Minor Trauma

Chapter 57 Minor Trauma



Sabina B. Singh, MD, FAAP, Magdy W. Attia, MD



1 What are the major considerations in wound assessment?




image Local factors include location, mechanism of injury, wound age, possibility of foreign body, and degree of contamination. Soil contamination with organic matters has the highest rate of wound infection if not properly cleansed. The possibility of a retained foreign body should be entertained in wounds caused by broken glass or other debris. Imaging studies should be obtained if a foreign body is suspected.


image Host factors include disease states, tetanus immunization, allergies, sedation, and pain control.



2 How does location of injury affect assessment?




image Injuries over a joint or adjacent to tendons should be checked for crepitus, which may signify disruption of the joint capsule. Loss of function may indicate tendon injury.


image Lacerations close to the neurovascular bundle are at risk for nerve damage. Assess capillary refill and pulses and conduct a careful neurologic examination of motor and sensory functions.


image Wounds in proximity to areas of high bacterial concentration, such as the perineum, axilla (particularly in adolescents), and exposed parts (hands, feet) are at a higher risk for infection.



3 Why are bites and crush injuries of special concern?


Bites and crush injuries are more difficult to repair. They are often associated with devitalized tissue and are more likely to become infected. Injury over a metacarpophalangeal joint from a fist punch should be managed as a human bite.



4 How do disease states affect wound assessment?


Higher infection rates are seen in conditions such as diabetes, immunosuppressed states (e.g., AIDS, long-term steroid use), and chronic disease (e.g., renal insufficiency, cyanotic heart disease). Exposure to smoke delays proper healing.



5 Which allergies are of particular relevance to wound assessment?


Allergy to latex, anesthetic agents, and antibiotics.



6 What is the ideal time frame for repair of wounds?


Ideally wounds should be repaired within 6 hours of injury. Clean wounds can be closed within 12–24 hours after injury.



7 When should delayed closure of a wound be considered?


Delayed closure is usually carried out 3–5 days after the original injury. Wounds that should be considered for delayed closure are those with high potential for infection (heavily contaminated wounds, bite wounds, puncture wounds) and wounds in immunocompromised patients in areas of low cosmetic concern. Facial and scalp wounds should be considered for primary closure for best results.



8 Which wounds are allowed to heal by secondary intention?


Infected wounds and small puncture wounds in areas of low cosmetic concern may be allowed to close by secondary intention. A small wick of iodoform gauze may be placed in the wound to decrease chances of infection.



9 How should the emergency physician approach sedation and pain control?


Options, risks, and benefits should be discussed with parents and older children. Parents often can predict the level of cooperation expected from the child.



10 When should a consultation be obtained for wound care?


Consider consultation with a surgical or orthopedic specialist for wounds associated with:



image Fracture or violation of a joint cavity


image Injury to tendon, nerve, or large vessel


image Difficult-to-repair wounds located in areas of high cosmetic concern


Selbst SM, Attia M: Minor trauma—lacerations. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1571–1586.



11 When are radiographic studies indicated as a part of wound management?


Radiographs should be obtained for wounds associated with fractures or joint disruption or if a foreign body is suspected. Plain radiographs identify fragments of metal and glass if they are larger than 0.5 cm. Wood is identified in only 15% of cases because air trapped in the wood is resorbed within 48 hours. Ultrasonography has 90% sensitivity and specificity for nonopaque foreign bodies if the location is not near a bony or gaseous structure. Computed tomography or magnetic resonance imaging should be considered if a surgical approach is planned for the removal of a foreign body near vital structures.



12 How can you decrease the chances of missing a retained foreign body in a wound?


A detailed history of the mechanism and circumstances surrounding the injury is important. Good exploration with visualization of the base of the wound significantly reduces the risk. In one study, wounds less than 0.5 cm deep had a low risk of an embedded foreign body.



13 What are the signs of retained foreign body?


Extreme pain, pain on passive movement, or a mass with discoloration at the site of a wound is highly suggestive of a retained foreign body.



14 When should a retained foreign body be removed?


The material, location, and tissue response to a foreign body determine the necessity of its removal. Attempts at removal in the emergency department (ED) should be limited to 30 minutes. The foreign bodies listed below should be removed.



image Location: Intra-articular, intravascular, or in close proximity to vital structures or has the potential to migrate towards vital structures (e.g., lung, spleen)


image Material: Risk of toxicity (e.g., lead, venom from spines)


image Tissue response: Production of inflammatory response (e.g., organic matter, silica that causes large granuloma formation), persistent pain, infection, or cosmetic disfigurement



15 What are the contraindications to the removal of a foreign body in the ED?


Foreign bodies associated with penetrating injuries to the abdomen, neck, or chest should be explored and removed in the operating room. Small, deeply embedded foreign bodies may be difficult to locate without ultrasound guidance. They can be left in place with close follow-up or removed electively.



