Wounds - pediagenosis
Article Update

Thursday, September 12, 2019


Wounds often involve visible areas, the face and upper limb, where cosmetic as well as functional outcome is important. Wounds are generally incised – caused by sharp objects, or lacerated – caused by blunt force. An abrasion is a wound where the upper layers of the skin are removed, but there is no surface break. A wound where the depth exceeds the width or length is described as a puncture wound.

Wounds, Analgesia, Close the wound, Glue, adhesive strips, staples, dressings, Tetanus, antibiotic prophylaxis

Bleeding should be stopped using direct pressure or tourniquets: blind clamping should be avoided. Bleeding from scalp wounds can be controlled by full-thickness sutures using 2/0 nylon.
Any wound near a fracture is assumed to communicate with it, and should be covered by a clean saline-soaked dressing and anti-biotics administered immediately.
Toxic bites (e.g. from snakes, spiders) should be treated accord- ing to local protocols. Snake bites can be painless, and venom may cause paralysis or catastrophic anticoagulation. Antivenom derived from animal serum is quite toxic in itself, so should not be given unless toxicity is certain.

Medical notes from the Emergency Department are used to write legal reports: avoid words like ‘cut’ or ‘stab wound’ unless you are an expert. Unless you witnessed the injury, use ‘alleged’ and quote the patient’s own words wherever possible, e.g. ‘Alleged assault – patient says was “hit with bottle outside a nightclub”.’ Accurate descriptions with measurements, diagrams and photographs are very helpful. Occupation/hobbies, hand dominance, allergies and tetanus status should be recorded.

Look Assess skin loss and viability, contamination, cut muscle or crush injury.
Feel Test motor and sensation (before local anaesthetic infiltration).
Move Test muscle and tendon and muscle function while observing the wound. If the wound is very painful, this is best done after infiltration of local anaesthetic.

Foreign body
Examination cannot reliably exclude foreign bodies (FBs), which are common in motor vehicle accidents, puncture wounds and clenched fist injuries. Imaging is not necessary for most wounds; X-ray if the FB is radio-opaque, i.e. metal or most glass. Ultrasound is useful, but is operator dependent.

Assess the wound
Is the wound complex or dirty?
        Complex: the wound is large, involves crushed tissue, FBs, injection under pressure or extends into deep structures like muscles, tendons or joints. These wounds have a high risk of infection or compartment syndrome (Chapter 15).
        Dirty: if there is obvious contamination or the wounds is >6
hours old. Patients with reduced immune function (e.g. diabetes, steroids) are at increased risk of infection.
Consider the reason for the wound (e.g. fall, domestic violence), and any other potential injuries.

Is it safe to close the wound in the Emergency Department?
All complex or obviously contaminated wounds should be referred for exploration and closure in an operating theatre.
The options for wound closure are:
        Primary closure – close the wound immediately. This gives the neatest scar, but risks infection by trapping bacteria within the wound.
        Delayed primary closure – clean, give antibiotics for 48 hours, then close. This reduces the risk of infection in dirty wounds.
        Secondary healing – allow the wound to heal on its own. It heals more slowly, and there is more risk of scarring.

Local anaesthetic (LA) is injected around wounds to allow thorough cleaning and suturing (Chapter 5). Lidocaine1% ± adrenaline (epinephrine) 1 : 100 000 is the most commonly used LA. Pain on LA injection is reduced by using a small needle, warming the LA and injecting slowly through wound edges. For wounds to be glued, use topical lidocaine with adrenaline applied onto a piece of gauze, cover and leave for 20 minutes.

Clean the wound
A tourniquet can be used to ensure a bloodless field. Hair near a wound may need to be cut or shaved, but not eyebrows or eye-lashes. Use a syringe and 19 G needle and drinking-quality water to irrigate the wound under pressure: guard against splashback by wearing a mask and eyewear. Remove non-viable tissue and ensure embedded grit is removed to prevent tattooing.

Close the wound
Interrupted non-absorbable nylon sutures allow drainage and minimise tissue tension and ischaemia. If there are potential spaces within the wound where a haematoma could form, or there would be tension on the skin sutures, deep absorbable sutures (e.g. polygalactin/polyglycolic acid) are used.
Timing of suture removal is a balance between scarring (shorter time better) and wound strength (longer time better). For facial wounds, 5 days is best; for wounds over extensor surfaces of joints, 14 days.

Glue, adhesive strips, staples, dressings
Tissue glue (similar to domestic Superglue®) or adhesive strips are effective for simple wounds, providing the wound edges are easily opposed without tension. The effectiveness of adhesive strips is increased by pre-coating the skin with Friar’s Balsam. Staples are a fast way of closing linear wounds that do not need a perfect cosmetic result, especially scalp, limb or self-harm wounds.
If the wound is dry, a clear vapour permeable dressing allows inspection. If there are exudates, a dressing that is absorbent yet non-adherent is preferable.

Tetanus, antibiotic prophylaxis
Wounds that are dirty or complex are prone to tetanus. If a patient has had full tetanus immunisation, further boosters are not necessary unless the wound is heavily contaminated, e.g. with soil), in which case tetanus immunoglobulin is given.
Antibiotics are not a substitute for adequate wound cleaning. Antibiotics are indicated in wounds at high risk of infection or with established infection: flucloxacillin covers Staphylococcus and Streptococcus.

Special situations
Bite wounds from humans or animals are prone to infection due to the combination of crushed tissue and inoculation with saliva. Wounds should be cleaned and 5 days of broad-spectrum antibiotics (e.g. co-amoxiclav) prescribed.

Wounds that risk hepatitis or HIV transmission should be thoroughly cleaned. Blood should be taken and local policies consulted about follow-up.

Pre-tibial lacerations
Elderly patients can tear the thin skin over the anterior tibia. The skin should be stretched to cover as large an area as possible and early plastic surgery review arranged.

Facial wounds
Facial wounds are closed up to 24 hours after injury as cosmesis is important, and the excellent blood supply provides some protec- tion against infection. Antibiotic ointment can be used instead of systemic antibiotics.

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