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- Wounds and Lacerations: Emergency Care and Closure
- Noninvasive Wound Closure in the Emergency Department
- Wounds and Lacerations in the ED: Management Pearls and Pitfalls for Emergency Physicians
Wounds and Lacerations: Emergency Care and Closure
The evaluation and treatment of acute injuries accounts for approximately Lacerations and other acute wounds are an important subset of acute injuries with approximately 9 million seen yearly in US Emergency Departments alone Special considerations such as location and extent of injury as well as infection risk should be given to determine the optimal closure type and timing. We will delve into the basics of laceration management including evaluation, wound cleaning, closure methods, closure timing, special considerations based on location, and the diagnoses that cannot be missed.
Clinical Case 1: A healthy year-old male presents to your ER for a right arm laceration and pain. A man attacked him with a piece of a broken glass bottle in an attempted robbery. The patient reports only a painful stab wound to the right forearm. You inspect the arm and see a 2. The patient denies any sensory deficits at the site and distally. The patient is unable to tolerate both active and passive range of motion due to severe pain.
Clinical Case 2: A morbidly obese, otherwise healthy year-old female presents to your ED via ambulance with concerns for an open fracture. Patient fell onto her right leg with her proximal shin striking the edge of a metal step. She has a large 13 cm gaping laceration with exposed fat and muscle and without obvious bony or tendon injury. X-ray of her lower extremity proved there was no bony involvement of either the tibia or fibula but demonstrated extensive soft tissue injury. Upon further visual inspection, the laceration is rather close to the knee joint, and gapes open when she bends her knee.
The patient has normal sensation, normal capillary refill, and full range of motion distally with minimally decreased range of motion at the knee secondary to discomfort from the wound. Clinical Case 3: A year-old male with a history of hypertension and medication-controlled diabetes presents with a six-centimeter linear laceration to the left medial upper arm, with minimal extension into the axilla.
The patient injured himself while fixing a fence post on his farm two days prior to his arrival in the ED. He slipped and fell, sustained the wound and landed in a pile of mud and excrement. He has some mild pain, but the main reason he came today was because of increased drainage from his wound.
Clinical Case 4: An year-old female presents with foot pain after stepping on broken glass. She has full range of motion, normal capillary refill, and normal sensation. She has a 1. There are no obvious foreign bodies, but she feels a sharp sensation when pressure is applied to the area. The pathway to healing occurs in sequential fashion; briefly summarized by a hemostatic phase which includes platelet aggregation and clot formation, a proliferative phase mediated by leukocytes, and the maturation and remodeling phases that gradually improve wound tensile strength and integrity 2.
The history behind a wound is an important part of the initial evaluation i. The history helps determine whether radiographic data- either X-ray, computed tomography, or ultrasonography- is necessary. If the mechanism of injury e. Plain radiography can identify metallic or other radiodense foreign bodies, determine if there is underlying bone cortex involvement or overt fracture, and can also diagnose an open joint if intra-articular air is seen. Ultrasound, either formal or point-of-care, can be useful in the identification of retained foreign bodies by providing information on depth, location, and orientation relative to the probe.
A CT scan will allow for the most detailed evaluation- giving a 3-dimensional assessment that can visualize foreign bodies, bone injuries, joint involvement, vascular injuries, and muscle disruptions that need to be repaired. Imaging modalities, however, cannot diagnose compartment syndrome and the emergency physician should keep the possibility on their differential during initial and repeat evaluations.
Obtain tetanus vaccination history, and update as needed- for large, contaminated wounds ensure patient has had at least three prior doses and one within the last five years.
If anyone has a contaminated wound and has not yet had three doses, they will require tetanus immunoglobulin in addition to an updated tetanus toxoid vaccine 2. Immunocompromised patients- those on biologic agents or chemotherapy agents, chronic steroid use, and diabetic patients are automatically at higher risk for infection and poor wound healing. Patients with peripheral vascular disease also pose an infection risk, as a healthy blood supply is necessary to prevent infection 4.
