MINOR BRUISES AND WOUNDS

MINOR BRUISES AND WOUNDS



BRUISES


A bruise is a collection of blood that develops in soft tissue (muscle, skin, or fat), caused by a direct blow to the body part, a tearing motion (such as a twisted ankle), or spontaneous bleeding (ruptured or leaking blood vessel). With trauma, tiny blood vessels are torn or crushed and leak blood into the tissue, so that it rapidly becomes discolored. Pain and swelling are proportional to the degree of injury. People on anticoagulants (such as Coumadin) and hemophiliacs tend to develop larger bruises; elders and those taking steroid medications tend to bruise easily, often spontaneously.


The immediate (within the first 48 hours) treatment of a bruise is to apply cold compresses or to immerse the injured part in cold water (such as a mountain stream). This decreases the leakage of blood, minimizes swelling, and helps reduce pain. Cold applications should be made for intermittent 10-minute periods until a minimum total application time of 1 hour is attained. Do not apply ice directly to the skin (to avoid frostbite). Rather, wrap the ice in a cloth before application.


If the swelling progresses rapidly (such as with bleeding into the thigh), an elastic bandage can be wrapped snugly to try to limit the swelling. Continue cold applications over the wrap. It is important to keep the wrap loose enough to allow free circulation (fingertips and toes should remain pink and warm; wrist and foot pulses should remain brisk). Elastic wraps are indicated only if pain and swelling will not allow the victim to extricate himself to seek medical attention.


Elevation of the bruised and swollen part above the level of the heart is essential, to allow gravity to keep further swelling to a minimum.


Never attempt to puncture or cut into a bruise to drain it. This is fraught with the risk of uncontrolled bleeding and the introduction of bacteria that cause infection. The exception to this rule is a tense and painful collection of blood under the fingernail (see page 258).


After 48 to 72 hours, the application of moist or dry heat will promote local circulation and resolution of the swelling and discoloration. Heat ointments or liniments are ineffective; they only irritate nerve endings in the outermost layers of the skin and give a false impression of warmth.


People who have prolonged blood-clotting times and/or who have large bruises should avoid products that contain aspirin, which might cause increased bleeding. A hemophiliac who sustains an expanding bruise will likely need to be transfused with a blood-clotting “factor” to promote coagulation; transport to a medical facility should be prompt.


A severe bruise, usually caused by a direct blunt force, can on rare occasion develop into a compartment syndrome (see page 73).



BLACK EYE


A black eye is a darkened blue or purple discoloration in the region around the eye. It can be caused by a direct blow (bruise) or by blood that has settled into the area from a broken nose, skull fracture, or laceration of the eyebrow or forehead. “Raccoon eyes” are black eyes caused by a skull fracture. If a black eye is due to a direct injury (with swelling and pain), first examine the eyeball for injury (see page 182). The skin discoloration may be treated with intermittent cold compresses for 24 hours.



BLOOD UNDER THE FINGERNAIL


When a fingertip is smashed between two objects, there is frequently a rapid blue discoloration of the fingernail, which is caused by a collection of blood underneath the nail. Pain from the pressure may be quite severe. To relieve the pain, it is necessary to create a small hole in the nail directly over the collection of blood, to allow the blood to drain and thus relieve the pressure. This can be done during the first 24 to 48 hours following the injury by heating a paper clip or similar-diameter metal wire to red-hot temperature in a flame (taking care not to burn your fingers while holding the other end of the wire; use a needle-nose pliers, if available) and quickly pressing it through the nail (Figure 134). Another technique is to drill a small hole in the nail by twirling a scalpel blade, sharp knife, or needle. As soon as the nail is penetrated, blood will spurt out, and the pain will be considerably lessened. Before and after the procedure, the finger should be washed carefully. If the procedure was not performed under sterile conditions, administer dicloxacillin, erythromycin, or cephalexin for 3 days.


