今日の臨床サポート

マイナー外傷

著者: 徳永日呂伸 敦賀市立看護大学、市立敦賀病院 救急科、長良整形外科クリニック

監修: 林寛之 福井大学医学部附属病院

著者校正/監修レビュー済:2021/11/24
参考ガイドライン:
  1. 日本外傷学会:外傷初期診療ガイドライン JATEC 改訂第6版

概要・推奨   

  1. 破傷風トキソイド接種から5ないし10年以上経過していれば、追加接種を考慮する(推奨度2)。
  1. 創洗浄に過酸化水素水やイソジンを使用するのは、薄めたとしても創処置には不適切である。クロルヘキシジンを薄めて使用するのはよい。生理食塩水または水道水で洗浄する方がよい。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
徳永日呂伸 : 特に申告事項無し[2021年]
監修:林寛之 : 講演料(メディカ出版),原稿料(羊土社)[2021年]

改訂のポイント:
  1. Cochrane Library(2019)に基づき、動物咬創の項について改訂した。
  1. 外傷初期診療ガイドライン改訂第6版に基づき、破傷風予防の項について改訂した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 「創傷」という単語があるが、正式には皮膚表層が破損しているものを創(例:縫合が必要な挫創)、皮膚表層は保たれているが内部に何らかの外傷性変化を来したものを傷(例:皮下血腫のみの挫傷)と呼ぶが、いわゆる動物に咬まれた創傷は深さを問わず動物咬傷というなどの例外的な慣習もある。
  1. ここでは、切創・裂創・割創といった縫合処置を必要とする創の診療を中心に、擦過創および刺創の診療についても少し触れる。
  1. 受傷から受診までの経過時間、受傷部位、創部の形態、患者背景を含めた多くの要素をすべて考慮したうえで、適切な創処置を行う。
  1. 適切な「洗浄液(水道水を含む)」を選択する。
  1. 破傷風トキソイド接種から5年以上経過しているかどうかや、受傷・創汚染の状態に応じて抗菌薬の予防投与、破傷風トキソイドや破傷風免疫グロブリン接種を考慮する。
  1. 異物の残存、腱や神経の損傷を見逃さない。
 
破傷風トキソイド・破傷風免疫グロブリン製剤の投与基準

注:1967年以前出生の患者(2021年で53歳が目安)では、抗体が陰性または低値陽性のことが多く、より積極的にTIGの接種を検討すべきという意見もある(参考文献:[5][17])。

出典

問診・診察のポイント  
  1. 「いつ受傷したのか」を必ず確認する。長時間経過すればするほど感染のリスクが増大する。

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文献 

著者: National Center for Immunization and Respiratory Diseases
雑誌名: MMWR Recomm Rep. 2011 Jan 28;60(2):1-64.
Abstract/Text This report is a revision of the General Recommendations on Immunization and updates the 2006 statement by the Advisory Committee on Immunization Practices (ACIP) (CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2006;55[No. RR-15]). The report also includes revised content from previous ACIP recommendations on the following topics: adult vaccination (CDC. Update on adult immunization recommendations of the immunization practices Advisory Committee [ACIP]. MMWR 1991;40[No. RR-12]); the assessment and feedback strategy to increase vaccination rates (CDC. Recommendations of the Advisory Committee on Immunization Practices: programmatic strategies to increase vaccination rates-assessment and feedback of provider-based vaccination coverage information. MMWR 1996;45:219-20); linkage of vaccination services and those of the Supplemental Nutrition Program for Women, Infants, and Children (WIC program) (CDC. Recommendations of the Advisory Committee on Immunization Practices: programmatic strategies to increase vaccination coverage by age 2 years-linkage of vaccination and WIC services. MMWR 1996;45:217-8); adolescent immunization (CDC. Immunization of adolescents: recommendations of the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Medical Association. MMWR 1996;45[No. RR-13]); and combination vaccines (CDC. Combination vaccines for childhood immunization: recommendations of the Advisory Committee on Immunization Practices [ACIP], the American Academy of Pediatrics [AAP], and the American Academy of Family Physicians [AAFP]. MMWR 1999;48[No. RR-5]). Notable revisions to the 2006 recommendations include 1) revisions to the tables of contraindications and precautions to vaccination, as well as a separate table of conditions that are commonly misperceived as contraindications and precautions; 2) reordering of the report content, with vaccine risk-benefit screening, managing adverse reactions, reporting of adverse events, and the vaccine injury compensation program presented immediately after the discussion of contraindications and precautions; 3) stricter criteria for selecting an appropriate storage unit for vaccines; 4) additional guidance for maintaining the cold chain in the event of unavoidable temperature deviations; and 5) updated revisions for vaccination of patients who have received a hematopoietic cell transplant. The most recent ACIP recommendations for each specific vaccine should be consulted for comprehensive details. This report, ACIP recommendations for each vaccine, and additional information about vaccinations are available from CDC at http://www.cdc.gov/vaccines.

