Chapter 26 – Wound Care and Minor Trauma




Chapter 26 Wound Care and Minor Trauma



Anthony J. Ciorciari



Abscesses


A cutaneous abscess is a localized collection of pus, usually secondary to disruption of skin integrity. The organisms most often involved are methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant Staphylococcus aureus (MRSA), and Streptococcus pyogenes (GAS).



Clinical Presentation and Diagnosis


An abscess presents as a discrete, well-circumscribed swelling with central fluctuance. It is tender and is usually associated with erythema and warmth of the overlying skin. There may be an area of cellulitis adjacent to or surrounding the abscess. Lymphangitis and lymphadenitis are complications that can herald hematogenous dissemination and sepsis.


A patient with a significant abscess may exhibit signs of systemic disease such as temperature >38 °C, tachycardia, or tachypnea, and possibly an abnormal white blood count (>12,000/mm3 or < 4000/mm3).



ED Management


The definitive treatment of an abscess is incision and drainage, which can usually be performed in the ED. When the abscess is in immediate proximity to neurovascular structures, first perform either a needle aspiration to confirm purulence or obtain an ultrasound to avoid incising a vascular aneurysm. This precaution applies to abscesses in the neck, supraclavicular fossa, antecubital fossa, popliteal fossa, and inguinal and axillary areas.


Maintain strict aseptic technique to prevent the spread of the infection; prepare the skin with a povidone-iodine solution. Although total anesthesia may be difficult to achieve, use a combination of a regional field block (a ring of 1% lidocaine outside the perimeter of the abscess and erythema) and a linear injection of 1% lidocaine into the roof of the abscess along the planned incision line. The maximum dose of lidocaine is 4–5 mg/kg without epinephrine and 7 mg/kg with epinephrine. If this technique is unsuccessful, provide sedation and analgesia (pp. 715722).


Make the incision along the natural dynamic skin tension lines to prevent excessive scarring. In view of the increasing incidence of MRSA, after the incision, obtain a specimen for culture in case the patient subsequently requires antibiotic therapy. Explore the abscess cavity with a blunt instrument or sterile gloved finger to break up any loculated pockets of purulence. Copiously irrigate the cavity with NS under moderate pressure, pack it loosely with iodoform gauze to promote drainage and ensure hemostasis, and apply a sterile dressing.


Oral antibiotics are of no additional benefit after incision and drainage of uncomplicated abscesses <5 cm in otherwise healthy children. Antibiotics are indicated when the abscess is >5 cm or there is an area of surrounding cellulitis. Use cephalexin (40 mg/kg/day div qid) or cefadroxil (40 mg/kg/day div bid), but if MRSA is prevalent in the community, treat with clindamycin (20 mg/kg/day div qid) alone or add trimethoprim-sulfamethoxazole (which does not reliably cover group A Streptococcus) to one of the above regimens (8 mg/kg/day of trimethoprim div bid). Treat for 5–7 days. Arrange for follow-up in 24–48 hours to evaluate for complications, remove the packing, and repeat the irrigation. Loosely repack the cavity only if pus is found again. Usually, by 48 hours, the incision remains open without packing while the cavity heals from below. Instruct the family to irrigate the cavity under running warm water or to apply warm wet soaks three times daily at home for five days.


Refer breast, perirectal, fingertip (pulp), hand, and deep abscesses of the neck to an experienced surgeon.



Follow-up





  • After abscess drainage: daily for 2–3 days



Indications for Admission





  • Abscess associated with lymphangitic streaking, fever >38.9 °C (102 °F), or signs of toxicity



  • Abscess in an immunocompromised patient



  • Severe injuries and soft tissue infections



  • Infections that interfere with oral intake, urination, defecation



Bibliography

Gupta AK, Lyons DC, Rosen T. New and emerging concepts in managing and preventing community-associated methicillin-resistant Staphylococcus aureus infections. Int J Dermatol. 2015;54(11):12261232.

Korownyk C, Allan GM. Evidence-based approach to abscess management. Can Fam Physician. 2007;53:16801684.

Mistry RD. Skin and soft tissue infections. Pediatr Clin North Am. 2013;60(5):10631082.

Montravers P, Snauwaert A, Welsch C. Current guidelines and recommendations for the management of skin and soft tissue infections. Curr Opin Infect Dis. 2016;29(2):131138.