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Figure 134 Hot paper clip technique to drain blood from under the fingernail.



PUNCTURE WOUNDS


Puncture wounds are most frequently caused by nails, tree branches, fishhooks, and the like. Because they do not drain freely, these wounds carry a high risk for retained bacteria and subsequent infections. A puncture wound should be irrigated copiously with the cleanest solution that is available and left open to heal. Bleeding washes bacteria from the wound, so a small amount of bleeding should be encouraged. Never suture or tape a puncture wound closed, unless necessary to halt profuse bleeding; doing so promotes the development of infection. Similarly, do not occlude the opening of a puncture wound with a “grease seal” or plug of medicinal ointment; apply any antiseptic sparingly. If the wound is more than ¼ in (0.6 cm) at its opening, you can leave a piece of sterile gauze in the wound as a wick for a day or two, to allow drainage and prevent the formation of an abscess cavity (see page 241). If the wound becomes infected (see page 240), apply warm soaks four or more times a day. Treat the victim with dicloxacillin, erythromycin, or cephalexin for 4 days.



IMPALED OBJECT


See page 59.



SCRAPES


Scrapes (abrasions) are injuries that occur to the top layers of the skin when it is abraded by a rough surface. They are generally very painful, because large surface areas with numerous nerve endings are involved. Bleeding is of an oozing, rather than free-flowing, nature.


An abrasion should be scrubbed until every last speck of dirt is removed. Although it hurts just to think about this, scrubbing is necessary for two reasons. The first is the infection potential when such a large area of injured skin is exposed to dirt and debris. The second is that if small stones or pieces of dirt are left in the wound, these in essence become like ink in a tattoo, leaving the victim with permanent markings that require surgical excision. Soap-and-water scrubbing with a good final rinse should be followed with an antiseptic ointment such as bacitracin or mupirocin, or cream such as mupirocin, and a sterile nonadherent dressing or Spenco 2nd Skin. You can also place Hydrogel occlusive dressing over an abrasion; it will absorb up to 2½ times its weight in fluid weeping from the wound. It should be covered with a dry, light dressing. This technique is useful for burns as well. If the surface area is not particularly large or is on a difficult-to-bandage area, such as the nose or ears, the bandage (not the ointment) may be omitted.


The pain of cleansing can be relieved by applying pads soaked with lidocaine 2.5% ointment to the abrasion for 10 to 15 minutes before scrubbing. To avoid lidocaine toxicity, don’t do this if the surface area of the abrasion exceeds 5% of the total body surface area (an area approximately five times the size of the victim’s fingers and palm). In some cases, particularly when there is deeply embedded grime that will be extremely painful to remove, it is useful to inject the wound with a local anesthetic (see page 262).



CUTS (LACERATIONS)


Remove all clothing covering a wound so that you may determine the origin and magnitude of any bleeding.




1. Control bleeding. This can be done in almost every instance by direct pressure (see page 54). Apply firm pressure to the wound using a wadded sterile compress, cloth, or direct hand contact (wearing latex gloves, if possible; if you are allergic to latex, use other nonpermeable gloves, such as nonlatex synthetic). Hold the pressure for a full 10 to 15 minutes without release. If this does not stop the bleeding, apply a sterile compress and wrap with an elastic bandage, taking care to not wrap so tightly as to occlude the circulation (check for warm and pink fingers and toes). If bleeding is not controlled with pressure alone, you may need to apply a hemostatic (stops bleeding) dressing or compress. These are described on page 55. During all of these maneuvers, keep the victim calm and elevate the injured part as much as possible.


2. Clean the wound. In many cases, “the solution to pollution is dilution.” After you have controlled the bleeding, the minor wound(s) should be properly cleansed. If you have needed to use hemostatic gauze or other ancillary agent (such as Celox) other than brief pressure to control the bleeding, you should wait for at least 60 minutes before attempting to clean the wound. Otherwise, brisk bleeding may reoccur. Wear sterile, nonpermeable, nonlatex gloves if these are available; if you are not allergic to latex, latex gloves are acceptable. If sterile gloves are not available, wear nonsterile gloves. Examine the wound and remove all obvious foreign debris.


