Emergency Wound Care: An Overview

Key Practice Points

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The average laceration cared for by emergency caregivers is 1 to 3 cm in length, with 13% of lacerations considered significantly contaminated.
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The most common complication of wound care is infection, occurring in 3.5% to 6.3% of lacerations.
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The most important step for reducing infection in wound care is wound irrigation.
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All wounds form scars and take months to reach their final appearance.
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95% of glass in wounds is radio-opaque, and radiographs are recommended.
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The understanding of local practice when caring for wounds, such as the use of prophylactic antibiotics for wound care, is important.

Superficial wounds, including lacerations, bites, small burns, and punctures, are among the most common problems faced by emergency physicians and other providers of urgent and primary care. Each year in emergency departments (EDs) in the UnitedStates, 12.2million patients with wounds are managed. The most frequently performed procedure in the ED, other than intravenous-line (IV-line) insertion, is wound care.

Of 1000 patients whose clinical findings were entered into a wound registry, 74% of the patients were male, with an average age of 23. The average laceration was 1 to 3 cm in length, and 13% of lacerations were considered significantly contaminated. Most wounds (51%) occurred on the face and scalp, followed by wounds on the upper (34%) and lower (13%) extremities. The remaining wounds occurred on various sites of the truncal areas and proximal extremities.

The most common complication of wound care is infection. Approximately 3.5% to 6.3% of laceration wounds become infected in adults treated in the ED. Infection is more likely to occur with bite wounds, in lower extremity locations, and when foreign material is retained in the wound. The rate of infection in children is only 1.2% for lacerations of all types.

Goals of Wound Closure

Because wounding is an uncontrolled event and there are biologic limitations to healing, the wounded skin and related structures cannot be perfectly restored. Each step of wound care serves to achieve the best possible outcome with the fewest problems.

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Hemostasis: All bleeding from the wound except minor oozing should be controlled, usually with gentle, continuous pressure, before wound closure.
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Anesthesia: Effective local anesthesia before wound cleansing allows the caregiver to clean the wound thoroughly and to close it without fear of causing unnecessary pain.
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Wound irrigation: Irrigation is the most important step in reducing bacterial contamination and the potential for wound infection.
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Wound exploration: Wounds caused by glass or at risk for deep structure damage should be explored. Radiographs and functional testing do not always identify foreign bodies or injured tendons.
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Removal of devitalized and contaminated tissue: Visibly devitalized and contaminated tissue that could not be removed through wound cleansing and irrigation needs to be completely but judiciously débrided.
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Tissue preservation: At the time of ED or primary closure, tissue excision should be resisted. It is best to tack down what remains of viable tissue, especially in complicated wounds. Because of the natural contraction of wounds, cosmetic revisions done later can be accomplished successfully if sufficient tissue remains. Unnecessary tissue excision can lead to a permanent, uncorrectable, and unsightly scar.
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Closure tension: When laceration edges are being brought together, they should just barely “touch.” Excessive wound constriction when tying knots strangulates the tissue, leading to a poor outcome. If necessary, tension-reducing techniques, such as the placement of deep sutures and undermining, can be applied.
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Deep sutures: Because all sutures act as foreign bodies, as few deep sutures as possible are to be placed in any wound.
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Tissue handling: Rough handling of tissues, particularly when using forceps, can cause tissue necrosis and increase the chance of wound infection and scarring.
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Wound infection: Antibiotics are no substitute for wound preparation and irrigation. If the decision is made to treat the patient with antibiotics, the initial dose is most effective when administered intravenously as soon as possible after wounding.
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Dressings: Wounds heal best in a moist environment provided by a properly applied wound dressing.
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Follow-up: Well-understood verbal and written wound care instructions and timely return for a short follow-up inspection or suture removal at the proper interval are essential to complete care.