Acute Traumatic Wounds
Acute traumatic wounds such as lacerations ( Fig. 17.1 ) and crush injuries are frequent presenting complaints to emergency and urgent care settings. Acute wounds can be broadly classified as puncture, laceration, avulsion, amputation, or a combination of the aforementioned. A puncture is a wound that is deeper into the tissue than it is long across the tissue, whereas a laceration is longer than it is deep. An avulsion involves loss of soft tissue, whereas an amputation involves loss of bone.
The goal of acute wound care is to improve outcomes and reduce complications such as functional deficits and infection. Acute wound management is much more than simply suturing lacerations. Although suturing a wound decreases tension and improves cosmesis, it can also increase the risk of infection as wounds need to drain cellular debris and bacteria while healing. The “tighter” (meaning the closer together the sutures are placed as well as the number of tissue layers sutured) the wound is closed, the less it is able to drain, thereby increasing the risk of infection. Wound infections can put patients at risk of serious complications, including side effects from then required antibiotics, need for hospitalization and/or surgical interventions, significant scarring, decreased function of affected area, and even loss of limb or life. As such, proper wound care is essential to ensuring good outcomes.
Acute wounds can be managed in three general ways. Primary closure is the reapproximation of tissue using sutures, staples, skin adhesive, or surgical tape to close the wound at the time of injury. This is a common approach to relatively low-risk wounds to help improve cosmesis and healing time. Secondary intention occurs when the wound is cleaned and dressed but is not closed, allowing the wound to heal on its own. This approach is more commonly used in high-risk wounds where a potential infection is likely to worsen the outcome. A tertiary or delayed primary closure technique can be used for wounds that, are too contaminated or present outside the time frame for primary closure. On initial presentation, the wound is cleaned and a wet-to-dry dressing applied. Over the next 72- to 96 hours, host immune defenses will lower the bacterial load in the wound an enable a primary closure, either in the ED or by a specialist. This approach is an excellant option for high-risk wounds that cannot be closed at the time of injury but require primary closure to maintain function or cosmesis, such as a dog bite to the hand (function) or face (cosmesis).
To provide proper wound care, one should obtain a brief history, perform a good physical examination, and formulate an appropriate management plan specific to the patient and their injury. A brief patient history should include the location of the wound, patient risk factors, mechanism of injury, time of injury, and treatments rendered prior to arrival. The anatomic location of the wound must be considered, as highly vascularized wounds, such as those on the head, tend to heal faster with a lower risk of infection compared with wounds with poor vascularity, such as a wound on the foot. Diabetes, obesity, malnutrition, chronic renal failure, immunosuppression, anticoagulation, larger wounds, and extremes of age are also associated with impaired wound healing and increased risk of infection.
Time between injury and wound care also effects outcomes as bacterial load in the wound increases significantly around the 6-8 hour mark. The time frame in which primary closure of laceration is optimal is not well supported by research. Traditionally, closure times for low-risk wounds have been 24 hours for the face, 12 hours for upper extremities and 8 hours for lower extremities. Ultimately, the provider will dertermine the appropriagte timing and closure method based on the risk-factors of the patient and the wound as well as evidence-based best practices.
Understanding the mechanism of injury will provide insight concerning the type of wound, as well as additional factors associated with poor outcomes. Bites and other crush injuries can lead to devitalized and necrotic tissue, open fractures, and bacterial contamination. Conversely, a laceration from a clean knife may have less contamination risk, however, it can be associated with significant injury to blood vessels or tendons. The mechanism of injury can also provide insight as to the presence of a foreign body, a significant source of infection, and possibly even litigation if overlooked.
Once patient and wound factors have been considered, a physical examination should be performed. Appropriate evaluation requires adequate lighting and hemostasis. Wounds should be evaluated for devitalized tissue, involvement of deeper structures ( Fig. 17.2 ), and foreign bodies. A physical examination should include assessment of sensation, vascular involvement, range of motion, and strength. Anesthesia may be necessary for proper wound evaluation but should only be completed following a sensory examination. Specialist evaluation should generally be considered for all wounds involving sensory deficits, significant vascular injury, tendon injury, involvement of a joint space, or wounds communicating with fractures (termed open fracture ). Once a wound has been examined, always reapproximate the tissue as best possible and cover with slightly moistened gauze followed by a dry dressing in order to optimize vascular support and prevent desiccation and resultant necrosis of tissue while awaiting definitive care.
Preparing a Wound for Laceration Repair
Proper wound care can be performed following the patient and wound evaluation. Vasovagal syncope is a potential response to seeing blood and injuries. Always protect your patient by placing them in the supine position before performing wound care. Limit the number of people in the room and ensure that visitors remain seated. The ED technician should work in an ergonomic position to maintain comfort and efficiency. Proper personal protective equipment includes eye protection and gloves and should be used at all times. Any needed supplies should be ready at the bedside on a clean mayo stand.