The best way to clean a wound is to irrigate away the dirt and bacteria. The irrigating stream should be forceful enough (approximately 8 to 10 pounds per square inch) to dislodge the foreign material without injuring the tissues beneath the stream or forcing harmful material deeper into the wound. Use the cleanest disinfected water available. The best irrigants are “normal” saline (0.9% NaCl) solution (add 1½ level tsp, or 9 g of table salt, per quart or liter), or a quart of disinfected saline or water. Tap water or disinfected water without the addition of povidone iodine is fine for irrigation purposes. Addition of no more than 1 fluid oz (30 mL) of povidone iodine (Betadine) solution (not soapy “scrub”) into a liter of irrigating fluid has been recommended in the past, but has fallen out of favor. Certainly, don’t use a povidone iodine solution to irrigate eyes, and don’t drink this stuff. Hydrogen peroxide and other antiseptics are also tissue toxic. Try to use at least 500 mL (roughly one pint) of irrigation fluid per wound. There is no benefit from soaking a wound in water, disinfected or not. Soaking may actually increase the bacterial count. If there is grease in the wound, it is best to avoid commercial degreasing agents; use soap and water, followed by water irrigation.

Use a syringe (50 to 60 mL is best, but any size can be used) with a 16- to 20-gauge (18-gauge is best) plastic catheter or steel needle attached to draw up the irrigating fluid and act as a “squirt gun.” This creates a stream of the appropriate force (range of 5 to 12 pounds per square inch). Another way to obtain the appropriate stream diameter and force is to attach a Zerowet Splashield (www.zerowet.com) to a plastic syringe (Figure 135). A complete wound irrigation system (Klenzalac) with a 10 mL syringe, fill stem, and Splashield is also available. This technique protects the operator from splash exposure to blood and tissue fluid. If you don’t have these supplies, you can fill a small (as sturdy as possible) plastic bag with the irrigating solution, punch a tiny hole in the bag, and squeeze out the liquid (Figure 136). Irrigate the wound until it appears clean, usually with at least a pint to a quart (½ to 1 liter) of liquid. Take care to avoid splashing yourself.

Sometimes irrigation isn’t enough to remove all of the dirt from the wound, or you won’t be carrying irrigation equipment. In that case, the wound needs to be scrubbed out with a gauze or cloth, using a disinfectant solution or hand soap and the cleanest disinfected water available. This can be painful, so get everything ready in advance and then try to accomplish the task as quickly as possible. Rinse the wound thoroughly when you are finished.

Do not forcefully irrigate a puncture wound, because you may push fluid deeper into the tissues, and force germs and other contaminants further into the wound.

Scrubbing and irrigation will often cause a wound to begin bleeding again as blood clots are dislodged from tiny blood vessels. Stop this bleeding by holding absorbent gauze with pressure against the wound.

Do not pour tincture of iodine, rubbing alcohol, merthiolate, mercurochrome, or any other over-the-counter antiseptic into the wound (except for potentially rabid animal bites—see page 410). These preparations inhibit wound healing and are extremely painful. Although recommended by healers in ancient civilizations, herbal doctors, and professional woodsmen, the use of butter, pine sap, ground charcoal, hard liquor, or wine as an antiseptic is not recommended.