PMID 21293327  MMWR Recomm Rep. 2011 Jan 28;60(2):1-64.
著者: William L Atkinson, Larry K Pickering, Benjamin Schwartz, Bruce G Weniger, John K Iskander, John C Watson, Centers for Disease Control and Prevention
雑誌名: MMWR Recomm Rep. 2002 Feb 8;51(RR-2):1-35.
Abstract/Text This report is a revision of General Recommendations on Immunization and updates the 1994 statement by the Advisory Committee on Immunization Practices (ACIP) (CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 1994;43[No. RR-1]:1-38). The principal changes include expansion of the discussion of vaccination spacing and timing, recommendations for vaccinations administered by an incorrect route, information regarding needle-free injection technology, vaccination of children adopted from countries outside the United States, timing of live-virus vaccination and tuberculosis screening, expansion of the discussion and tables of contraindications and precautions regarding vaccinations, and addition of a directory of immunization resources. These recommendations are not comprehensive for each vaccine. The most recent ACIP recommendations for each specific vaccine should be consulted for additional details. This report, ACIP recommendations for each vaccine, and other information regarding immunization can be accessed at CDCs National Immunization Program website at http.//www.cdc.gov/nip (accessed October 11, 2001).

PMID 11848294  MMWR Recomm Rep. 2002 Feb 8;51(RR-2):1-35.
著者: K Farion, M H Osmond, L Hartling, K Russell, T Klassen, E Crumley, N Wiebe
雑誌名: Cochrane Database Syst Rev. 2002;(3):CD003326. doi: 10.1002/14651858.CD003326.
Abstract/Text BACKGROUND: Tissue adhesives have been used for many years to close simple lacerations as an alternative to standard wound closure (sutures, staples, adhesive strips). They offer many potential advantages over standard wound closure, including ease of use, decrease in pain and time to apply, as well as not requiring a follow-up visit for removal. Many studies have compared tissue adhesives and standard wound closure to determine the cosmetic outcome as well as these other secondary outcomes in their respective study populations. However, due to the wide variation in study parameters, there are no generalisable, definitive answers about the effectiveness of tissue adhesives. No study has been adequately powered to assess differences in complications, which are rare.
OBJECTIVES: To summarize the best available evidence for the effect of tissue adhesives in the management of traumatic lacerations in children and adults.
SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (CD ROM 2001 Issue 4), the Cochrane Wounds Group Specialized Trials Register (Nov 2001), MEDLINE (1966 to Oct 1, 2001), and EMBASE (1988 to Sept 1, 2001) for relevant randomised controlled trials (RCTs). We also searched the citations of selected studies, and we contacted relevant authors and manufacturers of tissue adhesives to inquire about other published and unpublished trials.
SELECTION CRITERIA: We included RCTs comparing tissue adhesives versus standard wound closure or tissue adhesive versus tissue adhesive for acute, linear, low tension, traumatic lacerations in an emergency or primary care setting. Trials evaluating tissue adhesives for surgical incisions or other types of wounds were not considered.
DATA COLLECTION AND ANALYSIS: Data from eligible studies were extracted by one reviewer and checked for accuracy by a second reviewer. Two reviewers independently assessed masked copies for quality. Outcomes of cosmesis (subgroups of age, wound location and need for deep sutures), pain, procedure time, ease of use and complications were analysed separately for two comparisons: 1) tissue adhesive versus standard wound care; and 2) tissue adhesive versus tissue adhesive.
MAIN RESULTS: Eight studies compared a tissue adhesive with standard wound care. No significant difference was found for cosmesis at any of the time points examined, using either Cosmetic Visual Analogue Scale (CVAS) or Wound Evaluation Score (WES). Data were only available for subgroup analysis for age; no significant differences were found. Pain scores (Parent VAS WMD -15.7 mm; 95% CI -21.9, -9.5) and procedure time (WMD -5.6 minutes; 95% CI -8.2, -3.1) significantly favoured tissue adhesives. No studies reported on ease of use. Small but statistically significant risk differences were found for dehiscence (favouring standard wound care NNH 25 95% CI 14, 100) and erythema (favouring tissue adhesive NNH 8 95% CI 4, 100). Other complications were not significantly different between treatment groups. Only one study was identified that compared two tissue adhesives (butylcyanoacrylate (Histoacryl TM) versus octylcyanoacrylate (Dermabond TM)) for pediatric facial lacerations. No significant difference was found for cosmesis using CVAS at 1-3 months, or using WES at 5-14 days and 1-3 months. Similarly, no significant difference was found in pain, procedure time or complications. Results for ease of use were incomplete as reported.
REVIEWER'S CONCLUSIONS: Tissue adhesives are an acceptable alternative to standard wound closure for repairing simple traumatic lacerations. There is no significant difference in cosmetic outcome between tissue adhesives and standard wound closure, or between different tissue adhesives. They offer the benefit of decreased procedure time and less pain, compared to standard wound closure. A small but statistically significant increased rate of dehiscence with tissue adhesives must be considered when choosing the closure method (NNH 25).