Wounds that present to the ED are dirty by definition, not the same clean incisions that surgeons often manage in the operating room. Removal of gross contamination of dirt, debris, foreign bodies as well as bacterial load begins with wound irrigation.
Start with wiping away visible contamination with dampened cloth to be able to visualize wound edges appropriately 5. A recent randomized control trial including over patients performed in an ER setting showed no statistical difference between infection rates with sterile saline wound irrigation compared to potable tap water irrigation 6. The double-blinded study controlled for important factors including volume of irrigation, pressure and technique of irrigation while a small study with an ultimate sample of , it is the largest study to date.
Potable tap water is a safe option for wound irrigation and should be considered if cost or availability of sterile saline is an issue 6. The pressure used to irrigate a wound has implications beyond cleaning and can lead to damage of the wound bed, wound edges, or vascular supply which can inhibit proper healing 2. A multitude of opinions exist to describe the optimal pressure for irrigation, but varied data results are available for consideration There are difficulties reliably measuring the pressure of irrigation across an entire wound bed, so assumptions are made regarding the actual pressure attained.
A common rule seen is to aim for pressures of approximately 5 to13 psi- which is the pressure to break the adhesion between bacteria and surfaces 2. Multiple techniques have been described to obtain this pressure including irrigation caps attached to bottles, or gauge angiocatheters attached to cc syringes filled with solution, or simply running under a tap of clean water 2, 3. There is no evidence-based consensus on how to achieve optimal pressure with the irrigation fluid of your choosing, so local practice habits should be taken into consideration The volume of irrigation is another debated topic, but more is generally better.
The minimum recommended is about cc solution per 1cm of wound. Adjust the amount of solution used based on the amount of contamination as necessary 2, 7. The earlier you can irrigate the wound, the better. Ideally irrigation is performed after anesthetizing to decrease pain and improve ability to fully explore wound 3. Do not let a delayed presentation to treatment prevent full irrigation and exploration.
This involves immediate fixation of the deep and dermal layers with sutures, staples, adhesive tapes or tissue adhesive 8. Involves wound packing with return visit in days after wound occurrence and decision to close with sutures, staples, adhesive tape, or tissue adhesive if no signs of infection are present. This is a good method for older wounds or wounds at risk for infection 2. Devitalized wounds have areas of skin or tissue with compromised blood supply and are at risk of infection due to affected delivery of blood products.
Healing is unaided by sutures, staples, or adhesives 2. This is a good method for infected or highly contaminated wounds 2. Instead of closing the skin around debris or bacteria, healing from the inside out allows contaminates to escape as the wound heals.
This type of closure will result in scar formation as wound edges are not approximated, keep this in mind during your discussion with the patient. Local anesthetics typically work by disrupting sensory nerve conduction 8.
Typically, ester or amide anesthetics are used i. Warming anesthetics to body temperature can reduce the pain on injection 8. Other options for local anesthesia can include topical lidocaine-epinephrine-tetracaine LET , diphenhydramine or ketamine 8.
LET is frequently used in children but has application in adults as well 3. LET, however, is not readily available and requires local compounding. Diphenhydramine is an option for local anesthesia, however, is the least effective in terms of analgesia 8.
Finally, local infiltration of ketamine has been shown to have as effective analgesia as bupivacaine 8. Pros: Provides the most amount of tensile strength — necessary for gaping wounds and wounds near moving joints. Explore the wound for underlying skull fracture, and consider head CT scan before or after evaluation based on clinical picture and circumstances surrounding the injury.
Large lacerations, blunt trauma, loss of consciousness, current altered mental status are some examples to consider head CT scan during your full evaluation The easiest closure method are staples as this provides a rapid closure with good strength in an area with low cosmetic concern Simple interrupted with nonabsorbable sutures can also be a consideration if time permits, or cosmesis is concerning e. When exploring wounds, ensure the galea aponeurosis is intact and if not, repair the galea prior to superficial repair The galea is the attachment of facial musculature, and therefore has an important role in maintaining facial structure and symmetry especially during facial expression.
