Emergency Wound Management

8/9/2019 Emergency Wound Management

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Source : Emergency Medicine, a comprehensive study guide, by Judith E Tintinaly



FIG. 42-1. Handling of the skin withskin hook (left) and open limb of fine f orceps (right).

[Reproduced with permissionf rom Singer AJ, HollanderJE(eds): Lacerations and Acute Wounds.An Evidence-Based Guide. Philadelphia,PA: FA Davis, 2003, p. 109.]



I More tissue \in

depth than \at

surface

Needle rolled in arc

Needle holder rolledSkin edge retracted

FIG. 42-2. Placement of simple interrupted percutaneous sutures. The

distance of the suture f rom the wound edge is greater at the depth of the wound than at the surf ace,

promoting wound edge eversion when tightened. [Reproduced with permission f rom Singer AJ, Hollander JE

(eds): Lacerations and Acute Wounds. An Evidence-Based Guide.

Philadelphia, PA: FA Davis, 2003, p. 115.]



FIG. 42-3. Placement of continuous percutaneous

sutures. The suture crosses the wound superf icially at

a 65° angle and traverses the depth of the wound at a

90° angle, perpendicular to the wound.

FIG. 42-5. Placement of continuous subcuticular sutures.

Small horizontal bites are taken beneath the dermal-epidermal junction. Slight backtracking of the needle path

should be perf ormed to ensure wound coaptation.

[Reproduced with permission f rom Singer AJ, Hollander

JE (eds): Lacerations and Acute Wounds. An Evidence-Based

Guide. Philadelphia, PA: FA Davis, 2003, p. 125.]



FIG. 42-4. Placement of deep dermal sutures.

The needle is inserted at the depth of the dermis and directed upward, exiting beneath

the dermal-epidermal junction. Then the needle is inserted across the wound and directed

downward, exiting at the wound base. The suture knot is then placed deep in the wound.

[Reproduced with permission f rom Singer AJ, Hollander JE (eds): Lacerations and Acute

Wounds. An Evidence-Based Guide. Philadelphia, PA: FA Davis, 2003, p. 121.]



FIG. 42-6. Placement of horizontal half-buried

mattress sutures.

The needle enters the skin on one side of the

laceration, passes across the gap, traverses the

tip of the f lap underneath the epidermis,

crosses the gap at the other side, and then

exits the skin f rom the other side. [Reproduced

with permission f rom Singer AJ, Hollander JE(eds): Lacerations and Acute Wounds. An

Evidence-Based Guide. Philadelphia,

PA: FA Davis, 2003, p. 130.]



FIG. 42-7. Placement of vertical mattress sutures.

The f irst bite is taken f ar f rom the wound, the needle is

reversed, and the second bite is taken close to the wound

edge. The wound edges evert as the knot is tied.[Reproduced with permission f rom Singer AJ, Hollander JE

(eds): Lacerations and Acute Wounds. An Evidence-Based

Guide. Philadelphia, PA: FA Davis, 2003, p. 127.]

FIG. 42-8. Application of tissue adhesive.

The wound edges are held in apposition with the f ingers of

the nondominant hand as the tissue adhesive is applied.

[Reproduced with permission f rom Singer AJ, Hollander JE(eds): Lacerations and Acute Wounds. An Evidence-

Based Guide. Philadelphia, PA: FA Davis, 2003, p. 90.]



FIG. 43-2. Skin tension lines are perpendicular to

underlying muscles



TABLE 43-2 Suturing Guidelines for the Face and Scalp

Area Suture Size Anasthetic RemovalScalp & Face

Galea

Muscle

Skin

Forehead

Face

Eyelids

Nylon

Monof ilamet or braided absorable

Staples

Nylon

Rapidly Absorbing

Coated or Plain Nylon

Tissue Addhesive


Tissue addhesive


4-0

4-0

Standard

4-0

4-0

6-0

May need deep layer

6-0

May need deep layer

6-0 or 7-0

Local or Supraorbital




Local, inf raorbital,or mandibular

Supra- or Inf ra-orbital

Not Removed

Not Removed

7-10 days

5 days

5 days

3 days

Nose

Cartilage

Skin

Braided Absorbable


5-0

6-0

Intranasal pack (no epinephrine)

Intranasal pack (no epinephrine)

Not removed

3-5 days

Ears

Cartilage

Skin

Coated Nylon

Coated Nylon

6-0

6-0

Auricular Block (no epinephrine)

Auricular Block (no epinephrine)

Not Removed

5 days

Lips

Mucosa

Muscle

Skin

Rapidly Absorbing

Monof ilament or Braided Absorbable

Plain or Coated Nylon

5-0

4-0 or 5-0

6-0




Not Removed

Not Removed

3-5 days



FIG. 43-3. Key stitches in the forehead.

