Abrasions, Avulsions, Lacerations, and Puncture Wounds
EXTENSIVE INJURIES
After evaluation and stabilization in the emergency department (ED), many patients with multiple or extensive injuries are best managed in the operating room. This is especially true in young children, particularly those with extensive facial injuries; in patients with extensive abrasions; or in patients with such widespread injuries that the acceptable maximum limits of local anesthesia will be exceeded.
INJURIES IN THE UNCOOPERATIVE PATIENT
Most patients classified as “uncooperative” will be either intoxicated or very young. Most children may be treated satisfactorily after proper reassurance and manual or mechanical restraint, if required. Procedural sedation may be necessary to facilitate suturing children, especially with significant facial or perioral injuries. For pediatric sedation, see Chapter 60, pp. 544-549.
In the intoxicated patient, a period of observation, either in the ED or in the hospital, depending on the presence of other injuries, will generally facilitate primary closure after 2 to 4 hours.
INSTRUCTIONS REGARDING WOUND CARE AND FOLLOW-UP
Written instructions regarding the daily care of any wounds, the signs and symptoms of infection, and a specific referral at an appropriate interval for suture removal or other care should be provided to all patients (see Table 48-1).
ANESTHESIA
Allergy
There are two major classes of locally active anesthetic agents that may be used for infiltration, field, or block anesthesia. Esters, of which there are two principal types, procaine (Novocain) and chloroprocaine (Nesacaine), are chemically and antigenically distinct from the amides, which include lidocaine (Xylocaine), bupivacaine (Marcaine), and mepivacaine (Carbocaine). Patients who report an allergic reaction to one class of agents may safely be treated with a member of the other group without fear of crossreactivity. Most reported allergies are actually caused by preservatives contained in the solution (usually methylparaben). The use of solutions without preservatives (pure cardiac lidocaine) further reduces the incidence of allergic reactions. In some patients, it will not be possible to determine with certainty to which class of
agents an allergy actually exists; these patients can be given, by instillation, diphenhydramine, which should not produce an allergic reaction.
agents an allergy actually exists; these patients can be given, by instillation, diphenhydramine, which should not produce an allergic reaction.
Table 48-1 Recommended Suture Materials and Duration of Use According to Site | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Maximum Safe Dose
The maximum total adult doses for the various anesthetic agents are listed below. These doses assume that local infiltration is the method of administration and that epinephrine is contained in the solution. In patients not treated with a solution containing epinephrine, local vasoconstriction is not provided, and systemic absorption of the anesthetic agent is rapid; topical application to abraded skin surfaces similarly results in accelerated absorption; therefore, under either of these conditions, dosage reduction is indicated.
When administered by local infiltration, and when epinephrine is present in the solution, the upper limits of safe dosage for the various agents are as follows: procaine (9 mg/kg), lidocaine (7 mg/kg), and bupivacaine (3 mg/kg); when epinephrine is not present in the solution, maximal safe doses are as follows: procaine (7 mg/kg), lidocaine (4.5 mg/kg), and bupivacaine (2 mg/kg). In adults, no more than 150 to 200 mg topical lidocaine and no more than 50 mg of tetracaine (Pontocaine) should be administered.
Duration of Action
The expected duration of action for the various agents when epinephrine is not present in the solution is as follows: procaine (15-45 minutes), lidocaine (1-2 hours), and bupivacaine (4-8 hours). When epinephrine is present in the solution, the duration of action for all these agents is approximately doubled.
Route of Administration
Topical
Topical agents are useful for providing local anesthesia for laceration repair without the pain associated with needle infiltration; these agents provide reasonable hemostasis and do not cause infiltration-related distortion of wound edges.
Topical solutions containing lidocaine, epinephrine, and tetracaine (LET) or tetracaine, adrenaline (or epinephrine), and cocaine (TAC) have been shown to be quite effective in providing anesthesia before suturing. Typically, several drops of the agent are dripped into the wound using a syringe; alternatively, a piece of gauze is cut to approximately correspond to the size of the laceration, after which the gauze is applied over the laceration, and the solution, using a syringe, is dripped onto the pad, which when saturated is gently taped down; the gauze is resaturated in approximately 5 minutes. Blanching of tissue surrounding the laceration usually indicates that sufficient anesthesia has been provided.
