Acute Traumatic Wounds: Evaluation, Cleansing, and Repair in Urgent Care

Table of Contents

 

About This Course

Traumatic wounds are common presentations to urgent care centers. 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 course reviews evidence-based recommendations for management of acute traumatic wounds, including evaluation, cleansing, anesthesia, selection of closure methods and materials, and post-repair instructions. Management of high-risk wounds and special considerations for the evaluation and repair of selected lacerations are also reviewed. In this issue, you will learn:

The key factors to consider in the initial evaluation of traumatic wounds and lacerations in urgent care

The safest and most cost-effective methods of wound cleansing and closure

The indications for prophylactic antibiotics

Post-repair wound care instructions for patients

The wound characteristics that should prompt consultation with a specialist or transfer to the ED

1. About This Course
2. Case Presentations
3. Introduction
4. Pathophysiology
   1. Anatomy
   2. Mechanism of Injury
   3. Phases of Wound Healing
      1. Hemostasis and Inflammation
      2. Proliferative Phase
      3. Maturation and Remodeling
5. Differential Diagnosis
6. Urgent Care 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
   5. Sutures
      1. Simple Interrupted Suture
      2. Continuous Running Suture
      3. Mattress Suture
      4. Corner Stitch
   6. Tissue Adhesive
   7. Staples
   8. Hair Apposition
   9. Adhesive Tape
   10. Prophylactic Antibiotics
   11. Post-Repair Wound Care
9. Special Circumstances
   1. Specialist Consultation
   2. Facial Lacerations
      1. Eyelid Lacerations
      2. Intraoral Lacerations
      3. Lip Lacerations
      4. Cheek Lacerations
   3. Finger Lacerations
10. Controversies
    1. Absorbable Sutures for Percutaneous Closure
11. Disposition
12. Time- and Cost-Effective Strategies
13. 5 Things That Will Change Your Practice
14. Risk Management Pitfalls in Wound Management
15. Case Conclusions
16. Clinical Pathway for Management of Acute Traumatic Wounds in Urgent Care
17. Tables and Figures
18. References

Case Presentations

A 69-year-old man presents to UC after sustaining a laceration to the palmar surface of his left hand…

• Before entering the room, you read in the EMR that he has diabetes.
• The patient reports that he accidentally cut himself on broken glass while discarding trash.
• You examine the wound and find no palpable foreign bodies, no evidence of neurovascular injury, and no injury to deeper structures in his hand. You wonder whether you should obtain imaging or proceed to wound preparation and closure...

A 38-year-old woman presents to UC with a laceration through the vermillion border of her upper lip…

• She tells you that she sustained the laceration approximately 12 hours prior while playing recreational softball.
• Given the location of the laceration and the length of time since the injury, you wonder if primary closure is appropriate for this wound...

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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), accounting for >5% of all ED visits annually.⁴ A 2014 study found that 17.2 million medical visits to hospital and outpatient settings in the United States were related to acute wounds.⁵

Complications of wound care that may lead to malpractice claims include missed foreign bodies, wound infection, joint capsule violation, and failure to detect nerve or tendon injury.⁶ 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 complication has been found to account for 3% to 11% of all dollars paid out in malpractice claims.⁶

This issue of Evidence-Based Urgent Care reviews the evaluation and treatment of minor traumatic wounds in urgent care (UC), with a focus on evidence-based recommendations for the evaluation, cleansing, and repair of wounds.

Clinical Pathway for Management of Acute Traumatic Wounds in Urgent Care

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

5. Steiner CA, Karaca Z, Moore BJ, et al. Surgeries in hospital-based ambulatory surgery and hospital inpatient settings, 2014: Statistical Brief #223. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. U.S. Agency for Healthcare Research and Quality; 2017. Updated July 20, 2020. Accessed July 10, 2022. (Review)

6. * 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

9. Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2017 emergency department summary tables. 2017. Accessed July 10, 2022. (Government data set)

10. * 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

20. * 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

22. * 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

26. 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

55. Swaminathan A. Local Anesthetic Systemic Toxicity (LAST). Updated May 18, 2017. Accessed July 10, 2022. (Review)

92. * 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

99. * 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

108. *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

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