Schmitz GR. How do you treat an abscess in the era of increased community-associated methicillin-resistant Staphylococcus aureus (MRSA)? J Emerg Med. 2011;41(3):276281.

Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59:e10.


Bite Wounds


About 1% of all ED visits are for bites, the majority of which are caused by dogs. More than one-half of bite victims are children, most of them toddlers. While a patient may seek medical attention because of cosmetic concerns, bleeding, or fear of rabies, the most common complication is infection. An increased risk of infection occurs with puncture wounds, hand wounds, or when there has been a delay (>24 hours) in seeking medical attention.



Clinical Presentation and Diagnosis


Usually, the history of an animal bite is readily obtained, so the diagnosis is evident. The three major types of bite wounds are puncture wounds, lacerations, and closed-first injuries (CFIs). Puncture wounds are of particular concern, as the small break in the skin belies the significant risk of infection. Suspect that a laceration over the metacarpophalangeal joint of an adolescent represents a CFI, sustained when the patient punched another person in the mouth.



ED Management



General Measures

Thoroughly clean every bite wound with soap and water. Moderate-pressure irrigation in the ED is indicated for lacerations and CFIs, but it is probably ineffective for punctures. Use an 18 or 20 gauge IV catheter attached to a 1 L bag of NS, around which a blood transfusion cuff is inflated to 300 mm Hg. If the irrigation is not tolerated, anesthetize the intact skin margins of the wound with 1% lidocaine and then irrigate. Debride devitalized tissue, which is an excellent culture medium. This is particularly important with dog bites, which are, in part, crush injuries.



Suturing


Dog Bites

Do not suture puncture wounds; hand, forearm, or foot lacerations; wounds more than eight hours old (except the face in children over one year old); wounds over a joint; crush wounds that cannot be debrided; or if the patient is immunosuppressed. In these circumstances, if the wound appears clean and cosmesis is a concern, close the wound in approximately four days (delayed primary closure). Alternatively, allow the wound to granulate (secondary closure). Low-risk dog bite wounds can be sutured, but avoid deep closure to minimize the possibility of infection.



Cat Bites

Because the infection rate is high, leave cat bite wounds open. Exceptions are easily cleaned wounds that are not on the hand, forearm, or foot. Once again, avoid deep closure to minimize the possibility of infection.



Human Bites

Do not close wounds on the distal extremities, but suture facial bites less than eight hours old that can be cleaned adequately.



Other Bites

Consult with a pediatric infectious disease expert to determine the risk of infection.



Antibiotics


Dog and Cat Bites

Organisms causing infections include Pasteurella multocida, Staphylococcus aureus, and Streptococcus species. Give antibiotics for puncture wounds, hand and forearm wounds, injuries that are considered deep or have penetrated the joint capsule, and lacerations that are sutured. Also give antibiotics to a patient who is immunocompromised, asplenic, or has moderate to severe injuries to the hand and/or face. Use amoxicillin-clavulanate (875/125 formulation; 45 mg/kg/day of amoxicillin div bid). If MRSA is a concern, use either clindamycin (20 mg/kg/day div qid) alone or add trimethoprim-sulfamethoxazole (which does not reliably cover group A Streptococcus) as described for an abscess (p. 763).



Human Bites

Etiologies of infections include Eikenella corrodens, Staphylococcus aureus, Streptococcus spp., Haemophilus spp., Fusobacterium spp., Veillonella spp., and Pervotella spp. Use the same guidelines as for dog and cat bites (above).



Other Bites

Consult a pediatric infectious diseases expert (as above).



Tetanus

Clostridia can be present in the mouths of coprophagic animals. Give tetanus toxoid unless it is certain that a booster was received in the previous five years. For patients under seven years of age, use 0.5 mL of DTaP, unless pertussis vaccination is contraindicated, in which case use DT. For patients 7–10 years old, use 0.5 mL of dT. If the patient is ≥11 years old, use 0.5 mL of Tdap.