FIG. 43-4. Eyelid anatomy. A. External landmarks. B. Simple

closure of a superf icial laceration of the upper lid



Orbicularis Oris Muscle

FIG. 43-6. Irregular-edged vertical laceration of the upper lip.

A. Traction is applied to the lips and closure of the wound is begun f irstat the vermilion-skin junction.

B. The orbicularis oris muscle is then repaired with interrupted,

absorbable 4-0 synthetic sutures.

C. The irregular edges of the skin are then approximated.



FIG. 43-7. A. Laceration through auricle. B. One or two

interrupted,6-0 coated nylon sutures will approximate divided

edges of cartilage. C. Interrupted nonabsorbable 6-0 synthetic

sutures approximate the skin edges



FIG. 43-8. Pressure dressing for ear

lacerations.

A. Gauze placed behind auricle.

B. Bandage wrapped around head with two

ends cut f or tying.

C. Ends tied.



FIG. 43-9. Anatomic structures of the cheek.

(1): The course of the parotid duct is deep to aline drawn f rom the tragus of the ear to the

midportion of the upper lip. Branches of the

f acial nerve: temporal (T), zygomatic (Z), buccal

(B), mental (M), and cervical (C).



TABLE 44-1 Motor Testing of the Peripheral Nerves of the Upper Extremity

Nerve Motor Exam

Radial Dorsif lexion of wrist

Median Thumb abduction away f rom the palm

Thumb interphalangeal joint f lexion

Ulnar Adduction/abduction of digits

TABLE 44-2 Sensory of Peripheral Nerves in the upper extremity

Sensory Nerve Area of Test

Radial First dorsal web space

Median Volar tip of index f inger

Ulnar Volar tip of little f inger



TABLE 44-4 Flexor Tendons in the Forearm

Flexor Tendon Function

Flexor carpi radialis Flexes and radially deviates wrist

Flexor carpi ulnaris Flexes and ulnarly deviates wrist

Palmaris longus Flexes wrist

Flexor pollicis longus Flexes thumb at MCP and IP joint

At index, middle, ring and little f ingers:

Flexor digitorum superf icialis

Flexor digitorum prof undus

Flexes digits at MCP and PIP joints Flexes

digits at MCP, PIP, and DIP joints

Abbreviations: DIP = distal interphalangeal; PIP = proximal interphalangeal;

IP = interphalangeal; MCP = metacarpophalangeal.



FIG. 44-2. Horizontal mattress sutures for

multiple parallel lacerations



FIG. 44-3. Pull-through subcuticular suture.



FIG. 44-4. Extensor tendon laceration repair

with a f igure-of -eight stitch



FIG. 44-5. A. Mallet finger. B. Boutonniere

deformity.



FIG. 44-6. Anatomy of the perionychium.

[Reproduced with permission f rom Zook EG:

The perionychium, in DP Green, (ed):O perativeHand Surgery, 2d ed. New York, NY:

Churchill Livingstone, 1988,p. 1332.]

FIG. 44-7. Fingertip amputations.A. Volar angulation without bone exposure. B. Volar

angulation with bone exposure. C Transverse or

perpendicular angulation with bone exposure. D. Dorsal

angulation with bone exposure. [Reproduced with

permission f rom Russell RC: Fingertip injuries, in J McCarthy

(ed): Plastic Surgery. Philadelphia, PA: Saunders, 1990, p.

4479.]



FIG. 44-8. Technique for repair of an avulsion of

the germinal matrix using three horizontal mattress

sutures. (Reproduced with permission f rom

Chudnof sky CR, Sebastian S: Special woundsNailbed, plantar puncture, and cartilage. Emerg Med

Clin North Am 10:808, 1992.)



FIG. 44-9. String technique f or ring removal. A.

Completely wrapped. B. Unwrapping with ring

advancing off with the string



Posterior tibial a

Tibial n.

Achilles tendon

Lateral malleolus

Saphenous n.

Tibialis anterior tendon

Deep peroneai n.

Extensor hailucis longus tendon

Deep peroneai n.

Superf icial peroneai n.

FIG. 45-1. Anatomy of the ankle and f oot.



FIG. 45-2. Sensory innervation to the f oot.



FIG. 46-1. A. This patient's leg was punctured by a wooden stake 2 days prior to

presentation. Surrounding cellulitis and point tenderness lateral to the wound indicated theprobability of a retained f oreign body. B. The entrance to the wound was extended. C. A 1.5-

cm piece of woodwas removed f rom a 3.5-cm-deep wound.