For a variety of reasons, LET is the preferred topical agent; this is related to differences in cost, as well as to the status of cocaine as a controlled substance (which may limit availability of the agent). In addition, LET can often be used in locations where TAC is not recommended. Caution must be exercised when TAC is used in areas in proximity to the mucous membranes of the nose and mouth, because seizures, respiratory arrest, and a fatality have been reported in children, presumably resulting from the rapid absorption of cocaine from these sites. One must therefore carefully avoid any contact of the TAC solution with oral or nasal mucous membranes. Because of the particular vascular supply to the acral areas (nose, ear, fingers, toes, penis), the use of these solutions is contraindicated.
Topically active ophthalmic agents include proparacaine (Ophthaine) and tetracaine. These agents should be used routinely to facilitate fluorescein staining of the cornea, foreign body removal, irrigation, tonometry, and so on. They are also effective in the repair of conjunctival disruptions. Applying two or three drops, waiting approximately 1 minute, and then readministering a similar dose, will generally provide complete and sufficient anesthesia for most purposes. Topical ophthalmic anesthetic agents should not be provided to or prescribed for patients with ocular symptoms, because patient-initiated use, either currently or in association with subsequent injuries, may mask symptoms and thereby delay treatment. Indiscriminant use and therefore overdosage may also contribute to poor or delayed wound-healing and may cause toxicity.
The nose and throat may also be anesthetized topically with 0.5% or 2% tetracaine. When nasal procedures are contemplated that would benefit from local vasoconstriction, epinephrine may be added to the anesthetic solution. Viscous lidocaine (2%) or a combination of tetracaine and benzocaine (Cetacaine spray) is an additionally useful topical agent.
Topical lidocaine and tetracaine are also useful agents for anesthetizing abraded skin before cleansing or scrubbing for the removal of embedded foreign material.
Local Infiltration
In patients with lacerations that require cleansing, irrigation, debridement, or closure, needle instillation directly through and into the wound edges with 1% lidocaine is routine and most effective; when injuries are extensive, 0.5% lidocaine, usually without epinephrine, should be used to limit the total administered dose. Epinephrine is available commercially in many of these preparations and may be used to limit local bleeding; when injuries are extensive or involve the very young or elderly, however, the use of epinephrine should be limited. In addition and importantly, solutions containing epinephrine should not be used in patients with finger, toe, or penile lacerations, in digital blocks, or in patients with vascularly compromised avulsions or flaps; the use of epinephrine in these patients may precipitate or worsen ischemic injury via vasoconstriction of end arteries.
The usual discomfort associated with instillation of anesthetic may be limited by injecting first proximally with a 27- or 30-gauge needle and injecting very slowly.
Moderate mechanical pressure over the site before injection and cutaneous stimulation of the overlying skin during the injection may significantly reduce discomfort. Lidocaine solutions, using sodium bicarbonate and which are pH-balanced, significantly reduce discomfort associated with instillation anesthesia. These can be easily prepared in the hospital pharmacy or ED. Typically, nine parts of a 1% lidocaine solution is mixed with one part of an 8.4% solution of sodium bicarbonate.
Moderate mechanical pressure over the site before injection and cutaneous stimulation of the overlying skin during the injection may significantly reduce discomfort. Lidocaine solutions, using sodium bicarbonate and which are pH-balanced, significantly reduce discomfort associated with instillation anesthesia. These can be easily prepared in the hospital pharmacy or ED. Typically, nine parts of a 1% lidocaine solution is mixed with one part of an 8.4% solution of sodium bicarbonate.
Field and Nerve Blocks
Field blocks involve the instillation of anesthetic agents proximal to or surrounding the area to be anesthetized. Field blocks are often used to provide anesthesia for the cleansing of small abrasions, the repair of minor lacerations, and the draining of abscesses. A barrier of anesthetic agent is established proximal to or surrounding the area to be treated and provides appropriate anesthesia after 10 to 15 minutes.
