<<Emergency Trauma Care: Current Topics & Controversies Volume IV

Chapter 4: Acute Traumatic Wounds: Evaluation, Cleansing, and Repair in the ED (Trauma CME and Pharmacology CME)

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Although most minor traumatic wounds and lacerations will heal well, proper management is required to optimize outcomes and prevent infection. A thorough assessment of the wound characteristics and any patient risk factors will be essential to guide management decisions. This supplement reviews evidence-based recommendations for the evaluation, cleansing, and repair of acute traumatic wounds, including the following:

The key components of the history and examination of the wound

When imaging is appropriate for suspicion of a foreign body

How to prepare a wound for closure, including irrigation and anesthesia options

How to select the appropriate methods and materials for wound closure based on the wound characteristics and location

Indications for the selection of the best suture type and technique

The appropriate circumstances for administration of prophylactic antibiotics

Post-repair wound care instructions

Special considerations associated with facial lacerations

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Table of Contents

 

1. Abstract
2. Introduction
3. Pathophysiology
   1. Anatomy
   2. Mechanism of Injury
   3. Phases of Wound Healing
      1. Hemostasis and Inflammation
      2. Proliferative Phase
      3. Maturation and Remodeling
4. Differential Diagnosis
5. Prehospital Care
6. Emergency Department Evaluation
   1. History
   2. Physical Examination
7. Diagnostic Studies
   1. Laboratory Studies
   2. Imaging Studies
8. Treatment
   1. Closure Decisions and Time Since Injury
   2. Wound Irrigation
   3. Aseptic Versus Sterile Technique
   4. Anesthesia
      1. Topical Anesthetics
      2. Intradermal Anesthesia
      3. Nerve Blocks
      4. Anesthesia Adjuncts and Procedural Sedation
   5. Sutures
      1. Simple Interrupted Suture
      2. Continuous Running Suture
      3. Running Subcuticular Suture
      4. Mattress Suture
      5. Corner Stitch
   6. Tissue Adhesive
   7. Staples
   8. Hair Apposition
   9. Adhesive Tape
   10. Prophylactic Antibiotics
   11. Post-Repair Wound Care
       1. Sun Exposure
9. Special Circumstances
   1. Specialist Consultation
   2. Facial Lacerations
      1. Eyelid Lacerations
      2. Intraoral Lacerations
      3. Lip Lacerations
      4. Cheek Lacerations
10. Controversies
    1. Absorbable Sutures for Percutaneous Closure
11. Disposition
12. Time- and Cost-Effective Strategies
13. Risk Management Pitfalls in Wound Management
14. Clinical Pathway for Management of Acute Traumatic Wounds in the Emergency Department
15. Tables and Figures
    1. Table 1. Dosing Recommendations for Commonly Used Local Anesthetics
    2. Table 2. Optimal Suture Material for Facial Wounds
    3. Figure 1. Proposed Diagnostic Algorithm to Enhance the Detection of Radiolucent Foreign Objects in the Hand
    4. Figure 2. Digital Block Techniques
    5. Figure 3. Simple Interrupted Suture
    6. Figure 4. Continuous Running Suture
    7. Figure 5. Running Subcuticular Suture
    8. Figure 6. Vertical Mattress Suture
    9. Figure 7. Horizontal Mattress Suture
    10. Figure 8. Corner Stitch
    11. Figure 9. Hair Apposition Technique
    12. Figure 10. Skin Tension Lines
    13. Figure 11. Lip Laceration Repair
    14. Figure 12. Cheek Anatomy
16. References

Abstract

Traumatic wounds are a common presentation in the emergency department. While most minor traumatic wounds and lacerations will heal well, appropriate management is required to preserve function and cosmesis as well as to prevent infection and other complications. This supplement reviews evidence-based recommendations for management of acute traumatic wounds, including evaluation, cleansing, anesthesia, selection of closure methods and materials, and post-repair instruction. Management of high-risk wounds and special considerations for the evaluation and repair of facial lacerations are also reviewed.