PMID 12137689  Cochrane Database Syst Rev. 2002;(3):CD003326. doi: 10.・・・
著者: Sherry Yang, David Ozog
雑誌名: Dermatol Surg. 2015 Nov;41(11):1257-63. doi: 10.1097/DSS.0000000000000507.
Abstract/Text BACKGROUND: Bilayered suture repairs have become the standard of care in dermatologic surgery. However, the benefit of superficial sutures for fine epidermal alignment on high-tension areas remains unclear.
OBJECTIVE: To compare the overall cosmetic outcome of traditional epidermal sutures with adhesive strips in layered dermatologic repairs on the back.
METHODS: A total of 10 patients underwent standard elliptical excision on the back followed by subcutaneous closure with 4-0 polyglactin 910 buried sutures. Each half of the wound was then randomized to either 4-0 polypropylene running sutures or 1/4″ Steri-Strip films for epidermal approximation. Postoperative evaluations were completed in person at 2 weeks, 3 months, and 6 months using the Patient and Observer Scar Assessment Scale.
RESULTS: The adhesive strip group had superior appearance and greater patient satisfaction at 2 weeks. Evaluation at 3 months and 6 months revealed no statistically significant difference in overall scar cosmesis.
CONCLUSION: Adhesive strips result in equivalent long-term scar outcome when compared with traditional epidermal sutures and should be viewed as a time-saving alternative in layered dermatologic repairs on the back. This finding further corroborates that undermining and placement of deep buried sutures are the primary determinants of wound appearance.

PMID 26448315  Dermatol Surg. 2015 Nov;41(11):1257-63. doi: 10.1097/DS・・・
著者: Douglas D Cooper, Rawle A Seupaul
雑誌名: Ann Emerg Med. 2012 Nov;60(5):626-7. doi: 10.1016/j.annemergmed.2012.06.011. Epub 2012 Jul 28.
Abstract/Text
PMID 22841710  Ann Emerg Med. 2012 Nov;60(5):626-7. doi: 10.1016/j.ann・・・
著者: Ronald M Moscati, James Mayrose, Robert F Reardon, David M Janicke, Dietrich V Jehle
雑誌名: Acad Emerg Med. 2007 May;14(5):404-9. doi: 10.1197/j.aem.2007.01.007.
Abstract/Text OBJECTIVES: To compare wound infection rates for irrigation with tap water versus sterile saline before closure of wounds in the emergency department.
METHODS: The study was a multicenter, prospective, randomized trial conducted at two Level 1 urban hospitals and a suburban community hospital. Subjects were a convenience sample of adults presenting with acute simple lacerations requiring sutures or staples. Subjects were randomized to irrigation in a sink with tap water or with normal saline using a sterile syringe. Wounds were closed in the standard fashion. Subjects were asked to return to the emergency department for suture removal. Those who did not return were contacted by telephone. Wounds were considered infected if there was early removal of sutures or staples, if there was irrigation and drainage of the wound, or if the subject needed to be placed on antibiotics. Equivalence of the groups was met if there was less than a doubling of the infection rate.
RESULTS: A total of 715 subjects were enrolled in the study. Follow-up data were obtained on 634 (88%) of enrolled subjects. Twelve (4%) of the 300 subjects in the tap water group had wound infections, compared with 11 (3.3%) of the 334 subjects in the saline group. The relative risk was 1.21 (95% confidence interval = 0.5 to 2.7).
CONCLUSIONS: Equivalent rates of wound infection were found using either irrigant. The results of this multicenter trial evaluating tap water as an irrigant agree with those from previous single institution trials.