Field blocks are most useful in the treatment of patients with distal finger or facial injuries. The use of a field block, particularly in these locations, circumvents the problem of distension or “ballooning” of tissue, which frequently interferes with wound edge apposition when anesthetic is injected directly.
Digital Blocks
Digital blocks are extremely useful for anesthetizing the digit, thereby facilitating the repair of lacerations, cleansing or debriding of wounds, paronychia drainage, nail removal, and so on. Each digit is supplied by two dorsal and two volar nerve branches, each of which courses along the four “edges” or “corners” of the digit adjacent to the phalanx. To obtain adequate anesthesia using a digital block, all four branches must be anesthetized with local instillation. A small-gauge needle (25- or 27-gauge) may be inserted dorsally, into the web space, and should touch the periosteum at the base of the proximal phalanx; after withdrawing the needle slightly, 1.0 to 1.5 mL of anesthetic agent, usually 1% lidocaine without epinephrine, is then injected. Without withdrawing the needle, it may then be redirected toward the volar “corner” and a similar volume of anesthetic agent injected. This procedure must be repeated on the opposite side of the digit and will produce total anesthesia within 10 to 15 minutes. “Failure” of digital block anesthesia often results from an insufficient waiting period after administering the agent.
Nitrous Oxide
Nitrous oxide is a nonflammable gas administered in combination with oxygen. A mixture of 50% nitrous oxide and 50% oxygen may safely be used in the ED to provide short-term analgesia without significant respiratory or cardiac depression. Onset of action is rapid, and duration of action after discontinuing inhalation is brief.
Nitrous oxide may be used alone or as an adjunct to parenterally administered narcotics or sedatives or locally administered anesthetics. Nitrous oxide should not be used in patients with head injury, with emotional or psychiatric disturbances, or when nausea or vomiting is present. In addition, because of the high concentrations of oxygen usually coadministered with nitrous oxide, patients with chronic obstructive pulmonary disease who retain carbon dioxide should not be treated with this regimen.
WOUND REVISION BY EXCISION
Primary repair of a variety of different injuries by excision of involved tissue continues to be a valuable technique both to eliminate crushed or devitalized tissue and to improve cosmetic results. Injuries amenable to this type of therapy in particular
include multiple, closely spaced, parallel lacerations that would otherwise be difficult or impossible to close individually and wounds associated with central devitalization or crushing of tissue that will ultimately be nonviable.
include multiple, closely spaced, parallel lacerations that would otherwise be difficult or impossible to close individually and wounds associated with central devitalization or crushing of tissue that will ultimately be nonviable.
Before excision, the amount of available tissue surrounding the area to be excised must be determined to be adequate. Excision to facilitate closure is typically not possible in the digit, for example, because of the paucity of available tissue in this area; too aggressive excision in these locations may result in irreparable defects that will ultimately require skin grafting. Frequently, adjacent tissue must be slightly undermined to permit adequate approximation of the wound margins. To optimize the final cosmetic result, the long axis of the excised tissue should be approximately 3.5 to 4 times the short axis. This dimensional consideration will ensure that puckering of the wound ends or “dog ears” are not produced. If present, these may be corrected by slightly extending the long axis of excision. After excision, which should include all nonstructural devitalized tissue, closure may proceed in the usual fashion.
ABRASIONS
Superficial abrasions not associated with embedded foreign matter require only thorough cleansing with an appropriate antiseptic agent, removal of the agent by irrigation or cleansing of the wound with normal saline, application of an appropriate antibacterial ointment and a sterile dressing, recleansing and reapplication of antibacterial ointment at 24-hour intervals until healing is complete, and a wound check at 48 to 72 hours if indicated. Instructions regarding the signs and symptoms of infection should also be provided and antitetanus prophylaxis administered as discussed pp. 464 and 465.
Deeper abrasions not associated with embedded material are treated similarly; however, an occasional patient with more significant injuries will require a wound check ‘at 24 to 48 hours. If signs of infection have developed at that time, a wound culture should be obtained and antibiotics instituted. In addition to the administration of antitetanus prophylaxis as needed, analgesics may be required for 24 to 48 hours.