Introduction

Many of the wound care techniques used today were first practiced by ancient Egyptian, Greek, and Roman physicians, but certain aspects of wound management have evolved as medical technology has improved and new evidence has emerged, particularly in recent decades.^1-3 Traumatic wounds are among the most common conditions treated in the emergency department (ED). Approximately 7 million patients in the United States require treatment for traumatic lacerations each year, which is a rate of 1 laceration every 4.5 seconds. These injuries account for >5% of all ED visits annually.⁴ The most common location of lacerations is the upper extremity (35%), followed by lacerations to the face (28%), trunk (14.5%), lower extremity (12.5%), and head/neck (10%).^5,6

Complications of wound care that may lead to malpractice claims include missed foreign bodies, wound infection, joint capsule violation, or failure to detect nerve or tendon injury.⁷ Although the economic burden of an individual malpractice case may be relatively small, the overall financial impact of these claims is significant due to the large numbers of patients who present with wounds; litigation associated with wound management complications accounted for 3% to 11% of all dollars paid out in malpractice claims.⁷

This course reviews the evaluation and treatment of minor traumatic wounds in the ED, with a focus on evidence-based recommendations for the evaluation, cleansing, and repair of wounds.

Clinical Pathway for Management of Acute Traumatic Wounds in the Emergency Department

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, random­ized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the ref­erence, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

5. Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2017 emergency department summary tables. 2017. Accessed November 15, 2021. (Government data set)

6. * Singer AJ, Thode HC Jr, Hollander JE. National trends in ED lacerations between 1992 and 2002. Am J Emerg Med. 2006;24(2):183-188. (Retrospective systematic review) DOI: 10.1016/j.ajem.2005.08.021

7. * Pfaff JA, Moore GP. Reducing risk in emergency department wound management. Emerg Med Clin North Am. 2007;25(1):189-201. (Review) DOI: 10.1016/j.emc.2007.01.009

14. The American College of Surgeons. Stop the Bleed. 2021. Accessed November 15, 2021. (Website)

21. * Davis J, Czerniski B, Au A, et al. Diagnostic accuracy of ultrasonography in retained soft tissue foreign bodies: a systematic review and meta-analysis. Acad Emerg Med. 2015;22(7):777-787. (Systematic review and meta-analysis; 17 articles) DOI: 10.1111/acem.12714

24. * Singer AJ, Mach C, Thode HC Jr, et al. Patient priorities with traumatic lacerations. Am J Emerg Med. 2000;18(6):683-686. (Prospective observational survey; 724 patients) DOI: 10.1053/ajem.2000.16312

28. * Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘golden period’ for wound repair: 204 cases from a third world emergency department. Ann Emerg Med. 1988;17(5):496-500. (Prospective observational study; 372 patients) DOI: 10.1016/s0196-0644(88)80246-4

57. Swaminathan A. Local Anesthetic Systemic Toxicity (LAST). 2017. Accessed November 15, 2021. (Review)

96. * Nakamura Y, Daya M. Use of appropriate antimicrobials in wound management. Emerg Med Clin North Am. 2007;25(1):159-176. (Review) DOI: 10.1016/j.emc.2007.01.007

103. *Toon CD, Ramamoorthy R, Davidson BR, et al. Early versus delayed dressing removal after primary closure of clean and clean-contaminated surgical wounds. Cochrane Database Syst Rev. 2013(9):CD010259. (Meta-analysis; 4 randomized controlled trials, 280 patients) DOI: 10.1002/14651858.CD010259.pub3

112. *Sabatino F, Moskovitz JB. Facial wound management. Emerg Med Clin North Am. 2013;31(2):529-538. (Review) DOI: 10.1016/j.emc.2013.01.005

Keywords: wound, laceration, traumatic wound, wound care, wound management, wound closure, wound irrigation, wound cleansing, golden period, digital nerve block, topical anesthetics, EMLA, intradermal anesthesia, suture, suturing, suturing techniques, tissue adhesive, adhesive strips, staples, hair apposition, facial laceration, eyelid laceration, cheek laceration, intraoral laceration, lip laceration

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