Sunday, March 7, 2010

Ouch, Managing Acute Wounds

Certainly we see a lot of wounds in the ED. From scrapes to avulsions, the ED is THE place to get experience dealing with acute wounds. Despite such massive experience, misconceptions and improper practices abound in ED wound management. As EMPs, WE should become the hospital’s experts in acute wound management, practice accordingly, and avoid dogmatic and potentially detrimental practices.

Fortunately, the skin is a very resistant organ to injuries and the basic premise of wound management is to facilitate this organ’s ability to heal itself. In most cases this will require only minimal work, such as wound cleansing or approximation of wound margins. Only in rare cases are any specialized techniques required. I basically classify wounds according to their depth, superficial or partial-thickness, full-thickness, and puncture wounds. I am excluding penetrating injuries of the head, neck, or trunk in this blog article.

Superficial wounds would include such injuries as abrasions and partial-thickness lacerations. These wounds require little care. They should be appropriately cleansed and dressed and left to nature. Wound cleansing is simple; wash or irrigate the wound thoroughly. Remember that ED wounds are far from sterile and studies have shown that copious cleaning and irrigation with tap water is just as effective as using sterile solutions. A mild soap is sufficient. Betadine is a great skin disinfectant, but is highly cytotoxic and should never be used on non-intact skin. Said another way, it’s great to cleanse the skin before a procedure (chest tube, central line, IV) through intact skin, but it should never be put on an open wound.

If cleaning an abrasion is painful to the patient, I would suggest putting some viscous xylocaine on the wound before serious cleaning. Since this is water soluble, it will easily irrigate away. Partial thickness lacerations may be either left as is, or approximated with fingertip pressure and coated with cyanoacrylate glue. Unless the wound is glued, it may be treated with antibiotic ointment or cream. I recommend that if you use such an agent, a cream (water soluble) is preferable to an ointment for ease of cleansing. I also do not recommend any preparation with neomycin to avoid common and sometimes serious skin reactions (sorry Neosporin). None of these preparations have any real effect on the rate of infection, but epithelial migration in the early stages of wound healing is theoretically aided by maintaining a slightly moist, but not wet, environment.

Full-thickness wounds will likely require approximation of the wound margins to speed healing and reduce scarring. Initial treatment is the same as for superficial wounds, just more cleaning. In wounds where suturing will be required, local anesthesia should be performed after initial irrigation if any significant exploration or debridement will be needed. The patient will be grateful. Wounds must be explored until you can see the bottom of the wound. After all visible foreign material is removed, irrigate the wound thoroughly again. Debride only severely traumatized, non-viable tissue from the wound and avoid revising the margins or under-mining the skin unless absolutely necessary.

When suturing, remember that no void should be left deep to the surface. This will only increase the rate of infection or abscess formation after suturing. This may be accomplished by various methods depending on the thickness of the skin. Sometimes a well-placed simple suture is sufficient. In deeper wounds, the vertical mattress is an excellent method of closure. In very deep wounds, a layered closure with an absorbable suture deep to the surface may be required to eliminate voids. I will almost never use glue for primary closure of a full-thickness wound, but I have had excellent results using these products to approximate skin tears common in the elderly.

When closing the skin, approximate carefully and with only enough tension to bring the margins to approximation. The wound edges should be slightly everted if properly done. This is best accomplished by placing each suture in a single motion and at a uniform depth. While holding the needle driver essentially at the center of the wound axis, place the needle tip perpendicular to the skin and simple roll the needle driver 190 degrees through the skin until the needle reappears opposite the entry point. When the suture is tied, the skin should be well approximated and slightly everted. Rinse…repeat. With a little care and attention to detail, every wound should close nicely. Be careful not to place the sutures too close together, as this can compromise blood flow.

Occasionally there will be a question of how long after an injury can a wound be safely closed. Opinions vary from 6-12 hours depending on the location and other factors. In truth, almost any reasonably clean wound can be sutured within 24 hours if there are no signs of infection. Over 24 hours, or if the wound is grossly contaminated, it is a reasonable strategy to thoroughly clean the wound, dress carefully and delay closure for 72 hours. If there are no signs of infection at 72 hours, the wound may be closed with little effect on cosmetic outcome. Infected wounds should be cleaned and treated with appropriate antibiotic therapy. There is no evidence that prophylactic antibiotic therapy prevents wound infections and I generally reserve this practice only for those at extremely high risk (bites, punctures, significant wounds on diabetics, etc.).

A lot of providers often wonder when they should call plastics for a wound. In truth, with proper experience, most EMPs could close almost any wound quite well. Remember plastic surgeons mainly inflict and then repair wounds to achieve a cosmetic effect with a bit of pre-injury planning. For most ED type wounds, the results of a plastic surgeon will be no better cosmetically than that of a decent EMP. Even simple wounds of the lip can be closed quite well, as long as meticulous attention is paid to approximately the vermillion border. I will consult plastics in specific facial situations. These include the following:

· Wounds involving the eyelid margins, periorbital fat, canthal structures around the eyes;
· Wounds involving the full thickness of the lip, or at the corners of the mouth;
· Wounds injuring the cartilage structures of the ears or nose.

Once your wounds are closed, the final consideration is suture removal. Suture duration, along with excessive suture tension, is one of the most important considerations for cosmetic outcome. Sutures in areas that heal faster need to be removed sooner. The following guidelines generally work well:

· Face 3-5 days
· Scalp and trunk 7 days
· Extremities 10-14 days

Puncture wounds are generally treated as any other wound, with two exceptions; Bites and puncture wounds that penetrate through the sole of a shoe and into the foot. Wound cleaning remains basic. Wash and irrigate. If there are gaping wounds, these can be approximated loosely by suture. A snug closure may become problematic in the event of an infection. If the EMP elects to perform a meticulous skin closure following a bite injury, then a drain should be placed in the wound and follow-up arranged in 2 days. Simple wounds to the face are exceptions, as these are less likely to become infected because of excellent facial blood flow. Bite wounds to the hands, particularly joints, should be urgently evaluated by orthopedics and dog bites should be routinely radiographed for fractures or retained tooth fragments due to the bite forces even smaller canines can produce. These injuries are less likely from felines or humans and your clinical exam can be your guide in these cases.

In addition to routine would care, with or without closure, patients should be started on an antibiotic regimen for a minimum of five days with close follow-up evaluation. The agent(s) of choice are oral ampicillin or Augmentin. For potential open joint injuries, Unasyn or Rocephin are acceptable choices pending orthopedic evaluation in the ED.

Puncture wounds to the foot, particularly through the sole of a shoe may be problematic injuries. These punctures may carry foreign material and pathogens from shoe material into the foot and cause severe infections in the soft tissues or osteomyelitis. These injuries should be considered high-risk. Like canine bites, radiography may show any radiopaque foreign bodies or bone injury. Extensive exploration of the wound is generally unproductive, but a single incision at the entry site may reveal superficial foreign material. Antibiotic therapy should cover pathogens such as pseudomonas. Ciprofloxacin would be an acceptable initial choice.
The final consideration in wound care is tetanus prophylaxis. If the patient has current tetanus immunization status (full primary series and a booster within 5 years), then no booster is indicated. If the patient is not current (no primary series and/or no booster within 5 years), then a dose of TIG should be given along with the tetanus toxoid booster.

1 comment:

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