When embedded foreign material is present, aggressive treatment is required to prevent permanent “tattooing” of the skin. The use of povidone-iodine-impregnated brushes and forceps will facilitate cleansing of the wound. Excision may occasionally be required in wounds with devitalized tissue or deeply embedded material not otherwise extractable. Locally applied or topical anesthetic agents are required for adequate cleansing of abrasions in these patients. In patients with relatively small abrasions, topically applied 2% lidocaine or tetracaine or locally instilled 0.5% to 1% lidocaine will be reasonably effective. Topically applied agents generally require 10 to 15 minutes to become maximally effective. It is important to note that topically active anesthetic agents are absorbed extremely rapidly from abraded skin; therefore, the total maximally acceptable dose should be reduced. In addition, in patients with large injuries, if local instillation of 0.5% to 1% lidocaine is elected, the use of solutions containing epinephrine should be avoided.
When injuries are extensive, when the patient is uncooperative, or when the maximally safe dose of anesthetic is likely to be exceeded, early surgical consultation is recommended, because regional or general anesthesia may be required in the operating room.
AVULSIONS
Complete avulsions occur when tissue is torn away, exposing the underlying fat. Generally, when cosmetically or functionally significant areas are involved, that is, the face or finger, respectively, skin grafting will be required for primary repair.
When the fingertip is involved, the general rule is that avulsions exposing more than 1 cm2 of fat require grafting, whereas lesions smaller than this will heal completely without grafting. When the avulsed tissue is available, it should be thoroughly cleansed, defatted, and tacked in place with fine suture material. When grafting is not required, an antibacterial ointment, a nonadherent dressing next to the skin, and a bulky dressing should be provided. Most patients with fingertip injuries will require an analgesic for several days; patients should be instructed to strictly elevate the hand to reduce bleeding and discomfort. Patients should be seen in 48 to 72 hours for a dressing change, at which time, despite the use of a nonadherent dressing, hydrogen peroxide as a soak may be required to facilitate removal of the dressing without severe pain. A similar dressing should be applied, which can be changed at 24- to 48-hour intervals until healing is complete—usually within 2 weeks. Partial avulsions are defined as tangentially oriented lacerations that result in an undermined flap of tissue. Before considering the various treatment options for such injuries, the pathophysiology of the injury as it relates to vascular disruption and subsequently to scar formation and contracture should be noted.
Clearly, when tissue is undermined, local vascular structures, including arteries, veins, and lymphatics, are disrupted. Because of venous and lymphatic compromise, swelling and edema of the flap evolve over several hours to several days. Such expansion of the flap places increasing traction on the wound edges that results in the spreading or widening of the scar as it forms. In addition, flaps tend to become “boggy” or edematous as intradermal scar tissue increases in density; this further aggravates the tendency of the scar to widen. Furthermore, as the peripheral skin scar contracts, a “heaping up” of the tissue that composed the original flap occurs. Last, particularly in patients with distally attached flaps, the blood supply may be inadequate to support the most proximal tissue, resulting in ischemic necrosis at or near the suture line. The combination of these processes in patients with injuries occurring in cosmetically significant areas often produces less than optimal results, unless special measures are taken to minimize their impact on the healing process. Flap-type avulsions of the nasal bridge and forehead often have such outcomes; for this reason, in selected patients, subspecialty consultation for repair is often appropriate.
In patients with somewhat larger flaps, conservative excision of very thin or beveled edges of the flap to produce a more perpendicular union of tissue will reduce subsequent scar formation. In patients with extremely small flaps, excision of the flap and primary closure are acceptable therapeutic options and will often produce a cosmetically superior result.
A special problem is the elderly patient with very atrophic or thin skin who presents with a superficial avulsing injury of the distal anterior tibial area, dorsal hand, or forearm. Such lesions are typically quite superficial and impossible to suture without further tearing of the skin. Occasionally, in patients with only superficial involvement, the application of a light pressure dressing or Steri-strips alone after routine cleansing will be sufficient. In other patients, the placement of one or two large, interrupted mattress sutures, the outermost pass of which should be placed at some distance from the wound edge, followed by the application of Steri-strips to complete the closure and a bulky dressing will produce optimal healing. Importantly, when an extremity is involved, the importance of strict elevation for 48 to 72 hours,Related posts:
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