PMID 17456554  Acad Emerg Med. 2007 May;14(5):404-9. doi: 10.1197/j.ae・・・
著者: Ritin Fernandez, Rhonda Griffiths
雑誌名: Cochrane Database Syst Rev. 2012 Feb 15;2:CD003861. doi: 10.1002/14651858.CD003861.pub3. Epub 2012 Feb 15.
Abstract/Text BACKGROUND: Although various solutions have been recommended for cleansing wounds, normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective; however, there is an unresolved debate about its use.
OBJECTIVES: The objective of this review was to assess the effects of water compared with other solutions for wound cleansing.
SEARCH METHODS: For this fourth update we searched the Cochrane Wounds Group Specialised Register (searched 9 November 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Ovid MEDLINE (2010 to October Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, November 8, 2011); Ovid EMBASE (2010 to 2011 Week 44); and EBSCO CINAHL (2010 to 4 November 2011).
SELECTION CRITERIA: Randomised and quasi randomised controlled trials that compared the use of water with other solutions for wound cleansing were eligible for inclusion. Additional criteria were outcomes that included objective or subjective measures of wound infection or healing.
DATA COLLECTION AND ANALYSIS: Two review authors independently carried out trial selection, data extraction and quality assessment. We settled differences in opinion by discussion. We pooled some data using a random-effects model.
MAIN RESULTS: We included 11 trials in this review. We identified seven trials that compared rates of infection and healing in wounds cleansed with water and normal saline; three trials compared cleansing with no cleansing and one trial compared procaine spirit with water. There were no standard criteria for assessing wound infection across the trials, which limited the ability to pool the data. The major comparisons were water with normal saline, and tap water with no cleansing. For chronic wounds, the relative risk of developing an infection when cleansed with tap water compared with normal saline was 0.16, (95% CI 0.01 to 2.96). Tap water was more effective than saline in reducing the infection rate in adults with acute wounds (RR 0.63, 95% CI 0.40 to 0.99). The use of tap water to cleanse acute wounds in children was not associated with a statistically significant difference in infection when compared to saline (RR 1.07, 95% CI 0.43 to 2.64). We identified no statistically significant differences in infection rates when wounds were cleansed with tap water or not cleansed at all (RR 1.06, 95% CI 0.07 to 16.50). Likewise, there was no difference in the infection rate in episiotomy wounds cleansed with water or procaine spirit. The use of isotonic saline, distilled water and boiled water for cleansing open fractures also did not demonstrate a statistically significant difference in the number of fractures that were infected.
AUTHORS' CONCLUSIONS: There is no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it. However there is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents.