16 Should hair be removed from a wound site before repair?


The presence of hair usually does not interfere with repair of the wound. Petroleum jelly can be used to keep hair away from the wound site during repair. If hair removal is needed, clippers should be used because they have a lower rate of infection than do razors. Eyebrows should not be removed because regrowth can be slow or absent.



17 Outline the steps in preparing a wound for closure




image Follow standard precautions.


image Prepare the child and the family. An honest and caring explanation of the various steps is important to reduce anxiety.


image Determine whether sedation is required.


image Cleanse and irrigate the wound.


image Use local anesthesia.


image Always use sterile draping and technique.



18 How is irrigation and cleansing of the wound best achieved?


Irrigation is best achieved with normal saline or tap water under pressure using a 20- or 30-mL syringe on a 19- or 22-gauge plastic intravascular catheter. Splash shields (e.g., Zerowet) decrease splattering of irrigation fluid. A volume of 50–100 mL/cm of laceration should be used; for contaminated wounds, larger volumes may be needed. Avoid excessive pressure during irrigation because it can distort the anatomy and damage the tissues. Road rash (tar), dirt, and foreign material should be removed gently with irrigation and mild scrubbing to prevent tattooing. Scrubbing should be limited because it can damage tissues, leading to poor cosmetic outcome. The use of povidone-iodine is controversial. Several studies have shown that it affects fibroblasts and hence wound defenses. A study by Gravett et al showed that use of 1% of povidone-iodine for 1 minute reduces the risk of infection. If irrigation is not well tolerated, repeat it after giving a local anesthetic.


Gravett A, Stener S, Clinton JE, et al: A trial of povidone-iodine in the prevention of infection in sutured lacerations. Ann Emerg Med 16:167, 1987.


Valente JH, Forti RJ, Freundlich LF, et al: Wound irrigation in children: Saline solution or tap water? Ann Emerg Med 41:609–616, 2003.



19 What agents are used for local anesthesia?


Topical anesthetics such as LET (lidocaine 4%, epinephrine 1:1000, tetracaine 0.5%) are very useful. When applied to the wound locally in the form of a gel for 15–20 minutes, LET produces local anesthesia with 97% efficacy. It can be used for all superficial wounds as the sole local anesthetic agent. Topical agents should be avoided in areas of end-blood supply, such as the fingers, ears, nose, toes, and penis (do not use epinephrine for end-arterial structures). Occasionally, deeper wounds require infiltration with another agent, such as lidocaine 1% with or without epinephrine. Bupivacaine is an alternative in lidocaine-allergic patients. Bupivacaine has a longer duration of action.



20 What is the maximum dose of epinephrine in local anesthetic medications?


The does of lidocaine with epinephrine should not exceed 7 mg/kg body weight; the dose of lidocaine alone should not exceed 4 mg/kg.



21 How can the pain of infiltration of a local anesthetic be decreased?


The pain of infiltration can be decreased by:



image Prior application of LET gel (time permitting)


image Rubbing the skin near the site of injection (stimulates other nerve endings and thereby decreases the perception of pain)


image Buffering lidocaine with 8.4% sodium bicarbonate (ratio, 9:1)


image Warming the buffered lidocaine to 40 °C


image Use of 27- or 30-gauge needle to slow the rate of injection


image Injecting from inside the wound through devitalized tissue


Ernst AA, Gershoff L, Miller P, et al: Warmed versus room temperature saline for laceration irrigation—a randomized clinical trial. South Med J 96:436–439, 2003.



22 What is the best method of obtaining hemostasis during wound repair?


A tourniquet, such as a rubber band or blood pressure cuff, and a local anesthetic with epinephrine can decrease the amount of bleeding during wound repair. The blood pressure cuff should be inflated to just above systolic blood pressure. A tourniquet should be used for only 20–30 minutes at a time. It should be released periodically for 2–3 minutes to allow reperfusion. Prolonged continuous use can lead to nerve and vascular damage, with subsequent thrombosis and gangrene.



KEY POINTS: TIPS TO REDUCE PAIN OF ANESTHETIC INFILTRATION




1 Apply LET in advance.


2 Rub the skin near the site of injection.


3 Use buffered lidocaine.


4 Warm the buffered lidocaine.


5 Use a small needle (27- or 30-gauge) for infiltration.


6 Infiltrate slowly.


7 Inject from inside the wound through devitalized tissue.

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Sep 1, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Minor Trauma

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