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Management Of Soft Tissue Injuries

Soft tissue wounds are often managed in the ED, either by the emergency clinician or a consultant. High-velocity and shotgun wounds are the exception, as they often need meticulous debridement and frequently require second-look procedures. Smaller, isolated wounds to skin, subcutaneous tissue, and muscle are very amenable to simple irrigation and debridement. A large retrospective review by Ordog et al examined outcomes of gunshot wound patients managed with simple wound debridement, antibiotic ointment, and oral antibiotics. They found only a 1.8% incidence of wound infections, and 60% of the patients in this study were managed as outpatients.127 A small, retrospective observational study by Byrne and Curran examined the rate of successful ED management of isolated gunshot wounds to the lower extremity. They found a significantly low rate of complications compared to inpatient management, as well as significant savings in terms of total inpatient hospital days.109

When assessing injuries to the soft tissue and muscle of the involved extremity, general principles of wound care apply. The approach to wound closure must include evaluation of the degree of contamination, the timing of closure, the wound size and depth, and injury to underlying structures. Direct closure of the wound is generally not advised, so as to allow for an outlet of potential infection. Discharged patients will need to be followed for wound checks. Wounds that are large and/or deep, are not amenable to delayed closure, have significant potential cosmetic implications, or are > 8 hours old may require consultation and admission for operative treatment. In the interim, cover these wounds with saline-soaked gauze and consider a course of antibiotics. The extent of the wound should be noted, especially if the fascia is violated, as some surgeons use this to determine whether the patient needs to have formal operative debridement.128

With many penetrating injuries, compartment syndrome is possible. In particular, lower extremity vascular injuries above the knee and proximal tibia fractures are at high risk for compartment syndrome.115 The gold standard to assess intracompartmental pressure is by direct measurement of pressures within the affected compartment as well as all adjacent compartments. Pressure measurements should be performed using sterile technique and within 5 cm of the fracture site to avoid a falsely low reading. A compartment pressure > 30 mm Hg is considered positive. When the threshold pressure is crossed, fasciotomy is indicated. Delays in fasciotomy can have dire consequences, as found by Ritenour, who noted in a study of combat casualties between January 2005 and August 2006 that patients undergoing fasciotomy after evacuation from Iraq had higher rates of muscle excision (25% vs 11%), amputation (31% vs 15%), and overall mortality (19% vs 5%) versus those who had a fasciotomy prior to evacuation.129

 
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Last Modified: 07/19/2018
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