TABLE 46-3 Indications for Foreign Body Removal

Potential for inflammation or infection

Vegetative or chemically reactive material

Heavy bacterial contamination (e.g., teeth,

soil)Proximity to f ractured bone

Established inf ection

Allergic reaction

Toxicity

Spines with venom

Heavy metals Functional andcosmetic problems

Impingement on nerves, vessels, or tendons

Restriction of joint mobility

Proximity to tendons

Impairment of gait

Persistent painCosmetic def ormity (e.g., tattooing)

Psychological distress

Potential for later injury

Intraarticular location

Intravascular location

Migration toward important structures



FIG. 46-2. A. An incision is made

perpendicular to the needle at its midpoint.

B. The needle is grasped through the

incision with a hemostat and backed out of

the puncture woundFIG. 46-4. To remove a friable foreign body

such as a wood splinter that is parallel to the

skin surf ace, an incision is made along its long

axis. The object can be lif ted out and the entire

length of the wound inspected f or remnants.



FIG. 46-3. A. The entrance site is enlarged with a skin incision. B. If the

incision passes to the side of

the object, the skin is undermined. C. Pressureon the skin edges displaces the f oreign body into the center of the wound.



FIG. 46-5. Block excision is eff ective f or f oreign bodies that are f riable, diff icult

to f ind, buried in f atty tissue, or stain surrounding tissue. A. A small, elliptical

incision is made around the original wound. B. The incision is undercut untilcontact is made with the f oreign body. C. The block of tissue is grasped with a

f orceps, the f oreign body is clamped with a hemostat, and both are removed.



FIG. 46-6. Subungual f oreign bodies that are

beyond the reach of a splinter f orceps can be

exposed by excising a wedge of the overlying

nail.



FIG. 46-7. Anatomy of a fishhook.

FIG. 46-8. Simple retrograde

technique. While pressing the

skin over the tip of the hook to

disengage the barb and applying

gentle downward pressure on the

shank, the physician backs the

hook out of the skin. If the barb

catches on skin f ibers, other

techniques must be used.

FIG. 46-9. String-pull technique.

String or suture material is tied to the

curve of the hook. The hook is

positioned as described in the simple

retrograde technique, and a quick

pull on the string will dislodge the

hook.

FIG. 46-10. Needle-cover

technique. The area isanesthetized, and an 18-gauge

needle is inserted into the

entrance wound along the hook.

The lumen of the needle is placed

over the barb to cover it, and both

the hook and needle are backed

out of the wound.

FIG. 46-12. Incision technique.

The area is anesthetized, and a

smallincision is made along the

shaf t of the hook to the barb.

The hook iswithdrawn throughthe incision.



FIG. 46-11. Advance-and-cut technique. The area is anesthetized, and the tip of the

hook is advanced through the skin surf ace (A), the barb is cut (B), and the hook is

rotated back out of the original wound (C).



TABLE 48-1 Empiric Antibiotics for Wound Infections

Clinical Situation First-Line Agent Alternative Therapy Comment

Uncomplicated cellulitis First-generation cephalosporin or

antistaphylococcal penicillin

Macrolide

Patient with underlying

immunodef iciency

Amoxicillin-clavulanate or

secondgenerationcephalosporin

Clindamycin plus a f luoroquinolone

Patient with prosthetic heart valve

or orthopedic implant

Consider adding vancomycin

or orthopedic implant to standard

regimen

Give prophylaxis bef ore

manipulating abscesses

Barnyard injuries, f ecal

contamination


secondgeneration

cephalosporin

Fluoroquinolone plus either

clindamycin or metronidazole

Saltwater exposure Third-generation cephalosporin ±doxycycline

Fluoroquinolone V ibrio may cause hemorrhagic,bullous lesions

Freshwater exposure Antipseudomonal aminoglycoside

or

antipseudomonal penicillin

Fluoroquinolone Aeromonas or Pseudomonas may

be

involved

Abscesses, inf ections due to

intravenous drug use


secondgeneration

cephalosporin

Clindamycin Antibiotics usually not necessary,

incision and drainage essential

Necrotizing f asciitis Imipenem or meropenem Oxacillin plus gentamicin

plus clindamycin

Bite wounds Amoxicillin-clavulanate or

cef oxitin/cef otetan

Clindamycin plus either a

f luoroquinolone or

trimethoprimsulf amethoxazole

Open f racture First-generation cephalosporin or

antistaphylococcal penicillin

Vancomycin

Plantar puncture wound

osteomyelitis

Cef tazidime Ciprof loxacin



TABLE 48-2 Recommendations for Tetanus Prophylaxis



TABLE 48-3 Time from Wound Closure Until Removal of Sutures or Staples

Location Number of Days

Face 3-5

Scalp 7

Chest 8-10

Back 10-14Forearm 10-14

Fingers 8-10

Hand 8-10

Lower extremity 8-12

Foot 10-12

Emergency Wound Management

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