PMID 22336796  Cochrane Database Syst Rev. 2012 Feb 15;2:CD003861. doi・・・
著者: FLOW Investigators, Mohit Bhandari, Kyle J Jeray, Brad A Petrisor, P J Devereaux, Diane Heels-Ansdell, Emil H Schemitsch, Jeff Anglen, Gregory J Della Rocca, Clifford Jones, Hans Kreder, Susan Liew, Paula McKay, Steven Papp, Parag Sancheti, Sheila Sprague, Trevor B Stone, Xin Sun, Stephanie L Tanner, Paul Tornetta, Ted Tufescu, Stephen Walter, Gordon H Guyatt
雑誌名: N Engl J Med. 2015 Dec 31;373(27):2629-41. doi: 10.1056/NEJMoa1508502. Epub 2015 Oct 8.
Abstract/Text BACKGROUND: The management of open fractures requires wound irrigation and débridement to remove contaminants, but the effectiveness of various pressures and solutions for irrigation remains controversial. We investigated the effects of castile soap versus normal saline irrigation delivered by means of high, low, or very low irrigation pressure.
METHODS: In this study with a 2-by-3 factorial design, conducted at 41 clinical centers, we randomly assigned patients who had an open fracture of an extremity to undergo irrigation with one of three irrigation pressures (high pressure [>20 psi], low pressure [5 to 10 psi], or very low pressure [1 to 2 psi]) and one of two irrigation solutions (castile soap or normal saline). The primary end point was reoperation within 12 months after the index surgery for promotion of wound or bone healing or treatment of a wound infection.
RESULTS: A total of 2551 patients underwent randomization, of whom 2447 were deemed eligible and included in the final analyses. Reoperation occurred in 109 of 826 patients (13.2%) in the high-pressure group, 103 of 809 (12.7%) in the low-pressure group, and 111 of 812 (13.7%) in the very-low-pressure group. Hazard ratios for the three pairwise comparisons were as follows: for low versus high pressure, 0.92 (95% confidence interval [CI], 0.70 to 1.20; P=0.53), for high versus very low pressure, 1.02 (95% CI, 0.78 to 1.33; P=0.89), and for low versus very low pressure, 0.93 (95% CI, 0.71 to 1.23; P=0.62). Reoperation occurred in 182 of 1229 patients (14.8%) in the soap group and in 141 of 1218 (11.6%) in the saline group (hazard ratio, 1.32, 95% CI, 1.06 to 1.66; P=0.01).
CONCLUSIONS: The rates of reoperation were similar regardless of irrigation pressure, a finding that indicates that very low pressure is an acceptable, low-cost alternative for the irrigation of open fractures. The reoperation rate was higher in the soap group than in the saline group. (Funded by the Canadian Institutes of Health Research and others; FLOW ClinicalTrials.gov number, NCT00788398.).

PMID 26448371  N Engl J Med. 2015 Dec 31;373(27):2629-41. doi: 10.1056・・・
著者: Gregory W Thomas, Leonard T Rael, Raphael Bar-Or, Richard Shimonkevitz, Charles W Mains, Denetta Sue Slone, Michael L Craun, David Bar-Or
雑誌名: J Trauma. 2009 Jan;66(1):82-90; discussion 90-1. doi: 10.1097/TA.0b013e31818b146d.
Abstract/Text BACKGROUND: The cytotoxic effects of antiseptics on pivotal cell types of the healing process have been well documented. The purpose of our investigation was to explore the ability of subcytotoxic levels of antiseptics to interfere with fibroblast function.
METHODS: Cell proliferation assays were performed by culturing fibroblasts in the presence of commonly used antiseptics. Migration was evaluated using scratch assays in which monolayers were "wounded" and cellular movement was monitored by digital photography. Matrix metalloproteinase (MMP) release was analyzed by zymography.
RESULTS: H2O2 and povidone-iodine reduced both migration and proliferation of fibroblasts in a dose-dependent fashion. Treatment with silver-containing antiseptics and chlorhexidine exhibited reductions in proliferation at high concentrations, but enhanced growth at lower doses. Silver-containing compounds and chlorhexidine also proved to be the least detrimental to migration in these assays. metalloproteinase release from the cells was differently affected depending on the dosage and class of antiseptic applied.
CONCLUSIONS: When debridement of the wound bed is not sufficient to reduce bacterial loads, the application of broad-spectrum antiseptics maybe indicated. Our data would suggest that H2O2 and iodine are poor choices, potentially retarding the contribution of fibroblasts to the healing process. Silver sulfadiazine and chlorhexidine, at levels still proven to be bactericidal, had fewer detrimental effects on fibroblast activity in these assays. The silver-containing antiseptics may even increase the proliferative potential of these cells in culture.

PMID 19131809  J Trauma. 2009 Jan;66(1):82-90; discussion 90-1. doi: 1・・・

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