The closure is also needed to prevent the possible spread of infection through the potential space close to the skull Galea closure is best performed with absorbable sutures- either 3. Deep wounds require muscle repair to preserve function- this is best achieved with simple interrupted stitches with absorbable sutures 3. Remove superficial sutures in days To prevent downstream cosmetic and functional complications, included blocked lacrimal ducts and delayed infections.
Simple lacerations should be repaired with or nonabsorbable suture. Avoid adhesive in this area to prevent accidental eyelid closure or eyelash involvement. Remove sutures in days. Ears : Cartilage structures are at high risk for hematoma formation, which can lead to strangulation of the tissue and disfiguration. Apply pressure dressing to prevent hematoma formation- place gauze behind ear and wrap gauze circumferentially around head. See this article on EMDocs for examples of compressive dressing.
Establish a wound recheck in 24 hours to assess for hematoma formation. For lesions that penetrate through outside to inside, close mucosal layer first with absorbable suture, followed by muscular layer, then finally skin. Involvement of the Vermillion border should be the first approximated suture on the skin layer- this is an appropriate skill for emergency physicians, but is best to consider your local practice patterns. Use suture to improve cosmesis. Remove skin sutures in days 10, Fist Fight Injuries: Do not suture.
Provide prophylactic antibiotics if there are not yet signs of infection- cover for polymicrobial infection sources including S. Aureus, Streptococcus spp. Patient requires follow up for wound check in days; if signs of infection are present or develop patient will require IV antibiotics 12, Tendon injuries are often missed, particular partial tendon injuries and lead to decreased hand function if not appropriately identified 14, Tendons should be repaired with or nonabsorbable suture in a figure-of-eight stitch to bring the cut edges together or closely approximated simple interrupted sutures.
Noninvasive Wound Closure in the Emergency Department
The evaluation and treatment of acute injuries accounts for approximately Lacerations and other acute wounds are an important subset of acute injuries with approximately 9 million seen yearly in US Emergency Departments alone Special considerations such as location and extent of injury as well as infection risk should be given to determine the optimal closure type and timing. We will delve into the basics of laceration management including evaluation, wound cleaning, closure methods, closure timing, special considerations based on location, and the diagnoses that cannot be missed. Clinical Case 1: A healthy year-old male presents to your ER for a right arm laceration and pain.
Pages·· MB· Downloads·New!. Wounds and Lacerations: Emergency Care and Closure 3rd Edition Alexander T. Trott.
Wounds and Lacerations in the ED: Management Pearls and Pitfalls for Emergency Physicians
Traumatic wounds and lacerations are common pediatric presenting complaints to emergency departments. Although there is a large body of literature on wound care, many emergency clinicians base management of wounds on theories and techniques that have been passed down over time. Therefore, controversial, conflicting, and unfounded recommendations are prevalent.
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Join NursingCenter to get uninterrupted access to this Article. When you buy this you'll get access to the ePub version, a downloadable PDF, and the ability to print the full article. Emergency department ED providers spend a significant amount of time treating low-acuity medical conditions, such as simple laceration repairs.
With Wounds and Lacerations: Emergency Care and Closure, you'll get clear, concise guidance on the latest techniques and strategies for treating lacerations, wounds, and burns. This medical reference book will help you optimize every aspect of patient care based on current literature and guidelines. Sign Up Log In. Try a Free Sample. Trott With Wounds and Lacerations: Emergency Care and Closure, you'll get clear, concise guidance on the latest techniques and strategies for treating lacerations, wounds, and burns. Table of Contents Buy as you go Buy by the chapter and never pay more than the price of the full book. Chapter 2: Patient Evaluation and Wound Assessment.
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