Lawnmower Injuries. Kyle Kenoyer PGY-1 Madigan Army Medical Center

Transcription

1 Lawnmower Injuries Kyle Kenoyer PGY-1 Madigan Army Medical Center

2 Demographics ED visits per year 75 deaths annually 7% require hospitalization 2-5 surgeries per injury 64% require amputation $457 million annually Prosthetic costs of $73140 to $ from the time of injury to the age of % of all injuries are to the lower extremities 50% of amputation from lawn mower injuries occur in the foot

3 Demographics 58-77% males Age <14 and >44 years old 20% are in children under 18 years old 11.9/ children 2000 children permanently impaired per year.

4 Recommendations American Academy of Pediatrics and the United States Consumer Product Safety Commission. Children less than 14 years of age should not be allowed to operate ride-on lawn mowers Adolescents should be trained in the use of these tools before independent use. Young children, especially those 5 years or younger, should be kept indoors when a lawn mower is in use. Continue to develop safety devices that will reduce the risk of injury to all lawn mower users.

5 Regulations Deadman s switch Required in July of 1982 Decreased lawn mower related injury by 40% Riding mower Operator presence control Higher seat back

6 Mechanism of Injury Blade spins at 3000 RPM Equivalent of dropping 211 lb weight 100 ft 3x the power of a % pulling mower backwards 24% pulling mower up a slope

7 Types of injury Laceration 41% 71% occurring on the hands or feet Soft tissue 21.4% Burn 15.5% Fracture 10.3% Missile injury 5-9%

8 Types of injury Anger DM 33 patients 40 open fractures 20 amputations 18 lacerations involving skin and nail bed 9 tendon lacerations 2 closed fx 2 segmental loss of bone 1 segmental achilles

9 Complex soft tissue wounds Types Degloving injuries Soft tissue avulsion Mutilation

10 Zones of injury Corcoran

11 Evaluation Soft tissue Osseous involvement Thorough exam (may need to use local anesthesia) Remove debris and contaminates

12 Tetanus Tetanus immune globulin is administered in the event a child has not received a minimum of three doses of tetanus toxoid, or if the immunization status is unknown. Tetanus toxoid (dt, DT, or DTaP) also is given in this situation. A booster dose should be administered if the child has not received a dose of tetanus toxoid in the last 5 years.

13 Treatment Intraoperative cultures Aerobic, anaerobic, fungal, and acid-fast organisms Open fractures -> bone biopsy Immediate and vigorous surgical debridement Pulse lavage as soon after the injury as possible

14 Infection Campbell Meta-analysis 9 studies, 355 cases 5-60% of injuries became infected Anger Mean of 3 infecting organisms

15 Organisms Harkness Fertilizer Enterobacter spp, E. coli, Klebsiella spp, Serratia spp, Citrobacter spp Environmental gram negative Enterobacter spp, E. coli, Klebsiella spp, Serratia spp, Citrobacter spp Gram Positive Enterococcus, coagulase negative Staphylococcus Staphylococcus aureus Soil related anaerobes Clostridium spp and Bacteroides spp Fungal infection has also been reported

16 Antibiotics Traumatic contaminated wounds Danger Ciprofloxacin first line Bactrim second line Ceftazidime in children Anaerobes Penicillin G or Clindamycin Absence of infection Abx course for 5-10 days

17 Antibiotics cont. Therapeutic Guidelines: Antibiotic Initiate monotherapy with zosyn or timentin or clindamycin combined with either gentamicin or ciprofloxacin For heavily soiled wounds: recommend initial therapy with vancomycin, imipenem and an aminoglycoside Fungal infection amphotericin B or voriconazole Modify once cultures become available.

18 Antibiotics cont. Gustillo and Anderson I. Clean Wound <1cm in diameter -Abx choice: 1st generation cephalosporin (Ancef) II. Wound cm in diameter with minimal soft tissue damage -Abx choice: Ancef, Clindamycin III. Wound >5cm in diameter with extensive soft tissue damage -Abx choice: Ancef (or high dose PCN), Clindamycin and Aminoglycoside

19 Treatment cont. Love 2 nd intra-operative debridement hours after injury. Planned delayed closure Graham 28 Pts multiple debridement with irrigation Peterson Multiple debridement necessary Ryan and Hume 6 cases Primary closure is contraindicated Myerson 1991 under no circumstances should the skin be closed before 5-7 days

20 Treatment cont. Corcoran 96 wounds in 70 patients Primary closure does not increase chance of infection Anger No difference between primary closure and secondary closure in regards to infection Goldsmith 9 patients Advocated for primary closure of digits and NWB surfaces.