Rabies

Decisions regarding rabies treatment depend on the prevalence of the disease in the species in the area where the animal lives. See pp. 771772 for the indications for prophylaxis. Give post-exposure prophylaxis (PEP) for any patient with a bite, scratch, or mucous membrane exposure to a bat, unless the bat is available for testing and is negative for evidence of rabies. Also give PEP when direct contact between a child and a bat has occurred, unless the exposed person can be certain that there was no bite, scratch, or mucous membrane exposure. If a bat is found indoors and there is no history of bat–human contact, the likely effectiveness of PEP must be balanced against the low risk of such an exposure. PEP may also be indicated for a patient who was in the same room as a bat and might be unaware that a bite or direct contact had occurred (e.g., a sleeping person awakens to find a bat in the room or an adult witnesses a bat in the room with a previously unattended child, mentally disabled person, or intoxicated person) and rabies cannot be ruled out by testing the bat.



Follow-up





  • Bite wound: daily for 2–3 days; initiate antibiotic therapy if the patient develops fever, increasing pain or erythema, or a purulent discharge



Indications for Admission





  • Bite wound infections unresponsive to oral antibiotics



  • Infected bite wounds in patients who initially seek attention >24 hours after the bite



  • Bite wounds in immunocompromised patients



Bibliography

Aziz H, Rhee P, Pandit V, et al. The current concepts in management of animal (dog, cat, snake, scorpion) and human bite wounds. J Trauma Acute Care Surg. 2015;78(3):641648.

Ellis R, Ellis C. Dog and cat bites. Am Fam Physician. 2014;90(4):239243.

Lohiya GS, Tan-Figueroa L, Lohiya S, Lohiya S. Human bites: bloodborne pathogen risk and postexposure follow-up algorithm. J Natl Med Assoc. 2013;105(1):9295.

Rothe K, Tsokos M, Handrick W. Animal and human bite wounds. Dtsch Arztebl Int. 2015;112(25):433442.


Foreign Body Removal


Small fragments of wood or pieces of glass are the most common foreign bodies embedded in the skin.



Clinical Presentation


A fresh wound is usually tender, and the foreign body is often seen or palpated just below the skin surface. Delayed presentations are associated with induration and tenderness, often with purulent or serosanguinous drainage.


Fishhooks embedded in the skin merit special consideration, as there may be more than one barb. The barb may completely penetrate a finger or earlobe, emerging from the other side, leaving the hook shaft still embedded.



Diagnosis


Radiographs can be helpful in identifying and locating foreign bodies. Use a radiopaque marker, such as a bent paperclip taped to the overlying skin, as a reference point for estimating the exact location of the object. A radiograph is also indicated when the presence of a foreign body cannot be ruled out, as when an old wound does not heal, continues to drain serosanguinous or purulent material, or remains tender. Virtually all glass is radiopaque, and wooden splinters can occasionally be seen if they are covered with dirt particles. Obtain an ultrasound to locate a nonradiopaque foreign body such as a thorn or piece of plastic.



ED Management


Attempt to remove a foreign body in the ED only if it is close enough to the surface to be seen or palpated. Cleanse the skin with povidone-iodine, and anesthetize the area by local infiltration, field block, or regional nerve block. Using the paperclip marker and x-rays for reference, make a stab incision with a No. 11 blade directed at the foreign body. Carefully explore the wound with a small hemostat to find and remove the object. Then gently palpate over the wound with a gloved finger to identify any remaining fragments.


When removal attempts are prolonged or unsuccessful, consult with a surgeon to plan for a definitive operative procedure under fluoroscopic or sonographic guidance. Foreign bodies in the plantar surface of the foot are especially difficult to remove in the ED. Refer patients with foreign bodies in the face or hand to a surgeon, and consult with a surgeon before attempting to remove a foreign body from the neck, unless it is clearly superficial.


When the foreign body is small or cannot be palpated, probing the wound is usually fruitless. If the wound is tender and crusted over, however, unroof it with the point of an 18 gauge needle to facilitate the drainage of any pus; the object may emerge over the next several days. Continue with warm soaks at home, and reevaluate the wound in 48 hours.


To remove a fishhook, advance the barbed end until the skin is tented and anesthetize that area with 1% lidocaine. Then advance the point until the barb leaves the skin, sever the barbed point with wire cutters, and pull the shaft of the hook back out through the original entrance wound. Small-barb hooks may be removed in a retrograde fashion through the original wound site. If the fishhook has several barbs, separate them with wire cutters and remove each one individually. If the barb is already through the skin, cut it off and pull the shaft out without using any anesthetic.