3. Anesthetize (numb) the wound. Most laypeople will never be called on to sew (suture) or staple a wound closed. However, for the benefit of rescuers who might need to practice advanced skills, here are the basics:


Local anesthesia of a wound can be achieved by injecting sterile 1% lidocaine or 0.25% bupivacaine solution into the edges of the wound using a 25-, 27-, or 30-gauge needle attached to a 10 mL syringe. There will be less stinging sensation with injection if you add 1 mL of 8.4% sodium bicarbonate solution to each 10 mL of the lidocaine solution before using it. Bicarbonate should not be added to bupivacaine, because it causes precipitation if the solution is not used immediately. Once bicarbonate has been injected, the shelf life of the multidose vial of anesthetic decreases considerably, so this maneuver may not be practical in the field. Whenever possible, use a new ampule or vial of anesthetic for each episode (event, or victim). This minimizes the risk of injecting a contaminated (with bacteria) product and causing a wound infection. Never share needles between victims.

To draw up medication into a syringe, follow the instructions given for subcutaneous injection on page 474. The onset of anesthesia from injection of lidocaine or bupivacaine is 2 to 5 minutes, with duration of action 1 hour for lidocaine and 4 hours for bupivacaine. The maximum safe adult dose (volume) of 1% lidocaine is 30 mL; for 0.25% bupivacaine, it is 70 mL. For a child, the maximum safe dose for 1% lidocaine is 0.4 mL/kg (2.2 lb) of body weight, up to 30 mL; the maximum safe dose for 0.25% bupivacaine is 1 mL/kg, up to 70 mL. Of course, it is best to stay as far as possible below the maximum safe dose.

The wound should be cleansed of all major debris and dirt before injecting an anesthetic, so as not to plunge the needle through the grime. Inject through the open (cut or torn) portion of the wound, rather than through the surface of the skin, unless this is necessary to avoid gross contamination. One useful technique is to insert the short needle up to its hub, and then inject while you slowly withdraw the needle back out from the skin, rather than injecting during entry. As with any other medical intervention, it is important to have practiced ahead of time before attempting to numb a wound by injecting it with an anesthetic.

Numbing a wound can be done before it is definitively cleansed and irrigated, particularly if the cleansing process will be extremely painful (as when an abrasion needs to be scrubbed). In order to not have to reinject the wound because the anesthetic has worn off, have all of your supplies gathered and your helpers ready to assist before you inject.

Reapproximate the anatomy (close the wound) as best as possible. Most cuts do not involve tissue loss, so that edges fit together like a jigsaw puzzle. Because of the infection risk away from the hospital or doctor’s office (a relatively germ-free environment), do not close a wound tightly with stitches of thread (sutures) unless absolutely necessary. Instead, bring the wound edges together with paper tape with adhesive specifically made for wound closure (such as elastic or nonelastic Steri-Strips) or with butterfly bandages (see also page 266 ’”Taping a Wound Closed”). The latter can be fashioned from regular surgical adhesive tape (Figure 137). A small scar is preferable to a wound infection caused by tight closure that requires hospitalization for surgical management of a wound infection. If nothing else is available to hold together the edges of a widely gaping wound that prevents the victim from seeking help, use one or more safety pins.

No matter what method you use to close a wound, the best way to make the opposite sides match up properly, and to take tension off the wound while the remainder of the closure is completed, is to place the first piece of tape, staple, or suture (thread) at the midpoint of the wound (“halve the wound”) (Figure 138). The second fastener should then “halve the halves” (Figure 139), so that the wound is now quartered, and so forth until the closure is complete. A final long locking strip can be placed over the ends of the crossing strips to complete the closure (Figure 140).

When aligning the two sides of a cut lip, be sure to match the vermilion border (the line where the skin of the lip meets the skin of the face) perfectly (Figure 141). The same concern holds for aligning a laceration of the eyebrow. Never shave an eyebrow, because it might not grow back! In fact, there is no absolute need to shave hair from the skin around any wound. Shaving hair may increase the risk for infection, because you create micro-nicks in the skin with your razor or knife edge.

Regardless of which technique you choose to close the wound, it is useful to splint the repair (see page 74) for at least a few days, to allow healing to begin without the wear and tear of motion, particularly across a joint.

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Aug 11, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on MINOR BRUISES AND WOUNDS

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