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22 Treatment Cont. Laing Split skin grafting in 17 patients, Local fasciocutaneous flap reconstruction in 3 patients Microvascular free tissue transfer in 3 patients to reconstruct amputated heels 2 free latissimus dorsi flaps and 1 free thoracodorsal artery perforator flap.

23 Case 19 year old active duty male presents to the ED with right hallux wound secondary to a lawnmower injury. Pt was wearing military boots while mowing on a hill and slipped with his right foot ending up under the mower.

24 History PMH: denies Meds: denies Social History Current smoker 1 pack year hx Denies alcohol 11 Bravo (infantry) ROS unremarkable except what was mentioned above

25 Physical exam

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27 Plan Irrigation Wound dressed and posterior splint applied NWB to right lower extremity Ancef 1gm q8h Surgery in the AM

28 OR Debridement Pulse lavage Application of wound vac

29 Discharge Augmentin 125/875 BID Gram stain no organisms seen Pre-irrigation cultures results unavailable Post-irrigation cultures showed no growth

30 2 nd OR visit (6 days s/p injury) Debridement Graft application

31 Follow up 1 month Applied dermacell graft

32 Follow up 1 month + 1 week Reapplied dermacell

33 Follow up 2 month Pt still in CAM boot Prescribed orthotic with Morton's extension.

34 8 month follow up

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38 References Anger DM, Ledbetter BR, Stasikelis PJ, Calhoun JH. Injuries of the foot related to the use of lawn mowers. J Bone Joint Surg Am. 1995;77(5): Brook I. Recovery of anaerobic bacteria from wounds after lawn-mower injuries. Pediatr Emerg Care. 2005;21(2): Campbell JR. Infectious complications of lawn mower injuries. Pediatr Infect Dis J. 2001;20(1):60-2. Corcoran J, Zamboni WA, Zook EG. Management of lawn mower injuries to the foot and ankle. Ann Plast Surg. 1993;31(3): Costilla V, Bishai DM. Lawnmower injuries in the United States: 1996 to Ann Emerg Med. 2006;47(6): Erdmann D, Lee B, Roberts CD, Levin LS. Management of lawnmower injuries to the lower extremity in children and adolescents. Ann Plast Surg. 2000;45(6): Goldsmith JR, Massa EG. Primary closure of lawn mower injuries to the foot: a case series. J Foot Ankle Surg. 2007;46(5): Greenhagen RM, Raspovic KM, Crim BE, Ryan MT, Gruen GG. Lawn mower injuries to the lower extremity: a 10-year retrospective review. Foot Ankle Spec. 2013;6(2): Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4): Hammig B, Childers E, Jones C. Injuries associated with the use of riding mowers in the United States, J Safety Res. 2009;40(5):371-5.

39 References cont Harkness B, Andresen D, Kesson A, Isaacs D. Infections following lawnmower and farm machinery-related injuries in children. J Paediatr Child Health. 2009;45(9): Loder RT, Dikos GD, Taylor DA. Long-term lower extremity prosthetic costs in children with traumatic lawnmower amputations. Arch Pediatr Adolesc Med. 2004;158(12): Lau ST, Lee YH, Hess DJ, Brisseau GF, Keleher GE, Caty MG. Lawnmower injuries in children: a 10-year experience. Pediatr Surg Int. 2006;22(3): Laing TA, O'sullivan JB, Nugent N, O'shaughnessy M, O'sullivan ST. Paediatric ride-on mower related injuries and plastic surgical management. J Plast Reconstr Aesthet Surg. 2011;64(5): Mullins J. Lawn mower injuries: a review. J Emerg Nurs. 2010;36(1):83-4. Nugent N, Lynch JB, O'shaughnessy M, O'sullivan ST. Lawnmower injuries in children. Eur J Emerg Med. 2006;13(5): Park WH, Demuth WE. Wounding capacity of rotary lawn mowers. J Trauma. 1975;15(1):36-8. Ren KS, Chounthirath T, Yang J, Friedenberg L, Smith GA. Children treated for lawn mowerrelated injuries in US emergency departments, Am J Emerg Med. 2017; Robertson WW. Power lawnmower injuries. Clin Orthop Relat Res. 2003;(409): Vollman D, Smith GA. Epidemiology of lawn-mower-related injuries to children in the United States, Pediatrics. 2006;118(2):e273-8.