Give tetanus toxoid unless it is certain that a booster was received in the previous five years. For patients under seven years of age, use 0.5 mL of DTaP, unless pertussis vaccination is contraindicated, in which case use DT. For patients 7–10 years old, use 0.5 mL of dT. If the patient is ≥11 years old, use 0.5 mL of Tdap.



Follow-up





  • Small or nonpalpable foreign body: 48 hours



Bibliography

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):777787.

Sidharthan S, Mbako AN. Pitfalls in diagnosis and problems in extraction of retained wooden foreign bodies in the foot. Foot Ankle Surg. 2010;16(2):e18e20.

Varshney T, Kwan CW, Fischer JW, Abo A. Emergency point-of-care ultrasound diagnosis of retained soft tissue foreign bodies in the pediatric emergency department. Pediatr Emerg Care. 2017;3(6):434436.


Insect Bites and Stings


Insect bites and stings usually cause a local reaction. Systemic anaphylactic reactions occur after 1–3% of Hymenoptera stings (honeybees, wasps, hornets, yellow jackets, harvester and fire ants) in susceptible patients.



Clinical Presentation


Reactions can be classified as immediate (within two hours) or, rarely, delayed (after two hours). Immediate reactions may be local or systemic.



Immediate Local Reactions

These include local pain, erythema, swelling, tingling, warmth, and pruritus at the sting site. Local reactions usually last 24–48 hours; they can be extensive, although all affected skin is contiguous with the sting site.



Delayed Reactions

These can occur after a 1–2-week interval. They present as large local reactions, serum sickness (fever, arthralgia, urticaria, lymphadenopathy), and rarely, peripheral neuritis, vasculitis, nephritis, or encephalitis.



Immediate Systemic Reactions

The hallmark of a systemic reaction is swelling that occurs at locations not contiguous with the sting site. The reaction may be mild, with itching and urticaria. More severe anaphylactic reactions can occur with hypotension, wheezing, laryngeal edema, and shock. Eighty-five percent of sensitive patients manifest symptoms within five minutes; all have symptoms within 1–2 hours.



Diagnosis


The diagnosis is suggested by the history of a sting or by the typical appearance of a local reaction in the warm-weather months. Stings, as opposed to insect bites, are always painful. Cellulitis may look similar, but a bacterial infection usually does not develop abruptly. A cellulitis may be associated with fever, lymphangitic streaking, and local lymphadenopathy.


Consider other causes of systemic allergic reactions, such as drugs (penicillins, sulfonamides, contrast dyes) and foods (shellfish, eggs). Try to ascertain whether the insect was a member of the Hymenoptera order, and inquire about a history of allergies and any previous systemic reactions to insect stings.



ED Management



Local Reactions

Among the Hymenoptera, only honeybees lose their stingers, which may remain at the sting site. Remove the stinger (if it is still in place) by grasping as close to the puncture site as possible with a small forceps. Cleanse the site, apply ice or cool compresses to the area, and give oral diphenhydramine (5 mg/kg/day div qid, 50 mg/dose maximum) or hydroxyzine (2 mg/kg/day div tid, 50 mg/dose maximum). If the erythema continues to spread during the 24 hours after the bite or sting, consider the wound to be infected. Treat with 40 mg/kg/day of cephalexin (div qid) or cefadroxil (div bid), warm compresses every two hours, and elevation. If MRSA is a concern, use either clindamycin (20 mg/kg/day div qid) alone or add trimethoprim-sulfamethoxazole (which does not reliably cover group A Streptococcus), to one of the above regimens (8 mg/kg/day of trimethoprim div bid).



Systemic Reactions

Treat mild reactions (itching, urticaria) with oral diphenhydramine or hydroxyzine. The management of severe systemic reactions is the same as for anaphylaxis (see pp. 3840). Prescribe an EpiPen and refer the patient to an allergist for evaluation and possible immunotherapy.



Follow-up





  • Local reaction: 24 hours, if the erythema is spreading



  • Systemic reaction (not anaphylaxis): 2–3 days


Sep 22, 2020 | Posted by in EMERGENCY MEDICINE | Comments Off on Chapter 26 – Wound Care and Minor Trauma
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