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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.
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 issue of Emergency Medicine Practice: Trauma Extra! 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.
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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
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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, intradermal anesthesia, suture, suturing, suturing techniques, tissue adhesive, adhesive strips, staples, hair apposition, facial laceration, eyelid laceration, cheek laceration, intraoral laceration, lip laceration
Price: $99
+4 Credits!
Stacey Barnes, DO; Katrina D’Amore, DO, MPH; Marco Propersi, DO; Miguel Reyes, MD
Bonny J. Baron, MD; Jennifer Maccagnano, DO, FACEP, FACOEP
December 15, 2021
December 14, 2024
4 AMA PRA Category 1 Credits.™ Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME and 1 Pharmacology CME credits, subject to your state and institutional approval.
CME Information
Date of Original Release: December 15, 2021. Date of most recent review: November 15, 2021. Termination date: December 15, 2024.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME and 1 Pharmacology CME credits, subject to your state and institutional requirements.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) identify areas in practice that require modification to be consistent with current evidence in order to improve competence and performance; (2) develop strategies to accurately diagnose and treat both common and critical ED presentations; and (3) demonstrate informed medical decision-making based on the strongest clinical evidence.
CME Objectives: Upon completion of this activity, you should be able to: (1) describe the initial steps of wound evaluation in the emergency department; (2) prepare a wound for closure, including irrigation and anesthesia; (3) select the appropriate methods and materials for wound closure; and (4) identify wounds that are at high risk for complications.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Barnes, Dr. Baron, Dr. D'Amore, Dr. Maccagnano, Dr. Propersi, Dr. Reyes, Dr. Shah, and their related parties report no relevant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This supplement to Emergency Medicine Practice did not receive any commercial support.
Earning Credit: Read the PDF and complete the CME test online.
Hardware/Software Requirements: You will need a computer, tablet, or smartphone to access the online archived article and CME test.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit www.ebmedicine.net/policies
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