Preparation for closure begins with skin preparation, including the removal of any debris and cleaning of the skin surrounding the wound. Any area of skin that will be part of the aseptic field should be prepped so as to prevent cross-contamination. Common skin preparation agents include iodine and chlorhexidine-based agents. These should only be used to cleanse intact skin, as they are cytotoxic. Soaking wounds in antiseptic solutions should be avoided. Hydrogen peroxide is also cytotoxic; however, it can be used to break up stubborn dried blood around the wound. Never use hydrogen peroxide in or on a wound.
Wound preparation is achieved through irrigation under pressure. When done properly, irrigation mechanically debrides contaminates and dilutes bacteria concentrations to levels not associated with infection. Wounds should ideally be irrigated with sterile saline or sterile water. Sterile saline is used more frequently than sterile water as it is more physiologically similar to human tissue and does not damage healing tissue. Research suggests that tap water irrigation and wound cleaning does not necessarily increase infection rates and may be an acceptable alternative for wounds that are at very low risk for infection or complicated wound healing. A pressure of 5 to 8 psi is required to achieve adequate cleaning without causing tissue destruction. This can be achieved using a 30- to 60-mL syringe with commercially available products ( Fig. 17.3 ) that also prevent splashing of the technician or by using an 18- or 20-gauge angiocath with a medicine cup used as a splash guard. Wounds with little to no contamination should be irrigated with a minimum of 50 to 100 mL/cm of wound. Use at least twice that amount for contaminated or higher-risk wounds. Wounds involving open bone or tendons require 1 to 2 L of irrigation. Open joints typically require washouts with high volumes in the operating room. After cleaning, wounds can be prepped for closure or dressed appropriately if no closure is indicated.
Aseptic Technique
Wounds that are closed in the ED should be done so using aseptic technique to limit risk of infection. Aseptic technique involves the use of special processes, sterile materials, and sterile barriers to prevent transmission of microorganisms from the environment and provider to the patient during a procedure.
Aseptic wound closure is achieved by:
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Reducing microorganism load on the skin with an antiseptic skin preparation
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Reducing microorganism load within the wound with irrigation
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Creating a dry sterile field around the wound using sterile drapes
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Using sterile equipment and materials placed only on a sterile surface, including:
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Sterile gloves
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Sterile instruments
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Sterile supplies
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Avoiding contamination while performing the procedure, including:
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Maintaining a sterile field between the wound and sterile procedure tray
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Minimizing traffic, visitors, and personnel around the procedure area
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Allowing only sterile-to-sterile contact during procedure (e.g., only sterile gloves touch sterile instruments)
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Sterile procedure trays are typically set up on a mayo stand that is placed near the patient in such a way as to limit the space between the patient and procedural supplies while optimizing the provider’s position during the procedure ( Fig. 17.4 ). Always wipe down the mayo stand with an antimicrobial product according to the product’s instructions, and allow it to dry before use.
Equipment and supplies commonly used for a laceration repair that should be included on the sterile tray include ( Fig. 17.5 ):
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Laceration tray
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These typically include sterile drapes and instruments but may also include a plastic tray for irrigation solution, a splash guard, a syringe for irrigation or injection, needles of varying size, plastic cups that can be used for skin preparation product, and gauze.
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The sterile wrapping around the tray is often used as the sterile drape that covers the mayo stand, thereby creating the sterile field that all additional supplies can be placed on.
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Irrigation solution (sterile saline or water poured into plastic tray using aseptic technique)
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Skin preparation product
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Suture material
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Bacitracin or emollient-impregnated dressing
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Gauze wrap (2 in for digits, 3 in or 4 in for extremities)
If not already included in the laceration tray, add:
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Sterile instruments including Webster needle driver, Adson 1 × 2 teeth forceps, and Iris scissors
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Sterile 4-in × 4-in gauze (can use the container to hold sterile irrigation solution off the field if needed)
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Splash guard
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30- to 60-mL syringe for irrigation
Always ask the provider performing the procedure if they have any specific needs, including suture type, size and needle, scalpel (commonly #10, #11, or #15), as well as postprocedural dressing, which may include antibiotic ointment, impregnated gauze (such as Xeroform), nonstick gauze (such as Telfa) and nonsterile items such as elastic bandage or splint (See , Sterile Field for Laceration Repair). Remember, only sterile items should be placed on the sterile field. Once the technician has prepared a wound for closure, it is important that the wound and field be kept aseptic and that the wound be closed by the provider as soon as possible (See , Preparing for Laceration Repair).
