in the Department of Plastic Surgery (Kasturba Medical College, Manipal, India) from January 2005 to June 2006. Primarily closure by means of SSG/flap was not indicated for any of the wounds due to the extent of contamination.   LAD application. LAD was applied after saline wash. After application of antimicrobial agents, pre-sealed ethylene oxide sterilized plastic bags with naso-gastric tubes were applied and sealed with hydrocolloid and polyurethane film. Pressure bandaging and splints were applied over the dressing if needed. Intermittent negative pressure by ordinary ward suction machine was applied for 30 minutes followed by a 3.5-hour rest period3 (interval without negative pressure or “moist wound healing period”). When indicated, physiotherapy and occupational therapy were started on day 1.   Wound debridement was performed after 5–7 days and LAD re-applied. The LAD was changed if significant leakage occurred that prevented maintaining negative pressure above 30 mmHg. Daily LAD saline wash was performed. Secondary elective procedure was performed (SSG) to cover the wound after healthy granulation tissue had covered exposed tendon, bone, and vessels.   Percentage graft take was used to assess reconstruction results: Excellent (> 99%); Fair (95%–99%); Poor (< 95%), and time taken to coverage with SSG: Excellent (within 3 weeks); Fair (SSG within 6 weeks or flap cover after 3 weeks); Poor (after 6 weeks). Results of functional recovery of hand were assessed by the requirement of post discharge physiotherapy to achieve maximum possible mobilization: Excellent (in-home physiotherapy not required 3 weeks post discharge; Fair: in-home physiotherapy not required 6 weeks post discharge; Poor (physiotherapy home program required after 6 weeks of discharge or hospital admission for physiotherapy was required).

Results

  Patient age ranged from 2- to 78-years-old (median age 34.5 years). The male to female ratio was 17:3. Of the 20 cases, 16 had crush/avulsion/degloving injuries (Figures 1–3), and 4 patients sustained blast injuries. The upper extremity was involved in 10 cases and the lower extremity in 10 cases. In eight cases bone was exposed, in three cases tendon was exposed, in two cases both bone and tendon were exposed, and in one case an injured brachial artery was exposed.   Total debridement procedures were 23 in 20 patients (range 0–3; average 1.15/patient). Of the 23 debridements, two were done in the operating theatre, seven under monitored anesthetic care, seven under spinal anesthesia, and seven under general anesthesia.   All cases had granulation over the bone, tendon, and vessels. In 18/20 cases the wound was resurfaced with SSG. One case (1/20) healed by wound contraction and epithelialization, and another healed by secondary suturing (1/20). The average cost of treatment was Rs. 16071.00, which was less than one third of the treatment cost for similar procedures using wet-to-dry dressing (cost calculation was done based on reduced number of debridement, reduced anesthetic requirement, excellent graft take, reduced post treatment physiotherapy, and rehabilitation cost). Edema under LAD in these cases was minimal. None of the cases required flap coverage.   The cases (18/20) where SSG was done under LAD had excellent graft take (> 99%). Time taken to prepare the wound for resurfacing by SSG was 3 weeks or less in 5/18 cases (excellent), less than 6 weeks in 11/18 cases (fair), and more than 6 weeks in 2/18 cases (poor). Post discharge physiotherapy to achieve maximum possible mobilization in upper extremity cases (10/20) was 3 weeks (excellent) in 4/10 cases, 6 weeks (fair) in 2/10 cases, and > 6 weeks (poor) in 4/10 cases.

Discussion

  From an administrative point of view, a reduction in required resources in emergency situations improves the quality of care. Successful damage control operations require a multidisciplinary team effort. While it is often the surgeon who makes the key decisions and initiates the strategy, he or she cannot complete the mission without the cooperation of anesthesiologists, operating room and SICU nurses, respiratory therapists, laboratory technicians, and ward clerks.⁴   Hence, to minimize the resource requirement, staging major procedures for a later date, as an elective procedure, is desirable. Postponing the resurfacing procedure in cases of large, open wounds may increase morbidity and mortality due to local (eg, infection/damage to regenerating tissue due to increased dressing changes) and systemic complications (eg, SIRS/sepsis).⁵ While waiting for the appropriate time to stage a major procedure, it is desirable to reduce complications in order to achieve the best outcome. Application of LAD and the damage control concept may reduce complications in uninfected wounds within the first 24 hours after trauma.³ LAD combines the principles of moist wound healing and topical negative pressure therapy. The moist environment protects exposed structures such as bone, tendon, and neurovascular bundles from desiccation, while negative pressure wound therapy (NPWT) has its own advantages.   More than 10 years experience with NPWT has shown its ability to significantly reduce wound infection.^6–9 Negative pressure wound therapy reduces patient anxiety and pain medication requirements.¹⁰ Patients treated with NPWT typically require dressing changes every 2–3 days compared to wet-to-dry dressings, which are changed up to 2–3 times daily.¹¹ This advantage was extended in the LAD trauma protocol by keeping it for 7 days.   In LAD occlusive dressing with limited access to the wound through tubes reduces the chances of local infection/cross-contamination infection/hospital-acquired infection, and systemic complication (sepsis). The LAD’s leeching effect reduces the risk of SIRS.³ Pain is also reduced due to the reduced frequency of dressing change and debridement.¹² In the present study, anesthetic requirements were reduced considerably. It has been well documented that chances of airway crisis is reduced if cases are treated as a staged elective procedure.¹²   Debridement procedures in the present study were on average 1.15 per patient, while in closed conventional methods, the average number of required debridement procedures is three.¹³ The LAD trauma protocol reduced the number of debridements and anesthetic requirements, provided faster wound coverage, and contributed to reducing treatment costs.   Total treatment time for all 20 cases was 773 days, and was on average 38.65 days per case (range 14–66 days; median 35 days/per case). Similar data were not available for comparison.   The ability to salvage extremities that sustain severe injury has improved through advances in surgical techniques. The chance of secondary damage due to infection will increase if definitive reconstructive procedures are postponed, especially in cases of large wounds.¹⁴ Effective infection control via LAD prevents damage and reduces antibiotic requirements and the complications prolonged antibiotic use can cause.¹⁵

Conclusion

  Substituting conventional closed dressings with LAD in trauma cases reduced the number of debridements, wound coverage time, and total hospital stay while lowering treatment costs. Hence, LAD appears to be an effective tool for damage control in trauma cases. LAD application is simple and can even be applied at the accident site using pre-ethylene-oxide sterilized bags, which will reduce infection risk and pain.
 

References

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