Acute Wound Dressings
Although multiple specialized dressings are available, most sutured and open acute wounds can be dressed with an application of a thin layer of antibiotic ointment or other emollient, such as petroleum jelly, followed by a nonadherent bandage and then wrapped in gauze. If the wound was closed primarily, this is done using aseptic technique. The dressing acts to both maintain moisture balance and to protect the wound from contamination. Facial wounds typically do not require a gauze covering because the face is highly vascular and fast healing, which inherently decreases risk for infection. Always ask a patient about allergies before using antibiotic ointment. If they do have an allergy or if it is unknown whether they do, use petroleum jelly. Wounds susceptible to hematoma formation should be covered with a gentle pressure dressing. Circumferential dressings should not impede circulation; always check for good capillary refill (<2 seconds) and distal pulses after a dressing is applied. Extremity wounds, particularly those on the hand and/or fingers, should be elevated whenever possible to help decrease swelling. Wounds that occur on or near joints should be splinted, typically in the position of comfort, to decrease tension on the wound as it is healing (See , Finger Dressing).
Follow-up and aftercare are crucial aspects of proper acute wound management. Patients should be instructed to observe wounds for signs of infection, such as redness, warmth, drainage, and/or swelling, and to be cognizant of symptoms such as fever and increased pain. They should be advised to seek immediate medical attention for these or other concerning symptoms. Wounds at higher risk for infection, such as bites, punctures, crush injuries, highly contaminated wounds and wounds involving deeper structures such as tendons or bone, should be reevaluated in the ED in 24 to 48 hours.
Patients with wounds closed with sutures or staples should return for removal after adequate time has passed to allow healing, but before the inflammatory reaction from the suture becomes problematic. A general guideline is 7 days for scalp wounds, 5 days for facial wounds, 7 to 10 days for extremity and trunk wounds, and 12 to 14 days for wounds over joints or in areas of high tension.
Suture and Staple Removal
When a patient returns for suture or staple removal, the wound must be evaluated for appropriate healing prior to removal. Factors that may complicate the healing process include:
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Foreign body reaction: Look for nontenderness, redness without tissue warmth, occasionally with swelling, localized to wound edges or suture sites.
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Infection: Look for erythema spreading out around the wound edges; feel for increased tissue warmth, induration, fluctuance, and tenderness.
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Dehiscence: Look for well-approximated wound edges versus overlapping or rolled-in edges. Edges that rolled in or overlapped without notice during wound closure tend not to heal properly. In such cases, leaving the sutures or staples in longer will not improve healing; they will need to be removed and the wound be allowed to heal secondarily.
Always have a medical provider evaluate a wound prior to removing sutures or staples. Once they are removed, apply a clean wound dressing. For the face and scalp, an emollient dressing like bacitracin or petroleum jelly alone can be used (See , Suture Removal; See , Staple Removal).
Chronic Wound
When a wound fails to heal by normal healing processes, it is considered a chronic wound. Common medical conditions associated with poor wound healing or development of chronic wounds include diabetes mellitus, infection, malignancy, peripheral vascular disease, poor mobility, and venous hypertension. Other contributing factors include foreign bodies, poor nutritional status, medications, focal pressure, and a history of radiation. Based on the causative etiologies, the Wound Healing Society classifies chronic wounds into four categories: pressure ulcers, diabetic ulcers, venous ulcers, and arterial insufficiency ulcers. Patients may also present with poorly healing traumatic or surgical wounds resulting from significant tissue loss, infections, poor wound care, or limited access to appropriate resources.
Assessment
A detailed wound history helps determine causative factors and guides treatment. This includes underlying medical conditions, inciting or contributing factors, progression of the wound (changes in size, drainage, or other symptoms), current wound care regimen, previous treatment, and prior wounds. Physical examination includes evaluation for signs of infection, including blanching erythema surrounding the wound, increased warmth of tissue, edema, lymphangitis (red streaking proximally), foul odor, warmth, fever, increasing tenderness, and purulent drainage. Additionally, the provider will look for the presence and quality of peripheral pulses and evaluate sensation in the surrounding area and distal to any wound.
Chronic Wound Types
Arterial Insufficiency Ulcers
In patients with arterial insufficiency, arterial blood flow to the tissue is diminished, leading to a decrease in the delivery of oxygen and nutrients to the wound. Patients may present with claudication and/or pain at rest depending on the severity. The locations of the ulcers are typically in the most distal part of the toes where there is the least blood flow or in areas of pressure or repetitive trauma, such as contact points with footwear or between toes. The ulcers usually have sharply demarcated, punched-out margins with minimal drainage ( Fig. 17.6 ). Due to the insufficient blood flow, the wound bed of the ulcers is usually pale, gray, or yellow with very little evidence of granulation tissue growth. Gangrene may be present. Pulses may be diminished or absent. Chronic ischemia makes the skin of the foot appear thin, dry, shiny, and hairless, and the nail beds appear brittle, hypertrophic, and ridged.
Venous Ulcers
Venous ulcers are typically located between the knee and the ankle, with the medial and lateral malleolus being the most common sites. The patients generally describe a dull ache and swelling that improve with elevation. Venous ulcers are generally shallow and irregular with a wound bed lined with beefy red granulation tissue ( Fig. 17.7 ). There can be scaling, weeping, crusting, and pruritus of the skin surrounding the ulcer. The leg is usually edematous, firm, and warm with reddish-brown hyperpigmentation.
